Abstract On her death in 1910, Florence Nightingale left a vast collection of reports, letters, notes and other written material. There are numerous publications that make use of this material, often highlighting Florence’s attitude to a particular issue. In this paper we gather a set of quotations and construct a dialogue with Florence Nightingale on the subject of statistics. Our dialogue draws attention to strong points of connection between Florence Nightingale’s use of statistics and modern evidence-based approaches to medicine and public health.
We offer our dialogue as a memorable way to draw the attention of students to the key role of data-based evidence in medicine and in the conduct of public affairs. 1. Introduction 1. 1 Who Was Florence Nightingale? Florence Nightingale (1820 – 1910), hereafter referred to as FN, made remarkable use of her ninety years of life. She was the second of two daughters, born in England to wealthy and well-connected parents. There were varied religious influences. Her parents both came from a Unitarian religious tradition that emphasized “deeds, not creeds”.
The family associated with the Church of England (Baly 1997b) when property that FN’s father had inherited brought with it parochial duties. A further religious influence was her friendship with the Irish Sister Mary Clare Moore, the founding superior of the Roman Catholic Sisters of Mercy in Bermondsey, London. Her father supervised and took the major responsibility for his daughters’ education, which included classical and modern languages, history, and philosophy. When she was 20 he arranged, at FN’s insistence, tutoring in mathematics.
These and other influences inculcated a strong sense of public duty, independence of mind, a fierce intellectual honesty, a radical and unconventional religious mysticism from which she found succour in her varied endeavours, and an unforgiving attitude both toward her own faults and toward those of others. At the age of 32, frustrated by her life as a gentlewoman, she found herself a position as Superintendent of a hospital for sick governesses. Additionally she cooperated with Sidney Herbert, a family friend who was by now a Cabinet minister, in several surveys of hospitals, examining defects in the working conditions of nurses.
On the basis of this and related experience she was chosen, in 1854, to head up a party of nurses who would work in the hospital in Scutari, nursing wounded soldiers from the newly declared Crimean war. Her energy and enthusiasm for her task, the publicity which the Times gave to her work, the high regard in which she was held by the soldiers, and a national appeal for a Nightingale fund that would be used to help establish training for nurses, all contributed to make FN a heroine.
There was a huge drop in mortality, from 43% of the patients three months after she arrived in Scutari to 2% fourteen months later, that biographers have often attributed to her work. Upon her return to England at the end of July 1856 FN become involved in a series of investigations that sought to establish the reason for the huge death rate during the first winter of the war in the Crimea. Theories on the immediate cause abounded; was it inadequate food, overwork, lack of shelter, or bad hygiene?
In preparation for a promised Royal Commission, she worked over the relevant data with Dr William Farr, who had the title “Superintendent of the Statistical Department in the Registrar-General’s Office”. Farr’s analysis persuaded her that the worst affects had been in Scutari, where overcrowding had added to the effect of poor sanitation. Sewers had been blocked, and the camp around had been fouled with corpses and excrement, matters that were fixed before the following winter. The major problem had been specific to Scutari.
FN did not have this information while she was in the Crimea. The data do however seem to have been readily available; they were included in a report prepared by McNeill and Tulloch (1855). The strain of FN’svarious involvements, and perhaps residual effects from an illness that she had suffered while in the Crimea, in due course took their toll. A year after her return to England, she suffered a nervous breakdown, emerging from this personal crisis with views that were often remarkably different from those that she had held earlier.
Of particular interest is a change from her demand that nurses should follow to the letter instructions from doctors, to her view that nurses ought, within their proper area of responsibility, to make their own autonomous judgments. Small (1998, pp. 119 – 127, 178) has extensive and perhaps overly speculative comment on the reasons for the nervous breakdown, and an interesting analysis of ways in which her views changed. The data that showed that the high mortality was specific to Scutari were included in FN’s 1858 report, but omitted from the 1857-1858 Royal Commission report.
It was feared that continuing and acrimonious attempts to assign blame would jeopardise ongoing efforts at army reform. FN, unhappy at this suppression of her evidence, sent copies of her report to a number of carefully chosen recipients, each time with instructions to keep it confidential. One of the recipients was the freethinking popular journalist Harriet Martineau. With FN’s help, she wrote a book (Martinueau 1859), ostensibly based on information from public documents but using FN’s confidential report for additional background information, that gave the facts as FN understood them.
FN’s biographers, perhaps relying too much on official documents, have not until recently been mindful of these nuances. See Small (1998, p. 198 – 200) for further discussion is one of the first to recognise them. A comprehensive biography of FN, that will do justice to the wide-ranging sympathies and interests of this remarkable woman and show how her views changed and developed over time, has yet to be written. Small (see the note on his web site) and Baly (1997b, pp. 1-19) both draw attention to inaccuracies in earlier biographical accounts.
Vicinus and Nergaard (1989) have much carefully documented biographical information. Among the numerous web sites that have material on FN note C. J. McDonald (2001) who emphasises connections between Nightingale and the experiences of soldiers in the Vietnam War; L. McDonald (2002) who is leading a project to publish all Nightingale’s writings; and Small (1998). Small’s web site has the data (from Nightingale 1858) that the Royal Commission suppressed. 1. 2 Hospitals and Hospital Nursing FN had remarkably radical views on hospitals and on hospital nursing. Both in 860 and in 1876, she describes hospitals (Baly 1997b, p. 25; Nightingale 1876) “as an intermediate stage of civilisation. ” In 1867 she wrote (Baly 1997b, p. 21) “my view you know is that the ultimate destination is the nursing of the sick in their own homes. … I look to the abolition of all hospitals and workhouse infirmaries. But it is no use to talk about the year 2000. ” Consistent with these views, FN’s Notes on Nursing (1859) are not intended “as a manual to teach nurses to nurse”, but are “meant simply to give hints for thought to women who have personal charge of the health of others. It may thus seem ironic that, in her work with the Nightingale fund, FN was deeply involved in the development of hospital nursing training. She opposed the British Nurses’ Association’s 1890 proposals to make nursing into an accredited profession (Baly 1997b, pp. 184-196). She noted that there was no widespread agreement on what constituted an adequate training or what the minimum qualification should be, and argued that a much longer experience was needed before a register could be contemplated. The qualities that were required in nurses were not amenable to test by public examination.
FN did however see an important role for women medical professionals. She wanted women to take leading roles in midwifery and in the diseases of women and children, and to be as well or better trained for these tasks as the men who at that time had a professional monopoly. It was her view that “There is a better thing than making women into medical men, and that is making them into medical women” (Nightingale 1871). She looked to a time when, as had happened in France, women would be professors of midwifery.
She set out the immediate steps that she thought would best achieve that end. FN worked relentlessly for reform, in the army, in the hospitals, and in public health. She was meticulous in researching the reforms that she proposed. Where, as often, data were unavailable or inadequate, she pressed for their collection. Data inadequacies are strong themes in her Notes on Hospitals and in her Introductory Notes on Lying-In Institutions, i. e. , on maternity institutions. She made strong, consistent and carefully argued cases for enlightened and data-based public decision-making.
This is not to say that FN was always correct in her judgments. In her next to final contribution to the dialogue, FN comments on a controversy that erupted following the publication of the third edition of her Notes on Hospitals. Her use of the term mortality percent for deaths per hundred beds per day, which she copied from Farr’s report as Registrar-General, was unfortunate. As she seems to admit a page later in the Notes, these figures were not a good basis for comparing the sanitary states of different hospitals.