Evaluating a major innovation in hospital design: workforce implications and impact on patient and staff experiences of all single room hospital accommodation

Research approach

The research includes a pre/post mixed-methods evaluation in a single hospital within which there are three distinct but related workstreams:

1. a before-and-after mixed-methods case study design (with four nested cases) within a single hospital

2. a quasi-experimental before-and-after study using two control hospitals (one steady state and one move to new build with fewer than 100% single rooms)

3. an analysis of comparative costs associated with single rooms.

This chapter provides an overview of the research approach and questions. It also presents the methods used and provides details of the study design, sampling, data collection and analysis.

In our original project proposal we included applying a realist evaluation framework1 to explore the effect of single rooms in different circumstances and on different stakeholder groups. This proposal was reconsidered during the project for a variety of reasons. First, and most importantly, realist evaluation is an approach developed for evaluating large-scale complex social change programmes. While bringing a new hospital into operation has some similarities with implementing a programme, important differences became apparent to the project team that made a realist framework problematic to apply. 89–91 Second, during the course of the project, unresolved methodological issues relating to how to define context–mechanism–outcome configurations that form the basis for realist analysis became the focus of critiques of the approach. 92,93 In view of these, the research team decided that there were few advantages in adopting a realist framework over and above using conventional methods, such as case study and quasi-experimental design. However, our approach has been broadly informed by ‘realist’ perspectives, particularly in terms of identifying stakeholder intentions; utilising their knowledge of ‘how things work’ on the ground; and defining and testing ideas about ‘what works’ in different contexts. Thus, our aim was still to understand what worked and for whom, in what circumstances, and how.

Research ethics and patient and public involvement

The study was approved by Maidstone and Tunbridge Wells NHS Trust Research and Development department as a service evaluation project in July 2009 and access renewed for phase 2 in December 2012 (reference 09/07/049A). Ethical approval was obtained from King’s College London Psychiatry, Nursing and Midwifery Research Ethics Subcommittee (approval granted January 2010 and for phase 2 in January 2012, reference PNM/09/10-30).

Patients and the public were involved throughout this study, as detailed in Appendix 2.

Research questions

The research seeks to identify the impact of the move to 100% single room accommodation on five key areas:

1. care delivery and working practices

2. staff experience

3. patient experience

4. safety outcomes

5. costs.

The overall aim of the project is to explore the implications for the clinical workforce and patients of a move from ‘traditional’ facilities – comprising primarily open-plan ‘Nightingale-style’ wards – to a newly built facility in which all accommodation is in single rooms.

Table 1 provides details of the specific research aims, the research questions that align with these and the principal methods that were used to gather data to answer them.

Organisational context: key stakeholder interviews

Data on organisational context were collected through a series of key stakeholder interviews (n = 41) which were undertaken between August 2009 and July 2010 for phase 1 (n = 20) (see Appendix 5 for phase 1 sample and interview guide) and between August 2012 and May 2013 for phase 2 (n = 21). In addition to these interviews in phase 2, a mini focus group was undertaken with Allied Health Professionals (AHPs). Trust staff interviewed were sampled purposively and through snowball sampling (Table 2).

Key stakeholders were provided with the staff research interview information sheet (see Appendix 4), which lasted 30–60 minutes. The topic guide prompted exploration of the early challenges and experiences across the trust and issues of implementation relating to transition to all single room ward accommodation (see Appendix 6).

Observation of practice

Staff travel distances

Staff survey

Staff interviews

Patient interviews

Data analysis

Design

To isolate any effect of single room accommodation on safety outcomes, a quasi-experimental approach (as a before-and-after study with non-equivalent controls) was taken. 103

Selection of comparator sites

The new Tunbridge Wells Hospital is a 100% single room facility. Main characteristics required of potential comparator sites were (1) no change but planning to move in the future (indicating wards that were nearing the end of their expected useful life, to ensure comparability with the ‘intervention’ site) and (2) moving to a new building with mixed accommodation with 50% single rooms (as a control for changes associated with a move to a new facility but not 100% single rooms). After several potential NHS trusts were contacted, one hospital in the South West region (no move, planned move in 2014) and one hospital in London (new building, mixed accommodation, move in 2011) agreed to participate in the study (Table 9).

Analytical approach

Theoretically, the comparison of trusts by trends of infections or safety events could be conducted at the individual, ward or hospital level. However, safety incidents such as falls, as well as hospital-acquired infections, are usually recorded in dedicated reporting systems, which contain information only about the harmed patients, thereby excluding information about the overall population of the ward or the trust. These data are often used for performance measurement and are available on the ward and/or trust level as volume-standardised rates (e.g. falls per 1000 bed-days). While individual-level data would allow risk adjustment and therefore reduce selection bias in the comparison of trusts or wards, individual-level data are rarely available in routine data. A different way of addressing selection bias is based on risk stratification, which groups in strata patients with similar characteristics. Analysing at the ward level by comparing wards of the same type (e.g. medical ward) partially achieves this goal, since most wards have specific populations where patients share similar characteristics. Therefore, safety incidents and hospital-acquired infection rates are analysed on the ward level. In addition, we use administrative data containing information on age, LOS, primary diagnosis based on the International Classification of Diseases, Tenth Edition (ICD-10),104 Healthcare Resource Group (HRG) codes, and diagnoses used in the Charlson comorbidity index,105 to match wards with similar characteristics between trusts and to identify changes in the population over time.

Assessing trends before and after the move, or identifying differences between trusts, and associating these trends with a single room effect requires four conditions to be met: (1) the outcomes of interest (safety events, hospital-acquired infections) change after the move to the ‘intervention’ (single room) site, while (2) the core characteristics of the patient population remain the same over time and (3) the core characteristics of the patient populations of the compared wards at the different trusts are broadly similar. Finally, (4) any identified effect is strongest at the single room site (Tunbridge Wells Hospital), weaker at the new building with mixed accommodation site and not present at the steady state control site. Based on these considerations, we first considered the data from Tunbridge Wells Hospital. When trends of a single room effect supported by statistical process control charts (SPCs) were apparent, we considered the comparator sites to assess if the pattern of results was consistent with a single room effect.

Statistical process control charts

Given the nature of the available data as monthly rates, and to analyse changes in safety events and hospital-acquired infection outcomes before and after the move, the analysis was conducted as an interrupted time-series analysis augmented by SPCs. SPCs plot the outcome of interest over time on a chart which contains a centre line (representing the mean) and upper and lower confidence limits, which are defined as three standard deviations below or above the centre line. SPCs allow differentiating between common cause variation, which refers to random error, and special-cause variation, which arises from actual changes in the level of the variable of interest. 106 Several rules identify special-cause variations, of which two are of particular interest to identify changes to safety events after the move: (1) one data point outside the confidence limits and (2) eight or more data points above the centre line. 106 This approach was taken because of the nature of the available data (generally monthly reports of rates over relatively short time periods). A regression-based analysis would be more appropriate if it were possible to risk adjust for differences in patient characteristics. However, this was not possible given the available data. Another alternative would have been to pool all data before and all data after the move and test for differences. However, this would have not allowed us to identify the patterns we have found. We therefore believe that this was the most appropriate approach to the data that we were able to collect.

For all outcomes, u-charts with Cornish–Fisher (CF) expansion were used, which are appropriate to handle varying sample sizes and count data with a Poisson distribution. 107 All charts were plotted with the Improved Quality Control Charts (IQCC; version 0.5; http://cran.r-project.org/web/packages/IQCC) package in R (version 3.1.1, The R Foundation for Statistical Computing, Vienna, Austria).

Matching

To identify similar wards across sites, individual-level data for age (mean), LOS (mean) and the percentage of diagnosis included in the Charlson comorbidity index were aggregated at ward level and inspected for matching with existing case study wards. Wards that most closely matched the aggregated measures and were of the same ward type (e.g. surgery) as the case study wards were selected for inclusion in the study (see Table 9). The wards at the new build mixed accommodation control site consisted before the move of eight-bedded, three-bedded and single rooms. With the move, the proportion of single rooms increased from 14% to 38% for the three included wards. The steady state control site had less than 10% single rooms.

Data management

Trusts were asked to provide data for a 3-year period from January 2010 to December 2012. Outcome data (safety events and hospital-acquired infections) were requested for the four case study wards (acute assessment, older people, surgery and maternity) at the old Pembury Hospital and their succeeding wards at the new Tunbridge Wells Hospital. These outcomes are all regarded as being sensitive to the quality and quantity of nursing care provided, with some (falls, infections) reflecting specific challenges or hypothesised advantages attributed to single rooms. 108 The same was requested from four wards of the same type at each of the control sites. Because of the low incidence – pressure ulcers, falls, MRSA and C. diff. – maternity wards were excluded from further analyses.

Routine data are captured in various ways. Table 10 summarises the sources and definitions of the different outcome and risk stratification variables. Data were received from several departments within each trust, including finance, human resources, infection control and nursing management. While definitions of ‘incidents’ recorded in this routine quality data are generally standardised (e.g. using recognised grading systems for pressure ulcers), the approaches to gathering data may not be. There is a risk of under-reporting. However, as the key aim was not to compare trusts but to scrutinise (differences in) changes within trusts, these data remain potentially useful, if limited.

Data availability

Because of the diverse range of sources, analysis on the ward level and changes in the data infrastructure, not all data were available for all wards throughout the investigation period from January 2010 to December 2012 (Table 11).

Missing data handling

For the mixed accommodation new build site, only 32 months of administrative data were available, which would have reduced the observation period that could be matched to outcome data. To impute the missing aggregate bed-days we calculated the mean and standard deviation of the previous 5 months (all post-move phase) and used these values assuming a normal distribution to randomly generate and impute four aggregate values. For missing outcome and staffing data, listwise deletion was used, which subsequently reduced the number of available time points.

Design

Available data are described above (see Tables 10 and 11). Where possible, we aimed to gather differences in terms of unit of resources and outcomes before and after the move to single room design. Where it was feasible and relevant, changes in resource consumption and outcomes were investigated using real costs (e.g. cleaning and staff costs).

Data collection from expert opinion

A range of experts from the architecture, construction and facilities management industries were consulted, along with experts from hospital management and operations. The aim of these interviews was to seek views on the relative impact of different hospital designs on costs and resource use. These experts also provided opinion on the emerging research findings. Use of expert opinion is a relatively informal technique, but can be useful in clarifying the issues relevant to a particular topic and its evaluation, especially where the available research evidence or data are poor. Individual experts can be consulted, but groups of experts together are generally preferred to draw on a wide range of experience. 109

We drew up a list of experts from personal contacts and used a snowball sampling strategy to add to this list, and to include those connected with hospital construction (Table 12). Experts were contacted directly through e-mails or telephone, and meetings were arranged in person. An interview schedule with the main discussion topics was prepared in advance, together with a list of questions to be addressed (see Appendix 15). Nine experts were gathered in a group setting in order to stimulate and allow different perspectives or opinions to be discussed. One-to-one telephone interviews were arranged with three other experts.

Analytical approach

Acute admissions unit

The acute admissions unit (AAU) admitted patients from A&E for further assessment, diagnosis and treatment, prior to discharge or transfer to a specialist ward. Patients were intended to stay in the unit for a maximum of 48 hours, which was extended if beds on other wards were not immediately available. The AAU admitted 350–400 patients per month, including many who were acutely ill or in an unstable condition.

The AAU was adjacent to the A&E department and had 30 single patient rooms around the perimeter of the ward, with ward support facilities down the centre, as shown in the ward diagrams (see Appendix 18). Compared with the old hospital’s acute assessment ward, which had 16 beds in a compact layout of three bays, the AAU was a much larger and longer ward, designed to be nursed as two sides (14 beds and 16 beds). Through trial and error, nursing staff found it better to work as three teams each responsible for clusters of 10 rooms, although this configuration did not fit so well with features of the ward layout (staff bases, call bell system, location of facilities) (see Chapter 6, Maintaining teamwork and communication). Ward-based medical staff used a room in the central area of the ward, occupying space that on other wards was used for storage; no additional storage was provided on the AAU. There was no day room for patients. The staff break room was located off the ward and shared with A&E, as it had been at the old hospital. Nursing staff considered it too far away and instead used a small interview room on the ward, which also housed a desk and work station and had no window or kitchen facilities. Table 18 shows the staffing allocation for the AAU after the move. The nurse staffing ratio decreased slightly (from 1 : 4 to 1 : 4.2) and the HCA staffing ratio increased (from 1 : 16 to 1 : 10) (Table 19).

On the AAU the ward manager and some of the nursing staff had transferred from the previous ward, which had a high turnover of staff and recruitment problems. A cadre of newly qualified nurses was recruited before the move and a further cohort from Portugal joined after the move. The ward continued to have difficulties retaining staff; consequently, the workforce included a high proportion of inexperienced nurses, and bank and agency staff were used to fill vacancies.

The AAU had a medical team based on the ward, and dedicated physiotherapists and occupational therapists (OTs). The ward clerks staffed a desk near the ward entrance from 09.00 to 22.30 daily – the longest of all the case study wards – consistent with patterns of 24-hour activity and visitor access on this busy ward.

Older people’s ward

This case study ward was one of two older people’s wards in the new hospital and admitted patients with a variety of medical conditions, diagnoses and disabilities, including dementia and impairments of mobility, eyesight, hearing and speech. The ward had 30 beds (28 before the move), including 10 orthogeriatric beds (typically patients with fractured neck of femur). Patient LOS varied greatly: some patients were discharged within a few days, but those with more complex needs tended to stay much longer if there were delays in finding an appropriate placement. After the move to the new hospital, patient stay decreased but not as much as expected; staff attributed the smallness of the decrease to the ward’s changing case mix (see Chapter 8). Nurses said they were caring for higher-dependency patients, with increasingly complex conditions and comorbidities, including physical disabilities and cognitive impairment, and there were more patients requiring intensive rehabilitation. As on the old ward, staff found it challenging to care for patients who were confused, demanding or aggressive, but their greatest concern on the new ward was the risk of patients falling.

The older people’s ward was located on level 2 of the new hospital and had 30 single rooms (see Appendix 18, Figure 44). Nursing staff were deployed in three teams, each relating to a cluster of 10 rooms. It had a similar layout to most of the general wards, with three nursing stations, centralised ward support facilities and a small patient day room, which could accommodate a maximum of six patients. Despite its limitations, the day room was used regularly to hold a ‘lunch club’ for five or six patients, and staff had plans to create another communal area for patients. The reception desk was covered by the ward clerk from 08.00 to 15.00. There was a staff break room on the ward.

The staffing allocation for the older people’s ward after the move is shown in Table 18 above. After the move the nurse staffing ratio increased substantially (from 1 : 9.5 to 1 : 5) and the HCA staffing ratio decreased (from 1 : 5.6 to 1 : 7.5) (Table 20).

An extra member of staff had recently joined the weekday day shift to co-ordinate discharge planning. The ward reported a fairly stable nursing workforce with a core of experienced nurses and HCAs, although, in the first year, periods of short-term sickness absence and unfilled vacancies led to increased use of bank nurses and agency staff.

The ward nursing team was formed when the new hospital opened and comprised staff from six wards at the old hospital. The new ward manager was newly appointed and it was her first substantive ward management post. The team reportedly ‘gelled’ quickly and, despite the ward manager being seconded to another hospital in the trust for 3 months of the first year, staff interviewed said that they worked together well and there was a good atmosphere on the ward. The ward manager provided leadership in ‘caring thoughtfully’ for patients with dementia, which she acknowledged as a ‘real passion’. Two medical consultants and their teams were based on the ward and there were twice-weekly multidisciplinary team (MDT) meetings, including nursing staff, physiotherapists, OTs and the care managers who had aligned themselves to the ward.

Surgical ward

This case study ward admitted acutely ill patients for emergency or unscheduled surgery, providing pre- and postoperative care (or conservative management) and rehabilitation, and specialising in upper gastrointestinal and colorectal surgery. Before the move, the ward accommodated elective and emergency surgical patients, and beds were often used for patients from other specialties. The number of beds reduced from 35 to 30, and in the new hospital included four beds designated for patients with C. diff. infections. Average patient LOS was just over 7 days before the move and increased slightly after the move. Nurses said that they now had older and more dependent patients, which could make nursing ‘heavy going’.

The surgical ward had an almost identical footprint and layout to the acute older people’s ward (see Appendix 18, Figure 45); nursing staff were deployed in three teams each relating to a cluster of 10 rooms. The small room assigned for a patient day room (as on the older people’s ward) was not used for this purpose; staff could take relatives there if a patient died, for example, and patients’ relatives occasionally slept there. The reception desk was covered by the ward clerk from 08.00 to 15.00. There was a staff break room on the ward.

The staffing allocation for the surgical ward after the move is shown in Table 18. After the move, the nurse staffing ratio increased (from 1 : 5.8 to 1 : 4.3) and the HCA staffing ratio decreased (from 1 : 7 to 1 : 10) (Table 21).

Staff turnover was said to be relatively low and there was a core group of experienced and competent staff. About one-third of the nursing staff were from the Philippines, where some had experienced nursing patients in single rooms.

The ward manager, who had been in post for more than 10 years, the nursing team and the ward clerk all transferred together from the old hospital, preserving continuity of leadership, ward identity and an ethos of strong teamwork and high standards of care. Medical cover for the ward was provided alternately by two surgical teams (upper gastrointestinal and colorectal) and the team in charge changed every 3 or 4 days. The ward clerk played a key role helping the clinical team to work effectively, particularly managing telephone communication.

Postnatal ward

Maternity services from two trust hospitals were centralised in a wing of the new hospital dedicated to women’s and children’s services: the unit from old Pembury Hospital moved into the building in January 2011 followed later that year by services from Maidstone (see Chapter 3). The antenatal ward, delivery suite and neonatal unit were on one floor; on the level above was postnatal and transitional care (for babies requiring additional treatment or observation). Although midwives perceived they were busier than before, managers pointed out that the total number of births had not changed and it was likely that staff perceptions were influenced by the size of the new unit. The postnatal ward had 31 beds, almost double the number on the previous ward at Pembury Hospital (n = 16). Patient LOS ranged from 24 hours after uncomplicated deliveries to 2 weeks for babies or for women needing extra care.

This part of the hospital had a different ward footprint, with a shorter ward ‘finger’ and a large curved area at the end of the building (see Appendix 18, Figure 46). The ward was originally planned to be dedicated to postnatal care, but a section was redesignated as gynaecology beds that were nursed and managed separately. This divided the postnatal ward into two distinct zones, with 16 beds on the ‘finger’ and 15 on the curve, nicknamed ‘the west wing’. Each zone had two midwife bases, with staff at each covering seven or eight rooms. Ward support facilities had been reallocated between postnatal and gynaecology, leaving ‘the west wing’ with inadequate support, which staff found inefficient and inconvenient. The patient lounge was described by midwives as ‘not appealing’, ‘underused’ and not big enough to accommodate women with their babies. Initially, ward clerks were at the reception desk for a few hours a day, but subsequently staffing was extended to cover peak evening visiting time. The staff break room was located just outside the ward.

The staffing allocation for the postnatal ward after the move is shown in Table 18. After the move, the midwife staffing ratio increased slightly (from 1 : 8 to 1 : 7.75), as did the HCA staffing ratio (from 1 : 10.6 to 1 : 7.75) (Table 22).

Midwives and support workers rotated on a 6-monthly basis between the antenatal unit, delivery suite and postnatal ward, although a few staff worked permanently on the postnatal ward. The workforce included a high proportion of long-service midwives and HCAs. The ward manager post was created when the two maternity units merged, and included responsibilities in the wider maternity department that sometimes took the ward manager away from the ward. Unlike the other case study wards, there was no shift co-ordinator role on the postnatal ward, although designating a ‘midwife in charge’ on each shift was under consideration. There were no formal ward rounds: paediatricians had a room on the ward and doctors usually discussed a patient only with the midwife responsible.

Statistical analysis

The data were analysed using a repeated measures general linear mixed model (GLMM) with steps per hour as the dependent variable and pre/post new build, ward (maternity, surgical, older people, AAU), observation session (repeated measure), staff group (midwife, RN, HCA) and day of the week as independent variables. The first GLMM analysis investigated the main effects of ward, pre/post move, staff group and day of the week. The second GLMM analysis investigated the interactions between pre/post move and ward, and between pre/post move and staff group. Because midwives were employed only on the maternity ward, there was potential confounding between the effects of ward and staff type. Initial analyses confirmed that removing maternity from the analyses improved the fit of the models. The first sensitivity analysis added a variable to the model that indicated whether or not a member of staff contributed to both the pre- and post-build samples. Only five staff contributed to both. The effect on the overall results was minor. A second sensitivity analysis fitted a model to first observation session data only, but allowed data to repeat across individual staff before and after the build. We report the results below, including where sensitivity analyses identified differences.

The data set contains information on 140 sessions collected on 53 staff (49%) prior to and 56 staff (51%) after the new build. A number of staff contributed more than one observation session: 85 provided one session, 18 provided two sessions, five provided three sessions and one provided four sessions. There were 73 sessions (52%) collected prior to the new build and 67 sessions (48%) after the new build. The average numbers of sessions per member of staff were 1.38 and 1.20, respectively. A small number of staff (n = 5, 4%) were observed at both times (one RN and four HCAs). Table 27 shows descriptive data for ward and staff group.

The unadjusted means (see Table 27) show an increase in the number of steps per hour for all wards and staff groups. Staff working on the older people’s ward (from 664 to 845) and RNs (from 639 to 827) have seen the biggest increases.

Table 28 shows results for the main effects of ward, pre/post move, staff group and day of the week. The number of steps per hour increased significantly from a mean of 715 before the move to a mean of 839 [F(1,83) = 10.36; p = 0.002] after the move. HCAs took significantly more steps per hour than nurses [F(1,83) = 8.01; p = 0.006]. There were also significant differences between days of the week [F(4,21) = 3.40; p = 0.027]. There was no significant difference between wards in the distances travelled (Table 29).

Table 30 shows results for the interactions between pre/post move and ward, and between pre/post move and staff group. Neither of the two interactions was statistically significant.

The estimated marginal means (Table 31) showed that there was an increase from pre to post build across all wards. Although the size of this increase did not differ significantly between wards, the increases in the surgical and older people’s wards were larger than for the AAU. RNs experienced a larger increase (from 624 to 811) in the number of steps per hour (from 3.74 to 4.86 miles) than HCAs (from 828 to 862 steps; from 4.96 to 5.17 miles).

The estimated marginal means from the second sensitivity analysis suggested a decrease in the number of steps per hour for the AAU from 901 to 836 and for HCAs from 876 to 855, rather than an increase as shown in Table 31. The change in means for the remaining two wards and for RNs, from pre to post build, were in the same direction, and of the same order of magnitude (see Table 31).

Results

Because of staff leave, shift patterns and staff turnover during the course of the study, it was not possible to use a completely within-subjects design, in which the pre- and post-move surveys were completed by the same people. Despite this, 19 participants did complete surveys at both times, which meant a mixed within- and between-subjects design. One potential problem with this is that the subgroup who completed both surveys could have been sensitised to the research questions and, therefore, could have been more likely to report differences after the move than those who completed only one survey; that would bias our results. We addressed this by treating the design as a between-subjects design and checking for bias by comparing the results of our analyses for the whole group with separate within-subjects analyses on the subgroup who completed both surveys. The results were identical except for a small difference: perceptions of the effect of the accommodation on the delivery of care approached significance (0.099) in the within-subjects analysis whereas for the whole group this effect was significant (0.011). This can be attributed to lack of power in the subsample of 19. On this basis we proceeded with the analysis by treating the ‘before’ and ‘after’ samples as independent groups.

There were 152 items in the staff survey. Our approach to analysis was multifaceted. First, we explored the potential for grouping questions into subscales that would summarise a topic area. We thematically analysed the questions to determine those that were likely to be measuring attitudes to related aspects of the ward design, and then tested these subscales using statistical reliability analysis. Where reliability was not adequate we revised the items in the subscales until we had identified coherent subscales. These were then analysed using independent sample t-tests to determine if post-move responses were significantly different from the pre-move scores for each subscale. Similar analyses were undertaken for the teamwork and safety climate scales. Qualitative open-ended questions were analysed thematically using a content analytic approach. The well-being and stress items were compared before and after the move using the Pearson chi-squared test and Fisher’s exact test when expected frequencies were less than 5.

One of the aims of the study was to investigate if there were differences between the case study wards in their perceptions of the positives and negatives of the new single room accommodation. However, the relatively small number of staff in each of the case study wards meant that it was not possible to explore this question statistically. We therefore used correspondence analysis and perceptual mapping to examine the interaction between ward attributes and case study wards. Correspondence analysis is an exploratory mapping tool that allows visualisation of relationships in the data that would be difficult to identify if presented in a table. 114 It is related to other techniques such as factor analysis and multidimensional scaling. It does not rely on significance testing and is best viewed as an exploratory technique that provides insights into the similarities and differences between two variables. 115 Correspondence analysis does not address questions of whether or not there were differences in ratings between the attributes (e.g. whether or not privacy for patients was rated more highly than staff teamwork). Instead, it focuses on the differences between case study wards and the interaction between ratings and wards. It allows an examination of to what extent which wards are associated with particular ratings. In this way it allows us to qualitatively explore the quantitative data.

Ward environment survey subscales

Ten reliable subscales were formed. Table 32 shows the subscales and example items from each.

Appendix 19 contains a complete list of all items used for each subscale.

Table 33 summarises the statistical analysis of the subscales showing means, Cronbach’s alpha and the number of items for each subscale before and after the move. According to accepted criteria,115 alpha above 0.60 is acceptable for exploratory analyses, above 0.70 is acceptable for confirmatory purposes and above 0.80 is good for confirmatory purposes. Obtained coefficients were generally good, ranging mostly between 0.67 and 0.92. The lowest alpha, of 0.53, was obtained for the family/visitors subscale after the move, suggesting that this subscale is not internally consistent. However, the pre-move alpha was good (0.70), so it was decided to retain this subscale for exploratory purposes.

Table 34 shows the results of independent sample t-tests comparing subscale scores before and after the move. Staff perceived significant improvements in the efficiency of the physical environment, the patient amenity, the effect of the environment on infection control, patient privacy, and family and visitors. The largest increases were found for perceptions of infection control and patient privacy. Perceptions of the effect of the ward environment on teamwork and care delivery were significantly more negative after the move. There were no significant differences in staff perceptions of staff facilities, patient safety and staff safety.

Although all subscales showed moderate to very good reliability, changes were not uniform for all items in every subscale; there were some exceptions to the overall trend. Overall ratings for the subscale ‘efficiency of physical environment’ increased, but ratings for the item ‘ward design/layout minimises walking distances for staff’ decreased. These perceptions were confirmed by our findings from the analysis of travel distances showing that staff took significantly more steps after than before the move. Some aspects of the design increased the amenity of the ward for staff but others did not. For example, staff toilet facilities, locker facilities and space at staff bases were rated more highly but ratings for social interaction and natural light decreased. These positive and negative aspects meant there was no significant difference in staff amenity before and after the move. The new ward was rated as much more positive for patients but there were reduced scores for three items after the move: social contact between patients, ability of patients to see staff and way finding. All aspects of teamwork and training were rated less positively, except for the item ‘discussing patient care with colleagues’, which increased. This finding is supported by our analysis of observation data showing that professional communication activities were less fragmented.

Although there were no significant differences in the effect of the ward layout on perceptions of patient safety, examination of the items showed that ratings for two items increased (‘minimising risk to patients of physical/verbal abuse from other patients/visitors’ and ‘minimising the risk of medication errors’) while ratings for two items decreased (‘responding to patient calls for assistance’ and ‘minimising the risk of falls/injury to patients’). This suggests that, although staff thought some risks to safety were reduced, they perceived an increased risk of falls and delays in responding to calls for assistance. Staff perceptions of a rise in risk of falls are detailed in Chapter 6. Staff also reported being unable to hear calls for assistance when in a single room with a patient.

There were five items that did not fit into any of the subscales. These items were analysed singly using Fisher’s exact test and the results are shown in Table 35. There was a significant relationship between the move and ratings for the number and location of hand basins, ease of keeping patient areas clean and quiet, and the overall comfort of patients, which all increased after the move. There was no relationship between the move and judgements of whether or not the location of the dirty utility room (where bedpans are stored and disposed of) reduces cross-contamination.

The distribution of responses for the four significant items showed that significantly more staff rated these aspects of single room accommodation as more positive after the move than before (Tables 36–39).

Expectations before the move and reality after the move

Before the move, staff were asked to rate on a five-point scale whether they thought single rooms would be better or worse for different aspects of clinical work (e.g. minimising the risk of patient falls, maintaining patient confidentiality, knowing when other staff might need help). After the move they again rated whether single rooms were better or worse for clinical work, thus providing a measure of whether or not their expectations about single rooms were met in reality. The questions were a subset of 23 questions from the first part of the survey and were analysed using Fisher’s exact test.

Results (Table 40) showed that staff perceptions of whether or not single rooms were better than multibedded wards changed after the move for five items. Staff perceptions of whether or not single rooms were better for responding to calls for assistance, knowing when other staff might need help and minimising walking distances were rated as worse or much worse by significantly more staff after than before the move. Staff rated single rooms as positive for patient sleep and rest and for interactions between patients and visitors after the move.

Tables 41–45 show the distribution of significant responses.

Teamwork and safety climate survey

To take into account our changes to the survey, we combined the four items about the quality of communication with doctors, nurses, nursing assistants and AHPs with the items in the information handover subscale to form a new subscale of seven items. Although this is different from the scales reported by Hutchinson et al. ,98 reliability analysis confirmed the original factor structure of the survey. There were two teamwork subscales and three safety climate subscales with good to high reliability (Table 46). See Appendix 20 for a list of the items contained in each subscale.

Mean scores for all subscales decreased following the move. Independent sample t-tests showed that ratings for information handover and communication decreased significantly following the move [t = 3.23, degrees of freedom (df) = 108, p = 0.002], indicating that information exchange and sharing within teams was perceived to be worse after the move. There were no other significant differences.

Correspondence analysis

Correspondence analysis transforms cross-tabulated data into a biplot showing distances between variables. In this study, case study ward was a column variable and mean questionnaire subscale score was a row variable (see Table 33). As appropriate when analysing mean scores, Euclidean distance was used and standardisation by removing row means was used. 114,116 This means that differences between the subscale means were not represented in the perceptual map, as we were not interested in whether or not, for example, infection control was rated more highly than privacy. Differences between wards, contained in the columns, were of interest and are represented in the perceptual map. Separate analyses were conducted for before and after the move and for the ward attributes and teamwork/safety climate survey.

Figure 11 shows perceptual maps of the association between ward attributes and wards before and after the move. The pre-move map shows that the points on the map were dispersed, indicating that the ratings were not strongly associated with particular wards. There was one exception in that ratings for the efficiency of the physical environment, privacy and infection control were higher for the older people’s ward than for the other wards. The post-move map shows that the highest ratings for the efficiency of the physical environment, the delivery of care, the staff facilities and teamwork were obtained in the older people’s and surgical wards, indicated by proximity on the map. Ratings for patient amenity, infection control, privacy and family/visitors were highest for the surgical ward. High ratings for patient safety were obtained in maternity and the surgical ward. Ratings for staff safety were similar in the older people’s, surgical and maternity wards. The acute assessment ward was not associated with any particular ward attributes, as was the case before the move.

FIGURE 11.

Perceptual maps of (a) pre- and (b) post-move ward attributes by ward.

Figure 12 shows perceptual maps before and after the move of the association between teamwork/safety climate ratings and wards. The teamwork/safety climate survey consisted of two teamwork subscales – team input into decisions, and information handover and communication – and three safety climate subscales – attitudes to safety within own team, overall confidence in safety of organisation and perceptions of management attitudes to safety. The pre-move map shows that ratings of input into decisions, information and handover, and overall confidence in safety of the organisation were highest for the acute assessment ward. Ratings of safety attitudes within the team and management attitudes to safety were highest for the surgical ward. After the move, the surgical ward had the highest ratings for safety attitudes within the team, overall attitudes to safety and management; ratings for team input into decisions and information handover and communication were highest for the older people’s ward. Ratings for all safety climate subscales decreased in the acute assessment ward, which is indicated on the perceptual map by its location in a quadrant by itself. Maternity scores did not show a consistent pattern.

FIGURE 12.

Perceptual map of (a) pre- and (b) post-move ratings of teamwork/safety climate by ward. Att., attitude; mgt., management.

These maps reveal some differences between wards in perceptions of the ward environment and show that perceptions were different before and after the move.

Staff ward preferences

Nursing staff were asked to indicate whether they would prefer single rooms, multibedded accommodation or a combination. There was a range of views (Figure 13). In each phase, fewer than 18% of staff indicated a preference for 100% single rooms. The most common preference in each phase was a combination of 50% of beds in single rooms and 50% in bays (see Figure 13). In the pre-move survey, more staff reported a preference for more beds in bays (n = 20) than in the post-move phase (n = 12).

FIGURE 13.

Nurse preferences for single room or multibedded accommodation.

Staff stress and well-being

There were five categorical questions about staff well-being that investigated whether or not they had experienced injuries and harassment in the previous 12 months (Table 47). There were three items about job stress that asked participants to rate their stress on a five-point Likert scale (Table 48). Results showed no differences in staff well-being and stress before and after the move.

Staff were asked 10 questions about their satisfaction with their own performance of various tasks during their last shift, and one question about their overall job satisfaction. Results (Table 49) showed no significant effect for any of the job satisfaction items.

Qualitative survey data

Four open-ended questions were used to gain qualitative data about staff attitudes. The questions were:

1. What two things do you think would most improve the current ward environment for staff?

2. What two things do you think would most improve the current ward environment for patients?

3. Before move:

   1. What two things are you most looking forward to in relation to the move to 100% single rooms in the new hospital?

   2. What two things are you most concerned about in relation to the move to 100% single rooms in the new hospital?

4. After move:

   1. What two things do you like the most about single room wards in the new hospital?

   2. What two things do you dislike most about single room wards in the new hospital?

In the following sections we present the results of the thematic analysis with frequency data (almost equal numbers of staff responded before and after the move, n = 55 and n = 54 respectively) and examples from participants’ written responses where appropriate. Table 50 shows that staff identified a number of things that would improve the ward accommodation for patients. The need for more space, improved patient facilities, privacy, and rest and sleep were largely met, since there were fewer people identifying these as needs after the move. However, the need for improved patient–staff ratios and a day room to provide patient social interaction were still reported after the move.

The need that staff perceived before the move for space around patient beds and staffing levels had decreased after the move (Table 51). However, ventilation/heating/lighting, access to equipment and supplies and facilities for staff, including staff bases, were identified as needing improvement after move. In addition there was a need for improvements in monitoring patients, keeping track of colleagues, reducing isolation and reducing walking distances. These have all been identified by other parts of our results (see Chapter 6).

Staff were asked about the features of the ward they were most looking forward to in the pre-move phase, and most liked in the post-move phase (Table 52). Results showed that staff most liked the increased patient privacy, patient sleep and rest, increased space, working in a modern environment and improved patient bathroom facilities.

Table 53 shows that staff were most concerned about being able to monitor patients, patient isolation and the risk of falls. Being unable to find staff and increased walking distances also emerged as features staff disliked about single rooms.

Privacy, dignity and confidentiality; more personalised patient care

Staff compared single rooms favourably with open-plan wards in terms of providing privacy, dignity and confidentiality for patients. Patients had their ‘own space’, including an en suite bathroom and toilet, where personal care could take place away from other patients. A staff nurse on the surgical ward (S16) said that she would ‘hate to go back to nursing patients behind curtains’ because, ‘dealing with gastric surgery, it can be embarrassing when patients don’t make it to the toilet in time [. . .] now they have the dignity and privacy of being in their own room.’

Single rooms were also seen as advantageous as they allowed patients to sleep, rest and recuperate without disturbance. They could also better accommodate visitors. Privacy was particularly valued for patients who were seriously or terminally ill and for their families. This had been difficult to provide on open-plan acute wards. Staff also felt that single rooms helped facilitate discussion with patients and families together.

I think from a privacy and dignity point of view, when patients are dying, or when relatives are in there, or in extremis, when you don’t really want the next patient to be making a noise, then [single rooms are] fantastic. [. . .] I used to feel very embarrassed when people would be at the nursing station or having a joke about something and somebody’s dying 3 yards away, and the relatives are round the bed. I found that very uncomfortable.

KSI28, consultant

[At the old hospital] you’d have to find a room outside the ward to bring the family to, to have a discussion with them, whereas here, you might be able to speak a bit more openly and privately with the family and with the patient present. Almost have a mini-MDT with the family and the patient in their room.

AHP40, dietitian

At interview, nurses and AHPs said that single rooms enabled them to ‘focus on the patient’ and respond with appropriate emotional engagement. One HCA described how moving between rooms allowed her to adjust her manner to suit each patient’s circumstances. The privacy afforded by single rooms meant communication with patients could be more open. Staff also reported less likelihood of interruption and distraction. ‘You’re able to give your patient the attention and care because you’re with them; you haven’t got someone else shouting from the other side of the room for you’ (M01). Observation on the wards suggested that staff were more likely to respect patients’ privacy – perhaps because rooms were perceived as the patient’s personal space. This was reinforced by staff knocking on the door before entering ‘so that the patient feels they’ve got some control over their environment’ (S16).

[At the old hospital] I could be doing a personal task, giving someone’s bottom a wash, and a doctor would put their head through the curtains, even though you had ‘Do Not Disturb’ [. . .] And the poor patient would be mortified. Whereas now, we shut the door, we close the screens, yes sometimes you see them peek, but the moment they see nurse, pinny, back to them, they’re away and they don’t come in. So they respect the privacy a bit more as well. So that is better.

S11, staff nurse, surgical ward

Staff associated spending uninterrupted time with individual patients with providing effective and personalised care. However, nurses and midwives also explained that the potential of the single rooms for developing better relationships with their patients was not always fully realised, because they felt unable to give sufficient time and attention to each patient. The tensions staff experienced around apportioning time between patients and prioritising their workload was an important theme in the interviews. While this is an issue recognised by nursing staff in many settings, for staff interviewed in this study the all single room environment accentuated the tensions, which they linked to not being able to see and interact with a number of patients at the same time. Staff had not foreseen that the move would make this aspect of practice more challenging (see An unforeseen challenge: time management and prioritising workloads below).

Improved room design; improved care delivery

Staff thought that single rooms provided an improved working environment for delivering patient care and described the rooms as modern, clean, spacious and safe. The en suite facilities were considered to be one of the most positive aspects, allowing nursing staff to more easily assist patients with personal care. Nurses particularly valued being able to give patients showers, and sensed that this was appreciated. A staff nurse took a photograph of the en suite shower (Figure 14) to illustrate that showering patients was now ‘so much easier’ and ‘much more civilised and pleasurable’ (S16). This view was also expressed by other nurses.

FIGURE 14.

The en suite shower. Taken by S16, staff nurse, surgical ward.

[The single rooms] are really accessible and for patients that want to hold on to things while they’re walking, they’ve got bars around the side, from the bed to the bathroom, they’ve got the bars alongside of the toilet and the bars on the wall to hold onto, bars by the shower, so I think that’s really good. The floors are non-slip as well, so I stand patients up quite confidently in there, without worrying that they’re going to slip because they’ve got that special dappling. And again, they just look cleaner, they look tidier. The bathrooms are really spacious as well, and it’s just the freedom that it gives patients.

S14, HCA, surgical ward

Although staff generally thought single rooms were a ‘huge advantage’ when delivering patient care, they also identified less positive aspects of the particular room design. Five main issues were identified from our analysis of staff interviews and participant-produced photography, which were also observed by the researcher when shadowing staff:

1. room layout: getting beds into/out of patient rooms

2. en suite bathroom layout

3. windows in patient rooms

4. location of the nurse call cancel button

5. patient televisions.

It should be emphasised that these were issues specific to the Tunbridge Wells Hospital design rather than generic problems of single rooms per se. However, for staff they created obstacles to safe and efficient working or diversions from direct patient care, which they found frustrating (presented in Table 55 and illustrated by Figures 15–17). Some issues also had an impact on quality of care and patient experience. Most of the problems had not been picked up in the mock-up of the single room during the design process and became apparent only once the new hospital was operational.

FIGURE 15.

Patient chair next to en suite door, impeding bed moves. Taken by S15, staff nurse, surgical ward.

FIGURE 16.

Layout of en suite where position of sink limits access to toilet. Taken by OP24, HCA, older people’s ward.

FIGURE 17.

Location of nurse call cancel button behind patient bed. Taken by S15, staff nurse, surgical ward.

Improved ward design; increased efficiency

Staff made many positive comments about the ward environment in the new hospital. They found it clean, spacious, modern and quiet and calm, and compared it favourably with the ‘hustle and bustle’ of open-plan wards. Staff felt proud of the new hospital and privileged and professional working in it.

It’s light; it looks clean, whereas although I think [the old hospital] was clean, it never looked clean because it was such an old building. [. . .] It just looks more professional. I feel better about my job, I feel like a professional working in a professional environment.

S11, staff nurse, surgical ward

One aspect of the new wards noted by staff was their length in comparison with the open wards they had worked on previously, which meant they had to walk increased distances. This was particularly apparent to nurses on the AAU, which in the old hospital was a compact shape with half the number of beds.

I spend hours walking round and round and round in figures of eight [. . .] It’s good for my figure but it hurts my feet. It’s just the sheer size in comparison to the old [ward] that was tiny.

M05, junior sister, AAU

Nursing and midwifery staff identified features of the new ward design that facilitated working efficiently and effectively, but the benefits were sometimes offset by challenges that hindered and frustrated them. We highlight here five aspects of ward design, discussed in interviews and observed by the researcher while on the wards, which staff experienced as having both benefits and challenges:

1. ward support facilities

2. ward entry system

3. nurse call system

4. staff break rooms

5. natural light in staff work areas.

These aspects (presented in Table 56 and illustrated by Figures 18–20) were not consistent across all four case study wards, because of variations in ward design and operational issues, nor were they equally salient for all staff working on a ward.

FIGURE 18.

The clinical room on the surgical ward. Taken by S16, staff nurse, surgical ward.

FIGURE 19.

The staff break room on the surgical ward. Taken by S14, HCA, surgical ward.

FIGURE 20.

Interview room on AAU used as a staff break room.

Staff who identified problems associated with ward support facilities (e.g. location and adequacy of storage space, utilities, kitchens), ward entry arrangements and the nurse call system, also felt their ability to work efficiently was affected, particularly by increasing the distances they had to walk.

Staff well-being was affected by inadequate break rooms and lack of natural light on the wards. In general, however, staff perceived the advantages of the new working environment as outweighing the disadvantages.

Reduced risk of infection

Staff expected that single rooms would reduce infection risk. Certainly the new wards were perceived by staff to support good hygiene practices, with no-touch clinical hand wash basins in every patient room, and personal protective equipment, alcohol hand gel and antibacterial wipes available from wall-mounted dispensers outside every room. This provided a visual reminder for staff entering a patient room to comply with infection control procedures (Figure 21).

FIGURE 21.

Protective equipment, alcohol hand gel and antibacterial wipes outside the patient room. Taken by OP25, junior sister, older people’s ward.

I’ve taken a picture of the gloves on the wall, just outside the general patients’ room, the gloves, alcohol dispenser, aprons, and the wipes [. . .] they’re very clean, clear, easy to refill and they really benefit from being where they are, which is perfect, the fact that they’re outside every single patient’s room, there’s no question about it.

OP25, junior sister, older people’s ward

Because you’ve got individual basins, you’re not sharing a sink. You’re able to wash your hands very quickly after having patient contact, rather than having to walk around looking for a basin to use. [. . .] So you just feel that you’re able to carry out infection control procedures more effectively.

S16, staff nurse, surgical ward

However, staff attitudes to infection control had to be challenged to avoid complacency associated with the belief that single rooms solved all infection control issues (see Chapter 3). On open wards, staff could see which patients had infections (e.g. trolley with gloves and wipes by the bed and signage). After the move, a warning system was introduced: magnetic signs on room doors to indicate specific procedures that staff should follow.

Summary: were the expected advantages of single room wards confirmed?

In general, staff found that single rooms brought the advantages they expected, but the benefits were not always fully realised because of unforeseen issues in the new environment. Staff found that single rooms improved privacy, dignity and confidentiality for patients, allowing them to rest and recuperate without disturbance, and were better for visitors. Single rooms facilitated communication with patients, as staff could spend time caring for individual patients without interruption. However, contrary to expectations, single rooms did not necessarily enable staff to deliver more personalised care, because they felt unable to give sufficient time and attention to each patient. The challenges experienced around dividing time between patients and prioritising workload had not been foreseen by staff (see An unforeseen challenge: time management and prioritising workloads, below).

The design of patient rooms and wards in the new hospital largely met staff expectations for an improved working environment, and supported staff working more effectively. However, various aspects of the design of rooms and wards at Tunbridge Wells Hospital presented obstacles to safe and efficient working (room and bathroom layout) and increased the distances they had to walk (location and adequacy of storage space, utilities). Staff also felt that they were diverted from patient care by the ward entry and nurse call system, and that their own well-being was affected by inadequate break rooms and lack of natural light. However, in general the design benefits were felt to outweigh these issues. Staff liked the new hospital (clean, spacious, modern, quiet and calm) and it gave them a real sense of professionalism. They also perceived single rooms as reducing the risk of infection. Managers feared this would lead to complacency about infection control, so they reasserted infection control policy and developed a visual warning system to prompt staff to take specific measures before entering a patient’s room.

Reduced visibility of patients: difficulties monitoring and safeguarding patients

The biggest challenge experienced by staff working on the single room wards was surveillance and monitoring of patients. In interviews carried out before the move, nurses and midwives represented the open-plan ward as a panoptic space that enabled them to observe and control what went on within it. They could see and hear patients easily, acknowledge requests for help and prioritise their responses. In contrast, they found that the possibilities for such panoptic surveillance were severely curtailed by the design of the single room wards.

When we were on an open ward I could walk on the ward and I could view everybody. And when you knew your patient you could see [if they didn’t look well]. Whereas now I can walk up and down the rooms, but as soon as I’m in a room I’m away from everybody. [. . .] That time has gone where you could just stand and have a quick chat with a patient while you were still keeping an eye on everybody else.

S11, staff nurse, surgical ward

[Some clusters of rooms] they’re just corridors, if you’re in the first room, you can’t hear the last room. So if there’s a machine buzzing, say you’re in 11 and there’s a machine buzzing in 21, until you physically get down the corridor a bit more you can’t hear it.

S15, staff nurse, surgical ward

Staff described how visibility of patients from the ward corridor was limited to the patient room they were directly outside, and then only if the door or vision panel in it was open (Figure 22). Although the bed head was visible from the doorway, the line of sight into the rest of the room was interrupted by the wall of the adjacent room’s en suite bathroom. Each en suite bathroom also protruded into the ward corridor (‘inboard’ single room design) obscuring the view of patient room doors for staff looking down the corridor (Figure 23).

FIGURE 22.

Door to a patient room, showing Vistamatic vision panel. Taken by OP24, HCA, older people’s ward.

FIGURE 23.

Single corridor with rooms opposite each other. Taken by S16, staff nurse, surgical ward.

All staff interviewed perceived that lack of visibility of patients in the single room wards had contributed to an increase in falls in the new hospital. Experienced nursing staff thought that it had been easier to prevent falls in multibedded accommodation because they could ‘keep an eye’ on patients and were more aware of warning signals, such as patients becoming agitated or attempting to get up from their chair or bed. Nurses also described how on open-plan wards they would be alerted by other patients calling them when they saw a patient at risk of falls begin to move, which enabled staff to respond in time to ensure the patient was safe. In contrast, ‘You’re not able to predict things as easily when people are behind closed doors’ (S16).

Last week, we had about three people [. . .] climbing out of beds and falling [. . .] And I know on an open ward [patients] can still climb out of bed but at least as you’re walking up and down the ward you could physically see them [. . .] now the only time we know somebody has fallen out is when we hear the clump and they’re on the floor.

S15, staff nurse, surgical ward

Nursing staff on the acute wards expressed anxiety, concern and distress about falls, which a ward manager confirmed were ‘a big fear’ in the new hospital; confused patients and those with dementia were particularly difficult to safeguard from falling. It was generally felt that the new environment placed additional demands on nurses in terms of monitoring patients.

The next section explores how staff adapted their working patterns in response to the challenge of reduced visibility of patients and the perceived increased risk of falls.

Social isolation of patients

Before the move to the new hospital, nursing staff were concerned that single room wards would reduce opportunities for interaction between patients and could result in some patients feeling isolated. Staff interviewed after the move felt their experiences confirmed that social isolation was a disadvantage of single room wards, describing how lack of social contact with other patients could influence not only patients’ satisfaction with their hospital stay, but also their emotional well-being and recovery. Social isolation of patients in the new hospital was compounded by ward design with limited day rooms (surgical, older people’s and postnatal wards) or none at all (AAU). Staff thought that the rooms were too small, inconvenient for patients to access, uncomfortable and unattractive (Figure 24). They felt that provision of social or communal space for patients should have been given much higher priority.

FIGURE 24.

Day room on surgical ward, with narrow access and limited visibility. Taken by S16, staff nurse, surgical ward.

Staff accounts tended to associate isolation with particular groups of patients, notably older, less independent patients, including those who were confused or cognitively impaired, and whose stay in hospital lasted more than a few days. Nurses expressed concern about these patients and felt they benefited least from single room wards. Although staff valued the contribution of volunteers, who talked or read to patients on the general wards, there was consensus that voluntary help alone could not resolve the problem. Without the company of other patients, older patients were described as becoming lonely, withdrawn, unhappy, discouraged and less motivated to engage with the therapeutic efforts of staff.

I just do sometimes feel sorry for the older patients that are in for weeks [and] don’t necessarily have a lot of contact with other people. And I guess mood has a massive impact on everything in hospital, on your recovery, on your eating, on how likely you are to get up and work with the physio that day. And sometimes if you’ve other patients motivating you, or even just speaking to you, it just picks up your mood, it can help.

AHP40, dietitian

Staff also recognised that patients of all ages could be disadvantaged by not mixing with others; hearing their experiences was thought to help individuals assess their own progress and could be reassuring, motivating and encouraging:

for postnatal ladies it’s important that they can see what’s going on around them and it’s not all about them and their baby [. . .] they don’t understand that every baby feeds all the time and cries and everything. They can’t see what is normal and I think they think, ‘My baby is going to feed and go to sleep for 6 hours’. But if they see the other women struggling as well it sort of normalises it for them.

PN36, midwife, postnatal ward

Socially isolated patients were seen as likely to make more demands on staff, for example pressing call bells frequently or talking a lot to keep nurses in the room with them. For some staff this created tensions because they wanted to alleviate patients’ loneliness but felt that they had no time to talk.

It tends to be older patients who have no company at home [. . .] especially if they’re being barrier nursed and the door needs to be closed, they find it very isolating, and I’ve had quite a few older people get quite upset. And then the impact it has on us because they’re lonely, they’ll be pressing their bell all the time for nothing other than just wanting someone to be there with them, [but] you just don’t have that time [. . .] Yeah, and if they don’t see you for a little while, patients often think you must not be doing anything.

M01, HCA, AAU

The fact that some patients might think staff were not busy or working hard (as indicated by the quote above), was something most nurses and midwives alluded to in the interviews and clearly found challenging. They felt that this misperception increased demands on staff and denigrated their professionalism. For staff, a significant negative aspect of single room wards was that patients were unable to see them working, and therefore could not judge whether or not it was appropriate to seek attention. Having no cues about ward activity that could help them modify their demands, patients in single rooms became what some nurses’ narratives described as ‘demanding’, ‘difficult’ or ‘more selfish’ in single rooms. There was also a general view that the style and quality of the single room accommodation influenced some patients to behave as though they were in a hotel rather than a hospital and to treat staff accordingly.

Maintaining teamwork and communication

Nursing staff anticipated that they would spend more time working alone on single room wards, and were concerned about maintaining contact and communication with colleagues, which they considered essential to delivering effective nursing care. Open-plan wards enabled nurses to see, hear and interact with each other, which facilitated co-ordinating patient care and providing each other with assistance; this indicated good teamwork that was universally valued. After the move, staff felt that this quality of teamwork had been difficult to recreate. Nurses described seeing less of their colleagues, being unaware of what was happening in other parts of the ward, and sometimes feeling isolated. One of the main difficulties described by staff was finding colleagues to obtain assistance and information. This was a cause of much frustration, especially for HCAs.

It can be a bit difficult sometimes, if you’re really stuck and, you know, I’ve been hanging out of rooms calling for a nurse sometimes, but if somebody’s in another room, you can’t see them. [. . .] [If] you really need a nurse, or you really need somebody to come and help you, then you have to go through all the rooms to try and find them [. . .] So if you do need assistance [. . .] we often just press the call buzzers ourselves.

S14, HCA, surgical ward

Well, I suppose sometimes, on a really busy day, you can feel a bit isolated [. . .] I know you shouldn’t, but at times it does make you put your own health at risk. I’ve done that with my own back, you just think, ‘Oh I can’t find anyone, [the patient] desperately needs the toilet, I’m going to help them’.

OP23, HCA, older people’s ward

Allied Health Professionals and medical staff said that after the move it took them more time to find nursing staff and speak to them about patients. Nurses generally were perceived to be busy and therefore less interruptible or available. Nursing staff also thought that single room wards had disrupted interaction with colleagues from other professions. Nurses said that they might not notice a doctor or AHP going into a patient’s room, and unless the professional made an effort to find them, or the patient told them, they would have no immediate information about the encounter.

The size and design of general wards required nursing staff to work in small, decentralised teams, caring for patients in a cluster of 8 to 10 rooms, and based at a nearby nursing station. One member of each team was responsible for carrying a wireless telephone, so that they were contactable by the shift co-ordinator or supervisor, and the receptionist could forward calls relating to patients in that cluster directly to the team. A shift co-ordinator or supervisor was responsible for overseeing the ward as a whole, which was thought to help the ward team function efficiently.

Nurses were generally positive about working in decentralised teams and felt that good communication and co-operation were important in helping staff deliver effective patient care. However, there was also a widespread perception that decentralised working had reduced opportunities for interaction among the wider ward nursing team. Many nurses and midwives said that they had now less professional and social contact with colleagues; they felt that this not only was a personal loss, but also detracted from the sense of community in the hospital:

there’s a feeling that it’s almost like three separate wards, in a way. You’re very much self-contained within your own team. Whereas before, I think there was far more interaction between nurses.

S16, staff nurse, surgical ward

Some nurses spoke positively about the nursing team on their ward but others felt that the mutual support they had experienced on multibedded wards could not always be relied on in the new hospital. A staff nurse spoke candidly about her experience of, and attitude to, reciprocity among nurses:

to be honest I’ve got enough on my plate with my 10 beds. Unless somebody needs me, [when] they can come and get me, I’m too busy. It sounds awful, but they’ve got their 10, I’ve got my 10. I think it’s a bit like that. [. . .] You get the right group of people on shift and we do try and muck in and help each other out. If one end is particularly quiet they will go and help out the end that is busy. But some people will just think, ‘Thank God, I’ve got a quiet day today,’ and make the most of it.

S11, staff nurse, surgical ward

Some experienced nurses also indicated that single room wards impacted on the ability to support, train and develop staff. They explained that it was more difficult to supervise juniors: ‘that is a direct result of the environment really, because you can’t eyeball nurses enough to know that they’re drowning and they need help’ (M06). There were also fewer opportunities for informal learning than on multibedded wards.

You overhear someone working behind a curtain and you pick up and you think, ‘That was a really nice thing they did for that patient. Maybe I’ll try that’. I think that’s definitely missing, picking up on things from each other that way, because [. . .] it’s not as easy to hear how they interact with people.

M05, junior sister, AAU

Staffing levels to support safe and effective care

Before the move to the new hospital, nurses and midwives expressed concerns about staffing levels, and this was a recurrent theme in post-move staff interviews. Nurses felt that more staff were required in the new hospital to aid patient surveillance and overcome the challenges identified above. After the move, staff reported that they were ‘busier’, which they attributed to both service reconfiguration and the single room wards. Nurses in the new hospital described themselves as under greater pressure than they had been when working on open-plan wards, using terms such as ‘constantly running’ or ‘pulled’; they felt they had insufficient time for patient care:

if everything is going smoothly the nursing levels are fine [. . .] Mornings aren’t too bad [. . .] But this afternoon [. . .] it’s just one trained, one care assistant. I’ve had a patient from ITU [intensive therapy unit] that needs constant monitoring, I had a patient dying and the relatives needed quality time with me and their loved one, and then I had a patient that suddenly became septic, and a patient that was on a blood transfusion, all at the same time. And with one trained member of staff and one care assistant it wasn’t safe at all.

S11, staff nurse, surgical ward

Some ward managers said that increased staffing levels were necessary. However, other managers thought that at least some of the pressures experienced by nurses were not connected with the size of the workforce; rather they were due to staff not prioritising their workloads or managing their time effectively. Staff also identified this as an unforeseen challenge of working on single room wards (see section An unforeseen challenge: time management and prioritising workloads).

Summary: were the expected challenges of single room wards confirmed?

All of the challenges foreseen by staff arose in practice and required accommodation and adaptations to working patterns. Some challenges became more significant than expected because they were compounded by other factors in the new environment. The most important challenge for staff was surveillance and monitoring of patients because the design of the single room wards limited the visibility of patients even more than expected. Staff on the general wards had introduced a variety of measures to facilitate monitoring and prevent falls. Staff considered social isolation a real disadvantage for patients and staff on single room wards. Some groups of patients, notably those who were older, confused or cognitively impaired, were perceived to be most affected, becoming lonely and more likely to make demands that staff saw as inappropriate or excessive. Staff had limited scope to increase interaction among patients, because day room facilities on the wards were inadequate or non-existent. As staff had expected, maintaining teamwork and communication on single room wards presented a variety of challenges. Staff adapted successfully to working in decentralised nursing teams, although finding the optimal configuration required trial and error on one ward. Decentralised working disrupted the coherence of the ward team as a whole and some nurses noticed less trust and reciprocity among staff. Experienced nurses found it harder to supervise staff and there were fewer opportunities for informal learning. Face-to-face communication was more difficult to accomplish, but alternative methods that could have saved staff time, such as telecommunications and whiteboards, were not well established.

Staff expressed concerns that staffing levels on the new wards were insufficient to support safe and effective care, but some pressures may have been due to difficulties managing time and prioritising their workload, the final and unforeseen challenge identified by staff.

Adapting work patterns to improve time management and prioritise workload

To address the tensions of managing time and prioritising workloads, nurses and midwives took a more systematic approach to delivering care, with greater emphasis on assessment and planning rather than working in a reactive and fragmented way.

Advantages and challenges of single room working

Staff working on single room wards experienced the advantages they had expected before the move, although the expected benefits were not always fully realised because of issues and challenges in the new environment. Staff found that:

• Single rooms improved privacy, dignity and confidentiality for patients, allowing them to rest and recuperate without disturbance, and were better for visitors. Single rooms were perceived to facilitate communication with patients and reduce interruptions. However, staff found single rooms did not always enable more personalised patient care, because they felt unable to give sufficient time and attention to each patient.

• The design of patient rooms and wards met many staff expectations for an improved working environment and supported them to deliver efficient and effective care. However, staff also identified various design elements specific to Tunbridge Wells Hospital that presented obstacles to safe and efficient working, increased the distances they had to walk, diverted them from patient care and affected their well-being.

• Staff liked the new hospital (clean, spacious, modern, quiet and calm), which gave them a sense of professionalism.

• Staff believed that the new wards supported good hygiene practices and reduced the risk of infection. However, to avoid complacency, managers reinforced infection control policy and developed a visual warning system to prompt staff to take specific measures before entering a patient’s room.

Staff working on single room wards experienced the four main challenges they had anticipated before the move, which in some cases represented more significant disadvantages than expected. Staff found that:

• The design of the wards limited visibility of patients even more than they had anticipated. Their greatest challenge was monitoring and safeguarding patients, especially those at risk of falls, which increased pressure on staff.

• Social isolation was a real disadvantage for patients and staff on single room wards. Patients, who were older, confused or cognitively impaired, were perceived as most affected, becoming lonely and more likely to make demands on staff that were considered inappropriate or excessive. Staff wanted to increase interaction among patients but had limited options because of the lack of communal space on the wards.

• The quality of ward teamwork enjoyed in the old hospital had been difficult to recreate on the new wards. Staff adapted to decentralised nursing teams, but experienced less interaction with colleagues and disruption to the ward team as a whole, resulting in diminished trust and reciprocity among staff; difficulties supervising staff; and fewer opportunities for informal learning. Face-to-face communication was harder to accomplish, but aids that would have saved staff time (telephones and whiteboards) were not well established.

• Concerns were expressed that staffing levels on the new wards were not always sufficient to support safe and effective care.

Staff also highlighted an unanticipated challenge of time management and work prioritisation in single rooms. They had to divide their time between patients individually and could not give the time and care they wanted, resulting in frustration and dissatisfaction. Some nurses suggested that care had become more task orientated.

Disruption and reconstitution of work patterns

• Staff developed new ways of working and new processes of care. Successful examples included monitoring patients; decentralised nursing teams; supervisory roles for situation awareness; regular room checks; and falls interventions.

• Trial and error was a feature of innovations, with staff teams trying, for example, different ways of preventing falls and different configurations of decentralised teams.

• Locating colleagues to obtain information and assistance was one of the main difficulties described by staff, and was, on the whole, unresolved by new ways of working.

• New ways of working that were considered successful had some disadvantages; for example, room checks supported surveillance and helped reduce patient isolation, but increased paperwork and risked a ‘tick box’ approach to care. In addition, sitting patients at a high risk of falls in the corridor might have prevented falls, but it was considered ‘perverse’ in an all single room hospital.

• Tools to optimise single room working were largely underutilised; they were most extensively adopted for falls prevention and less well embedded in terms of enhancing team and patient/staff communication.

• Staff recognised that they required different strategies for time management and prioritisation on single room wards, to enable them to divide their time between patients and feel satisfied that they were giving all patients sufficient personalised care. Building good teamwork may help, but nurses found patients’ expectations and inability to assess the extent of demands on staff complicated finding satisfactory approaches.

Key dimensions of post-move patient experience

Analysis of interviews with patients carried out after the move to the new hospital revealed that their experiences of single rooms had four key dimensions: comfort, control, connection and isolation.

• Comfort: the dimension of comfort was common to patient experience before and after the move. Patients in single rooms identified aspects of the environment that contributed to their comfort, particularly the en suite facilities, in contrast to patients on the old wards, who experienced significant levels of discomfort. The design of the room helped reduce patients’ anxiety, promote rest and sleep, and support physical comfort.

• Control: patients interviewed after the move talked much more about aspects of experience that related to being in control while staying in hospital. The privacy of the single room meant patients felt that they retained their independence and freedom; they were able to do what they liked, when they liked and in their own time. They perceived the room as their own space and compared it with being at home. It was important to patients that they were not being observed by others, so they did not feel self-conscious; the room allowed them to be ‘backstage’ and removed any anxiety associated with impression management. 117

• Connection: this dimension relates to the quality of interaction with staff experienced by patients in single rooms. Patients felt connected when they had good communication and relationships with staff; they did not feel alone. In contrast, patients who perceived staff as ‘too busy to talk’ and care as task oriented felt a sense of disconnection. They were disinclined to initiate conversation with staff and found time passing slowly.

• Isolation: patients who felt little connection with staff were likely to report feeling isolated in single rooms. Isolation was also associated with unmet expectations of interaction with other patients on the ward; some patients who missed company felt confined in their rooms.

Comfort

An important difference between pre-move and post-move patient experience was in perceptions of comfort. Patients on the old wards identified aspects of ward design and facilities as increasing their discomfort. In contrast, patients in the new wards were universal in their praise for the comfort afforded by the single room environment. The language patients used to describe the environment often included frequent comparisons with a ‘hotel’, with patients favourably comparing the standard of accommodation and level of comfort with that experienced in a hotel room.

You had a shower, toilet, and washing facilities. Got your own TV, which when you’re in hospital you want something to do, which is a bonus [. . .] I would rate it really as probably on a par with a three-star hotel [. . .] That’s how good it was.

P11, male surgical patient, age 70 years

I went into the room, a beautiful room, lovely condition, lovely toilet and bathroom, I’ve got to say. To stay there is like a five-star hotel. It’s lovely.

P15, female surgical patient, age 65 years

Patients noted the quality of the lighting, ventilation and views from the bed and these were important factors in the overall levels of comfort experienced. There was also a sense in which patients experienced these aspects of the environment as healing or aids to their recovery.

The lighting was fantastic, because obviously, there are different settings. So I could turn the main lights off and you had some lights you could control behind your bed [. . .] You could turn the up light or the down light on, so the lighting was fantastic.

P1, male AAU patient, age 44 years

The temperature was fine and there was a long window, floor to ceiling, which I could open easily. [. . .] That was nice, very nice. [. . .] by the Sunday I could get out of bed and just go and open my window, which was lovely.

P2, female AAU patient, age 74 years

To be able to look out and see the trees and the sunlight, and the sky when it turns a different colour [. . .] it’s lovely to look at [. . .] just being able to look up, where trees are, and look up at the sky and the sunlight [. . .] It makes a difference, [. . .] you just feel happier [. . .] in spite of everything.

P21, female patient, older people’s ward, age 85 years

Patients with recent experience of shared hospital accommodation acknowledged that the single rooms gave them peace and quiet, compared with the noise of an open or bay ward environment. They described disturbed nights and feeling exhausted and in need of sleep following their discharge from an open ward. In contrast, single rooms meant patients were able to sleep well at night, and rest during the day. Postnatal patients also experienced reduced anxiety about their own baby crying and better sleep in comparison with postnatal patients interviewed in the pre-move study.

I know you can’t say, ‘I don’t want to be in that ward’, but if you have someone in there that has got dementia, it’s very frustrating because they don’t settle [. . .] Your whole time that you stay in there is a constant being awake, listening [. . .] whereas when you’re in a room and you’re on your own, you haven’t got anybody. You couldn’t hear a sound in that room, not a sound.

P15, female surgical patient, age 65 years

The single room is, I think, the most perfect solution they came up with because [. . .] sometimes babies are crying constantly, [. . .] but I had that peace and at least if baby was asleep, I could also go to sleep because there wasn’t anyone next to me with a baby crying or anything.

P26, postnatal patient, age 26 years

All patients interviewed found having an en suite toilet and shower particularly beneficial. The proximity of the en suite facilities meant that patients could easily mobilise to the toilet or shower, either independently or with assistance. For older, frail patients, this meant being able to enjoy a shower and a hair wash, and was a great source of comfort.

This business of having a nice wet room is marvellous. They wheel you in, strip you off, hose you down, rub soap all over you, hose you down again, dry you, and whip you back into bed again. It’s quick and easy for them. I mean, when you think of that and a blanket bath – what a performance that is – they [en suite facilities] really are [marvellous].

P12, male surgical patient, age 84 years

I’ve been in there [en suite]. Mind you, they have to help to get me in there. But what surprised me so was that I had a shower, yes. And at the same time as having the shower, they’ve washed my hair, yes. And that was wonderful! [laughs].

P21, female patient, older people’s ward, age 85 years

For many patients, the privacy of the en suite toilet was important; they did not have to feel embarrassed about using the toilet or not getting to the toilet in time.

The first few days I couldn’t go to the toilet normally [. . .] With my problem [diverticulitis], having my own toilet was brilliant.

P11, male surgical patient, age 70 years

I only just made it into my bathroom in time [. . .] I would have been so embarrassed, if I’d had to go out of my [room] and across the corridor and feel sick, and wet myself, I would just die of embarrassment [. . .] but there it was absolutely fine.

P16, female surgical patient, age 45 years

The en suite bathroom also meant patients could be as comfortable as they would be at home, being able to keep their toiletries in the bathroom, take their time and, for postnatal ward patients, leave the door open so that they could hear their baby.

If I think back to when I’d had surgery [at Maidstone], it’s a communal toilet, so you’re kind of in and out as quick as you can. And the fact that it was more difficult to wash and stuff in a communal bathroom, rather than if you’ve got your own private one, and you can spread out and just feel much nicer, much more like you’re at home or wherever. So, I think that made a big difference.

P7, female AAU patient, age 44 years

Being a new mum you didn’t really want to leave your baby at all, so I’d leave the door of the en suite open and I could still hear [baby] [. . .] it was just convenient that when you’ve got a newborn, sometimes it just feels like you haven’t got a minute to yourself, so just to quickly be able to pop to the loo. And especially to keep changing pads and things like that, so you need all of those essentials nearby.

P30, postnatal patient, age 29 years

Control

The second dimension of experience identified from the post-move interviews was ‘control’. Control rarely featured in patients’ accounts of staying on open wards. In single rooms, control was closely associated with privacy and freedom; not being observed by others; and retaining independence and agency. The level of physical comfort discussed above supported patients’ sense of control. Female patients also talked about being able to ‘think’ what they liked, and valued not having to worry about what other patients might be thinking about them. Patients compared the single room with being at home, in their own space, with similar control and privacy.

Being in a room on my own where I didn’t have to talk to people if I didn’t want to, I could watch the telly, I’d got my iPad, I’d got stuff that I could amuse myself with [. . .] And the fact that I’d got privacy, and things like being able to go to sleep when I wanted, and wake up when I wanted, was really beneficial [. . .] not being disturbed by other people. So, I was quite happy to be in my own room, and I think I would have been really unhappy to be on a ward.

P7, female AAU patient, age 44 years

I love it in here, because you can do what you like, think what you like, and [. . .] go to sleep, and look at magazines.

P21, female patient, older people’s ward, age 85 years

You’ve got your own TV [. . .] when I was alone in here, when [baby] was sleeping I would catch up a little bit on things that are happening in the world, what I would do at home anyway [. . .] even if [baby] cries I can take my time to get out of the bed and take her. There’s no hurry, ‘Oh, my god, she’s crying. Maybe she’ll wake up the baby next to me’. It was a home from home.

P26, postnatal patient, age 26 years

Patients also reported that having their own space and privacy meant they felt relaxed.

When you’ve got your room it’s just nicer, it makes you feel more relaxed [. . .] you’ve still got your little bit of independence [. . .] your space rather than just a curtain between you and the next bed.

P16, female surgical patient, age 45 years

It just gives you time to properly relax, and you haven’t got other people shouting across the ward, and other people perhaps who are very ill and making a lot of noise. You don’t get to hear all that. It’s just nice because you can relax in your own time. You’re given that privacy, and that’s what I like.

P14, female surgical patient, age 72 years

In the pre-move interviews, anxiety and vulnerability due to lack of privacy were most evident in the experiences of postnatal ward patients. In the post-move interviews, all patients talked about the enhanced confidentiality offered by the single room, but postnatal patients were especially grateful for the privacy afforded by the single room. In one case, a mother was able to ‘speak frankly’ with staff about her baby’s medical condition [talipes (clubfoot)] and appreciated being able to concentrate only on her baby without having to see babies with normal feet. For another mother, the privacy of the room was helpful in her feeling comfortable asking about what to expect following her caesarean section (c-section).

With having medical check-ups on [baby] having my own room meant I could speak frankly. You didn’t feel that somebody was going, ‘Oh?’ And his feet were really bad, [. . .] we knew about it from 21 weeks, but seeing his little feet all pushed in, it was quite a thing to get your head around and deal with, and it was nice not to be looking at some other baby whose legs were fine.

P32, postnatal patient, age 32 years

You can ask them anything [. . .] I had a c-section and I would ask them about the pains, the bleeding, the catheters, how everything worked. Because it’s private, I felt comfortable and they could even show me and [. . .] actually demonstrate it for me.

P26, postnatal patient, age 26 years

Finally, another key factor in patients’ experience of control was the privacy and flexibility of the single room environment for having visitors. Patients described being able to talk to their visitors freely and in confidence and liked the longer visiting hours and relaxed attitude of ward staff towards the length of visits. For parents, the single room was especially valued for ensuring a relaxed visit, for both patient and child(ren). Patients did not have to worry about their visitors disturbing other patients.

I’ve done quite a lot of visiting in hospitals, in wards, and I do think visiting in here is very much easier, in single rooms. [There’s] more space. And there’s more confidentiality, you feel not everyone’s hearing your business [. . .] it is nice really [visitors] can come whenever they like, in a single room, and that’s a very big bonus.

P17, female patient, older people’s ward, age 80 years

It was lovely because you had the privacy. So my daughter, she climbed onto the bed with me and had a cuddle, she felt more relaxed to be able to do that, whereas in the other hospital I could tell that she was self-conscious because there were a lot of people watching [. . .] [children] can talk, joke, laugh and be more relaxed in themselves, which was good for me, being the patient, because you get more out of the visit. They [wife, daughter and son] tended to stay longer as well [. . .] I think they extended their visits because you don’t feel like you’re in people’s way so much.

P1, male AAU patient, age 44 years

Although the single room was viewed as beneficial for visitors, postnatal patients felt that they had little control in relation to fathers staying overnight following the birth of their child(ren), a new policy enabled by single rooms. There was a lack of information about what fathers could expect, except that they would need to bring their own bed (e.g. camp bed or airbed) and bedding. One patient and her partner were able to plan in advance, but this was as a result of a visit that had been arranged because of the patient’s disability. The patient was extremely positive about midwives’ support and the environment enabling her independence, and was grateful her partner could stay. Other postnatal patients experienced a lack of control and increase in anxiety because of the lack of facilities and encouragement for fathers to stay overnight.

For him to come and stay would mean bringing a blow-up mattress [. . .] If there was a bed there, or even if there was a couch that he could lie down on, then he definitely would have stayed [. . .] It was really hard for both of us, him having to leave . . . especially his [baby’s] first night, second night [. . .] I was very emotional, I was exhausted, yes, and it’s your baby, you just want to be there. So it was really tough having to say goodbye and him going home.

P32, postnatal patient, age 32 years

It is a really important time in a family, when you have a baby, and it would have been nice for [partner] to spend the baby’s first night there, with her [. . .] If he knew that he was going to be able to get some comfortable sleep, he would have stayed. [It] would have made me less anxious, if he could have been there.

P25, postnatal patient, age 40 years

Connection

The main interaction or connection patients had with other people, apart from their visitors, was with staff, including nursing and/or midwifery staff, AHPs, medical staff, domestic staff and catering staff. There was also interaction with volunteers, for example volunteer readers on the older people’s ward and breast feeding peer supporters on the postnatal ward. Unlike in the pre-move wards, patients had limited, if any, interaction with other patients.

In contrast to the wholly positive experiences of comfort and control in single rooms described above, there was a dichotomy in patients’ experiences of connection. Patients reported similar frequencies of visits to their room by the various staff groups listed above, and they described nursing staff conducting regular intentional ward rounds (usually stating that nursing staff came hourly to ask them if they needed or wanted anything). However, the quality of interaction with staff was experienced differently.

For one group of patients, the single room was perceived as ‘a busy place’, where there was ‘always some activity’, where you were rarely ‘on your own’, and ‘weren’t isolated’. Staff were ‘always in and out’, ‘always checking on you’ and ‘always asking’ if they needed anything. This activity and communication with different staff led to a sense of connection for these patients. As one patient described it, they ‘weren’t isolated’.

If you’re in hospital, you’re ill, you’re not there for a holiday, and if you’re ill you need a lot of treatment, you have your blood pressure taken three times a day, your temperature and all that, they have to draw blood samples to send for analysis. So you are being constantly attended by nurses because of your condition. Also people are coming in and taking orders for meals and meals are coming in, so actually, a [single room] is a very busy place, you’re not on your own, hardly ever.

P12, male surgical patient, age 84 years

They came in quite often, because obviously you had the cleaner come in, and then I had several blood tests so somebody else came in [. . .] They were taking your pulse maybe three times a day, and then there was the meal times and the coffee times. So there was always some activity [. . .] you weren’t isolated.

P4, female AAU patient, age 74 years

Some patients thought that the single room enabled staff to give them undivided attention and supported one-to-one care. Other patients thought that staff had been trained in interpersonal skills, which improved the quality of interaction.

Nothing was too much trouble. I didn’t feel like I was sharing somebody with everybody else, I felt like she was my midwife [. . .] there was real one-to-one care and attention being provided for me, and I think that’s part of what you get with having a room on your own, because you’re not conscious of other people being around, the midwives aren’t conscious and distracted by what’s going on elsewhere.

P25, postnatal patient, age 40 years

They stood still and listened. They didn’t try to get away quick. You know how if somebody has got to go and do something else so they’re backing away. They didn’t do that [. . .] When they came in you wouldn’t have thought that they’d been rushing about with somebody else and then come panting up to you. That didn’t happen. I think they must be trained in that way, that they can shut off from one and go to the next one. It’s wonderful what they do. [. . .] I was perfectly happy in there, really I was.

P14, female surgical patient, age 72 years

In contrast, the other group of patients, although reporting a similar frequency of interactions with staff, perceived these interactions as largely task driven or functional rather than relational, and as a consequence said they found the single room ‘very quiet [. . .] you never saw anybody’ (P9), and that staff were ‘very distant’ and ‘busy’, and ‘did not have time to chat’. This led to patients feeling disconnected and disinclined to ask questions or ‘delay’ staff; consequently some needs might be unmet. It also meant that patients felt the day went very slowly.

They didn’t really have time to chat. [. . .] They just came in and did what they had to do, the temperatures and blood pressures, and things like the obs, as they call them. And that was it [. . .] You get more time [in a multibedded bay], not to chat to the staff, but to ask them questions, because they’re in a bay more than they are in a single room. They would only come to your room just to see if you’re okay, every so often or if you called them.

P10, male surgical patient, age 71 years

They’re [nursing staff] mostly quite friendly [. . .] but of course, they’ve all got their own jobs to do and they can’t stay and talk or anything [. . .] it is a long old time from 7 in the morning until 7 at night.

P24, female patient, older people’s ward, age 78 years

The dichotomy of experience in relation to a sense of connection with staff suggests that there may be variability between wards and among different staff members in the quality of intentional rounding. Some patients experienced lack of continuity in the staff caring for them, which interfered with establishing a sense of connection. Team nursing and intentional rounding integrated with task-based care may result in several different members of staff delivering care to a patient during a shift. The patient quoted below links discontinuous, task-focused care with missed opportunities to increase his comfort.

One nurse takes your blood pressure and another takes your blood sugar [. . .] and the way they do it, they’ve got all the records, it’s time to do insulin, they come in, ‘Hello, Mr X, you need your insulin injection’. They do it and walk straight out. So, there is no chance to say anything that has just cropped up, like, ‘Could you open the window? Could you close the window? Could you turn the light off?’[. . .] and those ordinary things you don’t need to make a great fuss about, but you can ask for in passing [on an open ward].

P23, male patient, older people’s ward, age 80 years

Senior nursing staff recognised that there was variability in intentional rounding (see Chapter 6, Reduced visibility of patients: difficulties monitoring and safeguarding patients) and that staff needed to be encouraged to enter the room and stand close to the patient, rather than simply ‘popping their head round the door to see if patients are okay’. This would encourage patients to ask questions or make requests. The quality of intentional rounding is also heavily dependent on staffing levels, and, where wards are short-staffed or staffed by agency staff, the quality of intentional rounding may suffer. Patients frequently mentioned how busy staff seemed to be, and this is perhaps surprising given the lack of visibility for patients of the ward beyond their own single room. However, it was clear from patients’ accounts that staff were monitoring patients regularly, carrying out hourly room checks, which helped patients in single rooms – like patients on open wards, who could see nurses going about their work – to feel safe and secure, even if they did not always experience a sense of connection with the staff who checked on them.

There were other simple, yet important to patients, measures that encouraged connection between staff and patients. One such measure was putting nursing staff names on patient whiteboards in the room, so that patients knew who was caring for them that shift. Patients reported variation in this practice, and highlighted how important it was for them as a means of building rapport in the single room environment.

The highlights are they [. . .] introduced their self to you. You know, ‘Hello, Mr _____ , I’m so-and-so’, and they used to put on the board, Sister in Charge, blah, blah, blah, and you knew exactly who you were dealing with.

P11, male surgical patient, age 70 years

I think the first couple of days, they came in and they wrote on the board who was in charge and so on. That happened for a couple of days, and then it didn’t happen afterwards [. . .] It was quite nice to have a name, because if you’re not seeing people going up and down, there’s no kind of other rapport with anybody, so it’s quite nice to know who’s who.

P7, female AAU patient, age 44 years

Isolation

For some patients, lack of interaction with other patients was a striking feature of their stay in hospital, and led to strong feelings of isolation in some cases.

It would have been nice to have been able to see other people, or maybe just to chat with other mothers [. . .] If you’re in an open ward, you just see people coming and going [. . .] you can chat to people across the ward [. . .] you can see other people going through what you’re going through [. . .] I just wanted to get home [. . .]because there isn’t anyone to chat to and I just felt a little bit isolated being in the room on my own.

P31, postnatal patient, age 36 years

Once you’re on the mend and you can get up out of bed that’s when it seems to be very lonely in a way, and isolated, I suppose [. . .] and the days and the nights seemed very, very long [. . .] If you’re alone in a room you tend to think about your illness more than if you’re chatting to somebody about the weather or your car, or something like that. That’s how I felt.

P10, male surgical patient, age 73 years

I don’t like it here [. . .] It’s boring sitting indoors all day either watching [TV] or reading [the paper] and looking at four walls. You can talk to [other patients on an open ward/bay]. Who are you going to talk to here? There’s nobody to talk to. The staff, you do talk to them sometimes but they’re busy, they’ve got their work to do.

P19, male patient, older people’s ward, age 86 years

The isolation and lack of interaction experienced by some patients led to them feeling confined or constrained in their single room, and patients described a lack of information from staff about day room facilities or other communal areas that they could access (although patients in the AAU had no day room).

It did get a little bit lonely [. . .] you don’t really get to talk to many people, other patients. [. . .] I wanted to go for a walk just to get out of the room and maybe have a chat with someone. You do start to feel a little bit stir crazy stuck in a room [. . .] I don’t know if there was a common area, no one ever said. No one basically told me the rules, that you’ve got to stay in your room or if you want you can go and get a cup of coffee and sit in this room and watch a bit of TV with other people. So I guess if anything could be improved it could be telling patients what they can and can’t do. You know, is it okay to leave the ward? [. . .] I kind of felt like I had to stay in my room.

P1, male AAU patient, age 44 years

I did feel that perhaps I’d get shouted at if I walked past the nurses’ station [. . .] I did feel constrained to stay and not explore too much; they could help that by saying, ‘Well, no, if you walk up that corridor, there’s a communal room there’. And so you would feel that you can walk there.

P8, male AAU patient, age 69 years

Staff considered the limited day room facilities a disadvantage of the new hospital. The AAU did not have a day room, and the older people’s ward was the only other case study ward which made structured use of its day room, running a lunch club for patients (see Chapter 6). Some patients particularly wanted opportunities to interact with other patients, and made suggestions for how this could be encouraged by staff.

They do have a lunch club which operates on lots of days of the week, but it depends on the nurses being able to take the time to take you down there and be with you [. . .] I go down there most days [. . .] I like talking to the other patients and finding out why they’re there [. . .] When it’s cancelled and I have to sit in here it’s terrible.

P24, female patient, older people’s ward, age 78 years

I think maybe that [patient interaction] could have been encouraged [. . .] maybe the midwives could say, ‘Right let’s all come and have a cup of tea together,’ or something like that. I don’t know if that would be a way forward to socialise a bit more, and just to share your stories maybe, a bit like mother and toddler groups that I’m trying to get to now.

P30, postnatal patient, age 29 years

Does all single room accommodation affect diverse patient groups differently?

Single rooms were a clear preference for many patients (and most postnatal patients) but a significant minority, including patients of varying ages and patient groups, wanted greater choice, in terms of either having the option of shared accommodation or being able to interact with other patients in communal spaces of the hospital. Approximately one in three patients interviewed (11 of 32) experienced lack of interaction with other patients as a main disadvantage of the single room. More male patients (6 of 13) expressed a preference for multibedded accommodation to counteract this experience of isolation, but female patients also wanted opportunities to interact with other patients.

It was very mixed for me. The concept I think is great and it’s great that people have that choice but I think going to the future, it should be a choice, not ‘Yes, you’re going to have a room by yourself’.

P8, male AAU patient, age 69 years

It is important to reiterate here that these preference findings are based on qualitative data from four case study wards and are not necessarily generalisable to other settings or groups of patients. It is also important to note that in the older people’s ward we were not able to interview patients who were very sick or who had dementia or delirium, and our sample primarily comprised older people in the designated orthopaedic beds. Trauma patients, paediatric patients and patients with dementia may have different preferences and particular experiences of the single room environment that are not adequately represented by the four core concepts discussed above.

While staff associated loneliness particularly with older, less independent or confused patients, patient interviews indicate this experience was more widespread and experiences more varied. Maternity patients expressed a preference for single rooms, which they expected would provide more security, privacy and physical comfort than an open ward. Patients across all groups identified the potential benefits (sleep, rest and en suite facilities) and the disadvantages (loss of proximity to staff, loneliness and isolation).

Special-cause variation at Tunbridge Wells Hospital

Overall, 15 36-month periods of outcome data were available from Tunbridge Wells Hospital. Falls, pressure ulcers, medication error, C. diff. and MRSA rates were available for all three wards (acute assessment, older people and surgical).

Five of the eleven time series revealed special-cause variation that could be associated with moving to the new Tunbridge Wells Hospital: increased fall, pressure ulcer and C. diff. rates in the older people’s ward and temporary increases in falls and medication errors in the acute assessment unit (Figures 25–28).

FIGURE 25.

Older people’s ward at Tunbridge Wells: u-chart with CF expansion – (a) falls, (b) pressure ulcers and (c) C. difficile. CL, centre line; LCL, lower control limit; StdDev, standard deviation; UCL, upper control limit.

FIGURE 26.

Older people’s ward at Tunbridge Wells: case mix – (a) LOS and (b) HRG codes.

FIGURE 27.

Acute assessment unit at Tunbridge Wells Hospital: u-chart with CF expansion – (a) falls and (b) medication errors. CL, centre line; LCL, lower control limit; StdDev, standard deviation; UCL, upper control limit.

FIGURE 28.

Acute assessment unit at Tunbridge Wells Hospital: case mix – (a) LOS and (b) HRG codes.

Figures 25 and 26 show a pronounced increase in fall, pressure ulcer and C. diff. rates at the older people’s ward at Tunbridge Wells Hospital that occurred after the move to single rooms. Two criteria for special-cause variation are met: overall 17 measurement points above the upper control limits (indicated in blue) and more than seven consecutive points above the centre line (indicated in green). However, the case mix of this ward changed substantially in the same time period: the LOS decreased from 37 to 20 days and the proportion of orthopaedic trauma patients (orthopaedics/trauma HRG subgroup) increased from 4.6% to 24.8%, which, therefore, does not allow us to attribute the changes in falls and pressure ulcers rates to single room accommodation (for additional case-mix data see Appendix 21).

In the acute assessment unit, falls and medication errors at Tunbridge Wells Hospital were increased but returned after 7–9 months to the same levels as before the move (see Figures 27 and 28). In the same time period, LOS increased from 1.2 to 1.4 days and some changes in case mix (e.g. a reduction of the cardiac HRG subgroup by 7%) could be observed. Because the change in adverse events is not sustained, it is unlikely that the change in case mix is the sole cause (for additional case-mix data see Appendix 21). Therefore, this change might be attributed to the move to single rooms.

Special-cause variation at new build with mixed accommodation comparator site

Although data from the case study wards at Tunbridge Wells Hospital did not show a clear consistent single room effect, the new build with mixed accommodation comparator site provides another opportunity to explore single rooms (Figures 29–32). In particular, the temporary increase in falls and medication errors on the AAU is a possible (temporary) single room effect, but might simply be associated with general disruption associated with a move to a new environment. Overall, 15 24- to 36-month time series across all wards and outcomes were available from the new build mixed accommodation control site. Whereas in the AAU at Tunbridge Wells Hospital we saw a temporary increase of medication errors and falls following the move, no such special-cause variation could be identified in any ward in the new build mixed accommodation comparator site (see Figures 31 and 32). Although there were special-cause variation events visible, these were either single time points below or above the control limits or violating runs (seven consecutive runs below/above the centre line) not synchronous to the move. These were therefore discarded as potentially attributable to a move or to an increase in the proportion of single rooms.

FIGURE 29.

Older people’s ward at new-build mixed accommodation control site: u-chart with CF expansion – (a) falls and (b) pressure ulcers. CL, centre line; LCL, lower control limit; StdDev, standard deviation; UCL, upper control limit.

FIGURE 30.

Older people’s ward at new-build mixed accommodation control site: case-mix – (a) LOS and (b) HRG codes.

FIGURE 31.

Acute assessment unit at new-build mixed accommodation control site: u-chart with CF expansion – (a) falls and (b) medication errors. CL, centre line; LCL, lower control limit; StdDev, standard deviation; UCL, upper control limit.

FIGURE 32.

Acute assessment unit at new-build mixed accommodation control site: case-mix – (a) LOS and (b) HRG codes. MHNE, mouth, head, neck and ears.

Special-cause variation at steady state comparator site

Overall, 12 36-month time series across the three wards for fall, pressure ulcer, MRSA and C. diff. rates were available from the steady state control site. Various special-cause variations were present at the older people’s ward (Figures 33 and 34) and the AAU at the steady state control site (Figures 35 and 36). For example, the fall rate on the older people’s ward declined while the pressure ulcer rate at the AAU increased, indicating in both cases that the patient population changed to some extent; however, other factors might have played a role too.

FIGURE 33.

Older people’s ward at steady state control site: u-chart with CF expansion – (a) falls and (b) pressure ulcers. CL, centre line; LCL, lower control limit; StdDev, standard deviation; UCL, upper control limit.

FIGURE 34.

Older people’s ward at steady state control site: case mix – (a) LOS and (b) ICD-10 codes. HS, health services.

FIGURE 35.

Acute assessment unit at steady state control site: u-chart with CF expansion – (a) falls and (b) medication errors. CL, centre line; LCL, lower control limit; StdDev, standard deviation; UCL, upper control limit.

FIGURE 36.

Acute assessment unit at steady state control site: case mix – (a) LOS and (b) ICD-10 codes. HS, health services.

Trust-level fall trend

Staff at Tunbridge Wells Hospital reported increased fall rates after the move. Triggered by this and the evidence from the older people’s ward and AAU, we also analysed the overall fall rate for the entire trust, including data from the old Kent and Sussex Hospital before the move, Tunbridge Wells after the move and the old hospital in Maidstone.

From April 2011 to September 2013, falls in the trust increased from 4.74 to 7.84 falls per 1000 bed-days, which represents an increase of 65% (Figure 37). To assess changes in the underlying risk of the trust population, we took the percentage of patients with an increased fall risk as simple measure of fall risk. We defined patients with an increased risk as patients (1) having one of the Charlson comorbidity diagnoses or (2) having a diagnosis that specifically indicates a high risk of falls or (3) over the age of 70 years (see Appendix 22 for more details). In the time period from April 2011 to December 2012 (which is the overlap of the planned study period and the trust-level data that were available) the fall risk increased in close proportion to the fall rate (see Figure 37). The correlation between the fall risk and the fall rate is strongly positively associated (r = 0.68). Thus, although there has been a clear sustained increase in the rate of falls, it is not possible to attribute this clearly to single rooms per se given the overall increase of patients at risk of falls.

FIGURE 37.

Standardised fall rate and percentage of patients with increased fall risk. Lines are based on LOcal regrESSions (LOESS). Black dashed line represents the time of the move. Grey shading represents the 95% CI area.

National infection trends

Infection rates are the safety outcomes which have gained the most attention in empirical research on the effect of single rooms. This study has 18 time series of infection rates (MRSA and C. diff. for each study ward). Although 18 time series were available, nine of these referred to MRSA, which had a very low incidence at all sites. For example, there was only one documented MRSA case at Tunbridge Wells Hospital on the three wards over 36 months. Although the incidence of C. diff. was higher, in comparison with MRSA it was still low. Two (AAU at Tunbridge Wells Hospital and the surgical ward at the steady state control site) of the nine time series had fewer than five cases, which did not allow any further scrutiny. Of the remaining seven time series, six showed a reduction in C. diff. rates (one at Tunbridge Wells Hospital, three at the mixed accommodation site and two at the steady state control site). Only one did show an increase (older people’s ward at the single room site; see Figures 25 and 26). Given the low incident rates at all sites, the research team decided to investigate how the national trends for MRSA and C. diff. have developed in the investigation period from 2010 to 2012.

The mandatory reporting for Public Health England includes MRSA bacteraemia and C. diff. and data are published regularly. Figure 38 shows the mean standardised quarterly MRSA rate. MRSA infections decreased from 279 cases in the first quarter of 2010 to 92 in the fourth quarter of 2012. This trend is also visible for Tunbridge Wells Hospital. Trust-level data for C. diff. are not publicly reported, but the overall national trend is similar: the trust-apportioned number of infections decreased from 3489 (Q1, 2010) to 1525 (Q4, 2012), which represents a reduction of 56% in the 3-year period.

FIGURE 38.

Quarterly standardised MRSA counts for NHS England (National) and Maidstone and Tunbridge Wells (M/TW). Lines are based on LOcal regrESSions (LOESS). Black dashed line represents the time of the move. Grey shading represents the 95% CI area.

Construction and facilities management costs at Tunbridge Wells Hospital

Over the life cycle of a hospital, there is typically a 1 : 1 : 20 ratio of capital expenditure to estates-related operational expenditure to medical costs in discounted cash flow terms; that is, if it costs £100M to build a hospital, it will cost about the same in discounted total maintenance costs through its lifespan, but 20 times that in costs relating to the provision of medical care. 119–123 This means that any overall (small) increase in initial capital expenditure or annual estates-related operational expenditure would be negligible compared with the total life-cycle running costs of a hospital.

To get a feel for the significance of the identifiable incremental costs of the 100% single room design of Tunbridge Wells Hospital, we modelled the cash flows over the full assessed project life of 60 years (using a 3% discount rate), of which around half falls within the scheme’s PFI contract. This review was based largely on data in the original outline business case for the new hospital. While the absolute figures date back to 2004, they nevertheless provide an order of magnitude estimate for the impact, given that the ratios between the various parameters will not have changed significantly since then. This analysis shows 1 : 1 : 12 ratios of capital expenditure (including major life-cycle work) to estates-related operating costs (building running costs, equipment upgrades) to medical costs.

In net worth terms (i.e. discounted cash flow, net present value at 3%), were the capital expenditure and operating cost to have been decreased by building a conventional 50% single room facility and assuming (conservatively) 5% and 10% reductions, the full life-cycle costs of the site would have reduced by only 0.7% and 1.4% of the original respectively.

However, given that, in the case of Tunbridge Wells Hospital, the construction company contends that the higher proportion of single rooms did not lead to any increased floor area, we can assume that capital expenditure and estates-related operational expenditure (i.e. ‘hard facilities management’) are scarcely higher, if at all, than in a 50% single room hospital.

Impact on distribution of meals to patients

Moving from multiple to single room design has implications for the way patient meals and refreshments are administered. Multibedded wards allow more patients to be served at the same time, whereas distribution of meals to rooms in the single room model potentially requires more time for distribution because of layout.

Administrative data from Tunbridge Wells Hospital show a 49% increase in the cost of preparing and serving meals after the move to the new hospital. However, according to interviewees this was largely due to a change from a central kitchen to a ward-based kitchen model, a decision taken at the planning stage and not directly related to the single room design. It is, therefore, not possible to draw any firm conclusions on the impact of single room design on catering costs in Tunbridge Wells Hospital.

Planned investment in nursing staff

Before the move, in November 2010, an investment of an additional £1,669,000 per year in additional nursing staff was planned (Table 60). This comprised three main components:

1. an additional number of WTE nurses, midwives and support staff required across the wards, to cope with the additional surveillance required by the single room design

2. an increase in price of WTE

3. an increment in the number of beds in a number of wards.