Florence Nightingale’s other legacy: innovator in descriptive statistics

“To understand God’s thoughts we must study statistics for these are the measure of his purpose” Florence Nightingale

The lady with the lamp….Florence Nightingale is best remembered as the pioneer of modern nursing. What is less known about Florence is that she was deeply committed to the field of statistical analysis in health care.   So much so that Florence was in 1859 elected the first female member of the Royal Statistical Society.  Florence was an innovator in the field of descriptive statistics and she was part of a transformation that showed how social phenomena could be objectively measured and subjected to mathematical interpretation.

Nightingale realized that she had to make data come alive to effectively convey a message; one of her persistent messages was that health care facilities needed to improve. Nightingale held the belief that visual aids and graphs should be easy to understand.  She believed that Queen Victoria and parliament who were not accustomed to statistical data would not understand traditional statistical reports.  So Nightingale innovated and developed the polar area diagram; occasionally called the Nightingale rose diagram.  This was an innovation on the pie chart, invented by William Playfair in 1801.

She was the first person to use visual presentations to report the conditions of health facilities. Data that she presented visually to implement health care reform includes the illustration of seasonal sources of patient mortality in military field hospitals, graphs to report on the nature and magnitude of conditions of medical care in Crimean war, bar charts to show how soldiers living in barracks in England were dying at a faster rate than civilians in the cities around them because of sanitary conditions. She used the visual graphs to demonstrate how mortality could be decreased and after implementation of her recommendations how it was decreased.

“…for me this experience emphasized the great importance of correct hospital statistics as an essential element.” Florence Nightingale

Nightingale was the first to use systematic documentation of deaths in hospital, using the records to calculate death rates due to different causes.   She convinced the politicians of the role of statistics in government pointing out inconsistencies in data such as mortality rate measurements that needed standardisation.  She then took it one step further designing a hospital statistical form for hospitals to collect and generate consistent data.

“…of what use are statistics if we don’t know what to make of them?” Florence Nightingale

Data visualization is the modern branch of descriptive statistics. It involves the creation and study of the visual representation of data with the goal of communicating clearly and efficiently.   It can be used in health care improvement to indicate what should happen and what are happening.

It is not recorded whether nursing documentation existed before Florence used it to drive improvement of care in hospitals and I think that she was the first nurse to use nursing documentation. Her aim with keeping nursing documentation was to illustrate the implementation of doctors’ orders and to use nursing documentation data for statistics on hospital environment, patient safety and quality of nursing care.

It is as imperative now as it was then that nurses should use documentation to push for change and improvement. Nursing documentation should not only be limited to patient care it should extend to drive health care change in the hospital environment.

Health care practitioners are already experts at using visuals to present patient information by taking real time clinical measures of patients, presenting it on charts and then using it to make decisions, implement actions and measure effectiveness. For example vital signs charts, input and output charts, temperature charts, pressure area charts, medication charts.

“Not that the habit of correct observation will by itself make us useful nurses, but without it we will be useless.” Florence Nightingale

We also intuitively understand the importance of taking the right measure and an exact measure. We don’t report that the patient has an ok blood pressure or mild blood pressure.  We don’t expect “some” temperature or “slight” outputs.  We know that if we are to care for the patient to the best of our ability exact measures and trends are important when interpreting charts and vital signs.

“It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm.” Florence Nightingale

We need to follow Nightingales guidance and use visual data to improve health care as a greater whole.  Innovating on her concepts and using functional visuals to plan our actions better and at a glance know where the bottlenecks could direct our daily work.  Imagine how we would or could perform if we had this data available to us throughout the day.  I can just imagine the state of nirvana for most emergency nurses glancing at the information and knowing that the EC does not need to overflow with patients because the wards are discharging and there is space for our patients….mmmm…what a happy thought!

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A little note: this blog was supposed to be on the visual management of data for improvement, I completely ventured off the topic when I started reading about Florence Nightingale. I’ve read her work on nursing before and visited her museum in the UK, and I’ve always been aware of her nursing accomplishments. Somehow I missed the significance of her other work! They reckon that she was the driving force behind most health related legislation in England for a period spanning more than 50 years, she was instrumental in developing nursing in other countries, health care reform in India, and I could go on and on.  It is mind blowing that one person could impact change on so many levels.  Such an inspiration!  And they reckon that there are more than 300 Nightingale biographies alone!

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