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Florence Nightingale – The Lady with the Lamp AND a Pioneering Informatician

May 8, 2025 | Community Chats, Community of Practice, Nursing & Midwifery Informatics, Nursing Editorials

Florence Nightingale – The Lady with the Lamp AND a Pioneering Informatician

Named after the city in which she was born (Florence, Italy), Florence Nightingale is generally known for establishing modern professional nursing. Every International Nurses Day, held on her birthday – 12 May, encourages those in the profession to reflect on her life and accomplishments. Yet her pioneering achievements as a social reformer extend far beyond what she contributed to nursing and midwifery, and she is considered the first nursing informatician.

Early years (1820-1852)

Born to wealthy parents in 1820 and living in Derbyshire and Embley, Nightingale benefited from her father’s advanced ideas about women’s education [1]. Studying history, mathematics, Italian, classical literature and philosophy, she developed an attraction to statistics – displaying an extraordinary ability for collecting, classifying, and analysing data [2]. Her early letters were evidence of this – often incorporating lists and tables of information, methodically catalogued flower specimens, and transcriptions of poems, shell and coin collections [3]. Able to review data, draw conclusions, and create an image in her mind of the end result, she discovered that accurate statistics were fundamental to understanding how and why things happened [3]. She was introduced to a wide range of intellectuals by her parents, including the polymath Charles Babbage who originated the concept of a digital programmable computer and is considered the ‘father of the computer’ [1].

Florence Nightingale

Figure 1: Florence Nightingale, Wellcome Collection [6]

Despite this extensive education, her parents still expected her to marry, have children, and adhere to the conventions of the day. This required Nightingale to spend most of her time in what she referred to as ‘frivolous pursuits and domestic routines’ of Victorian home life, for which she struggled to find any fulfilment [4]. Her 1854 authored novel Cassandra was a powerful feminist essay, criticising the Victorian family and the oppression of British educated and privileged women and firmly believing they could contribute so much more to life if social constraints did not confine them to petty, idle, boring duties and a life that lacked autonomy and independence [3].

Much to her parent’s disdain, Nightingale believed she was called by God to service and indicated that her destiny lay in nursing – where she could use her intelligence and energy. They bitterly opposed this notion; however, she managed to spend time in hospitals in Kaiserwerth, Germany, London, Edinburgh, Dublin, and Paris – all the while collecting specifics of hospital conditions and nursing methods [5]. Finally, winning her independence from her parents, she was appointed Superintendent of the Hospital for Invalid Gentlewomen in Harley Street in 1853 [5]. A year later, she led an expedition of 38 women to manage the barrack hospital at Scutari during the Crimean conflict.

Crimean War experience (1853-1856)

The Crimean War, although only three years in duration, was the first high-technology conflict of the modern age (using high explosive shells) and one of shocking death statistics (estimated at 500,000 total casualties, of which the British Empire suffered around 22,000 deaths) [7]. Arriving in Scutari in 1854, she was faced with hospitals that had no beds, blankets, furniture, food, cooking utensils, or dietary, ventilation, and sanitation standards, but were overrun with rats, lice, and fleas [7-8]. More concerning to her were three soon-to-be-discovered revelations about the sick and wounded soldiers – vital supplies were being withheld from them; there was a lack of systematic recording or reporting of the care provided; and they were more likely to die from preventable diseases (frostbite, dysentery, cholera, and typhus) than from battlefield wounds [1]. Initially blaming the high death rate on inadequate nutrition, she then realised that the unventilated building sat on top of a damaged sewer [6]. It was then her assertion that sanitation and ventilation were the cause, given she was familiar with John Snow’s 1854 epidemiological research that linked cholera with contaminated water from London’s Broad Street Pump [6]. Her seminal report Notes on Matters Affecting the Health, Efficiency, and Hospital Administration of the British Army brought an urgent focus on improving sanitation practices in healthcare facilities [6].

Florence Nightingale

Figure 2 Plate from The Illustrated London News, 224 February 1855, Science Museum Group Collection [8]

The Lady with the Lamp [Figure 2] set about organising activities that would improve the ventilation (opening windows), surroundings (flushing sewers, removing vermin and lice, washing linen and clothes, acquiring basic equipment and provisions), and the sick and wounded (cleansing their bodies from mud, dirt, blood, and gunpowder stains) [2]. Still concerned about the high death rate, given the British government continued to attribute the huge death rate to malnourishment and hypothermia on the front line, she travelled to the conflict front at Balaklava in 1855 to witness the conditions of the soldiers [8]. It also became apparent that the number of deaths in Scutari was not being recorded appropriately [9].

Nightingale found the lack of systematic recording frustrating and the gross inaccuracies unacceptable. Her approach to gathering validatory evidence – read the best information available, especially government reports and statistics; interview experts; design and send out your own questionnaire if available information is inadequate; test it first at one institution; consult practitioners who use the material; and send out draft reports to experts for vetting for publication – could not be used, as the best available information was deemed totally insufficient [1]. Soldiers in hospital were counted on one day of each week, omitting soldiers who were admitted and died between counts – leading her to estimate that hospital records during this war may have only shown a seventh of the true number of deaths. Some causes of death were also left out of data returns, such as specific diseases that were fatal at the time (e.g. cholera) and those in soldiers aged over 60 years of age [2]. She viewed this as a ‘new way of preventing preventable mortality to omit it altogether from any statement of mortality’ [2]. Nightingale began collecting statistics – counting the number of soldiers killed, injured, or diseased – and even employing others to collect data on her behalf so that a complete picture could be obtained. It was from this dataset that she realised that more soldiers were killed by preventable diseases than by battlefield wounds [7]. This troubled her greatly; however, the bureaucratic inertia prevented her from identifying obvious flaws in the system and escalating these to the appropriate authorities [7].

Figure 3 Polar Area (or Rose) Diagram of the Causes of Mortality in the Army in the East, Wellcome Collection [8]

Nightingale’s appreciation of data encouraged her to collect various types of data, analyse it, and visually represent it so that statistical evidence could cut through hearsay and appeal to a non-specialist readership. Rather than presenting statistical information in a dense mathematical report, she posited that a lay reader would be receptive to this type of information if presented in a literary format with an accompanying graphic [7]. She was able to identify that wounded soldiers hospitalised in hospitals at the front had a mortality rate of 12.5%, whereas those transferred to Scutari had a mortality rate of 37.5% [8].

A commonly cited polar chart – Diagram of the Causes of Mortality in the Army in the East – also known as Nightingale’s Rose Diagram or Coxcomb Diagram [Figure 3], allowed multiple data comparisons in one diagram. It clearly demonstrated that more soldiers died in the Crimea in 1854-1856 from disease (blue) than from wounds (red) and also displayed the differences between her initial arrival and after she implemented a series of reforms to the hospital and nursing practices. Her intent for this diagram was for Members of Parliament and Army Officials (essentially a non-specialist audience) to obtain a quick visual understanding of the scale of the problem and counteract their entrenched belief that soldiers died from wounds rather than unsanitary hospitals [8]. In the decades that followed, statistical graphics became common as a means to share complex data with non-mathematicians [1].

Return to England

Nightingale returned to England in August 1856 and continued to campaign for the reform of nursing and for cleaner hospitals [7]. She understood that she needed exposure to get her message out, and collaborated with radical writer, journalist, and sociologist Harriet Martineau [7]. Knowing that her work would likely be censored by the British army, deemed likely to reduce troop morale, she advised Martineau that her reform proposals would need to be disguised in the book’s narrative [1]. Martineau’s 1859 book – England and her Soldiers – a literary account of the Crimean War based on Nightingale’s statistical studies of mortality during the conflict, was widely read outside of the arm rank-and-file [1]. Her questioning of the integrity of officials who were responsible for what data should be collected and her criticism of army medical data and the process of data collection were pivotal in changing the way that British military data were gathered and recorded from that point on [2]. That same year, she became the first female member of the Royal Statistical Society, in recognition of her pioneering statistical methods to convince other people that widespread reform was vital [2]. Nightingale was the first of eight women to receive the Order of Merit, and some of her postwar achievements are highlighted in Table 1.

Table 1 Post-Crimean War Activities [2, 4, 9]

1850s Soldier mortality

  • Through various graphs, identified that the mortality rate among soldiers stationed at home was higher than the mortality rate of ordinary British men, despite soldiers being healthier at the start of their careers.
  • Concluded that the problem was poor sanitation and over-crowding of military barracks, encampments, and hospitals that exacerbated the spread of disease.

1860s Hospital statistics

  • Identified a lack of uniform approach to hospital statistics collection, and commented on the misuse of statistics and data, such as discrepancies between datasets.

Nightingale worked with Dr William Farr (a prominent epidemiologist appointed to the General Register Office of England and Wales who was organising diseases by anatomical site – this nomenclature becoming the foundation of the International List of Causes of Death [ICD]) on several projects examining hospital statistics.

  • Recommended counting the total sick population – the number of beds constantly occupied during the year by disease, age and sex, the number of cases by age, sex and disease admitted for medical or surgical treatment during the year, the average duration in days and parts of a day of each disease by age and sex, the mortality from each disease by sex and age, the annual proportion of recoveries to beds occupied and to cases treated for each age, sex and disease.

Despite opposition, based on the practicality of collecting all this data, the classification system was adapted – with several London hospitals agreeing to a common patient registration system (Nightingale’s Model Forms) and the annual publication of their statistics. Unfortunately, the system was later abandoned due to laborious data collection and checking, and costs to ensure the data was uniform and accurate.

1870s Maternal mortality, Maternal hospital design, Maternal pathways

  • Argued for a better system of statistics, indicating a proportion of preventable mortality – particularly puerperal fever. Identified that puerperal fever was less frequent in summer.
  • Supporter of home delivery, as ‘lying-in’ maternity hospitals lacked fresh air, ventilation, and cleanliness.
  • Argued that training schools should be purpose-built and safe, rather than converted buildings
  • Recommended number of beds to a ward, number of wards to a floor, amount of space per bed, number of windows to a bed, healthy walls, ceilings and floors, healthy and well-lit delivery ward, scullery, lavatory, ventilation, furniture, bedding, linen, watery supply, drainage, washing, medical officer’s room, waiting room, segregation ward, kitchen and site.
  • Recommended moving women three times – 7-8 hours in the delivery ward, 5-6 days in the postnatal ward, then 9-10 days in the convalescent ward.

Nursing Informatics Pioneer

Whilst the term informatics only came into effect in the late 1950s from the Russian word ‘informatika’, Mihailov defined informatics in 1976 as the scientific approach that ‘“studies the structural and general properties of scientific information and the laws of all processes of scientific communication’ [9]. Various authors have provided definitions of nursing informatics, with Goossen’s 1996 definition identifying it as ‘the multidisciplinary scientific endeavour of analysing, formalising and modelling how nurses collect and manage data, process data into information and knowledge, make knowledge-based decisions and inferences for patient care, and use this empirical and experiential knowledge in order to broaden the scope and enhance the quality of their professional practice’ [9]. In 2009, the International Medical Informatics Association Nursing Informatics (IMIA-NI) group proffered that ‘nursing informatics science and practice integrates nursing, its information and knowledge and their management with information and communication technologies to promote the health of people, families and communities world-wide’ [4].

Florence Nightingale can be considered the first nursing informatician, given her ability to demonstrate the power of data collection and analysis to improve patient care. There is evidence she ‘processed data into information and knowledge’ and made knowledge-based decisions and inferences for patient care’ to ‘enhance the quality of their (midwives) professional practice’ [9]. She demonstrated a multidisciplinary approach to data analysis, collecting data from several sources for her reports and not restricting her observations to just nurses [9]. Her broad education had equipped her to research thoroughly, record in detail and think laterally, to work closely with others and to shut out friends and family who were not like-minded and could be seen as distractions to her various goals [9].

Conclusion

Her broad education prepared her to research meticulously, document in detail, and think creatively. With her analytical mind, she devoted her life to reforming healthcare in all sections of society. Her pioneering work laid the foundation for evidence informed nursing and emphasised the significance of data-driven decision making in improving patient outcomes. Her groundbreaking approaches to sanitation also laid the groundwork for global health standards, radically reducing the spread of infectious diseases. Whilst her experience during this war is what she is best known for – the founder of modern nursing and often referred to as The Lady with the Lamp, this turned out to be a prelude to her more significant postwar efforts. Her return from this war witnessed her painstaking overhaul of the health of the army in peacetime through accurate data, overshadowing her reform of civilian nursing in Britain.

Author

Dr Jen Bichel-Findlay FIAHSI FAIDH CHIA

Dr Jen Bichel-Findlay FIAHSI FAIDH CHIA

References

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