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