Florence Nightingale combined medical and sanitary work with statistical evidence, using charts to explain military deaths and related problems while advocating hospital and public-health reform.
Her nursing work extended far beyond the familiar image of a woman making rounds with a lamp. Data analysis, administrative advocacy, and training systems were also important parts of it.
Statistics and sanitary reform
Florence Nightingale exhibited a gift for mathematics from an early age and excelled in the subject under the tutelage of her father. Later, Nightingale became a pioneer in the visual presentation of information and statistical graphics. She used methods such as the pie chart, which had first been developed by William Playfair in 1801. While common now, it was at the time a relatively novel method of presenting data.
Indeed, Nightingale is described as "a true pioneer in the graphical representation of statistics" and is especially well known for her usage of a polar area diagram, or occasionally the Nightingale rose diagram, equivalent to a modern circular histogram, to illustrate seasonal sources of patient mortality in the military field hospital she managed. While frequently credited as the creator of the polar area diagram, it is known to have been used by André-Michel Guerry in 1829 and Léon Louis Lalanne by 1830. Nightingale called a compilation of such diagrams a "coxcomb", but later that term would frequently be used for the individual diagrams.
She made extensive use of coxcombs to present reports on the nature and magnitude of the conditions of medical care in the Crimean War to Members of Parliament and civil servants who would have been unlikely to read or understand traditional statistical reports. In 1859, Nightingale was elected the first female member of the Royal Statistical Society. In 1874 she became an honorary member of the American Statistical Association.
Her attention turned to the health of the British Army in India and she demonstrated that bad drainage, contaminated water, overcrowding, and poor ventilation were causing the high death rate. Following the report The Royal Commission on India (1858–1863), which included drawings done by her cousin, artist Hilary Bonham Carter, with whom Nightingale had lived, Nightingale concluded that the health of the army and the people of India had to go hand in hand and so campaigned to improve the sanitary conditions of the country as a whole.
Nightingale made a comprehensive statistical study of sanitation in Indian rural life and was the leading figure in the introduction of improved medical care and public health services in India. In 1858 and 1859, she successfully lobbied for the establishment of a Royal Commission into the Indian situation. Two years later, she provided a report to the commission, which completed its own study in 1863. "After 10 years of sanitary reform, in 1873, Nightingale reported that mortality among the soldiers in India had declined from 69 to 18 per 1,000".
The Royal Sanitary Commission of 1868–1869 presented Nightingale with an opportunity to press for compulsory sanitation in private houses. She lobbied the minister responsible, James Stansfeld, to strengthen the proposed Public Health Bill to require owners of existing properties to pay for connection to mains drainage. The strengthened legislation was enacted in the Public Health Acts of 1874 and 1875. At the same time, she combined with the retired sanitary reformer Edwin Chadwick to persuade Stansfeld to devolve powers to enforce the law to local authorities, eliminating central control by medical technocrats. Her Crimean War statistics had convinced her that non-medical approaches were more effective given the state of knowledge at the time.
Historians now believe that both drainage and devolved enforcement played a crucial role in increasing average national life expectancy by 20 years between 1871 and the mid-1930s during which time medical science made no impact on the most fatal epidemic diseases.