Counting the Dead

The altar of murdered men

National History Day Documentary–Junior Level (Middle School)
Gold Medal winner
Produced by Lexie Van Den Heuvel
University School of Milwaukee
Milwaukee, Wisconsin
June 14, 2012

This strong documentary examines a vital but little known achievement of the legendary Florence Nightingale:  her innovative use of health statistics to drive hospital reform. Wisconsin middle schooler Lexie Van Den Heuvel’s 2012 National History Day entry focuses on Nightingale’s invention of the polar area graph, which helped her show the terrible toll of preventable diseases on British soldiers during the Crimean War and on wider populations after the war. Nightingale’s painstaking research and statistical graphing, combined with her fierce advocacy, sparked critical reforms in hospital design and sanitation practice. Of course, almost anything that promotes understanding of Nightingale’s work is likely to help nursing, since she is so widely recognized as the founder of the modern profession.

The video includes a few references to her leadership in what anyone would recognize as nursing, caring for the soldiers in Crimea as well as providing care to patients and education to nurses back in the U.K. There is even a short interview clip from University of Wisconsin nursing professor Laurie Glass, who is identified as “PhD, RN, FAAN.” And the video counters the still-common image of Nightingale as a cuddly, deferential saint. Unfortunately, viewers could come away with the idea that her statistical and hospital reform efforts were not “nursing.” However, despite the common assumption that nursing is limited to bedside custodial tasks, the profession–as embodied by Nightingale and the many nursing pioneers who came after her–encompasses health advocacy and policy reform on the widest scale. Indeed, the video makes clear that Nightingale had to overcome strong resistance from physicians to effect positive change, and in fact that remains part of the nursing experience for many today. In any case, the documentary uses compelling images of Nightingale’s world and her innovations, along with concise and persuasive narration, to convey valuable information about her work to an important audience.

Van Den Heuvel was a student at the University School of Milwaukee when she made the 10-minute video, which ultimately won first prize for junior-level individually-created documentaries in the nationwide NHD competition. Early on, the narrator says that many historians remember Nightingale as “the pioneer of professional nursing, the ultimate patient care advocate, and the tireless military nurse.” But her

most unknown yet most important contribution to medicine had more to do with mathematical statistics than bedside care.

Later, the narration similarly notes that Nightingale’s most important tool of reform was “not found in any nursing textbooks,” but in “statistics.” The narrator explains that Nightingale “revolutionized health care by counting the dead,” which refers to her effective use of mortality data to promote systemic reforms. Of course, the contrast between the common understanding of Nightingale and this work is well worth drawing. But it would be easy for viewers to think that Nightingale’s big “contribution” was more important than “nursing,” that it was not nursing, that nursing consists only of bedside care, and that nursing does not depend on or include statistics. Sadly, none of that is correct. Nursing was and is a distinct health science, as Professor Glass can attest.

The film begins with some background on Nightingale, and this is where most of the “nursing” discussion occurs. After overcoming her well-off family’s resistance to a nursing career, Nightingale got training in Germany and become superintendent of the Invalid Gentlewoman’s Facility back in the U.K. When the Crimean War broke out between Turkey and Russia in 1854, Britain sent troops to help Turkey, but not the supplies they needed, resulting in disease and starvation. Nightingale got the permission of Secretary of War Sidney Herbert to help. She and her “team of 38 nurses” arrived at the military hospital in Scutari, Turkey, in late 1854. We see footage of what seems to be an original interview with Laurie Glass, “PhD, RN, FAAN,” of the University of Wisconsin — Milwaukee. The use of these identifiers is very helpful, showing that nurses are experts with advanced education. Glass says that in Scutari Nightingale first had to clean up, since soldiers were lying in dirt, contending with rats, and sewers ran right through the barracks. Nightingale was appalled not only by the many missing limbs but also by the overcrowding, the lice, and the maggots in untreated wounds. Yet, the film notes, she did not have basic things needed for a hospital; there was little food and no soap, bandages, or clothes. Bed linens were not changed even when a patient died. The video offers a devastating quote:

Florence Nightingale:  “I stand at the altar of murdered men, and while I live I shall fight their cause.”

That quote alone, which might serve as an epitaph for Nightingale, makes the video worth watching. Despite a lot of resistance from “the military doctors,” she went to work and set up the Nightingale Fund in England to solicit funds to provide hospital necessities. When the supplies arrived, “the nurses changed bed linens, dressed wounds, conducted patient rounds and fed the hungry.” In conjunction with Nightingale’s efforts, the British Sanitation Commission arrived in March 1855 and cleared the “overflowing sewer system.” The documentary notes that the mortality rate for preventable disease was 42.2% when Nightingale arrived, but because of her many hospital reforms and the work of the Sanitation Commission, the rate dropped to 2% by the end of the war (though some contest these figures). A viewer might plausibly see all of this great work as part of her nursing project, although it might have been nice if the video had said so explicitly.

Moving toward its statistical focus, the video notes that Scutari was

only the beginning of a lifetime of reform. … By inventing the first statistical graph to represent mortality data, Florence Nightingale revolutionized the British military health care system.

We see her polar pie chart and the underlying health statistics she collected by hand in Scutari. The film explains that during her two years there, Nightingale carefully recorded details of the soldiers’ care and their recovery or cause death. After the war, “haunted by the tremendous loss of life,” she calculated that of the 21,827 lives lost, 17,225 were from preventable disease. But the peacetime military hospitals were just as dangerous, posing a threat to the entire British Army. So Nightingale got statistical data from many hospitals and public health organizations. She compiled a “devastating report” on British military health and sent it to high levels of the British government. Not surprisingly, military officers and Scutari surgeons fought back, trying to discredit her data and ideas. The video says that these arguments infuriated her, and she worked tirelessly on supplemental reports.

She also wanted to distil her 800-page report into something non-statisticians could grasp. In an audio clip from The Joy of Stats (2010), David Spiegelhalter, professor of the public understanding of risk at Cambridge, explains that data tables can be tedious and difficult, but visualizations tell a story. So, the video says, Nightingale consulted “Dr. William Farr, statistician and physician,” and “invented a graphical picture that has anchored her name in the statistical history books:  the polar area graph.” As we see in a moving illustration from The Joy of Stats, her chart displayed the causes and timing of deaths in Crimea by month, with blue wedges showing soldiers who died from preventable disease, red wedges from battles, and black wedges from accidents and other causes. It is clear that preventable disease deaths dominate. The graphs also showed that after Nightingale’s reforms and the sewer clearing, the death rate dropped 20% immediately and kept dropping till the war’s end.

With the power of her graphs, Nightingale persuaded the British government to set up a Royal Commission to investigate the deaths and initiate reforms. She prepared a list of suggested sanitation reforms based on her data, with diagrams and architectural plans specifying ward configuration, kitchen and library placement, and bed spacing. Based on the report, the Commission implemented improvements including proper ventilation, clean water, efficient drainage, sanitation procedures, and food preparation. Nightingale also won the right to reorganize how the army gathered and interpreted “medical statistics.” She established military medical and nursing schools at St. Thomas Hospital, another passing reference to her work in “nursing.” And the video notes that her reforms were so successful that hospital and military personnel from all over the world consulted her; her ideas on sanitation reform even influenced “doctors and nurses” during the U.S. Civil War. The video says that Nightingale was the first in history to “use hospital mortality data as statistical graphs to guide public health care policy.”

Moving quickly through later achievements, the video notes that Nightingale “spent the next 50 years of her life reforming hospital sanitation and health care delivery.” She developed other graphs, like “her famous line bar graph,” to describe differences in disease between civilians and soldiers. According to the video, that led to adoption of the British Sanitary Code, which in turn “led to substantial reform in barracks construction, diet, and the provision of medical and nursing services.” Together with “her mentors,” presumably including Farr, she also created uniform criteria that all hospitals were required to use to report disease and mortality. She was ultimately recognized as “a pioneer in the collection, interpretation, and graphical display of descriptive statistics and a foremost expert in hospital and sanitation reform.” The video concludes that this was due to her “incredible ability to create pictures from numbers so the whole world could see health care through her eyes.” And “she did it all for those she left behind in Scutari.”

This is a powerful story, recounting some of the contributions of a brilliant nurse who changed the world through innovation, tenacity, and hard work. The association of that work with nursing has to help the profession. And subverting the image of Nightingale as a faithful but meek angel has great value. In fact, the film might have done more along those lines, giving a greater sense of how she was perceived in her day, including by detractors (consider how her use of a term like “murdered” would affect people). The inclusion of a few elements mentioning Nightingale’s nursing leadership is also helpful. Perhaps viewers will relate those elements to her work in health reform. But it seems at least as likely that they will, as the film encourages them to do, regard her statistical, sanitation, and hospital reform achievements as distinct from her nursing. And of course, there is nothing here about the millions of lives later nurses have saved through health innovations like Nightingale’s and through clinical nursing care. Still, the award-winning video delivers a vital message to secondary school students in a highly engaging way.

Review by Harry Jacobs Summers
Nursing Editor: Sandy Summers, MSN, MPH, RN
Reviewed December 7, 2015

The views expressed herein do not necessarily reflect those of the Board Members or Advisory Panel of The Truth About Nursing.

See a more comprehensive list of Nightingale’s achievements.

What is Lexie Van Den Heuvel up to today / in 2015?

Lexie Van Den Heuvel, 2015

Documentary maker Lexie Van Den Heuvel is an impressive young woman who is obviously concerned about health, wellness, and social justice. Subsequent to her NHD victory, she started a 501(c)(3) non-profit organization–Cutting Costs for Celiacs–designed to help those living in poverty with celiac disease afford gluten-free foods. Celiac sufferers can offset these costs by applying to her non-profit for funds. And she posts detailed information about how those with celiac disease can get tax deductions for the cost difference between gluten-free foods and foods with gluten. We’re not sure of her career plans, but we would be excited to welcome to nursing such a strong, innovative young woman who wants to change the world!

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