The Healing Landscape – The influence of Florence Nightingale on Hospital Design

Few individuals have influenced modern hospital practice and physical design as did Florence Nightingale (1820-1910). A pioneer in epidemiology, nursing, and hospital administration, she advocated concepts in hospital design which permeate healthcare architecture to this day. In the bicentennial year we remember Florence Nightingale as founder of the nursing profession, but most people are not aware of her other many contributions to the development of the hospital as we know it today. She was, in a very real sense, the first hospital administrator and architect of the modern hospital.

There has been an increasing awareness amongst healthcare professionals, over the last 30 years, that the design of healthcare facilities should be guided, if not determined, by sound evidence, Evidence Based Design (EBD). The concept of EBD was first introduced to the medical literature in 1992. However, known best for her legacy as the Lady with the Lamp, Nightingale has been romanticized as one of the most compassionate and famous nurses in history, but few have considered her achievements in light of EBD. Although her work during the Crimean War (1854–1856) marked one of her greatest accomplishments, Nightingale’s post-war career in healthcare reform was her most significant contribution. She supervised the modernisation of nursing, advised governments on Army health reform, marshalled public health improvements in Britain and India, and influenced hospital design. Gathering evidence to support the need for such reforms, Nightingale used careful observation, record-keeping and statistical analysis to validate her work in each of these developments.

Although Nightingale recommended the implementation of windows for natural light and improved ventilation, current research has also shown that natural light and views of nature can reduce depression, pain and stress during hospital stays. Nightingale did not have the means to conduct the kind of prospective research studies that would substantiate her recommendations, but she still exhibited great prescience in addressing areas for potential reform and using the limited resources she had in order to validate her own claims.

The Advent of the Modern Hospital

Between 1801 and 1841 there was a rapid expansion of the UK’s population. As enclosure and technical developments in farming had reduced the need for people to work on farmland, many people moved to the cities to get accommodation and a job.

These cities were not prepared for such an influx in such a short period of time and cities such as Birmingham, Liverpool, Manchester (all vital to the Industrial Revolution) suffered public health problems not witnessed anywhere else in the world at this time. In response to poor public health modern general hospitals appeared in the mid-19th century when many of the UKs most famous hospitals were built.

The first structure built specifically to be a hospital (as opposed to another building being converted for the purpose) was London’s Herbert Hospital, opened in 1865. Its design was based on Nightingale’s concepts, and her philosophy of separate pavilions was a central element of hospital design for the next 150 years.

Florence Nightingale greatly influenced the design of the new St Thomas’ Hospital with its innovative ‘pavilion style’ of seven large separate buildings connected by walkways. She recognized the importance of design for improving hygiene and health and made careful calculations regarding dimensions and efficient use of space in hospitals. Nightingale proposed full-height windows at specified intervals in the wards, with the beds set between to encourage ventilation and allow air to circulate without creating drafts. She identified fresh air as ‘the very first cannon of nursing’ and considered the environment to be an element affecting the patient’s wellbeing.

Her recommendations included gardens at the heart of the design, “….I mention from experience….in promoting recovery, the being able to see out of a window, instead of looking at a dead wall; the bright colours of flowers….”

The garden functions in these hospitals were:

1. To provide fresh air
2. To give patients a place to exercise
3. To be used as a kitchen garden and

As a place where the apothecary could grow medicinal plants

Post War Hospital Design

With the coalescing of medical services after the introduction of the NHS in 1948 saw a decline in the establishment and maintenance of hospital gardens. The increasing number of technological diagnostic and treatment tools together with the ever-increasing need for car parking put pressure on the existing hospital grounds, many gardens and courtyards were sacrificed for buildings.

A new generation of hospitals in the mid-20th century were designed to be clinically effective. The shape of the contemporary hospital has evolved from its initial division into pavilions, to single-block buildings. The design of space efficient ‘deep hospitals’, buildings designed around artificial light and air conditioning, dominated the hospital design from the 1960s to 1980s. As one doctor at Addenbrookes hospital memorably spoke out about the disorientating effects of windowless rooms said, ‘Patients go berserk, everyone goes berserk!’

The re-emergence of EBD supporting the restorative and healing qualities of nature

The therapeutic value of natural light, fresh air and natural landscapes, originally identified by Nightingale, remerged in discussions with the medical profession approximately 30 years ago. These discussions were the threshold of the emergence of new ways of thinking leading to the research by Professor Roger Ulrich and others.

They explored the restorative qualities of a natural setting and the positive impact a natural setting had on patients, staff and visitors. Ulrich found that gardens not only provided restorative natural views but also improved medical outcomes. He advocated that the hospital should provide functionally efficient and hygienic environments that also have pleasant, stress reducing characteristics.

Ulrich theorised that nature reduces stress, he found that gardens foster restoration not only for stressed patients and family members but for staff too.

The EBD theory of the ‘Healing Landscape’ is now endorsed by the medical profession, the BMA. Their briefing document ‘The Psychological and Social Needs of Patients’ published in 2011 highlights the seriousness with which the physical environment is considered by the medical profession and has significantly influenced healthcare design.

In this bicentennial year when we remember Florence Nightingale as the first nurse and as the lady with the lamp, it is important to recognise that her real legacy was created by her prodigious administrative skills and her vision for what hospitals and the nursing profession could, and should, be.

Jane Findlay

25th March 2020