Florence Nightingale – Infographics Pioneer

Florence Nightingale was one of the pioneers in the use of statistics and infographics in achieving social reform. Florence Nightingale – Infographics Pioneer is Part 3 of The Can-Do Wisdom of Florence Nightingale series and covers the period of her life after the end of the Crimean War up to her death in 1910. It was during this period that she left the legacy for generations to come by using her knowledge and influence to affect lasting change in army health, medical health in India, hospitals, medical statistics and nurse education.

The most important practical lesson than can be given to nurses is to teach them what to observe.
– Florence Nightingale

Florence Nightingale and the need for reform

Florence Nightingale had already achieved fame by the time she returned from the Crimean War as a thirty-six year-old woman. Another phase of her life was over with the most important part yet to come in her remaining years.

Now having come back to London she was dismayed to find the government was ignoring the McNeill–Tulloch report into the mismanagement of supplies to the British forces. In February 1855, in response to the damaging press articles, Colonel Alexander Tulloch and Scottish surgeon John McNeill had been sent to the Crimea to report on conditions in the field. Although it was outside the scope of their enquiry they did bring attention to the high mortality and sickness rates. For all the mismanagement and criminal negligence no one responsible was to be called out. Instead the senior Army officers and civilians involved were being rewarded for their ‘contributions’, some with Knighthoods.

The losses were extraordinary. The British Army had lost 20,400 soldiers, with 4,400 dying in battles or from combat wounds. The scandal was that 16,000 of these deaths was due to illness and neglect.[2]

Nightingale believed that only a Royal Commission would uncover the true picture of what happened and make recommendations so that the same thing would not happen in the future. It meant that her obsession to bring about the training of nurses would have to wait but in her mind the priority was to change the culture of the Army.

But the Government, the Army chiefs and Queen Victoria had been embarrassed enough by the exposure of the press during the Crimean War and didn’t want any further disclosures of ‘dirty linen’. Military historian, Kevin W. Farrell, notes the importance of the reputation of the British Army for the Queen when he says, “ . . the one area of influence to which the Crown held on most fiercely was its relationship to the military. Queen Victoria deeply cherished what she understandably viewed as ‘her army.’”[3]

How was Nightingale going to convince these reluctant parties of the need for a Royal Commission?

How Florence Nightingale inspired others

Can-Do Wisdom FrameworkReferring to the Can-Do Wisdom Framework, Nightingale had by now acquired significant capabilities in the I Can quadrant through years of observation, reflection, learning and knowledge. She was experienced in how to act in the I Do quadrant through her leadership style of not only ‘do what I say’ to followers but ‘do what I do’ as an example to others. She was demanding of others and had high expectations of their performance. She wasn’t afraid to tell what she thought of their performance in her quiet, determined manner. Overall she had fame and credibility on her side.

Linking these two quadrants was Nightingale’s approach to life: hard work, organization, perseverance, and persistence – as well as her belief her work was God’s will.

She had also worked the We Can quadrant by establishing personal links to key persons of influence. So far she had used these contacts to cut through the bureaucracy as a way of getting things done in the Scutari Hospital from an operational sense. Being a skilled communicator – both written and oral – helped immensely.

After the War, Nightingale declined all public receptions and would only meet with those who could advance her cause. She now had the opportunity to use these same influencers to move into the We Do quadrant and cause major changes to social systems.

These would be the most important contributions she would make in her life with her first goal to bring about the reform of the entire Army medical service..

The First Royal Commission

The breakthrough came through a meeting with Queen Victoria and her husband, Prince Albert, at Balmoral, Scotland, on 21 September 1856. The Queen was already a great admirer and was well aware of the ‘goodness and self-devotion’ of Florence Nightingale. In January 1855 Victoria had sent her a brooch designed by Prince Albert inscribed with the words, “Blessed are the Merciful.”

The meeting lasted two hours and from it Victoria agreed there should be a Royal Commission but did not have the power to initiate one. Nightingale’s next challenge was to convince a reluctant Lord Panmure, Secretary of State for War, of the need for army reform. A few weeks later Panmure attended a meeting with Nightingale arranged by the Queen. Panmure was won over by Nightingale’s “powerful clear head and simple modest manner.”[4]

In agreeing to the Royal Commission, Panmure requested Nightingale to submit observations and recommendations from her period in Scutari in a confidential report.

She started writing the report late in 1856. She had been keeping meticulous notes while in Scutari and during her period at the Institution for the Care of Sick Gentlewomen in London but she also called on Alexander Tulloch and John McNeil, authors of the earlier discredited report, to contribute their knowledge. An important contributor was Dr. John Sutherland, an expert in ‘sanitary science’. Another key person who assisted was William Farr, a brilliant statistician, who helped identify poor hygiene as the main cause of preventable deaths in the Crimean War.

The 800-page report, Notes on Matters Affecting the Health, Efficiency and Hospital Administration of the British Army, included an extensive statistical analysis of the causes of illness and death in the army. But she had to do more to effectively communicate the key messages from the report, knowing that most recipients of the report would fail to read it.[5]

Panmure still delayed establishing the Royal Commission and by February 1857 Nightingale was threatening to make public the content of her report. This forced Panmure to finally establish the ‘Royal Commission on the Sanitary Condition of the Army’ in May under the chairmanship of her friend, Sidney Herbert.

Nightingale worked closely with Herbert, guiding him on how the Commission should be run, who should be called as witnesses and how they should be cross-examined.
She didn’t appear before the Commissioners herself but her report was the basis for the final report to come out six months later.

Infographics Pioneer

One of the remarkable aspects about ‘Notes on Matters’ is the use of infographics (information graphics). Nightingale was one of the pioneers of modern-day infographics where the intention is “to simplify the presentation of large amounts of data, to see patterns and relationships, and to monitor changes in variables over time.”[6]

The most frequent form of infographics to appear in Nightingale’s work is the comparative bar chart. In the example from the report shown below, the black bars represent the death rate of the English male population of four age groups between the ages of 20 and 40. The red bars represent the death rate of the Foot Guards at home, in peace time. These are the guards for the Royal Family at Buckingham Palace, St James’s Palace and Windsor Castle.

It’s obvious without looking at the data tables that the bar charts show the death rate for Foot Guards twice that of the English male population. Why should this be the case when the tough selection process means only healthy males become guards and any guards unfit for service are discharged?

Relative Mortality of the Foot Guards and of the English Male Population.[7]Further analysis in the report explains the cause of death:

We are at once struck by the remarkable fact that more than seven-ninths of the mortality in the Infantry are due to two classes of disease alone, namely, to zymotic diseases such as fevers, cholera, diarrhoea, and to chest and tubercular diseases, such as consumption, etc.[8]

Nightingale’s other innovation was to introduce the polar area form of infographics, also referred to as a pie chart, rose diagram and coxcomb. Again, the aim was to make complex data understandable.

An example is the annual rate of mortality of British Soldiers in Crimea covering the 12 months from April 1854 through March 1855. The table is shown below.

Annual rate of Mortality per 1000[9]The polar area graphic is similar to a pie chart except that the angles of the wedges are fixed and the radius of the segment changes to form an area representing the value. A pie chart has a fixed radius and the angles of the segments vary as determined by the data.

A recreation of a polar area diagram from the above data table in Nightingale’s 1857 report is shown below. The centre circle is called the Manchester Circle which represents the death rate in England’s worst city from a death rate perspective. Except for the period April-June 1854, the remaining months are many times the mortality rate for Manchester.

Diagram of the Mortality in the Army in the East, 1854-55[10]It is clear from the diagram that the mortality rate is many times higher than the Manchester Circle from July onwards, peaking in January 1855, and falling for the remainder of the War.

A more detailed diagram below show the causes of these deaths, as Nightingale explained:

The Areas of the blue, red, and black wedges are each measured from the centre as the common vertex.
The blue wedges measured from the centre of the circle represent area for area the deaths from Preventable or Mitigable Zymotic Diseases, the red wedges measured from the centre the deaths from wounds, & the black wedges measured from the centre the deaths from all other causes.
The black tine across the red, triangle in Nov 1854 marks the boundary of the deaths from all other causes during the month.
In October 1854, & April 1855, the black area coincides with the red. in January & February 1856, the blue coincides with the black.
The entire areas may be compared by following the blue, the red & the black lines enclosing them.[11]

Nightingale’s Causes of Mortality 1854-56[12]
For a larger image go to Royal Collection Trust

The key to this diagram is understanding what happened to cause the remarkable decrease in deaths from preventable diseases from February 1855 to the end of the War.

In March 1854, under the direction of Dr John Sutherland’s Sanitary Commission, clean up work started at the Barracks Hospital in Scutari. Sutherland’s report to Parliament stated, “During the week there were collected and removed from the vicinity of the Barrack Hospital 202 hand-carts or baskets full of filth, rubbish, and offensive matter. . . [t]he carcases of 15 dogs and 2 horses were buried and the sewers of the Barrack Hospital were flushed three times.”[13] This cleanup work continued for months.

Encouraged by the results of the statistical analysis by William Farr, Nightingale eventually attributed the reduction in the mortality rate to the sanitary reforms, rather than the soldiers inadequate diet and exposure to the cold when in the Crimea. Some biographers are not convinced improved sanitation was the sole reason, since the mortality rate was reducing even before the cleanup work started. For example, Mark Bostridge, in his recent book about the life of Florence Nightingale, contends the lower mortality rates were due the reduction in overcrowding and the improved health of arrivals from the Crimea.[14]

Certainly, Scutari Hospital was one of the worst affected places but the situation there was exacerbated by overcrowding.

The Beauty of Infographics

On 9 December 2010, BBC FOUR first broadcast the TV program, ‘Florence Nightingale – The Beauty of Diagrams’, presented by Oxford Professor Marcus du Sautoy. According to Lynn McDonald,[15] the program contains numerous factual errors and exaggerations but even so it demonstrates Nightingale’s skills in using infographics to communicate complex data in an easy-to-understand way.

Aftermath of the Royal Commission

The final Herbert Report of the Sanitary Commission was presented to both Houses of Parliament on 9 February 1858.[16]

Nightingale’s evidence was critical to the enquiry. In the 34 pages of ‘Answers to written Questions addressed to Miss Nightingale by the Commissioners’ she gave very detailed responses which included statistical analyses of data together with the theory and formulae behind the analysis.[17] She contended that statistical data was “critical to the evaluation of military hospitals’ sanitation effectiveness as well as medical-surgical outcomes.”[18]

Her research methods were recognised by the Royal Statistical Society in 1858 when she was elected as the first woman member of the Society.[19]

Four subcommissions were established to implement the recommendations from the Royal Commission, not without opposition from the Army medical chiefs. However, the Army did establish a medical school and statistical department. Other sanitary reforms recommended by Nightingale resulted in halving the mortality rate of soldiers.

British Army in India

Her actions in calling for the first Royal Commission, contributing to it and seeing the recommendations were carried out set the stage for the many projects that followed. However the work had exhausted her and in mid-1859 she collapsed and became bed-ridden. This didn’t stop her from calling for another Royal Commission to examine the health of British soldiers and the general population in India.

After the British Raj took over governing from the East India Company in 1858, the number of British troops sent to India increased markedly. She succeeded in prompting for establishing the Royal Commission on the Sanitary State of the Army in India in May 1859, again under the Chairmanship of Sidney Herbert. When Herbert resigned due to the defeat of the Derby Government in June 1859, Lord Stanley took over as Chairman with Herbert remaining a commissioner although ill. Herbert died on 2 August 1861, a loss felt deeply by Nightingale.

Nightingale led the research project which involved collecting data from the 200 major British military bases in India. The first draft of her report was completed early in 1863 with the final report from the Royal India Sanitation Commission published in July 1863. The findings were similar to those from the previous Royal Commission, but far worse.[20]

She would continue to work on sanitation and medical reforms for the civil population in India for the remainder of her life.[21]

Notes on Hospitals

Another of her projects was to address hospital construction, organization and management. Using her experience from visiting and working in hospitals in Europe and in the Crimea, the report, “Notes on Hospitals”, revolutionized hospital construction and administration principles for patient care. Three editions were published, the first in 1859 and the final one coming out in 1863. It opened with a statement that is relevant to us today:

It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm. It is quite necessary, nevertheless, to lay down such a principle, because the actual mortality in hospitals, especially in those of large crowded cities, is very much higher than any calculation founded on the mortality of the same class of diseases among patients treated out of hospital would lead us to expect.[22]

Notes on Nursing

Nightingale’s ‘Notes on Nursing’ was written for a different audience: women caring for their families and themselves at home. Again, it made use of her years of studying disease prevention and her experience in the Crimea in giving practical advice on achieving wellness rather than advice on sickness.[23]

The first version of 79 pages was published in January 1860 and was enthusiastically received by the public. An expanded second version known as the Library Standard Edition, with nursing hints directed towards professional hospital nurses, appeared in July 1860 and a third, shortened, version, ‘Notes on Nursing for the Labouring Classes’, was first published in 1868. Nightingale’s most popular book, ‘Notes on Nursing’, has been translated into many languages and is available even to this day.

Nightingale Training School for Nurses

While Nightingale had still been in the Crimea, in London a committee was formed in November 1855 to launch a national appeal for funds for her to use for training nurses. By June 1856, there was approximately £44,000 in the Nightingale Fund.[24]

Because of her other priorities, it took until June 1860 before the school, supported by the Nightingale Fund, opened its doors at St. Thomas’s Hospital in London. As she expected there was opposition from sections of the medical profession but she used her influential contacts and logic to overcome the objections.

Nightingale was unable to take any role in the school but did take an active interest in its operations. There were many difficulties in the first ten years but after that it became a model nursing school to be emulated around the world. At last, nurses were rercognised as being part of the medical profession.

Change Leadership Lessons from Florence Nightingale

Referring to the Can-Do Wisdom Framework above, Nightingale’s approach to change leadership can be seen as moving through the I Can, I Do, We Can and We Do quadrants, with quotes from Nightingale herself:

LEARN
“Let us never consider ourselves finished nurses . . . we must be learning all of our lives.”
Nightingale was a life-long learner. She was highly intelligent and learned quickly. She was not afraid to approach others to expand her knowledge, whether it be in nursing, statistics or whatever. The basis of the research she undertook for her projects is described by McDonald[25] as ‘The Nightingale Method’:
• Get the best information available
• Use government reports and statistics
• Read and interview experts
• If the available information is inadequate collect your own:
• Draw up a questionnaire
• Consult relevant practitioners.

LIVE
“I attribute my success to this – I never gave or took any excuse.”

Nightingale found her purpose in life after her ‘calling’. She followed this dream, realizing that being married would not allow her to achieve her dream. She worked extremely hard and expected others to do the same. She was dedicated to her work in achieving social reform all her adult life.

LEAD
“I think one’s feelings waste themselves in words; they ought all to be distilled into actions which bring results.”

Nightingale’s main activities in the latter part of her life was in her writing which was designed to bring about results. It is estimated she authored some 12,000 letters and 200 books, reports, and monographs.[26] The basis for her arguments were objective facts with statistical analysis to gain meaning from the facts.

INITIATE
“So never lose an opportunity of urging a practical beginning, however small, for it is wonderful how often in such matters the mustard-seed germinates and roots itself.”
It takes effort to convince others of the need for change, to get them to think ‘We Can’. Nightingale took advantage of knowing influential people to act on her behalf. She would pressure them and sometimes manipulate them to get her way. She also made it as easy as possible for others to understand complex issues by the use of infographics in her reports and ‘Notes’ wherever possible.

IMPLEMENT
“Let whoever is in charge keep this simple question in her head (not, how can I always do this right thing myself, but) how can I provide for this right thing to be always done?”
An implementation strategy is needed. There is often the need to push others to plan the changes. On many occasions Nightingale was told, “It will happen!”, only to find it didn’t. An example was when Lord Panmure, Secretary of State for War, delayed convening the first Royal Commission. Nightingale would resort to using the media to put pressure on politicians when necessary.

INSTITUTE
“Were there none who were discontented with what they have, the world would never reach anything better.”
The end result of a change initiative is a new operating system but often these don’t work as intended or there are unforeseen consequences. Nightingale viewed the nurse training as a ‘pragmatic experiment’ which one learns from to redesign as necessary.[Source: bf02737786.pdf] Learn follows Institute on the wisdom path so it requires observation of the social systems to ensure they are working. In fact, it took around 10 years before the Nightingale Nursing School was operating as Nightingale envisaged.

Florence Nightingale as a Strategic Leader

A recent Harvard Business Review article identifies six skills required for strategic leadership today. Nightingale would no doubt score highly on each of the edited dimensions shown below:.[26]

ANTICIPATE
Gather information from a wide network of experts and sources.
Predict opponents’ potential moves and likely reactions to new initiatives.

CHALLENGE
Reframe a problem from several angles to understand root causes.
Seek out diverse views to see multiple sides of an issue.

INTERPRET
Demonstrate curiosity and an open mind.
Test multiple working hypotheses with others before coming to conclusions.

DECIDE
Balance long-term investment for growth with short-term pressure for results.
Determine trade-offs, risks, and unintended consequences.

ALIGN
Assess stakeholders’ tolerance and motivation for change.
Pinpoint and address conflicting interests among stakeholders.

LEARN
Communicate stories about success and failure.
Course correct on the basis of discontinuing evidence.

Final Years

Up till the late 1890s Nightingale continued to work on hospital plans even though she was bedridden.

In 1907 she was the first woman to be awarded the Order of Merit by King Edward VII.

On 13 August 1910 she died peacefully in her sleep, aged 90.

This remarkable person, Florence Nightingale, can be said to be a wise person because she performed her great work, not for her own glory, but for the common good of all generations to come. We can learn a great deal from her example.

NOTES

1. “Florence Nightingale. Photograph by Millbourn,” Wellcome Collection CC BY, accessed December 21, 2017, https://wellcomecollection.org/works/ybzvjv2s.
2. Lynn M. Hamilton, Florence Nightingale: A Life Inspired (n.p.: Wyatt North Publishing, 2015), Kindle e-book, under “A Call for Reform.”
3. “The Military and the Monarchy Excerpt,” University of North Georgia, accessed December 21, 2017, https://ung.edu/university-press/books/excerpts/military-and-the-monarchy-excerpt.php
4. Cecil Woodham-Smith, Florence Nightingale 1820-1910 (New York: McGraw Hill, 1951), 186.
5. Florence Nightingale, Notes on Matters Affecting the Health, Efficiency, and Hospital Administration of the British Army founded chiefly on the Experience of the Late War (London: Harrison & Sons, 1858).
6. “Infographics definition” WhatIs.com, accessed December 21, 2017, http://whatis.techtarget.com/definition/infographics.
7. Florence Nightingale, Mortality of the British Army, at Home, and Abroad, and During the Russian War, As Compared with the Mortality of the Civil Population in England (London: Harrison and Sons, 1858), 33.
8. Nightingale, Mortality of the British Army, 3.
9. Nightingale, Notes on Matters, 315.
10. Nightingale, Notes on Matters, 310.
11. “Diagram of the Causes of Mortality in the Army in the East,” Royal Collection Trust, accessed December 21, 2017, https://www.royalcollection.org.uk/collection/1075240/notes-on-matters-affecting-the-health-efficiency-and-hospital-administration-of.
12. Royal Collection Trust, “Diagram of the Causes of Mortality.”
13. Great Britain. Sanitary Commission. Report to the Right Hon. Lord Panmure, G. C. B., &c., Minister At War: of the Proceedings of the Sanitary Commission Dispatched to the Seat of War In the East, 1855-56 (London: Harrison and sons, 1857), 240.
14. Mark Bostridge, Florence Nightingale: The Woman and Her Legend (London: Penguin, 2009), Kindle e-book, chap. 9.
15. Lynn McDonald, “Florence Nightingale, statistics and the Crimean War,” Journal of the Royal Statistical Society: Series A (Statistics in Society), 101: 569–586, doi:0.1111/rssa.12026.
16. Great Britain. Royal Commission Appointed to Inquire into the Sanitary Condition of the Army. Report of the Commissioners appointed to inquire into the Regulations affecting the sanitary conditions of the Army, the organisation of military hospitals, and the treatment of the sick and wounded (London: H.M.S.O., 1858).
17. Royal Commission, Report of the Commissioners, 361-94.
18. “Florence Nightingale: Where Most Work Is Wanted,” Nurse Key, accessed November 28, 2017, https://nursekey.com/florence-nightingale-where-most-work-is-wanted/
19. “Florence Nightingale. Passionate Statistician,” The Collected Works of Florence Nightingale, accessed November 20, 2017, http://www.uoguelph.ca/~cwfn/short/statistician.htm.
20. Nurse Key, “Florence Nightingale.”
21. Nurse Key, “Florence Nightingale.”
22. Florence Nightingale, Notes on Hospitals (London: Longman, Green, Longman , Roberts, and Green, 1863), iii.
23. Victor Skretkowicz, ed., Florence Nightingale’s Notes on Nursing and Notes on Nursing for the Labouring Classes: Commemorative Edition with Historical Commentary (New York: Springer, 2010).
24. Nurse Key, “Florence Nightingale.”
25. GreshamCollege, Florence Nightingale and her Crimean War Statistics – Professor Lynn McDonald (online video, December 7, 2017), https://www.youtube.com/watch?v=nr3uEg7a_m4.
26. David Bornstein, How to Change the World:Social Entrepreneurs and the Power of New Ideas, Updated Edition (New York: Oxford University Press, 2007), 45.
27. “Strategic Leadership: The Essential Skills, Paul J. H. Schoemaker, Steve Krupp, and Samantha Howland, From the January–February 2013 Issue,” Harvard Business Review, hbr.org, accessed January 4, 2018, https://hbr.org/2013/01/strategic-leadership-the-esssential-skills.