Let’s meet a Statistician

Florence Nightingale (1820-1910), known as The Lady with the Lamp, was born in May 1820 in Florence, Italy. She was a nurse by education, social reformer and best known as the founder of modern nursing. Because of her father was a wealthy landowner who inherited two estates: one in Derbyshire, other in Hampshire in England she received classical education that time including German, French and Italian. At the age of 16 she was ambitioned to be a nurse however her parents did not like it due to their hight social status. In 1844 Nightingale started studying nursing at the Lutheran Hospital of Pastor Fliedner in Kaiserwerth, Germany.

In 1850s she took a job as a nurse in the Middlesex hospital in London and impressed the employer within a short period of time. Soon after a cholera spread in the area and Nightingale made her mission to improve the hygiene in hospital that lowered the death rate significantly.

In October of 1853 the British Empire engaged in war with the Russian Empire in Crimea (Turkey). 18,000 British soldiers had been admitted into military hospitals by 1854. Nightingale was called to come to Crimea to nurse the sick and fallen soldiers in British base hospital. British base hospital in Constantinople which sat on top of a large cesspool which was contaminating the water and the hospital building itself. She led a team of 34 nurses there.

While nursing the wound soldiers Nightingale discovered that no meticulous record of admissions, deaths and cause of deaths was being stored. She then started recording that information (Joyece H., 2008). Though McDonald Lynne (2020) argued that Nightingale have not introduced the hospital data collection plan rather she appreciated the value of the recorded data. I am not going in that argument if she introduced or not however the way she analysed and presented the data is absolutely valuable and helped save life and policy changes in British hospital administration.

 After completing the mission at Crimea she return to London and she then analysed that data and observed that the soldiers were killed far more by preventable cause what she called that time “Mitigable Zymotic Diseases” than the wound by battle. Nightingale summarised the data in simple table and presented using graphical device known as polar area chart also called Nightingale Rose diagram or Coxcomb chart (see figure 2, a). Also, she accessed further data on British male death rates with their causes and analysed together with the leading medical statistician at that time Dr William Farr and produced more effective charts (see figure 2, b). Using these charts, they could convince the policy makers implementing new policies on hospital hygiene and administration. Therefore, it is an essential aspects of data analysis or statistical learning to communicate the data and data driven output to the right audience in a readable way.  Lynn McDonald (2020) acknowledged that,

“Nightingale was an expert on asking the right questions, analysing data and writing it up persuasively.”

To better understand the cause of death Nightingale compared the death rate by months to see the impact of barometric pressure and temperature (panel (a), Figure 2). She found higher death rate in the hotter months than the cooler months. She amazingly explored further considering time and environmental factors that uncover the reality of what was happening there at Crimea. I see that Nightingale possessed this excellent quality of a sound statistician to think one step further considering all other potential factors that may have an impact on outcome or the association of interest.

Nightingale compared the death rate of the British army with that of British male (15-45 years) over time using a stacked bar chart and found that army has higher chance of death compared to the civilians. She evaluated the contribution of Sidney Herbert (the junior war minister and chair for reform implementation commissions) and showed that the death rate reduced significantly even lower than the British civilians (panel (b), Figure 2) after Lord Herbert’s period in the reform commission. Nightingale appreciated the alternative analytical approach and how to communicate the output using right type of chart which is critical for a successful and impactful statistician. Lynn McDonald also stated that,

“Making results accessible and persuasive was always part of her mission.”

After noticing that more soldiers were dying from infectious diseases than from injuries incurred in battle, she introduced several interventions include cleaning the hospital from floor to ceiling; creation of an invalid’s kitchen; establishing a laundry, classroom and library for the patients for intellectual stimulation and entertainment. Moreover, while moving through the dark hallways carrying a lamp ministering to patient after patient, she provided them mental support. The soldiers took to calling her “The Lady with the Lamp” and others called her “the Angel of Crimea.” Nightingale’s interventions in hospital hygiene, food and mental support reduced the hospital’s death rate by two-thirds (History.com Editors, 2009).

Nightingale returns from Crimea to her childhood home in Derbyshire in the summer 1856 and received a hero’s welcome with a reward from the Queen with an engraved brooch that came to be known as the “Nightingale Jewel”. She was also granted a prize of $250,000 from the British government.

Nightingale did not stop at Crimea nor in England she continued asking right question while working with medical officers in preparing statistical report for Royal Commission on India. She observed in her analysis that the death rates were roughly twice than expected in the colonial schools and hospitals.

Despite the lack of data and challenges in collecting data Nightingale conducted a comprehensive data analysis on closing a midwifery programme and maternity ward in King’s College Hospital. The question is if the data were limited what she analysed. She talked with the doctors and gathered information from them which we may call qualitative data collection approach. Another source she used is the small number of published literatures around the Europe which we may call a review. She summarised her findings in a report Introductory Notes on Lying-in Institutions in 1871 which marked as immense advancement on the subject area (Nightingale 1871). This was simply amazing she understood what to do in case of lacking volumes of quantitative data. I guess this was one of the earliest forms of modern qualitative research and systematic review.

Nightingale maybe did not invent the rocket sciences however she was an expert in asking right question, analyse the data accordingly and communicate the results in persuasive manner. That is why she was acknowledged as a pioneer of evidence-based health care (McDonald L., 2001). Nightingale was elected as the first female fellow of the Royal Statistical Society (then Statistical Society of London) also she received honorary membership of the American Statistical Association.

References

• History.com Editors. (2009). Florence Nightingale – biography, Facts & Nursing. HISTORY. https://www.history.com/topics/womens-history/florence-nightingale-1
• McDonald, L. (2001) Florence Nightingale and the early origins of evidence-based nursing. Evidence-Based Nursing, 4(3), 68– 69.
• Nightingale, F. (1871) Introductory Notes on Lying-in Institutions. London: Longmans, Green, and Co.