Early Evidence-Based Practice (EBP): Florence Nightingale and the Pavilion-Style Hospital

Evidence-based practice (EBP) abounds today in journals, books, conferences, courses, and in the mind of every practicing nurse or soon to be nurse. Most clinicians would agree with Melnyk and Fineout-Overholt (2015) that globally it is the “key to delivering the highest quality of healthcare and insuring the best patient outcomes…” and results in “…improved health, safety, and cost outcomes, including a decrease in patient morbidity and mortality” (p.3). While the initiative began with Dr. Archie Cochrane about 1972 it has exploded in the past 2 decades with many researchers, authors, and nurses onboard.

However the first evidence of the use of EBP and the first completed EBP project was documented many decades previous by Florence Nightingale (FN) in the 1850’s with practice or application in the 1860’s and later. All nurses are familiar with FN’s famous book, Notes on Nursing: What It Is and What It Is Not (1859), but most nurses have never heard of her earlier book, Notes on Hospitals(1858/59). When the 2 books are viewed together with the steps of inquiry, the research question, the record & blueprint reviews, the observations, the clinician & patient interviews, the analysis, the statistics, the morbidity & mortality outcomes, and finally the dissemination, it is one enormous EBP project. Granted there are limitations and freedoms that must be taken, and given, due to the early evolution of nursing and medicine, obvious lack of technology, an understanding of the knowledge of the day, and the restriction of most of the research being completed by only one very dedicated lady nurse, but it meets the definition of EBP.

FN studied hospitals, their designs, and their patient outcomes throughout England, Germany, France, and the battlefields of the Crimean War during the 1850’s. From her research she determined the best hospital design – the pavilion-style – and the best hospital environment for the best patient outcomes. Her extensive research and her design findings were detailed in her papers of 1858 and then the book Notes on Hospitals in 1859. Her results detailing the best environment for optimal outcomes – light, ventilation, warmth, hygiene, food, cleanliness, and observation – were reported in her later book Notes on Nursing. That later book was a best seller in the U.S. in the early 1860’s and was used by many lay persons and volunteer nurses to guide their nursing practice during the American Civil War. Equally noteworthy was the fact that most newly constructed hospitals built during the same war (1861-65) for the military were constructed using the pavilion-style that she praised in her earlier book. Large military hospitals containing thousands of beds on both sides including Chimborazo in Richmond, Satterlee in West Philadelphia, and Armory Square in Washington DC all utilized her recommended design. She would continue on to be a consultant/advisor on design for 50 hospitals mostly in the U.K. and one in the U.S. – Johns Hopkins in Baltimore MD (McDonald, 2012). Her work was often interdisciplinary.