Nightingale as QI Expert and Hospital Designer

By Sue Hassmiller, PhD, RN, FAAN (this is the 4th in a series of posts by Hassmiller retracing Florence Nightingale’s influential and innovative career) 

Seeing the famous St. Thomas’ Hospital today, I thought Florence Nightingale would roll over in her grave with disgust! What were they thinking, I asked the tour guide? Well, she said, it was the ‘60s. No excuse, I barked back! Prince Charles doesn’t like it either, if that makes you feel any better, she responded.

Applying best practices. The most visually prominent buildings in the hospital now consist of a couple of plain, brown, nondescript, blocklike structures—not anything like Nightingale, once the most famous hospital designer in the world, would have had it. Or, rather, did have it. Her friend, Queen Victoria, laid the first stone and Florence Nightingale contributed to the design and relocation of the St. Thomas’ Hospital of the mid-1800s, with the intention of applying best practices she had brought back from the Crimean War as well as her own research and statistics. 

Nightingale was much sought after as a master designer of hospitals; architects, physicians, and royalty from around the world asked her advice. And here was supposed to be her masterpiece . . . but her version of St. Thomas’ is just about gone.

Physical, spiritual, mental health needs. Nightingale envisioned the relocated and rebuilt St. Thomas’ as a beautiful series of pavilions where different patients with different ailments lay. She connected the pavilions with corridors so that it was one massive, beautiful structure. She knew that big windows would provide light and cross-ventilation for patients, and that wards would be open with all nurses watching over all patients, so there would be no “that’s not my patient” nonsense. She called for porches on the fronts of all pavilions so all patients who were able could convalesce looking at the river. She designed reading rooms and chapels to take the patients’ minds off of their sickness. 

Nightingale always had physical, spiritual, and mental health needs in mind when designing her hospitals. She believed that bad design in hospitals could undermine the best nursing and medical care. 

Why don’t we learn? So here we are, in the 21st century, still making those claims, with some listening and some not. Why isn’t everyone listening? I did see remnants of Nightingale’s once-renowned version of St. Thomas’, now stripped of the patients who deserved to be there and deserved to be cared for in the way she hoped. I looked through the windows of a standing pavilion, now attached to the ugly brown structure, and saw men sitting at desks piled high with papers and single computers. I asked who had the privilege of sitting in that hallowed ground. The guide said it was the accounting department. I (inwardly) snarled at every last one of them and left hoping they would truly understand where they were sitting. I am not sure they did.

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2016-11-21T13:16:45+00:00 July 13th, 2010|nursing history, nursing perspective|8 Comments

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  1. Eileen Malone July 21, 2010 at 10:33 am

    Hello Susan,
    Thank you for the wonderful blog about your visit to St. Thomas to see what remained of Florence Nightingale’s hospital design expertise. I too am an enormous admirer of her many contributions. It continues to amaze me how her prescient recommendations for specific design features to improve patient care quality and other healthcare outcomes remain more relevant today. I frequently cite her inspirational hospital design work and use of statistics in presentations about the use of evidence based design (EBD) features to improve healthcare outcomes.
    EBD is the process of basing decisions about the built environment on credible research to achieve the best possible outcomes. The most current and comprehensive review of EBD research was funded by The Robert Wood Johnson Foundation (RWJF) and written by Dr. Roger Ulrich, et. al (2008) entitled, “A review of the scientific literature on evidence-based healthcare design.” Healthcare Environments Research and Design, 1(3), 61—125. I hope that you and those on this blog know of the EBD work led by the not-for-profit organization, The Center for Health Design (CHD) ( – a research, education and advocacy group of forward-thinking healthcare clinicians and design professionals who are leading the quest to improve the outcomes and quality of healthcare through building architecture and design. Nurses are very much engaged in CHD’s work, as well as with architectural and design firms and healthcare organizations that have healthcare facility projects.
    We have a once-in-a-lifetime opportunity to transform the healthcare environment using proven EBD features to improve outcomes for patients and their families, the staff caring for them and to positively contribute to healthcare organization’s bottom line. Because of shifting demographics, inadequate and aging facilities, and increased healthcare consumerism, healthcare construction investments have doubled during the past decade and are expected to rise to $64B by 2014. (FMI 2010 Construction Outlook, 2nd Quarter Report). With this boom, there is a growing field of practitioners who are dedicated to studying and understanding the impacts of the healthcare environment on patient safety, quality care and satisfaction; staff safety, satisfaction and retention and traditional financial outcome measures. However, more research funding is needed to evaluate EBD features – especially how the healthcare environment impacts human behavior – patient and provider – in the process of quality care delivery.
    I hope that leaders like you and The Robert Wood Johnson Foundation will continue fund and further support the work that Ms. Nightingale began in the 19th century by actively supporting EBD research. Funding nursing leadership development and research around the built environment has been over-looked, providing an ideal opportunity for the RWJF. We look forward to working with you, so that together we can create a next-generation of healthcare facilities that enables the best possible healthcare outcomes, one that Florence Nightingale would recognize as an extension of her own ground-breaking work.
    Eileen B. Malone, RN, MSN, MS, EDAC
    Member of the Research Coalition

  2. Lesley July 16, 2010 at 6:20 am

    lovely blog

    There are still some lovely old bits of St Thomas left buried in the new building – ask to see the governor’s hall!!! It is magnificent – and has the best views over the river – but I don’t suppose the average Victorian patient ever got to see all that splendour!! Or indeed today’s patients.

    A lot of the original hospital was bombed in the war – so new buildings were not an option
    and with little land available in London and money for rebuilding tight in the decades following the war (and still is…). that would have limited the scope….

    And don’t damn the new bits too much – there are some invisible benefits to modern design. It may not have Flo’s big windows for cross ventilation – but it has a state of the art kind of air conditioning designed to waft germs in particular directions to reduce cross infection….

    And if you are interested in Florence Nightingale – then hope you can get to see some of the Mary Seacole stuff too while you are in the UK….Brunel Uni just named their new health care building after her…

  3. Amy Berman July 14, 2010 at 4:07 pm

    Thanks for sharing, Sue. Florence Nightingale conceived of health delivery on so many levels. It is incredible to think of a woman in that time influencing the the architecture and environment of care; the relationship between member of the health team; the inclusion of mental, spiritual, and social supports; and the role of the nurse in support of the individual patient’s needs.

    While the building isn’t a showcase, it gives me great pride as a nurse to know that her legacy lives on inside those ugly walls with infection control and monitoring of health indicators that took root with our dear Florence Nightingale.

    Thanks again for doing these posts, Sue! Best, Amy

  4. Sue Hassmiller July 14, 2010 at 4:01 pm

    I am told that the most accurate/current account of Nightingale’s life is a book called Florence Nightingale: The Woman and Her Legend by Mark Bostridge.

  5. Angie Wooton July 14, 2010 at 2:42 pm

    Hello Sue,

    I spent the fall of 2009 in England teaching at Harlaxton College, with 13 senior nursing students. We also toured the museum and surrounding area. While we found the artifacts fascinating,there was a sense of disappointment in our progress toward holistic health. Perhaps we should think about providing assistance in order to improve the current situation in England.

    Many thanks for sharing,

    Angie Wooton
    Assistant Professor of Nursing
    University of Evansville

  6. Frances Crosby July 14, 2010 at 2:28 pm

    I just finished an interesting NOVEL about Florence Nightingale that is well worth reading, a little critical of the usual picture of Ms Nightingale, definatly fiction, but stretches one’s thinking a little. Might be of interest. It is called “Band of Angels”.

  7. Shawn July 14, 2010 at 2:22 pm

    Ah the accounting department – kind of says it all about where priorities are, doesn’t it?

  8. Ellen Brzytwa July 14, 2010 at 1:37 pm

    Wonderful idea, Sue. Sharing this makes your trip and insights available to nurses who will never be able to make this journey in person, but can, through your eyes! ENJOY! Ellen

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