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Florence Nightingale - her legacy to hospital design
Phil Nedin

Florence Nightingale died 100 years ago on August 13th 1910 at the age of 90. There can often be some discomfort in expressing a death in terms of a cause for celebration but with someone as significant in the history of healthcare and given that there are many countries in the world embarking on healthcare reform and the associated facilities review, a celebration of this particular life seems appropriate. For those engaged in the design of hospitals, an understanding of the legacy she has left behind is essential.

Perhaps the most straightforward thing about Florence was her name. She was born in Bellosguardo, Florence and hence her name choice would seem to have been inevitable. From her earliest days she was a prolific letter writer with a number of archives in evidence, the single biggest one being in British library. It is the libraries second largest personal archive, the first being that of Gladstone. Given the postal turnaround time and the general delivery difficulties during the 19th century, she still managed to write in her lifetime some 14,000 letters. Many were related to technical issues e.g. 10 pages on steam boiler advice, 13 pages on the use of cement for hospital walls and 12 pages on floor polish.

As one of only two children, she suffered from a mutual inter-reliance of a small family her need to break away from that environment to do what she felt was her calling was to be her biggest challenge. It was when Florence was about 24 years of age that she started her role as a carer. This started with relatives and friends that she felt had not got the necessary care from the established nursing profession. It became clear to her that there was a need for a more formal training process for nurses that would be suitable for educated women and those who did not wish to make religious vows. She had already been involved in a significant amount of travelling that her privileged

 

background was able to support and had been influenced of the best practices on the continent. One thing that she sought to influence was the typical role and reputation of the nurse, where the day nurse was a cleaner and a bed maker and the night nurse was typically a domestic servant who after working all day was paid a pittance to sit all through the night to keep a watch on the patients.

In July 1853, at the age of 33 Florence was offered a position as a Superintendent of a small facility in Harley Street. It was during its refurbishment that she was subjected to construction delays caused by over busy builders who did not turn up for work! She oversaw the installation of a vertical lift (dumb waiter), a hot water service to all floors and possibly the first nurse call system employing a series of valves and bells thereby ensuring that nurses were more efficient when responding to patients. Her first task was to balance the books particularly as she soon found a financial shortfall of £700. She did this by increasing subscriptions and keeping a check on the weekly running costs.

Many of her friends and family considered this work to be to mundane for her high intellect, but she was not deterred. In October 1853 Turkey declared war on Russia and in March 1854 Britain and France joined the war as allies to Turkey. The Times newspaper was soon to be reporting on the poor care for the soldiers in the military hospital at Scutari due to the lack of surgical preparations, nurses and dressings which became a national concern and in the autumn of 1854 Florence with a team of 40 nurses entered the hospital in Scutari. Eventually in 1855 Lord Aberdeen’s coalition government was overthrown and Lord Palmerston succeeded him. One of the new governments’ first duties was to instigate a Sanitary Commission to inspect and purify the military hospital from the diseases such as dysentery and diarrhea which was considered to be related to the generation and distribution of foul air and poor cleaning. Florence was supportive of their work which in part reduced the death rates in the military facility. It was in 1855 that the image of the “lady with lamp” was produced in the Illustrated London News. The lamp has since become the hallmark for nurse education.

Florence returned home to England in the summer of 1856 with the hospital in Scutari having reduced mortality rates and having been transformed into a best practice military facility. Soon after this she was introduced to Queen Victoria for the first time and used that meeting and others she had with the queen to influence the setting up of a Royal

 

commission by the Secretary of State for War to drive forward military healthcare reform. This commission was set in motion and its evidence is represented in “Notes on Hospital” published in 1859. It was stated in the report that “this evidence not only contains information of public importance, as regards the army and its hospitals during the late war with Russia, but gives the results of many years experience with regard to the principles of hospital construction and organization”.

The main issues in her report, relates her experiences in Scutari and elsewhere, to hospital construction, operation and building defects. Her detailed comments on the differences in the mortality rates within different hospitals were driven by demographics, early patient discharge and the impact of hospital infections. She carried out statistical analysis to prove her hypothesis. She identified “length of stay” as a measure of the effectiveness of hospitals. She highlighted the closeness of wards, overcrowding, defective ventilation and defective structure, deficiency of natural light, bad architectural and poor administrative arrangements. She refers to the hospital diseases being responsibility for illness of staff and that poor hospital cleanliness is the result of “carelessness and ignorance”. She further commented on the use of absorbent materials, defective water closets, defective ward furniture as well as the height of the wards spaces, the need for opposing windows and benefits of a “pavilion” footprint with a maximum number of floors.

You would by now be forgiven for thinking that this was a report written in the early 21st Century rather than the mid 19th Century and it is that point which is at the heart of this opinion piece - how much has healthcare design really moved on in the past 150 years?

For more information on the achievements of Florence Nightingale references include:

The Florence Nightingale Museum. St Thomas’s Hospital London.
Florence Nightingale. A Biography by Mark Bostridge, Penguin Books.
Notes on Hospitals by Florence Nightingale

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