Ward design must not be restricted to single rooms

2 July, 2010

There is little doubt that ward design impacts on nursing practice, and has significant outcomes for both nurses and patients.

Over centuries, approaches to hospital and ward design have been based around various notions: creating the best environment for care; patient pathways and care philosophies; efficiencies in workflow and assisting staff workload; minimising cross infection, and so on.

It is now generally accepted that single sex accommodation is the way forward, but room configuration varies from country to country. In the UK the jury is still out on the move to a major increase in the proportion of single rooms and the opinions and wishes of patients and nurses feel uncomfortably unresolved.

Whether you are a patient or a nurse, procuring a new hospital or managing an existing one, there are five primary concerns about the impact of a greater proportion of single rooms in our hospitals: levels of privacy and dignity; loneliness among patients; potential for patient observation; the impact on infection control, and relative cost.

‘It is possible to build an argument that says better levels of patient comfort contribute to healing, but “comfort” is achieved in different ways for different people’

While researching my current book, Nurse Past, Present and Future: The Making of Modern Nursing, I discovered we do not have enough of the right type of research to address these concerns and support a clear decision either way. Long term evaluation of relevant projects and consultation with the right people is required; we must listen to a range of professionals with the best experience, skills and expertise - particularly nurses.

Measuring what patients think about single rooms is challenging - it depends on whether they are in or out of hospital when they are asked, the nature of their illness and the length of their hospital stay. We can speculate that their feelings about single rooms relate to a cultural shift that sees the older generation enjoying the more personal contact and social interaction enabled by a multibed ward, whereas younger patients enjoy and expect single room accommodation. But we cannot know that a decision made now to increase the proportion of single rooms on this basis will be justified in the long term.

It is possible to build an argument that says better levels of patient comfort contribute to healing, but “comfort” is achieved in different ways for different people; some research tells us, for example, that for some patients loneliness is a major factor while, for others, privacy is the priority.

Single rooms cannot substitute for high quality hygiene regimens, nor can patient observation concerns prevent a greater provision of single rooms.

There are cost issues; while designers and architects have the design skills to optimise the space they are asked to work with, multiplying the number of rooms typically multiplies the number of costly components required. The economic argument is not straightforward.

And a preoccupation with the single room debate cannot divert attention from the other desirable design characteristics of hospital wards. In this year of Florence Nightingale celebrations, we need to remind ourselves that so many of her beliefs about ward design still hold true: light quality and levels of natural ventilation, noise reduction and views out are principles that can achieve long lasting, positive results in ward design.

So, where does this leave us? With such a range of opinions and requirements, it is important to increase, rather than restrict, choice about ward design. We must design for flexibility and offer choice - for patients and nurses - by offering accommodation with the flexibility to suit the widest possible range of care needs. With the UK’s hospital building programme diminished for now, we must consider the arguments carefully in the case of refurbishments as well as new builds.

The design of any healthcare building makes concrete the care philosophies of that era. These are likely to change during the lifetime of a hospital and, in an inflexible building, changes that require modifications to its physical fabric can require expensive retro-fitting. Briefing for flexibility from the outset offers a responsible approach to constructing buildings that can embrace and accommodate change in the long term.

In a climate of reduced resources, in which care is changing rapidly, decisions we make in the short term still need to be made with a long term view. And, with environmental sustainability at the forefront of our minds, it is increasingly important to think of buildings in terms of their embodied energy and to ensure that their lives are long. The building’s structure will be the longest surviving element of its construction; it is the interior systems, layout and design that offer design flexibility and the potential for change within the building’s lifetime.

A flexible approach that offers choice, developed with an ear for the professional opinion of the right people, and based on a longer term evaluation of existing and new models of ward design is required before a commitment is made to single rooms that cannot easily be undone.

Kate Trant is co-editor of Nurse Past, Present and Future: The Making of Modern Nursing and coordinates healthcare research for the Commission for Architecture and the Built Environment

Readers' comments (12)

mike | 2-Jul-2010 12:57 pm
The move toward the disproportionate use of single rooms is a massive mistake.

Single rooms are important yes, they provide us with a means to effectively quarantine infectious patients, they provide those who have a clinical need for it the isolation, privacy etc they need.

However they are not there for patient comfort alone.

I remember a survey done a while back with Nurses categorically saying that a move to an all private room hospital is a mistake. There were fears about staff safety in private rooms, the lack of staff to effectively cover the ammount of private rooms it would take and the difficulty in which we could effectively keep an eye on our patients with low levels of staff, there were concerns about those patients who clinically do better in a bay because of the company, etc etc.

Yet these were ignored.

It seems like as always, the patients 'rights' of privacy, comfort and their demands to have a hospital stay akin to that of a hotel, are put above and beyond clinical opinion.

Yes private rooms are important, but not at the expense of bays. They should be built according to clinical need (ie more private rooms would be needed in an infectious disease ward than say an ortho ward), and not patients wishes.
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Anonymous | 2-Jul-2010 11:54 pm
I couldn't agree more, I think people are now under the assumption that they are not in hospital and are in hotels!!! I have worked in areas that have en-suite single rooms and have felt very........'uneasy' when in a room with a patient as I can't see or hear the other patients in that area.

Having bays with a small number of patients in it not only encourages patients to interact and therefore speed up the recovery process and wards off the onset of depression for 'long-term' patients it enables the nurse or HCA to observe, patients indirectly whilst seeing to other patients enabling us to be able to make an accurate assessment of what patients need, as some can say they can manage doing various things but are actually struggling and too proud to say so.

It also improves patient safety as if an elderly or confused patient falls or becomes acutly unwell the other patients in the bay can alert the staff (if they are not already in the bay) about the patient in question.

Not only that but think about the increase in, in-hospital cardiac arrests!! in an area of a small number of patients the staff could see the signs and become aware that a patient is deteriorating and inform the ward doctors or crash team within the window of time, where as in a room it could be a while before the staff see a patient again once they have completed the wash rounds and ward rounds in a 30 bedded ward that could be quite some time.

I agree with the post above more en-suite rooms should be made more readily available in the appropriate clinical areas i.e. Infectious disease, heamatology and acute assessment areas.
Have a small number of 'isolation rooms' on medical/surgical ward.
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Anonymous | 4-Jul-2010 9:12 am
The need for daylight and a view are really important and research has shown that patients recover more quickly where they have both. I recently spent time on a ward with very high windows which you could not see through. After a few days patients were desperate to get outside even though it was very cold. It seemed to raise their stress levels being cooped up.
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mike | 5-Jul-2010 0:27 am
Anonymous | 4-Jul-2010 10:01 pm, Whilst I absolutely agree with that, what is wrong with sticking big windows (that open wide for real fresh air and have a nice view) in bays? Not everyone needs a private room.
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simon williams | 5-Jul-2010 3:58 pm
our local DGH (YSTRAD MYNACH) will be having single rooms. Fab in theory, however there are those especially the elderly who like person to person contact and conversation.
i on the other hand would beg for a single room
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mike | 5-Jul-2010 4:37 pm
Simon, I think a lot of us would like single rooms if we had the choice, myself included, but it should never be a choice. A hospital bed is not a hotel room. That decision should be down to clinical reasons alone.
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Anonymous | 6-Jul-2010 8:48 am
I work in a Private Patient 22 bedded unit. All patients have a single room with en suite facilities. We care for patients who have had major surgery including those with epidurals, central lines etc. Nursing them in a single room isn't a problem at all. I suppose it is mostly down to adequate staffing - 1 RN and HCA to 6 patients generally. Our patients tend to recover faster than those on the NHS wards (we are a PP unit within an NHS hospital) for example our TKR patients go home on average at day 3 or 4 and NHS it is day 7.
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kitchengoddess83@yahoo.co.uk | 6-Jul-2010 8:51 am
Simon & Mike I can see that in some instances single rooms don't work - e.g. on our PP unit we don't accept cardiac patients, dementia or acute stage of CVA's (rooms not big enough for hoists - no other reason).

We do also offer an 'amenity' service - ie. NHS patients can pay for a single room but have NHS treatment making it substantially cheeper than full PP care. Not only do they get a single room but a better menu and quality of food too.
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Alice P | 6-Jul-2010 12:33 pm
I think the compromise between single rooms and bays is if the hospital wants to provide single rooms, then the nurse:patient ratio needs to drop further.
As someone stated back in February, with all single rooms, patients don't appreciate that you have 5 or 6 OTHER patients to attend. It is hard to understand that your discharge is delayed because the faceless person in the next room requires pain med.
Ideal ratio for med/surg unit 1:4 with 1:8 HCA. Do the math: if a nurse has 6 patients in 12 hours, she can only spend 2 hours over the entire shift with each one. Take away time with physicians and other disciplines, time in the med room, and time charting, and how much face-to-face time does that end up being?
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mike | 6-Jul-2010 8:30 pm
I absolutely agree about staffing levels. That is the primary problem!

And Anonymous | 6-Jul-2010 8:48 am, you have 1 RN and 1 HCA for 6 patients? That is bloody ideal! I wish I had that!

Try 2 RNs (sometimes 1) and 1 HCA (2 if you are lucky) to 32 patients!
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vera howarth | 8-Jul-2010 12:10 pm
I work in a unit that has been recently upgraded as a single room unit,containing 12 rooms.Primarily we were meant to take CDT +ve patients but the reallity is we are taking anyone ,including acutely ill patients.
None of our patients are observable and we have to ensure regular -at least 1/2 hourly ,visits are made to them,and even more frequent if need be.We are extremely short staffed and none of the interiors are visible without going into the rooms.
A large proportoin of our patients are elderly and have a high requirement of nursingi nterventions, obviously a lot of time is spent in care delivery in most rooms.
Many patients have expressed concern about being in single rooms-trapped, imprissoned,lonely are some of the expressions used and some are clearly becoming depressed by their isolation.We make a concious effort to spend time ,socially with our patients but we have difficulty in finding enough time.
It is not always desirable to have just single rooms.
Pior to the opening of this unit we nursed our patients on a cohort ward with bays and our results for the containment of CDT were just as good as they are now.
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meba | 10-Jul-2010 12:49 pm
I can see the necessity for single rooms but equally I see the need for bays. It depends on the area of nursing and the dependency of the patients, hospitals should not make this move towards a hotel setting. Staff in many areas are already over worked and working short if it was to be the norm that single rooms were standard then this would be disasterous for safe running of some areas. And what about the cost of all this refurbishment? We are told belts have to be tightened and jobs are at risk and what about the waste of money that should be getting spent elsewhere.
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