[00:00] Michelle: Well, welcome to the Florence Nightingale miniseries. And this is minisode number two. These minisodes are based on Florence's book, Notes on Nursing, What it Is and What It Is Not, which was written in 1859. And today we are addressing the five elements Florence believed were essential for the health of people, both in the general population and for the sick in hospitals. And these are not necessarily in this order, but actually, they are pure air, pure water, efficient drainage, cleanliness, and light. You're listening to the Conversing Nurse podcast. I'm Michelle, your host. And this is where together, we explore the nursing profession, one conversation at a time. So let's just tackle these one at a time. First up is clean air. We all want it, we all love it, but we can't all have it because a lot of it depends on location. And in midcentury London, the air was pretty putrid. Florence says several times in her book she believes that the air on the inside should be as pure as the air on the outside. She talked a lot about ventilation, meaning ventilation of rooms, such as the windows should always be open and there should always be cross ventilation, especially if there are sick people involved. And she talks a lot about the word effluvia and this word is deceiving, which I will explain in a moment. Effluvia sounds to me like an expensive perfume or an exotic, exotic type of chocolate. Obviously, I was not familiar with it, so I looked it up on Dictionary.com, one of my best resources, and it's defined as a slight or invisible exhalation or vapor, especially one that is disagreeable or noxious. So essentially a really bad smell. And I can tell you as a former pediatric nurse back in the 1980s and the 1990s, that those kids that are admitted with gastroenteritis and dehydration, yeah, they put off some pretty bad effluvia and we didn't need a positive stool culture to confirm that it was rotavirus. Our unit was full of these sick kids every summer until the late 1990s when the vaccine was developed. And I think Florence is saying here that you definitely want to remove the smell from the environment, but more importantly, you want to treat the source of the smell, which is the infection. Now, something of interest around this time, which was the mid-19th century, there was a Scottish chemist, Dr. Angus Smith, and Florence makes reference in her footnotes to his air test. He is credited with discovering acid rain. And he did that by making the connection that sulfur was polluting the air as a byproduct of burning coal. While Florence goes on to talk about the air quality in regard to schools, and this is what she says, "oh, the crowded national school where so many children's epidemics have their origin. What a tale its air test would tell. We should have parents saying and saying, rightly, I will not send my child to that school. That school's air test stands at Horrid (with a capital H) and the dormitories of our great boarding school. Scarlet fever would be no more ascribed to contagion, but to its right cause. The air test standing at Foul, (capital F)". So Florence is saying sometimes the sick kids, they're not sick because of disease, but they're sick because of the bad air. And there's a direct correlation to our modern-day air quality issues. I mean, concern for air quality is real, especially here in California where I live. I live in a valley, the San Joaquin Valley, where pollution gets trapped, and when wildfires are burning, schools actually shut down because of that air quality. Florence was obviously concerned with air quality, so much so that she considered it essential for living a healthy life. And I definitely think most medical professionals would echo that sentiment today. Florence goes on to talk about the construction of houses, and I'm paraphrasing here, but she's pretty critical of the way houses are built. She says architects and insurance companies really just want your money. They're not concerned about if houses are constructed in a manner that promotes health. She goes on to say that people are just as ignorant buying houses that are poorly constructed and not investing in their own health. She says, "badly constructed houses do for the healthy what badly constructed hospitals do for the sick." Florence's sarcasm, it's really showing here. But what I think she's saying is people wake up, educate and advocate for yourselves. I mean, she's doing as a nurse then, as nurses do today, educate and advocate for our patients and communities. Around the same time in 1854, there was another doctor and this was Dr. John Snow. No, not the Jon Snow of the night's watch of Winterfell. This is a different John Snow. And this leads us to our second essential by Florence, which is pure water. So what did this John Snow do in particular? Well, during this time in London, there was an epidemic of cholera and Dr. John Snow suspected that people were being infected with cholera through the water supply. So he looked at the rates of cholera in two different communities. The water in London came from two companies who acquired their water from different areas of the Thames River. One company got their water from an area in the middle of London where Dr. Snow was pretty sure it was being contaminated with sewage. And the other company was getting their water from upstream of this area where he knew the water was cleaner. This area that he was studying, it served about 300,000 residents. What he found, I think, to us in the 21st century was not really surprising. But the company that got their water from upstream had a lower incidence of cholera and the company which got their water from the middle of the Thames, while they had a very high incidence, shocker, I know. Snow's study was novel, though, because, at the time, the germ theory of disease had not yet been established. So he's a pioneer. Moving on to the third essential, efficient drainage. Now, Florence seems to know a lot about construction and physics, or she just had a ton of common sense. Again, I'm paraphrasing, but she's saying that many people do not understand what a well-drained house is. She said you can't just take a pipe from the house and drain sewage into the street and think that that's good drainage. She goes on to say, though, "all the while, the sewer may be nothing but a laboratory from which epidemic disease and ill health are being distilled into the house." Yuck. Then she goes on to talk more about the placement of sinks and water closets, which is just a big word for a toilet, and all these things in the construction of a house that they're important in preventing disease. And I think she was just brilliant in how much she knew about these things and she was truly ahead of her time. And I think she owes a lot of it to her education that her dad provided her. So now we are at the fourth essential. We are almost to the finish line, so hang with me. The fourth essential is cleanliness. Now, Florence talked a lot about cleanliness in general, in terms of clean houses. And if you've ever seen a Victorian house or pictures of a Victorian house, well, they're beautiful. But she describes them as having, "old wallpaper, dirty carpet, and uncleaned furniture."  I think probably every room of a Victorian house was wallpapered and they had dark, heavy draperies and thick, heavy carpets, all of which were difficult and time-consuming to clean. And Florence suspected that these homes were not being cleaned on a regular basis or being cleaned well. And, of course, in hospitals today, we are so fortunate to have our amazing environmental teams, which are held to high standards in terms of cleaning and sanitizing, and disinfecting. And we also know how germs are spread, which they didn't know at that time. So we have one-upped them. All right, this is what you've been waiting for. So we are here, we are at the finish line, and thank you for staying with me. But we are at the fifth essential, which is light. There has been so much research on the benefits of light, and it should be Florence's number one. The health benefits of light are many. Improved vitamin D levels, better circadian rhythms, better sleep, reduction of dementia. I don't know if that's happening in my case. Reduced depression. And in the NICU, we practiced cycled lighting, which helps our little premature infants sleep and grow better. And we also know how indirect sunlight reduces neonatal jaundice, so lots of benefits. And Florence said, "light is not only a painter but a sculptor" and I think that's a beautiful thought sentiment phrase. She felt that light was extremely important to the human spirit as well as reducing disease and that in hospitals, patients always needed a view out the window and some source of direct or indirect sunlight. All right, cue the nostalgic music. So I'm going back to my days as a pediatric nurse, and we were blessed that our unit had a patio that we could access. And I remember on many occasions caring for very cranky little guys and girls and wheeling their bed or their wheelchair out onto the patio, playing a game or sitting at a table,  doing a puzzle, or coloring, something I love doing to this day. And within minutes, the child was greatly improved in terms of pain level and demeanor. And the nurses also had access to this patio. And it was very refreshing in a busy pediatric unit to have the patio door open with the breezes and the sunlight coming in. I can tell you 100% it greatly improved our twelve-hour shift experience. And I think it's just crucial that hospitals have light and open spaces that can be accessed by patients and staff. So at the very end of this chapter on the five essentials, Florence gives a kind of commentary on people who practice the five essentials and people who don't. I found it interesting and a little bit humorous in a cruel kind of way, but you can judge for yourself. Here's what she says on it. "The houses of grandmothers and great grandmothers of this generation with front and back door always standing open and a thorough draught always blowing through with all the scrubbing, cleaning, polishing and scouring which used to go on the great grandmothers and still more grandmothers, always out of doors, never with a bonnet on except to go to church. These things entirely account for the fact so often seen of the great-grandmother, who was a tower of physical vigor, descending into a grandmother perhaps a little less vigorous, but still as sound as a bell, and healthy to the core, into a mother languid and confined to her carriage and house and lastly, into a daughter sickly and confined to her bed. For remember, even with a general decrease in mortality, you may often find a race thus degenerating and still oftener a family. You may see poor little feeble, washed-out rags, children of noble stock suffering morally and physically throughout their useless, degenerate lives. And yet, people who are going to marry and bring more such into the world will consult nothing but their own convenience as to where they are to live or how they are to live." Wow. Florence, don't mince words, tell us how you really feel. This is a brutal commentary. She calls the kids poor little feeble, washed-out rags who suffer throughout their useless, degenerate lives. These words seem really harsh coming from someone in Florence's position. I mean, can we, as nurses, identify with Florence's frustration about people not being invested in their own health and the health of their families? That's a good question for sure. Thanks for listening. Please join me for the third minisode in the series, when Florence discusses topics like what it means to be in charge, the delegation of duties, and how nurses can get an undisturbed break. That's what I want to know.