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Florence Nightingale: Modern-Day Lessons and Legacies

1 June 2016 630 views One Comment
Jessica Utts

Jessica Utts

It was a coincidence that led to the topic of this month’s President’s Corner. I had been thinking about writing a column about the legendary Florence Nightingale (1820–1910), partly to honor women in statistics and partly because I find personal histories compelling. But a search for her name on the ASA website revealed several existing and accessible articles about her life and work. What could I add that isn’t covered by the biography of her on the ASA’s site, the much-visited page about her on This is Statistics, and the Science News article by Excellence in Statistical Reporting Award winner Julie Reymeyer, all of which discuss Nightingale’s fascinating life and her contributions to statistics?

Florence Nightingale

Florence Nightingale

And then the coincidence happened. I met Barbara Dossey, who had accompanied her husband to a conference in Portugal at which he and I were both invited speakers. I discovered Dossey is an internationally recognized Nightingale scholar. And I learned about the Nightingale Initiative for Global Health (NIGH), founded in 2004 by a small group of Nightingale scholars—including Dossey, who currently serves on its board of directors.

This chance meeting renewed my interest in learning and writing about Florence Nightingale. I decided to interview Dossey to see what she could add to our understanding of the enigmatic Nightingale and to learn more about NIGH. As I delved deeper into Nightingale’s work, philosophy, and life, I realized part of her legacy includes powerful lessons relevant to statisticians today. So before presenting the interview with Dossey, I offer here some inspirational quotes from statisticians writing about Nightingale over almost a century.

In 1916 in JASA, Edwin Kopf provided a graphic illustration of Nightingale’s ability to communicate the meaning of raw statistics:

In writing to Sir John McNeill, she said “[I]t is as criminal to have a mortality of 17, 19, and 20 per thousand in the Line, Artillery and Guards, when that in civilian life is only 11 per 1,000, as it would be to take 1,100 men out upon Salisbury Plain and shoot them.” (Kopf, 1916, p. 390).

In 1920 (also in JASA), Nutting and Kopf chided statisticians of the day for wasting time on purposeless statistical exercises and recommended that students and practitioners of statistics emulate Nightingale, a lesson that still resonates today:

“Statistics for statisticians” were, to [Nightingale’s] mind, an abomination. Analysis of tabulated facts on sanitation and on the conduct of public affairs were to her a lever for overcoming the inertia of the legislative mind, of smugly buttressed officialdom, and of an amorphous public conscience… A survey of statistical activity in America today [1920] would perhaps show that much of our effort is aimless. There is laborious and expensive endeavor to produce ponderous tomes, and then feverish activity to find a market for the product. (Nutting and Kopf, 1920, p. 651)

Throughout accounts of Nightingale’s thinking about statistics is found the message articulated by Karl Pearson, quoted by Smith (1996) in his Royal Statistical Society presidential address:

[Florence Nightingale] held that the universe—including human communities—was evolved in accordance with a divine plan… But to understand God’s thoughts, she held that we must study statistics, for these are the measure of his purpose. Thus, the study of statistics was for her a religious duty. (Smith, 1996, p. 380)

And in 2015, Henry Lynn commented on what Nightingale can teach us about the importance of curiosity in data science:

She was a problem identifier, a problem decoder, and also a problem solver. Her publications were not meant to be accolades for display but propaganda for a crusade against impediments to holistic health… Data scientists will need such inquisitive zeal to go beyond routine analyses in order to reveal the hidden story behind petabytes of data. (Lynn, 2015)
Larry and Barbara Dossey at Embley Park, the family home of Florence Nightingale, near Hampshire, England

Larry and Barbara Dossey at Embley Park, the family home of Florence Nightingale, near Hampshire, England

And now I turn to my interview with Barbara Dossey.

Q: How would you describe Florence Nightingale?

Nightingale, best known as the founder of modern, secular nursing, was also a mystic, visionary, educator, environmentalist, statistician, politician, networker, and social reformer. She worked till the end of her life, dying at age 90 in 1910.

Q: What was the basis of Nightingale’s passionate commitment to statistics?

Nightingale saw herself as a fellow worker with God, and her passionate commitment to statistics was based on her faith in a God of order, who created a world that ran by law. Her statistical analyses taught her the importance of the environment[al], biological, social, and cultural impacts on health, or illness and disease, and treatment and other outcomes.

Q: Some statisticians may be puzzled, or even distressed, by the mention of God and statistics in the same sentence. How did Nightingale define God?

Dossey: Her definition of God, in her own words, was: “What do we mean by ‘God’? All we can say is that we recognize a power superior to our own; that we recognize this power as exercised by wise and good will.” She saw statistics as a way to help her follow God’s creative work.

Q: What was Florence Nightingale’s formal education, and did it include statistics?

Nightingale received a classical Cambridge home education from her father, since women were not permitted to attend universities in the 1840s and 1850s. In her 20s, she began to read England and other countries’ blue books on health, illness, and disease and assembled her own vast “database” that led to her later research and publications. She spoke and read five additional languages (i.e., French, German, Italian, Latin, and Greek). She also insisted that a mathematician tutor her. Born into the “upper ten thousand” richest families in England, her family wanted her to marry into wealth and high society. She refused and made a conscious choice to serve God through social action.

Q: Can you give some examples of Nightingale’s use of statistics?

Nightingale’s commitment to statistics spanned her entire working life, from 1856 into the 1890s. She left 14,000 letters and 200 publications in the archives, with the majority in the archives at the British Library, Wellcome Institute Library, London General Record Office, Claydon House, and Royal Army History Museum. She pioneered army and military statistics, nursing and health outcomes statistics, health policy, hospital design, and environmental policy at the local, national, and global levels. She came to prominence during the Crimean War (1854–1856) with her Army Royal Commission work. Her pioneering statistical displays included polar area charts to show death per month from disease, wounds, and other causes. William Farr, the leading medical statistician, worked with her on her data analysis. For an example, see the article in Science News.

Q: Did Nightingale have a mentor in statistics, and what was the impact?

Nightingale’s main mentor was L.A.J. Quetelet, head of Belgium’s central statistical agency and an expert on the collection of official statistics and probability theory. Quetelet wanted to understand the statistical laws underlying social phenomena. He solved her great dilemma of how to reconcile a universe run by law, and she referred to this as social research—the investigation of God’s laws. Using Quetelet’s methods, she thought social laws could be stated in exact numerical results.

Q: What was Nightingale approach to statistics, and what were some of the consequences?

Nightingale had a holistic, integrative approach to gathering and analyzing data. She would use good data and, when not available, she designed her own questionnaires and sent them to physicians, army officials, politicians, and others who could collect good data. She referred to her statistics as her “business” and her work in it as her “must.” Based on her own foundational experience with battlefield conditions, Nightingale was the one who, behind the scenes, drafted the official British position papers—first presented as a series of Geneva Conventions—that directly led to establishing the International Red Cross, then the League of Nations, and, later, the United Nations. In 1858, Nightingale was the first woman to be elected a fellow of the Royal Statistical Society for her work on army and hospital statistics and hospital sanitation reform. She was given an honorary membership in the American Statistical Association in 1874.

Q: How did Nightingale view nursing?

Nightingale believed that nursing was a very high calling, and that nurses could be in service to others and to God without taking religious vows. She also advocated that nursing was a complement to medicine—that nursing and medicine were two distinct entities. Nightingale developed nursing into an art and science of caring for individuals. She also sought to cure millions by addressing the causes and conditions of illness and injury—both community-wide and globally.

Take a moment to listen to Nightingale’s inspiring voice (age 70), recorded on the Edison wax cylinder on July 30, 1890.

Q: What would Nightingale have to say about nurses today, related to research and statistics?

In the 1870s, Nightingale began to write that “it would take 150 years for the world to see the kind of nursing I envision…” Nightingale would be thrilled that today’s nurses are carrying forward her mission through both quantitative and qualitative research. Statistics is taught in undergraduate and graduate nursing education. In 1993, the National Institute of Nursing Research (NINR) was established to promote and improve the health of individuals, families, and communities. It is also preparing nurse scientists for work with interdisciplinary colleagues at the local, national, and global levels.

Q: Tell us about your work with the Nightingale Initiative for Global Health (NIGH).

The Nightingale Initiative for Global Health is a grassroots-to-global movement, created in Florence Nightingale’s name, to keep her flame alive in the 21st century. NIGH’s inter-related twin mandates are to increase public concern for global health issues and to inform, engage, and empower nurses, midwives, and concerned citizens to participate in this advocacy. Since NIGH’s founding in 2004, the “Nightingale Declaration for a Healthy World” remains our original credo for everything we develop.

Q: What is the significance of the 2020 Florence Nightingale Bicentenary of her birth, and what will NIGH’s 2020 focus be?

The 2020 Florence Nightingale Bicentenary will celebrate her birth and global impact on health, healthcare reform, and research throughout the world. NIGH will have a transmedia campaign, and one aspect is to create educational opportunities and integrative STEM learning opportunities for K–12, as well as a broad range of experiences, events, and interactive activities for a worldwide global audience. The United Nations has a mandate to achieve 17 sustainable development goals (SDGs) by 2030. A major focus for NIGH will be the UN SDGs. Nightingale is the perfect image for improving the health of humanity.

Q: One of the UN SDGs for 2030 is “Good Health and Well-Being.” Did Nightingale focus on teaching good health and well-being?

Anticipating the wider interconnected concerns we see today, she called for better conditions for women, children, the poor, and [the] hungry and for better education programs for marginalized people. She identified what we now call “environmental health determinants” such as clean air, water, food, and houses and “social health determinants” such as family and community relationships, literacy, education, and employment—all now identified as UN SDGs.

Q: How many nurses and midwives are there globally? What might be their impact on health by 2020 and leading up to 2030?

What if today’s 3.4 million nurses in the U.S., 20+ million nurses and midwives globally, and concerned citizens could be engaged and empowered to become champions for the broader health of humanity like Nightingale? Nightingale specifically called for nurses and midwives’ voices to be heard, reminding us “You must form public opinion!” We can focus our collective callings for the sake of 21st-century health care and for related global social, ecological, and human rights issues. Nightingale passed this vision on to nurses, midwives, and concerned citizens—to remember who we are, what we can do, who we care for, and why. Now it is up to us to share this vision, as she did, with our world.

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One Comment »

  • GLENIS PACAK said:

    Thank you Jessica,
    The information you have accessed for our reading is very much appreciated re: Nightingale and to add your interview with such a Nursing Leader as Barbara Dossey was excellent “synchronicity”! Statistics add a concrete dimension to the stories of Florence Nightingale!
    Glenis Pacak RN BN