How a ward nursing team improved facilities for patients, visitors and staff by using existing resources more effectively and considering others’ viewpoints
Hannah Foley, MNursSci, RN (adult), is staff nurse, St James’ University Hospital, Leeds.
Foley, H. (2009) Improving the ward environment to benefit patients, visitors and staff. Nursing Times; 105: 38, early online publication.
When the nursing team on the high dependency unit at St James’ Hospital, Leeds, moved to their new unit they discovered that aspects of the environment were not working to the best advantage of patients, visitors and staff.
This article outlines the process of identifying and assessing the scope of the issues and formulating an improvement plan. It concludes by sharing the lessons the team learnt, particularly in terms of better use of existing resources and putting patient experience at the centre of the process.
Keywords: High dependency, ward environment, patient experience
- This article has been double-blind peer-reviewed.
- Through this project we explicitly put the people who use our environment at the centre of the process.
- The most valuable part of the project has been analysing the environment from patients’ and visitors’ perspectives, to gain an understanding of their viewpoint.
- The project also showed there is much we can do to make the best use of the existing space and resources, which is an important lesson given current economic constraints.
In January 2008 the new high dependency unit (HDU) opened at St James’ University Hospital.
An HDU provides care that cannot be delivered on a general ward, called level 2 care. Level 2 patients are defined as “patients requiring more detailed observation or intervention including support for a single failing organ system or post-operative care and those ‘stepping down’ from higher levels of care” (Department of Health, 2000a).
The move from the old surgical high dependency unit saw the new one double in capacity and enabled us to extend admission criteria to non surgical patients. While the unit had been designed with the latest developments in healthcare in mind, in particular, infection control procedures, there were the inevitable teething troubles when it first opened. Over time these immediate issues were resolved.
However, from working on the unit and conversations with patients and relatives, we were aware that some environmental issues remained. This article outlines the scope of these issues and the formulation of an improvement plan. We feel the process of listening to staff, patients and visitors, and the solutions we developed, will be of value to the wider nursing community, particularly in view of the current economic climate.
The scope of the issues was clarified in four ways, with the aims of gathering as many perspectives as possible and establishing a clear evidence base. We conducted a small non validated questionnaire, used information we had gathered through the trust privacy and dignity audit, conducted a walk-round, and looked at the literature.
The questionnaire was designed to formalise the anecdotal evidence we were already aware of regarding the ward environment. It was aimed at patients, visitors and staff, and was given out over two days. Some patients were unable to participate because of their condition. We also gave out copies to patients who had been with us previously and were inpatients on other wards.
The questionnaire covered:
- First impressions;
- Navigating the ward;
- Experiences of the bedspaces;
- Experiences of day and night;
- Awareness of facilities;
- Receiving information;
- Spending extended periods on the ward;
- Experiences of the staffroom and office area.
The questionnaire showed there were many things that people liked about the unit, for example, the space and cleanliness. However, it was also evident they found it threatening, stark and unstimulating. The ward has little natural daylight and people commented on how disorientated they felt. Visitors struggled to access the ward and lacked information.
Privacy and dignity audit
The trust-wide privacy and dignity audit was introduced just as we were considering the environmental issues on HDU and proved a useful source of information. In relation to this project it revealed the following areas as points for improvement: meeting and greeting visitors; provision of information in the form of leaflets and noticeboards; storage of patient property; noise; availability of clocks; and clear signs.
A walk-round of the unit was done to try to understand how the ward appears to a person entering from outside the building or to someone sat in a particular bedspace. The experience of “standing” in patients’ or visitors’ shoes was invaluable.
Some bedspaces were dark and with blank walls surrounding them (see the patient comment in Box 1); other bedspaces were noisy and confidential conversations at the nurses’ station were clearly audible to patients and visitors. The division of the unit by the link corridor and lack of signs made access difficult. There was also a lack of information on what was allowed and what was expected of visitors and patients in such a specialist environment.
Box 1. A patient’s view of their bedspace
“I feel stranded. I feel horrible shouting for help. It feels like I am moaning. It is either too bright or too dark…Everywhere is very grey. I can’t see anything other than my own feet. I can’t see the nurses or doctors but can hear them talking about me. I’ve no idea what’s behind me. I feel strange when my mum and dad comment about the weather as I don’t experience ‘weather’ anymore. I feel psychologically drained.”
The literature showed that space, light, fresh air, cleanliness, a warm and friendly atmosphere, colour, privacy and noise levels were all concerns of visitors and patients (Rowlands and Noble, 2008; Kline et al, 2007; Douglas and Douglas, 2005).
Ward layout, design and appearance has been shown to have a significant impact on the recruitment, retention and performance of nurses in England (Commission for Architecture and the Built Environment, 2004). Daylight, a nice view, somewhere to go to relax away from the clinical area, and reducing clutter were all concerns of nurses. Nurses also said they viewed the appearance of a ward as indicative of its management style (CABE, 2004).
The limitations of our assessment process related to the questionnaire. The staff response rate was low and on investigation it emerged there were concerns about the lack of anonymity. It was a surprise that staff raised this as a concern as it had been assumed they would feel able to air their views in an open and honest forum.
It was also not ideal that patients and relatives were given the questionnaire while inpatients on the unit. Patients were often too ill to complete it without help from a member of staff. Patients and visitors may have felt they could not be honest in expressing their views under these circumstances.
An awareness of this limitation led to the decision to follow up patients on the wards they had been discharged to. Interestingly, the responses returned from this group did not differ greatly from those of current patients.
The first issue we decided to focus on was signage, to help people access and navigate the ward area. It was evident from our assessment that visitors struggled to locate the ward in the first instance and often became lost between the main unit and the visitors’ facilities on the other side of the link corridor. We ordered signs to indicate the ward entrance and to clearly mark facilities for visitors, for example, toilets. We also ordered greeting signs to improve the atmosphere of the ward entrance so that visitors felt welcomed and valued. We met with an estates manager to look at how we could make the route between the waiting area and the main unit more obvious for visitors.
In our questionnaire patients and visitors had suggested coloured lines on the floor. However, hospitals are moving away from this way of marking routes so we needed to find an alternative. We decided to consider artwork to act as route markers.
The next issue we decided to focus on was improved information and this was divided into two subgroups: information for patients and visitors, and information for staff.
Information for staff
For this group the main way of giving information was through a series of noticeboards located in the staffroom. These were cluttered and information had begun to spread onto the walls around the boards, creating a busy atmosphere in an area that was supposed to be for staff to relax in.
Following a clearance of out of date notices from the boards it was decided that all notices should be dated and removed after one month. A computerised interactive noticeboard was planned for the staffroom to cut down on what needed to be displayed on the walls. A resource room was also created from an empty office further down the corridor as an alternative space for accessing information.
The offices between the staffroom and the resource room house the clinical educator, critical care outreach team and a seminar room so it was felt appropriate to use the empty wall space along the corridor as a further means for displaying information. Some staff raised concerns that this might become an extension of the cluttered noticeboards in the staffroom. As a solution, lockable display cases were planned for this corridor so that what goes in them could be more carefully monitored. It was also decided that it would be beneficial if these cases were used exclusively for displaying relevant research and to present the work of staff members from the unit who had completed dissertations, projects or courses.
Information for patients and visitors
For patients and visitors the main route of accessing information was verbally from staff or through noticeboards in the waiting area. While it is mandatory to display certain pieces of infection control information on these boards, it was not necessary for every board to be occupied with this information, as had been the case.
It was decided that one board should be allocated for infection control and the remaining one should be used for a rolling programme of information prepared by ward link nurses on relevant topics. A suggestion sheet was pinned up in the waiting area for visitors to write down what they would like to see on the information boards. A computerised interactive noticeboard was also planned for the waiting room to cut down on what needed to be displayed on the walls. As some visitors did not use the waiting room facilities at all, it was decided to supplement this with two lockable display cases on the main unit.
In addition, from our assessment it was evident that visitors and patients were not being given basic ward information in a consistent manner, such as visiting times. It was also evident that some information, such as how long surgery may take, was not getting through at all. As a result visitors were expecting to visit a patient at lunchtime who would be unlikely to leave recovery until the evening.
Two senior nurses were asked to develop a leaflet that could be given out on the pre-assessment unit and be available to be given out on HDU. It was decided to repeat this information on two noticeboards, one at the waiting room entrance and one at the main unit entrance for those who miss the leaflet.
From our assessment it was clear that artwork on the walls would make a dramatic difference to everyone on the unit. It was felt that some bright pictures would help diffuse the unstimulating, clinical nature of the ward while also improving the working atmosphere for staff.
Initially we contacted local schools and colleges to involve children and young people as a positive and inexpensive way of producing artwork. We were fortunate to gain the input of the hospital arts development team (TONIC) who felt this would not be the appropriate place for non professional artwork to be used and they offered to draw up a proposal of work for us. We also planned to install projectors in the side rooms so that long term patients could choose a selection of their own pictures for the walls.
Light boxes and clocks
HDU has little natural daylight but several of the bedspaces were particularly dark and enclosed. We looked at research involving the use of light boxes as a way of helping to differentiate between day and night and intend to apply this to HDU.
Clocks had also been a difficult issue for us. In order for some patients to see a clock, other bedspaces had to display a very large clock that reinforced the length of the patient’s stay in that bedspace. Smaller bedside clocks posed other problems in terms of leads and visible displays. This was identified as another area that TONIC could help with.
While our assessment raised many physical alterations and improvements that needed to be made, it was also evident that we could improve the unit’s atmosphere by better use of it as it was.
It was noted that curtains should be pulled back, blinds fully opened, and lights put on. Patients and visitors appreciated some appropriate and subtle music or radio to distract from clinical sounds, such as alarms and oxygen systems. While the ward was generally clean and tidy, it was also noted that it was important to keep nurses’ easels and desks clear of clutter.
A photographic poster campaign was planned to improve awareness of how the bedspace can appear to a patient when there is poor housekeeping by staff.
We are hoping to evaluate the effectiveness of what we have put in place in April 2010, taking into account the limitations highlighted in our initial assessment process. We would like to start a formal follow up clinic of patients once they have returned home and use this to gather patient and visitor views. We are also exploring options for conducting research into the use of light boxes on the unit.
We intend to rerun the questionnaire and the privacy and dignity audit. We intend to conduct a second walk-round and will consider any new literature that has become available.
Much of the assessment work carried out as part of this project would also integrate well into the annual Patient Environment Action Team (PEAT) audit in line with the Standards for Better Health (DH, 2004) agenda. This would enable local information gathered by those using the environment on a daily basis to feed into the wider hospital trust agenda. A good example of this is the recent PEAT audit of the Royal Marsden Hospital in which similar work by staff highlighted signage as an area for improvement within their organisation (National Reporting and Learning Service, 2009).
While this is a project that is still very much at the implementation stage, we feel we have already learnt lessons that are worth disseminating to the wider nursing community. The most valuable part of this project has been the process of “standing” in patients’ and visitors’ shoes to gain insight and understanding of their viewpoint. It has been good to hear that most patients and visitors are deeply appreciative of, and happy with, the care they receive on HDU. Discussion with patients who have been confused or frightened on our unit has been humbling, and sitting in a patient’s bedspace, watching what they see, has been eye opening.
While it is clear there is much we hope to do in terms of physical changes to the ward environment, this process has shown us there are many things we can do to improve the space we already have by using it more effectively and by considering others’ viewpoints. These are useful lessons to learn in the current economic climate, which makes us even more aware of how we use NHS resources.
- This project fits in with the agendas laid out in Improving Working Lives (DH, 2000b), The NHS Plan (DH, 2000c), and Standards for Better Health (DH, 2004).
- It also complements the current emphasis on patient dignity, and the new DH guidance on using patient feedback to improve care (Hairon, 2009).
Commission for Architecture and the Built Environment (2004) The Role of Hospital Design in the Recruitment, Retention and Performanceof NHS Nurses in England. London: CABE.
Department of Health (2004) Standards for Better Health (Updated April 2006). London: DH.
Department of Health (2000a) Comprehensive Critical Care: A Review of Adult Critical Care Services. London: The Stationery Office.
Department of Health (2000b) Improving Working Lives. London: The Stationery Office.
Department of Health (2000c) The NHS Plan: a Plan for Investment, a Plan for Reform. London: The Stationery Office.
Douglas, C., Douglas, M. (2005) Patient-centred improvements in health-care built environments: perspectives and design indicators. Health Expectations; 8: 264-276.
Hairon, N. (2009) New guidance shows how trusts can use patient feedback to improve care delivery. Nursing Times; 105: 22, 16.
Kline, T. et al (2007) Patient satisfaction: evaluating the success of hospital ward redesign. Journal for Healthcare Quality; 29: 3, 44-49.
National Reporting and Learning Service (2009) Patient Environment Action Team (PEAT) Data 2009. London: National Patient Safety Agency.
Rowlands, J., Noble, S. (2008) How does the environment impact on the quality of life of advanced cancer patients? A qualitative study with implications for ward design. Palliative Medicine; 22: 768-774.