Providing high quality facilities for the relatives of dying patients is not always given priority in hospitals. A trust aimed to address this service gap
In this article…
- Carrying out an audit of existing premises
- Devising a template for rooms that meet relatives’ needs
- Combining a domestic feel with infection control bodies
- Choosing artwork, colour, furnishings and other contents
Sharon Bird is carer representative on the specialist palliative care practice development unit; Jacqui Candy is lead cancer manager; Paula O’Malley is arts coordinator and fundraiser; all at Aintree University Hospitals Foundation Trust; Michelle Maden-Jenkins is clinical information specialist at Edge Hill University, Ormskirk, Lancashire.
Bird S et al (2011) Safe haven: transforming relatives’ rooms. Nursing Times; 107: 5, early online publication.
The quality of facilities available for relatives and carers of hospital patients, particularly when distressing news is given, often receives little attention.
This article outlines a project undertaken at a Liverpool trust to improve these facilities. Informed by personal experience, the project adopted an evidence based, design led approach and used standard hospital materials and suppliers to refurbish relatives’ rooms.
Audit and feedback from relatives and staff was used to inform the project, and literature on enhancing the healing environment was used to formulate a trust wide standard for all relatives’ rooms.
Keywords: Relatives’ rooms, End of life care, ward environment, User experience
- This article has been double-blind peer reviewed
5 key points
- A poor environment and a lack of privacy can add to relatives’ distress when they hear bad news
- A collaborative approach that involves staff, patients, careres and relatives was vital to the project’s success
- Minimum standards for relatives’ rooms were met using existing NHS suppliers
- An evidence-based, design-led approach was adopted
- The project helped raise the profile of the needs of carers and relatives of patients who are receiving end of life care
The first End of Life Care Strategy for the UK aimed to promote high quality care for all adults nearing the end of their lives (Department of Health, 2008). It outlined a number of key quality markers and measures for end of life care for both commissioners and providers of healthcare.
One of the quality markers for acute hospitals was ”suitable quiet spaces in wards for families and carers which are specifically used for this purpose” (DH, 2009).
According to Lomas and Timmins (2004), best practice when breaking bad news is to deliver it in a private, non-clinical area where no disturbances are likely, and where patients and relatives can use the space for a time after the event.
However, the quality of facilities available for relatives and carers, particularly when distressing news is being given, often receives little consideration.
After a relative recounted a traumatic experience when receiving bad news (see box), we decided to improve facilities at the hospital.
The relative was invited to become the carer representative on the palliative care practice development unit’s (PDU) steering group at the trust. One of the group’s aims is to improve facilities for carers and relatives of patients receiving palliative and end of life care .
Relatives’ experience of breaking bad news
“In 2004, my world turned upside down. My husband was diagnosed with terminal gastric adenocarcinoma.
“A Whipple’s procedure was commenced but immediately abandoned. This news was broken to me in a room labelled Sister’s Office, but it was also used as a storeroom and as a thoroughfare for the ward staff toilet.
“What I was told about my husband’s chances of recovery left me feeling totally devastated, needing to escape. However, I was in this hectic environment with no safe haven to digest what I was being told or to think about the questions I should be asking. This memory lives with me today.”
Using relatives’ experiences, as well as user needs and attitudes, to inform the design of relatives’ rooms creates a partnership between relatives, patients and healthcare staff in leading service design (Bate and Glenn, 2006).
Additionally, consultation with users, staff and artists generates greater ownership and commitment, and ensures that the project really meets the needs of users (Waller and Finn, 2004).
To meet the aims of the project, it was vital to secure the involvement of a multidisciplinary team. The team included:
- PDU steering group;
- Ward staff;
- Estates department.
The project was led by the trust’s arts coordinator and the carer representative of the PDU steering group, with valuable support from the maintenance manager in the initial stages. It also had the full backing of the trust’s executive team.
We used evidence based approach in designing and refurbishing ward relatives’ rooms. This was informed by a literature review, audit results and the outcome of a survey of carers, relatives, patients and ward staff. Trust policies were also followed.
The rooms serve two purposes:
- They provide a private space where staff can talk to families in a calming atmosphere;
- They give family members a place to go when they need rest and respite.
We carried out an audit of the environmental conditions of areas used by carers and relatives of palliative care patients in April 2008.
Eight wards were included in the audit, which revealed:
- Two had no dedicated areas for carers or relatives;
- Three had rooms used for several purposes, including as a relatives’ room, staff handover area, interview room and ward clerk’s office, while three also used the rooms for storage
- Decoration in all rooms needed upgrading and furniture and facilities were in a varied state of repair.
Views on existing facilities – from patients, relatives and ward staff – confirmed the audit findings. Lack of privacy and comfort were highlighted as the main concerns.
Following the audit and feedback, we compiled a minimum standard for the relatives’ rooms, which included:
- A secure, heated room with an window that could be opened;
- At least two chairs and a small table;
- A folding bed with linen;
- A small TV;
- Tea and coffee making facilities;
- En-suite toilet and hand washing facility;
- Attractive decoration and artwork.
Art and design in health settings has long been recognised as playing an important role in reducing stress, improving outcomes and enabling effective communication (DH, 2007).
To inform the design of the relatives’ rooms, we researched four areas.
We initially thought there may be one ideal colour to improve the environment and reduce stress.
However, research showed that colour and design should be harmonious (Tofle et al, 2004) and reflect colours found in nature. We therefore chose three colour combinations: green and fawn; red and green; and turquoise and mocha.
The rooms can be used for intense periods of up to 48 hours, and by families needing a short rest.
After consulting a lighting supplier and the estates project team, we used two types of lighting - dimmable overhead lighting and dimmable spotlights over the wall art.
This provided high quality light for formal discussions between staff and relatives that could be turned down if relatives needed a short nap.
Originally we envisaged making a CD player available in the rooms. However, research showed that music can carry memories and associations related to the time it is heard (Ashley and Luce, 2004), so we decided thata television would be installed, which could be used for distraction.
Patients, carers and relatives have a clear preference for scenes depicting nature or unthreatening abstract art (NHS Estates, 2003).
The project team and ward staff were shown a variety of art fitting these criteria, and based their choices on creating harmony with their chosen colour scheme.
Like music, art carries memories so, rather than use widely available prints, we commissioned original artwork for a small fee by a local artist.
After this research, we drew up a design layout, and showed a series of mood boards incorporating all elements of decoration, furnishings and art to ward staff.
Although relatives’ rooms are not in the main clinical ward area, the fixtures, fittings and furnishings still needed to comply fully with hospital policies. Therefore, when planning the refurbishment of the rooms, we therefore considered issues relating to health and safety, infection control and people with disabilities.
Discussions with the equality and diversity, infection control, and estates and facilities departments identified a number of standards that had to be met. These related to access, temperature control, sanitary facilities, lighting, suitable fabrics and non-slip flooring. All fixtures, fittings and furnishing were sourced from existing hospital suppliers.
Based on the results of the audit, questionnaire, literature review and trust standards, we devised a new template for the relatives’ rooms. This differed from the original minimum standards and included:
- New flooring/lighting;
- Lined curtains;
- Wall mounted flatscreen TV;
- Modular furniture allowing for some flexibility in use;
- Toilet and handwashing facilities;
- Replacement of windows and ceiling.
Guided by the ward staff, including the matron, ward manager and housekeeper, we decided not to include drink making facilities or bedding in the rooms as these would be available from the ward at any time.
Silk flowers, complying with infection control and fire safety standards, and covered bins more in keeping with the domestic feel of the room were specified.
To date four relatives’ rooms have been refurbished and planning is currently underway for the refurbishment of the fifth. The protocol for the relatives’ rooms is being used to refurbish approximately 20 wards. The refurbishments are being undertaken as part of the trust’s ward upgrade scheme over a period of five years. The scheme is due to be completed in three and a half years.
The total cost of the refurbishment of a relatives’ room was up to £18,500. This included replacing the flooring, windows, ceiling, lighting and sanitary fittings, as well as purchasing furniture, soft furnishings and artwork. The bulk of the cost was for the capital works, with approximately £3,000 spent on furniture and soft furnishings.
The first relatives’ room was fully funded by the hospital, while some refurbishments were made possible ahead of schedule by using charitable funds. For example, the Kay Kendall Leukaemia Fund paid to refurbish the relatives’ room on the ward providing care to patients with haematological conditions.
The first refurbished relatives’ room opened in May 2009. Soon after completion, it provided a non institutional setting for the wedding of a terminally ill patient.
Our design led approach has set a standard that the trust is committed to for the future refurbishments of relatives’ rooms. The project has shown that, by using standard hospital materials and suppliers, it is possible to create a relatives’ room that is appropriate for the identified need: The provision of a safe and calm space for carers or relatives receiving distressing news (DH, 2009).
However, in some instances, it was not possible to meet all the identified requirements. For example, due to limited space, wheelchair access to the toilet facilities could not always be provided. Other needs were met by existing facilities – a hotel within the hospital removed the need for long term sleeping facilities, and there was no need to provide hot refreshment facilities as these were readily available on the wards.
After further consultation with ward staff and the project team, we produced a relatives’ room leaflet to provide carers, relatives and patients with information on the hospital facilities available.
Nothing can ease the pain of hearing difficult and distressing news about a loved one. However, we can try to ensure that a poor and degraded environment does not add to the distress of the situation. It is possible to create a comfortable and safe environment, without an institutional feel, by using a design and research-led multidisciplinary approach.
The environment should not leave distorted memories of the place the news is received, or of the person sharing difficult news. It should provide a safe haven in which relatives can digest what they are being told and give them the time and space to formulate the questions they will need to ask at this difficult time.
Ashley R, Luce K (2004) Music, autobiographical memory, and emotion. In: Libscomb SD et al (eds) Proceedings of the 8th International Conference on Music Perception and Cognition. Evanston, IL: Northwestern University.
Bate P, Glenn R (2006) Experience-based design: from redesigning the system around the patient to co-designing services with the patient. Quality and Safety in Health Care; 15: 307-310.
Department of Health (2009) End of Life Care Strategy. Quality Markers and Measures for End of Life Care. London: DH.
Department of Health (2008) End of Life Care Strategy. Promoting High Quality Care for all Adults at the End of Life. London: DH.
Department of Health (2007) Report of the Review of Arts and Health Working Group. London: DH.
Lomas D, Timmins J (2004) The development of best practice in breaking bad news to patients. Nursing Times; 100: 15, 28
NHS Estates (2004) Exploring the patient environment an NHS Estates workshop. London: The Stationery Office.
Tofle RB et al (2004) Color in Healthcare Environments: a Critical Review of the Research Literature. Columbia MO: Center for Health Design, University of Missouri.
Waller S, Finn H (2004) Enhancing the Healing Environment. A Guide for NHS Trusts. London: King’s Fund.