Title: It started with Florence Nightingale 100 years later another tradition is emerging
Pages: 34 - 43
Text: It started with Florence Nightingale 100 years later another tradition is emerging
The ward is the centre of hospital activity. It is where the patients live, and consequently - as Emergency Ward 10, for instance, vividly shows - where patient / hospital relationships are born and develop. Florence Nightingale created a ward which was virtually an enclosed community. But today's hospitals are centralised and merchanised. The basic ward is changing.
by H. L. Smith
The design of hospital equipment is indivisible from basic planning, not merely in architectural organisation but also in medical practice.1 This article deals with the development of the ward and the influence of its evolution on ward equipment, and indicates the rationalisation processes currently being undertaken to produce national standards.
It cannot hope to review the whole field of international ward planning. It will therefore concentrate on the 'milestone' plans that have had great significance in their particular era of hospital planning. In doing so, it highlights the basic ideas of almost all the plan types currently in use. Observations on current wards and equipment will be restricted to this country - for the ideas emerging here at the moment, certainly in planning, are as progressive and exciting as any in the world.
The starting point will be the ward designed to meet the requirements of Florence Nightingale in the 1860's. Before her time, hospitals created little for posterity; whereas the impact of her philosophy is with us today- indeed, in the South West Metropolitan region, 75 per cent of the hospitals still have wards laid out in her pattern.
The ward within the hospital pattern
The evolution of the ward cannot be divorced from the evolving hospital pattern. It is sufficient here to look at one hospital plan at each end of the time scale to see the impact which centralisation and mechanisation have made on the total concept. The Nightingale ward, 1 and 3, sited a considerable distance
from the main kitchen and administration, was a static - almost self-sufficient- community, often dominated with ruthless autonomy by the sister.
The contemporary hospital ward, on the other hand, 2, is designed to allow the nurse to devote the whole of her energies to restoring the patient to health, and is one element of a complex centralised supply and disposal system. How did the Nightingale ward develop into the contemporary wards in modern hospitals ?
Nightingale Ward (1860)
A typical ward of the period, 3, generally comprised 32 beds arranged in two rows at right angles to the windows, giving economy of staff movement with ease of supervision. But- in the then charitable nature of the hospital organisation - it discounted the patient's environment and his need for privacy. Comparatively high standards of hygiene were achieved by high ceilings and good cross-ventilation, with a floor area per bed of about 100 sq ft. Sanitary facilities were sited centrally or to one end, and together with a ward kitchen and an office they comprised the whole of the ancillary rooms that were considered necessary.
Later hospitals increased the number of service rooms and added single rooms, but the pattern of nursing by 'job assignment' (each nurse carrying out specific tasks for each patient in turn) continued. In addition, sterilising, serving food and washing up, checking linen, etc. were all carried out by staff within the ward.
Rigs hospital, Copenhagen (1910) _
Although many hospitals in the USA had wards of single rooms - mainly for paying patients - the first attempt to improve the environment of the charity patient appears in the ward layout of the Rigs Hospital which, still using large wards, arranged the beds in groups parallel with the walls, each group divided by screens. This layout had considerable influence on new hospital plans up to the outbreak of the 1939 war. Continental hospitals later completely enclosed the bed group.
1 Plan of a Nightingale hospital. This is Mayday Hospital, Croydon. The black areas indicate the original Poor Law Infirmary buildings of 1881. The later sprawling, uncoordinated development is typical of the present state of the majority of our district hospitals.
2 A typical modern hospital development (model of the preliminary redevelopment proposals for Mayday Hospital, Croydon, by South West Metropolitan Regional Hospital Board - architect to the board, Richard Mellor).
3 Typical early Nightingale ward.
Mineworkers' hospitals~ USA (1953-56)
As a result of high administrative costs and the scarcity of hospital personnel in America after the war, centralisation of services became essential. The use of vertical mechanical transport and communication systems from these central departments piled the wards one above the other. The beds within each were drawn tightly round a central core of service rooms and the staff base. Beds continued to be arranged either in small groups or single rooms, each served by its own sanitary facilities, day spaces being provided for ambulant patients. So emerged the first 'race track' plan in Gordon Freisen's hospitals for the Miners' Memorial Hospital Association in the USA,..
Nuffield Experimental Ward, Larkfield Hospital l Greenock (1955) ,
The publishing of the Nuffield Provincial Hospitals Trust Report in 1955, and the subsequent experimental wards at Larkfield Hospital, Greenock, 5, and Musgravo Park, Belfast, laid the foundation of new thought in hospital development in this country after the war. A reassessment of nursing patterns allowed the number of patients in the ward to be increased, the beds being arranged in two sections round the service room. The beds continued to be in small groups each with its own sanitary area, but the growing awareness of the problems of cross infection - coupled with the desire to avoid disturbance to other patients - introduced a special room on each ward for carrying out clinical procedures and treatments. The acceptance of the centralisation of services, but without the high American standards of mechanisation and artificial ventilation, resulted in a more elongated plan than the race track, which has subsequently become known as a 'Linear' ward plan.
Contemporary ward Planning
The most important developme operations (conceived over 65 years ago2). And second, its by-product, progressive patient care, in which the patient progresses in stages from an area of the ward reserved for critically ill patients requiring heavy nursing to an area where he is ambulant and requires little nursing. The exhaustive investigations and vast numbers of ward plans produced by the Ministry of Health, the teaching hospitals and the regional boards since the publication of the 10-year Hospital Plan are now being consolidated, and a new trend in ward design is emerging, of which the main principles may be summarised as follows: 1 All wards, with the possible exception of maternity, should ideally be concentrated into one complex. Wards which are to be built in phases should be integrated with other phases on completion. 2 Standard ward units should be used for the majority of specialities, the only modifications required being for children, infectious diseases, and psychiatric and possibly long term geriatric patients. 3 Patients requiring intensive care will be in a central hospital unit, not on the ward. 4 Ward units of about 30 beds, each with its own entry, should be linked to adjacent wards to form continuous peripheral banding of up to 120 beds, allowing flexibility in nursing groups. Each unit should be made up of bed groups of six to 10, supported by four to six single rooms. All the beds should have adjacent sanitary facilities, giving greater convenience to the patient and allowing mixed sexes to be nursed in the ward. 5 The nurses' station, backed up by the service rooms and treatment suite, should be the administrative centre of the ward used by all staff, and should face the bed groups and single wards in which the most critically ill will be nursed. The sister's room becomes a private office sited either at the entrance to the ward or with the nurses' station.
4 Typical nursing floor of 'race track' ward in R. E. Thomason General Hospital, Texas. Consultant architect, Gordon Freisen.
5 Experimental ward unit at Larkfield Hospital, Greenock. (Nuffield Provincial Hospitals Trust. Architect, Richard Llewelyn Davies.)
6 Clear supply and disposal routes are required for each ward service zone.
The two ward plans illustrated, one by the South West Metropolitan Regional Hospital Board, B. and one by the South Western Regional Hospital Board, 7 and', are good examples of standardised wards for use in district hospitals based on the principles described above. Both are direct products of the current restricted spending in the hospital world in that they both accept the ward complex as a defined hospital department to be built in phases, and both have minimum mechanical ventilation. It is
difficult to foresee the future pattern of in-patient care, or to forecast how far the current need for beds will be met or even continue; but it seems unlikely, with the present rate of development, that wards will be required to serve other functions. Peripheral banding of the bed groups should therefore allow all the flexibility and change required.
The rebuilding of St Alfrege's Hospital by the Ministry of Health, 6, essentially a development project, shows the most radical re-think of the whole hospital. Three floors of wards - each of 320 beds served by their own central supply and disposal zone, kitchen, and patients' end staff dining rooms - are peripherally banded round diagnostic and treatment departments. Circulation is by a system of primary and secondary internal streets linked by a single
8 Typical ward plan for redevelopment of St Stephen's Hospital Fulham, by South West Metropolitan Regional Hospital Board (architect to the board, Richard Mellor.) The large shaded area shows a typical 28-bed ward unit.
vertical communication zone. The basic concept is to move people, goods, information and services as far as possible on one level, and yet produce a compact hospital capable of assimilating change. Central sterilising supply department (CSSD), bulk preparation, kitchens, laundry, etc. are planned in an 'industrial' zone on a separate site, and will also supply other hospitals.
With a clearer view of the basic planning of our wards, how far have we come towards an equally clear view of the equipment that is
continued on page 40
6 First floor plan for the redevelopment of St Alfrege's, Greenwich, by the Hospital Design Unit of the Moth (chief architect, W. E. Tatton Brown).
7 and 9 Standard ward plan by South Western Regional Hospital Board (architect to the board, H. J. Woods). Three basic components of the plan, units a, b and c shown in a, may be used to form many different ward patterns. A typical pattern is shown in 7.
Ward planning and equipment
to go in them ? The Ministry of Health Hospital Equipment Lists obviously give considerable guidance, but tend to be superficial and lack information on the physical relationship of equipment to the building. To a large extent, the seemingly unlimited variety of hospital equipment is still with us.
But considerable headway has been made into the programme of research advocated by Archie McNab3, and a series of rationalised standard components is beginning to emerge under the co-ordination of the Ministry of Health.
The User Requirement Study Group's analysis of the Ministry of Health Building Notes showed that a high proportion of departmental schedules consisted of rooms common to many departments - eg, offices, utilities, etc - all of which might be standardised, the remaining rooms generally being special to one or two departments. The conventional list of rooms was used in the first instance as a convenient method by which to divide the initial work - though it was accepted that after the activities taking place in each room had been analysed, the room might merge with others or even disappear completely. Each room was then subjected to a study of activities taking place, to establish the most efficient equipment and layout (and rationalisation of these into the minimum number of permutations).
The first studies covering common rooms are now complete, and provide a more accurate picture of the type of equipment really required. Other inter-board study groups, each assessing the detailed requirements of building components, have also completed the first part of their particular studies, and have developed prototypes (a number of which are already in production). The hospital equipment section of the Royal College of Art, the King Edward's Hospital Fund and the equipment study groups of the Ministry of Health are all carrying out individual investigations into equipment that does not form part of the building structure. Much of this work is based on present hospital practice -as it must be if information is to be obtained quickly for the current building programme. It is anticipated that the long term development work being carried out by the Ministry of Health on the Greenwich project - which reappraises the whole hospital organisation (see page 29) will confirm some of the superficial decisions which form the basis of many of the present equipment briefs.
Each of the following sections looks at the
10 Central control panel for nurse/patient call system from all wards in Assen Hospital, Netherlands. Designer N. V. Nira. Maker Cass Electronics Ltd.
11 Patients' bed head plate designed by the South West Metropolitan Regional Hospital Board (regional architect, Richard Mellor).
12 Hospital lavatory basin, model 14001/6. Maker Twyfords Ltd. designed by the maker's design department under the leadership of E. S. Ellis.
main ward areas as they would appear in a general district hospital of the type shown in s and a.
The bed area
The patient's bed, in its development from the earlier fixed frame bed, reflects the current trends in ward planning more than any other item of equipment. It must now have mobility (to allow the patient to be moved progressively round the wards with minimum inconvenience), be variable in height (to suit the requirements of both the bedfast and the ambulant patient), and accommodate the majority of nursing positions required by the various medical specialities (de, it must tilt, fold, etc).
The bed designed by the hospital equipment section of the Royal College of Art (described in prototype form in DESIGN 195/52-57) is shown in 15 in its final form, and is currently undergoing field tests prior to its possible adoption as a national hospital bed. The associated furniture - locker and overbed table - is also in prototype form and, it is hoped, will emerge from the Ministry of Health Ward Equipment Study Group in the middle of 1966 as a recommended standard.
With the increasing use of medical equipment at the patient's bedside, the service requirements have grown far more complex. It is now generally accepted that each bed should have access to power, piped oxygen and piped suction. Further, the pattern of smaller, semi-enclosed bed bays - as opposed to the large open ward - has necessitated a mechanical communication system between patient end nurse. Opinion on how elaborate this should be varies from a simple call light to full two-way speech between nurse and patient. The St Stephen's ward, for example, will have the latter system, but all calls from the patient will be made via a central hospital control like that in 10. This will eliminate the unanswered calls which occur when the control station is placed in the more conventional purses' station. shows a proposed bedhead plate coordinating all the service requirements.
Similarly, the lighting of smaller bed units has grown more complex, and general and individual bed lighting, examination lighting and night lighting all have to be provided. Attempts are now being made to co-ordinate the present separate fittings into one unit,
13 and 14 Disposable bed - pans and urine bottles, 13, with bed-pan disposer, 14. Designer and maker Vernon & Co
(Pulp Products) Ltd. 15 Prototype hospital bed designed by the Hospital Equipment Group of the Royal College of
Art. Ancillary equipment designed by students in the school of industrial design (engineering) and by T. Coward
(locker unit) and A. Smallhorn (services and lighting unit).
16 Assembly of examples from the MoH standard HWD storage range, designed by the Inter-Regional Board Storage Study Group. Maker D. Meredew Ltd.
17 Medicine trolley. Designer Christopher Toon. Maker Minx of Watford Ltd.
and both the Ministry of Health and the North West Metropolitan Regional Hospital Board have prototypes under test.
Dissatisfaction with available equipment for bed areas prompted the Royal College of Art to give a group of students the task of providing a modern setting within which to display the prototypes of the new hospital bed. as illustrates part of their extremely interesting designs for a combined patient's locker/bedside table, a nurse-call handset and bedhead plate and combined light fitting - which together provide a highly integrated, consistent look at the bed area of the future.
Day rooms and sanitary and supply areas
As a direct result of early ambulation, the need for day spaces has increased. The fully ambulant patient will use the general day spaces for his meals and recreation; in addition, each bed group should be capable of providing some day space for semiambulant patients not yet strong enough to join the main group.
Each bed group is associated with wc and washing facilities. Although the sanitary fittings study group has not yet published its report, a number of fittings like that in 12, are now available, and these meet many of its general recommendations to provide easily cleaned surfaces, make clear junctions with wall surfaces, and eliminate the inaccessible crevices so common to much present sanitary ware.
In general, the ward holds only 36 - 72 hours' requirements, fresh supplies from the central areas being brought up daily on either a replacement or top-up system. Dressings and instruments are centrally sterilised and in pre-laid, ready-to-use packs. Drugs and medicines are in the main stored on mobile medicine trolleys which accompany the ward staff on their rounds. Linen is stored in a similar way.
The concentration of all moveable equipment not in use into the central stores area, whence it is 'celled' to the ward as required, leaves minimum quantities to be stored on the ward. Essential storage can be provided from the InterRegional Board Storage Study Group's standard HWD range- now in full production - which comprises shells, doors, shelves, drawers, plastics liners, etc. from which virtually any requirement can be met, 16.
Maximum consideration should be given to the use of disposables - eg, paper towels, sputum cups, etc. Disposable bed pans, urine bottles, vomit bowls, etc. 13 and 14, although not yet widely accepted, are gaining favour. Material for disposal centrally - linen, waste, dressings, etc - should be bagged immediately at the point of use, eliminating further handling of the material. The sealed bans should be removed directly from the dirty utility by hoist or other mechanical means.
Administration and kitchens
The staff base is the administrative centre of the ward, and provides desk space, stationery storage and telephones for the use of all ward staff. Records will be held in mobile storage trolleys, and will accompany doctors on their ward rounds.
The growing realisation of the importance of food as a factor in recovery has resulted in the patient being given a wider choice, and in a general desire to improve the quality of the food served -the latter being directly related to the number of times the food is transferred on its way from cooking pot to patient. A heated pellet system is to be installed in a number of hospitals. The food is served direct to the plate in the main kitchen as a prelaid tray passes down a conveyor belt. Food is kept hot by heated pellets in a special base plate, and is moved to the ward in trolleys for direct distribution to the patient; on completion of the meal, the whole tray is returned to the main kitchen. Many other systems - micro-wave ovens and frozen foods, peripheral finishing kitchens, etc - are currently under investigation. All of them remove the bulk of the service and all of the washing up from the ward kitchen area.
In general, the numerous extraneous pieces of equipment which formerly projected from walls - such as radiators, hose reels, etc - are being tidied away into the building structure to provide smooth, easily cleaned surfaces. Hospital signposting has been rationalised, and a complete sign system developed by the Inter-Regional Board Sign Study Group is now available,18.
A great deal has already been accomplished in terms of standardisation, but it would be dangerous to be complacent. Much of the early thinking both in planning and in detail has proved to be superficial. The need for clear, logical, thorough development together with a recognition that this must be paid for in time and manpower - cannot be emphasised too strongly.
H. L. Smith Dip Arch, ARIBA, is assistant regional architect, South West Metropolitan Regional Hospital Board. He is chairman of the Inter-Regional Board User Requirement Study Group and a member of most of the regional board's Planning and Development Groups.
References 1Hospitals: New Standards for Ward Beds, Archie McNab, DESIGN 157/52-59 2 Emil Ries (1889), J. Amer Med Ass, 33.454 3 Hospitals: The Case for Research, Archie McNab, DESIGN 160/65-69 4 Inter-regional board study groups set up by, and under the general co-ordination of, the Ministry of Health.
18 Example of standard hospital signs designed by Inter-Regional Board Sign Study Group. Consultant designer Jock Kinneir.