Old schooled

As healthcare communicators, we are often asked to present data in a meaningful way.

Numbers alone cannot tell a full story, but the context in which they are presented and the associations we then make give data meaning.

This is something that Florence Nightingale intrinsically understood and utilised in her campaign for healthcare reform following the Crimean War.

Florence Nightingale: the founder of modern nursing, the ‘Lady with the Lamp’. What about statistician and healthcare communicator?

While Nightingale (1820–1910) is perhaps most famous for her work as a nurse during the Crimean War (1854–1856), her return to Britain wasn’t followed by a career attending patients in hospitals.

Instead, she turned her attention to healthcare reform. And the way she went about it was thoroughly modern.

Nightingale and her team of nurses travelled to the army base hospital at Scutari (present day Üsküdar) in November 1854 at the request of then Secretary at War, Sidney Herbert. The scene they found themselves in was horrific.

The dilapidated hospital was built over a broken sewer, it was overcrowded with diseased and injured soldiers, and the meagre supplies they did have access to ran out, leading Nightingale to describe it as “the kingdom of hell”.

During that first winter alone, hospital mortality peaked at over 3,000 deaths per month. Officially, the British government recorded losses of 21,097 soldiers over the course of the two-year campaign. Of those losses, only 2,755 were killed in action, 2,019 died of their wounds while 16,323 men died of disease.

The nurses set about improving the hygiene of soldiers, while the later instated Supplies and Sanitary Commissions set about improving conditions of the hospital.

The combined effort from nurses to change wound dressings, provide clean and disinfected linens (amongs other tasks), and of the Commissions to reroute sewers, improve ventilation and provide sufficient, quality supplies all contributed to falling mortality rates.

Despite the dramatic shift in mortality outcomes from the start of the war, there was a fear that the solutions developed at Scutari wouldn’t be replicated in future conflicts.

The reforms implemented during the war needed to be institutionalised, and the bureaucracy of the British Army and Government could not be allowed repeat their mistakes.

Despite her reputation and experience, the reform Nightingale sought wasn’t guaranteed upon her return to England.

She needed to present a case that couldn’t be disputed; as she realised, it wasn’t enough to just be right.

In 1858, less than two years after the end of the conflict, Nightingale – aided by William Farr and his team from the General Register Office – published her first folio, Mortality of the British Army, to coincide with Sidney Herbert’s 600-page Report of the Commissioners.

Mortality of the British Army highlighted key data and had a thorough argument, one that could be easily comprehended by the influential minds who received a copy.

Herbert’s report contained the same set of diagrams as Nightingale’s folio (and additional figures besides), but by separating the diagram content into its own publication, Nightingale managed to elevate her argument for sanitary reform above the usual, dense government reports.

The ‘diagrams’ as they were called then might be called ‘data visualisations’ or ‘infographics’ today.

The folio opens with, ‘diagrams are of great utility for illustrating certain questions of vital statistics by conveying ideas on the subject through the eye, which cannot be so readily grasped when contained in figures.’

Clearly Nightingale understood the value of data visualisation for getting across statistics in a way that could be quickly understood by a variety of audiences. However, she further aided her argument by leaning into the power of persuasive statistics rather than purely analytical ones.

By providing comparisons to the mortality data of the British Army, Nightingale provided another lens that gave context to just how dire the situation was.

And she was clear in her purpose as to why: ‘We are thus enabled better to understand how far it is within the power of preventative science to diminish the risks to which the soldier is exposed, whether at home or in the field.’

The use of data visualisation is commonplace today in a variety of fields, but in the 1850s the use was revolutionary.

Diagrams featured go beyond standard tables of numbers (which also form part of the folio), they included comparative and stacked bar charts, filled-area tables, circular ‘rose’ diagrams (or polar charts) and circular charts representing population density.

The diagrams are also carefully considered, both in terms of their content and their design. The ubiquitous bar chart is subsequently given space on the page.

The bars are thin and vivid, with blood red used to represent soldiers’ deaths. The starkness against the page allowing the bars space, shown at a scale that reaches far beyond their civilian counterparts, creates a solemn and thought-provoking image.

Alongside the publication and distribution of the folio, Nightingale and her allies continued their campaign for reform – the battle was over, but the war had just begun.

Ultimately the campaign was a success; commissions were established to tackle sanitary construction, health codes, a military medical school, and standardised military statistics, and as a result, soldiers were less likely to die as compared to the English male population.

During the coronavirus pandemic, the public was presented with huge amounts of data as the severity of the situation unfolded.

Figures on infection rates led to statistics on mortality figures, and finally vaccination uptake.

As time progressed, the data gathered could be used to forecast future trends and patterns. The data visualisations that emerged, like those utilised by Nightingale, also had to be persuasive.

Public behaviour had the chance to ‘flatten the curve’ – a term that wouldn’t have entered common parlance unless for data visualisation.

In a study conducted during 2020, researchers found that presenting the same COVID-19 mortality data in different ways influenced participants’ risk perception.

They discovered that using a cumulative y-axis, which can only show an upward or flat trend, reliably led to people perceiving greater pandemic risk.

However, the sheer volume of data presented to the public at this time also lead to information fatigue, leading The New York Times to publish a stark representation of loss as the US approached the grim milestone of 100,000 deaths in May 2020.

Instead of another graph or chart, The New York Times used the full length of its broadsheet newspaper front page to publish the obituaries of nearly 1,000 people.

This figure was a fraction of the total deaths, a mere one percent, but a far more humanising way to see the real people behind the statistics and the scale of the death toll.

The fundamental skills and techniques used to construct Florence Nightingale’s Mortality of the British Army folio are the same as we use today, albeit with more modern, digital counterparts.

There will continue to be healthcare challenges to convey, and as designers and communicators, it is vitally important that we get it right when presenting data so it can be understood and acted upon appropriately.

When dealing with data it can be easy to forget that each point represents a real person. Florence Nightingale never forgot the soldiers at the heart of her diagrams. She wanted to make a difference to their lives, and she achieved it as both a nurse and a healthcare communicator.

Much has changed since then, but as Nightingale’s contemporary counterparts, I think we can all relate to her drive to put patients first and enact meaningful change.

Rachel Alexander is Designer at Onyx Health. Go to Onyxhealth.com