Florence Nightingale and
Crimean War Statistics:
Lessons for Public Administration,
Hospital Safety and Nursing
by Lynn McDonald
for Gresham College
October 30, 2014
Sources
Lynn McDonald, ed.,Collected Works of
Florence Nightingale (2001-12, 16 vols), of
which:
2 volumes on civil nursing, 1 on health care
2 on military nursing, 1 on hospital reform, 1 on
society and politics (statistics)
 former Canadian MP, author, Non-smokers’
Health Act, 1988

The Collected Works
Of Florence
Nightingale, 16 vols.
2001-12
Florence Nightingale (1820-1910)
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Fame from the Crimean War 1854-56
Major founder of the modern profession of
nursing
Social scientist, first woman Fellow of the
Royal Statistical Society; pioneer of
evidence-based health care
Pioneer environmental health theorist (from
the lessons of the Crimean War)
The glorified
view of the
Crimean War,
Jerry Barrett’s
“portraits”
The “Lady with
the Lamp,” the
enduring legacy,
which can be
misleading
Stained glass
window in a
chapel in Ontario
Hospital conditions in her day

Death rates per admissions, at London
teaching hospitals were around 10%, when
her nursing school opened in 1860

In Crimean War hospitals at 40% in the worst
months of the war (early 1855)
British Army death rate in Crimean War 22%
U.S. Army death rate in Vietnam 2.3%


Nightingale’s role

Much of Nightingale’s time spent on cleaning
up the hospitals (faeces on the floor) getting
supplies in (food, bedding, clothing)

Laundries established (laundresses quit from
the smell)

But the significant change not until March
1855, with the Sanitary Commission
Learning the lessons

Nightingale saw the terrible conditions, and
saw the changes made when the (civilian)
experts were sent by government to the war
hospitals: the Sanitary Commission (headed
by Dr John Sutherland, with Robert
Rawlinson, C.E.) and the Supply
Commission, which improved nutrition,
clothing and shelter
Sewers and drains, vermin

Massive clean-up, with “nuisance inspectors”
from Liverpool, the city that pioneered public
health measures

Removed dead horses from the water
supply, improved ventilation, removed tons of
“filth” (faeces) from the sewers and drains
Comparing the British and French

The British Army made changes

French Army did not

The results in the statistics—overwhelming
success for the British
Comparison of French and British
Mortality in the 2 War Winters

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1st winter
French
British
dead
total effectives
10,934 89,885
10,989 47,749
percent
12%
23%
2nd winter
French
British
21,191 106,634
606 27,384
20%
2.2%
Source: Jean Charles Chenu, De la mortalité dans l’armée et
des moyens d’économiser la vie humaine (Paris: Hachette
1870) 131
Get chart in here
Yet no fighting in the second winter!
Different interpretations

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Nightingale and her team learned and
applied the lessons of the war in radically
reformed public administration, improved
hospital design and the creation of a new
profession, nursing
My view--based on primary sources
Other views still popular, both positive and
negative
False claims for patient care

“Within several months of her arrival, she
implemented hygiene practices--use of clean
water, clean sheets and hand washing--that
decreased the facility’s mortality rate to
approximately that of London hospitals at
that time.” Gawande, “Notes of a Surgeon:
On Washing Hands,” New England Journal
of Medicine 350 (2004)
Some exaggerated claims for FN


“She kept extensive and accurate records of
military hospital conditions and mortality and
differentiated deaths related to hospital
conditions” (Munro, “The ‘Lady With the
Lamp’ Illuminates Critical Care Today,”
American Journal of Critical Care 19,4 (July
2010).
Nor did she invent “triage”
Negative views

Hugh Small’s claim that the death rates
highest at “her” hospital, and she to blame,
that she was “criminally negligent”

With not one table or figure to document this;
yet this view taken up by nurses, many
historians, the BBC, etc.--rough estimates,
general and regimental hospitals compared
Hospital deaths—which the worst?

Mortality high everywhere, but the highest,
when disaggregated data available, were at
Koulali, nursed by the Irish Sisters of Mercy

And this known since the war, in the official
statistics collected by the War Office (which
Small did not use)
Note 2 last columns, Feb 1855,disaggregated figures
Why the highest at Koulali?

Koulali had the worst sanitary conditions,
noted by Dr Sutherland in the report of the
Sanitary Commission

Major clean up helped, but Koulali given
back to the Turks
Learning the lessons
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Get the science right
Get the best experts
Get hard data
Review rigorously
The decline in death rates NOT from nursing
care—it required structural changes—sewers
and drains
Lessons from Quetelet

“Different treatments [have but a] small
influence on the death rate”

“Administration saves more hospital patients
than the best medical science” (comments
on Quetelet’s Physique sociale)
Sidney Herbert her collaborator on improving
public administration

Army Sanitary Administration & its Reform under the Late Lord Herbert
Row 1 Deaths in the English male pop. Row 2 Army deaths pre-Herbert
Row 3 Army deaths after his (their) reforms
Knowledge for application

To compare results when “neglect of the
laws of nature” and what may expect “from
their observance”

“Nature is the same everywhere, and never
permits her laws to be disregarded with
impunity” (“A Contribution to the Sanitary
History of the British Army”)
Research on surgical outcomes



“The law of life after operations has not yet
been ascertained. And no hospital statistics
have yet been kept so as to ascertain it.”
(Nightingale letter 1861)
Death rates post-surgery then around 50%
(pre-Lister and anti-septic surgery)
Nightingale published on safety from 1858
papers to her full Notes on Hospitals, 1863
Hospital defects
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Four great defects of hospitals (from 1858)
large numbers under one roof
deficiency of space
deficiency of ventilation
deficiency of light
Later editions of “Notes on Nursing”
expanded to 16 causes
Hospital-acquired infections


“Every nurse ought to be careful to wash her
hands very frequently during the day. If her
face, too, so much the better.” Florence
Nightingale, “Personal Cleanliness,” Notes
on Nursing, 1860.
“Proper hand hygiene is the primary method
for reducing infections,” A. Gawande, in
“Notes of a Surgeon On Washing Hands,”
New England Journal of Medicine, 2004.
Using charts

Her most brilliant charts combine crosssectional data (normal death rates and
excessive death rates)

With longitudinal (declining death rates over
time as reforms brought in)
Still a model to use!

1854March ‘55
April 1855
to end of war
Nightingale and Farr’s classic “polar area charts”; note break between the
2 charts on the arrival of the Sanitary Commission
War hospital death rates
and London peacetime
hospital death rates-centre circle
Y
Y sanitary improvements
begin, March 18, 1855
X start
here
Oct 1854
Comparisons

No other army learned the lessons of Crimea
as the British

French Army: its next war, Italian Wars of
Independence, 1859
At Solferino, the dead and dying left on the
battlefield for days (Henri Dunant was there
and went on to found the Red Cross)

American Civil War

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Nightingale gave advice to the Northern
Army (Harriet Martineau also acted for her)
Her Notes on Hospitals used by both armies
Nightingale concluded that, if the Americans
(the North) had used her advice properly,
their hospital death rates could have been
3%, instead of 10% (Wars and the War
Office, vol 15:679)
Franco-Prussian War, 1870-71

French Army hospital death rates in the
Franco-Prussian War were 12%, although
France declared war.

Better than Prussian Army hospital death
rates (they won the war) at 20%.
British Army applied the lessons


The British government acted on the
comprehensive recommendations of the
official royal commission (FN briefed
witnesses as well as giving her own
evidence)
Sidney Herbert chaired the royal
commission, then the 4 sub-commissions
created to implement key recommendations
Public administration

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Barrack and Hospital Improvement
Commission, later called the Army Sanitary
Commission (John Sutherland)
Army Medical School
Army Statistics Department
Army Cooking School
British Army death rates fell

In China, reforms brought the army death
rate down to 3% per year (like Crimea in the
second winter, 2.2%).

This in a “hostile” country, on “the opposite
side of the world,” “notorious for its epidemic
diseases” (15:347)
British Army peacetime hospitals

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Netley Hospital and Herbert Hospital both
overbuilt—beds provided for 10% of troops
With the reforms, beds needed for only 5-6%.
‘”It is not our fault if the number of sick has
fallen so much that they can’t fill their
hospitals” (Nightingale letter 15:408)
Unsafe hospitals
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“I know no class of murderers who have
killed so many people as hospital architects.
At this moment (1877) there are many
diseases less fatal in their most wretched
homes than in hospitals: i.e., hospitals
secure a higher mortality.”
FM advised on design: St Thomas’ London
(civil), Herbert Hospital, Woolwich (army)
Making hospitals safer

Solution in Nightingale’s day: the “pavilion”
model, in effect each pavilion (28-30 beds)
became a hospital on its own

In effect reducing the scope for crossinfection
Plan for general military hospital, Malta
Pavilion style
With gardens between
pavilions (each is a ward)
Pavilion style plan for
120-bed regimental
hospital
From Nightingale, Notes on Hosp
Hospitals around the world
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(previous) Edinburgh Royal Infirmary
Royal Victoria Hospital, Montreal
Johns Hopkins University Hospital, Baltimore
City Hospital, Berlin (Friedrichshain)
Hospital experts made the pilgrimage to
London, when before Nightingale sent them
to Paris
Hospitals—statistics key
Hospital statistics key to saving lives:
they enable tracking of epidemics,
judging success or failure of hospitals
(mortality rates, duration of stay)
 “There are laws which regulate disease.”
With “fixed data...the laws which regulate
diseased action would become better
known.”

Statistics needed

Yet workhouse and hospital statistics were
an “unworked mine”

While both types of institution were “created
for the relief of human distress,” they did not
know “whether they relieve it or not” (1858, at
the National Association for the Promotion of
Social Science)
From the war to Notes on Nursing


Chapters in Notes on Nursing on ventilation,
cleanliness, light, nutrition, patient comfort
From the causes of high death rates at the
unsanitary Barrack Hospital, Scutari –
environmental causes– overcrowding, lack of
ventilation, faulty toilets, overflowing sewers,
lousy food (scurvy frequent), polluted water,
dirty bedding, vermin and faeces in clothes
Environmental health

Nightingale’s theory of health and nursing
called “environmental”

From the lessons she learned in the Crimean
War

Basic external factors MUST be dealt with
first: clean air, water, floors, bedding, etc.
To achieve good results

May need political change, legislation, more
money, new building, different hospital site,
better training, different personnel and mode
of appointment, improved reporting
prodcedures

Must monitor, check results (causal links are
complicated)
Nightingale’s methods

Still needed?

Hospital-acquired infections (AKA
healthcare-associated infections) in U.K.
estimates of 6% of hospital patients

U.S. estimates 1,200,000 patients, of whom
some 100,000 die
Today’s challenges

Antibiotic resistant pathogens pose new
threats – which may require revisiting old
solutions (pre-antibiotics) MRSA, Ebola

Issues of priorities for spending and centrality
of patient care – the same now as ever
Causes of death--global (WHO)
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6,000,000 cigarette smoking (increasing)
2,200,000 alcohol-attributable
2,000,000 indoor air pollution
1,700,000 diarrheal
1,700,000 HIV/AIDS
1,300,000 outdoor air pollution
1,200,000 road injuries
660,000 malaria (decreasing)
300,000 maternal (decreasing)
Relevance to health care today

Nightingale’s research methods and
examples should be taught at the graduate
level, in nursing and public health

Also her policy work, briefs on legislative
changes needed, new programs

Useful for nursing leaders in advocacy
The Nightingale method
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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
The Nightingale method

Test questions (pre-test) before using

When writing up, consult experts (informal
peer review). practitioners who will actually
use the results

Use charts for major points; use stories to
flesh out the data
Then on to application
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Reports are not “self-executive”
A strategy for implementation is required
Media campaign
Political support (all-party desirable), leading
academics, NGOs
Nightingale’s great legacy: both the science
AND the application
A stained[glass
window in
Chautauqua,
New York
This volume
reports her
pioneering
study of maternal
mortality postchildbirth
Nightingale statue at
The Glasgow Royal
Infirmary (before the
Collected Works)
Nightingale statue
re-located to the
Main Lobby of the
Glasgow Royal
Infirmary, with a
relief of Joseph
Lister, who pioneered
anti-septic surgery at
Glasgow