Patient and political demand for single rooms in hospital is growing. In their favour are privacy, dignity and infection control. But could there be downsides - and would they create work for nurses? Graham Clews investigates
As the NHS struggles to finally do away with mixed-sex accommodation, a new challenge is already on the horizon.
The next step – in line with the government’s dignity agenda and the NHS Next Stage Review’s focus on improving patient experience – will be a move towards single-room accommodation.
The Department of Health’s current guidance on the issue states that all newly built NHS acute trusts should aim to have at least 50% of new inpatient beds in single rooms.
Additionally, last year shadow health secretary Andrew Lansley promised to double the number of beds in single-room accommodation in NHS hospitals in England by the end of a Conservative first term, if the party won the next election.
At present, single-occupancy rooms currently account for just under one-third of NHS beds in England. Latest Department of Health figures show that 30.7% of hospital inpatient beds are now housed in single rooms, up from 22.6% in 2002–2003.
While the first all single-room hospital in England is due to open in Kent in 2011, Wales has nosed ahead by announcing its plan for an all single-room hospital in Ebbw Vale next year, and both the Scottish and Northern Irish devolved governments have pledged that all new-builds should have only single-room accommodation, except in certain situations.
England’s first all single-room hospital is part of Maidstone and Tunbridge Wells NHS Trust in Kent.
The trust achieved a certain notoriety after a Clostridium difficile outbreak killed an estimated 90 patients in 2005 and 2006, the NHS’ worst outbreak of healthcare-associated infection.
The trust was severely criticised by a Healthcare Commission investigation, which demanded operational changes, and criminal charges were even considered.
This troubled history played a major part in the trust’s decision to build its new private finance initiative-funded Pembury Hospital with around 330 inpatient single bedrooms and no wards.
The trust’s hospital development director Graham Goddard said infection control and patient dignity measures had been ‘designed in’ to the hospital, although it would be up to nurses and other clinical colleagues to decide exactly how it would be set up.
The hospital is being built as 11 ‘fingers’ stretching out from a central block with 15 rooms on the outside of each finger to make best use of natural light, and views of the surrounding woodland.
All rooms will be hard-wired and incorporate wireless technology, with a small central nursing base for each stretch of 15 rooms. Each room has large observation panels that afford a clear view of the whole room.
Other design features for each room include an en-suite bathroom sited off the wall at the head end of the bed, with strategically placed handrails to reduce falls.
However, despite focused design features such as these, there is as yet little published UK evidence on the use of single-occupancy rooms.
‘Little is known about likely impacts on staff and patients,’ according to a recent review on single-occupancy rooms by the National Nursing Research Unit at King’s College London. The report has highlighted a range of possible advantages and disadvantages (see below).
|Advantages and disadvantages of single occupancy rooms|
|• Potential advantages for patients include: increased privacy, dignity and comfort and less disruption from other patients. Improved control over their environment, enhanced sleep, enhanced contact with families, increased patient comfort, privacy and safety, and increased patient satisfaction|
|• Potential outcome advantages include: reduced infection rates, fewer medical errors and faster patient recovery rates|
|• Potential disadvantages include: reduced social interaction and thus patient isolation; less surveillance by staff, increased failure to rescue and increased rates of slips, trips and falls|
|• Perceived advantages for staff include: potential for more personalised patient contact; potentially fewer interruptions and with medical storage in rooms, a decreased chance of prescribing errors and less walking for nurses|
|• Perceived disadvantages conversely include an increase in staff travel distances; the potential need for an increase in staffing levels as a result of more single room occupancy and/or adjustments to staff skill-mix|
|Source: National Nursing Research Unit|
Hillingdon Hospital in west London is currently working with the National Patient Safety Agency to test a single room pilot ward comprising 24 single-occupancy en-suite bedrooms with three different bedroom designs (see box at bottom).
Young people and adolescents, although they want communal and play areas, are very keen to have their own rooms
But Flo Panel-Coates, director of nursing at Maidstone and Tunbridge Wells NHS Trust, said senior managers and clinicians at her trust travelled to the US and Scandinavia to establish the advantages, and limitations, of providing care to patients in single rooms.
‘From the research we’ve done, it seems to fall into a generational issue in terms of who wants to stay in their own room,’ she told Nursing Times.
‘Young people and adolescents, although they want communal and play areas, are very keen to have their own rooms, for privacy and so that they can have visitors. But for other groups, such as older people, who may not have so many visitors we are looking at how volunteers and charities can help to reduce that possible isolation factor.
‘We think it is going to be fantastic, but we’ll need to pick up on the social care. High-dependency patients will receive regular care but it is those patients who don’t need to see a doctor or nurse from a medical point of view that we’ll have to look at,’ she said.
There are clearly a number of social and practical drivers for increasing single rooms in NHS hospitals, both from a nursing and from a patient perspective.
‘The likely increase in single-bed hospital rooms in the NHS is in part a response to the perceived public desire for such personal accommodation,’ according to the National Nursing Research Unit report.
This is perhaps a reflection of changes in wider UK society over the last decade, where the student room-mate and hotel rooms that lack en suite facilities are now virtually things of the past.
‘It’s obviously possible to design single rooms effectively, for the benefit of patients, nurses and doctors’
Michael Summers, vice chair of the Patients Association, said: ‘Privacy can be very important when you feel ill or low.’
He described NHS Nightingale wards as being ‘from a bygone age’, and while he accepted that there could be advantages from a nursing point of view of larger wards, such as better patient visibility, he said NHS hospitals needed to be ‘brought into the 21st century’.
‘When the NHS builds new hospitals it may be more expensive but they should replace the older ward system with single rooms,’ he said. ‘It’s obviously possible to design single rooms effectively, for the benefit of patients, nurses and doctors.
‘For instance, I can see that nurses need to keep an eye on patients, and that may be easier in a ward, but you can design a single-room system with alarms in every room and other ways of monitoring patients, which means that shouldn’t be too much of a problem,’ he added.
While many patients value the privacy of their own room, it is also true that some patients may feel isolated, with older patients in particular vulnerable to falls.
Patient monitoring may also prove more challenging – more nurses may be needed to staff individual rooms, and they may have to walk greater distances than if working on a traditional ward.
However, placing patients in single rooms could improve infection control. The tragic C difficile outbreak at Maidstone hospital was a key factor in its trust’s decision to pioneer 100% single-room accommodation, but not everyone believes single rooms will necessarily improve infection control.
In the independent sector, the use of single-room accommodation is far more common than in the NHS.
At one of the UK’s largest independent providers, BMI Healthcare, which runs 60 hospitals in the UK with 2,600 inpatient beds, more than 95% of those beds are in single rooms.
Sue Manning, head of infection and prevention control at BMI Healthcare, said both C difficile and MRSA are extremely rare in BMI hospitals, largely because all patients are, in effect, nursed in isolation from when they enter the hospital.
This does not mean they are cut off from nursing staff or from other patients. Individual room doors are left open as a matter of course unless a mandatory risk assessment calls for them to be shut.
Every room is cleaned every day, usually with the door shut, and Ms Manning said the presence of the doors helps to ingrain a hygiene culture, encouraging nurses to use the alcohol gels in every room with the door as a prompt.
‘If nursing and other staff do not follow good infection control practices, then it won’t help much’
But not everyone believes single rooms will improve infection control.
Rosemary Gallagher, nurse advisor in infection control at the RCN, said single-rooms are not a ‘silver bullet’, for defeating HCAIs. ‘If nursing and other staff do not follow good infection control practices, then it won’t help much,’ she said.
‘We know that infection can spread from single rooms, so staff should not be lulled into a false sense of security,’ she added.
There is, she said, a recognised shortage of single-room capacity for isolation purposes in the NHS, but even then single rooms are not necessarily the most appropriate place to house infected patients.
Small bays with two, or four, patients can be equally effective, she said, and it’s important for individual hospitals, or even individual units, to have the autonomy to determine what is appropriate for them.
And where there is a move towards single-room accommodation it needs to be as part of a complete overhaul and redesign of hospital sites, not by shoehorning single rooms into buildings that are not suitable.
The location of nurse workstations and dressings stores, for instance, need to be considered if nurses are to provide first-class care to patients in single rooms.
In addition, a European Health Property Network study, carried out for the NHS in 2004, found that any reduction of healthcare acquired infections from housing patients in individual rooms was not proved by randomised controlled trials.
But it did accept that ‘from logical reasoning it is clear that single rooms play a major role in reducing some preventable diseases and beyond all doubt in other specific disease areas.’
The report found that there were four factors in shaping decisions on the creation of single rooms: ‘science-based decisions’, relating to clinical and nursing care, and overall hygiene standards; ‘value-based judgements’, on what the community and the culture demanded; operational needs; and financial considerations.
‘The key is privacy and dignity and the important thing is to remember to ask the patient what they want’
It seems that, despite the possibility of some disadvantages to single room accommodation and a current dearth of research, this will be the future model for the majority of patients in NHS hospitals. It is simply what patients increasingly expect.
Rosemary Cook, director of the Queen’s Nursing Institute, said issues of patient dignity, care and confidentiality lie at the heart of how hospital accommodation should be arranged, and at the heart of nursing itself.
‘People’s expectations have changed over the years,’ she said. ‘If it ever was acceptable to be treated in front of other people, it probably isn’t now.
She added: ‘But we have to remember that people in hospital can become lonely. But the key is privacy and dignity and the important thing is to remember to ask the patient what they want.’
|An NHS pilot scheme for single bed rooms|
Hillingdon Hospital in west London is six months into a single-room pilot scheme that is to be widely analysed, and could have big consequences for future NHS bed provision.
The trust moved an existing haematology, oncology and gastroenterology ward into new purpose-built accommodation with three wings of eight single rooms, each designed differently.
Bev Hall, The Hillingdon Hospital NHS Trust deputy director of nursing, says the Bevan ward’s ‘yellow’ wing of eight rooms has been built with bathrooms jutting out into the corridor, to provide large outside windows for patients, but nurses have to enter the room to observe the patient.
The ‘blue’ wing has bathrooms on external walls, which allows for larger observation windows into corridors, and the ‘purple’ wing has interlocking, hotel-style, bathrooms between the rooms, which enable both sizeable observation and external windows.
There is no central nursing station on the ward, with smaller ‘touchdown bases’, arranged differently through the each of the wings. Some are more visible to patients, and others are more discreet, but the trust’s aim was to ensure greater contact between nurses and patients.
The pilot will be evaluated by two national research projects to gauge nurse and patient satisfaction, the effect on infection control, and nurse working patterns in the three different set-ups.
The trust’s own analysis will look at how clinical contact can be increased, how patients can take greater involvement in their own care, and how patient dignity and privacy is met.
Ms Hall says that although orientation training was given to nurses moving onto the Bevan ward, it was only once nurses started work in the different environment that they really learned to adapt.
‘An anxiousness that nurses would feel isolated on the ward has not been realised in quite the way some people feared, but nurses are still learning about how to work differently on a day-to-day basis,’ she says.
Should the NHS move to an all single-bed room model