5. Reduced visibility: difficulties monitoring and safeguarding patients | |
(i) Staff described visibility of patients from the ward corridor as limited to the patient room they were directly outside, and then only if the door or vision panel in it was open (ii) The line of sight into the patient room was interrupted by the wall of the adjacent room's en-suite bathroom (‘in-board’ single-room design) also obscuring the view of patient room doors for staff looking down the corridor (iii) 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 (iv) Experienced nursing staff thought that it had been easier to prevent falls in multi-bed accommodation because they could ‘keep an eye’ on patients and were more aware of warning signals, for example, patients attempting to get up from their chair or bed (v) Staff adapted work patterns to monitor and safeguard patients, but use of cordless telephones to locate each other was variable
| “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—Nurse, surgical ward “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—Nurse, surgical ward “You have to adjust your nursing practice just to make sure that everybody is seen and you keep an eye on them the whole time. With the bays you'd go in to see one patient but then subconsciously you're eyeballing everybody else, making sure everybody else is okay. Whereas here you have to physically go into each and everybody's rooms, or stop and have a look at them.” M03—Nurse, MAU “I walk around with my head permanently fixed to the side that all the rooms are on, just checking […] I've just adapted. I now look into every single room every time I walk past and I make the effort to go into the rooms.” M05—junior sister, MAU |
6. Social isolation of patients | |
(i) Staff felt social isolation was a disadvantage of single-room wards compounded by ward design with limited day rooms (ii) Social isolation influenced, patients’ satisfaction with their hospital stay and their emotional well-being and recovery (iii) Staff felt that provision of social or communal space for patients should have been given much higher priority (iv) Staff felt older patients likely to be more lonely (though our patient data does not support this from our sample) although staff also recognised that patients of all ages could be disadvantaged by not mixing with others and hearing their experiences, which was thought to help individuals assess their own progress and could be reassuring, motivating and encouraging (v) 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 which created tensions for 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—dietician “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 six hours.’ But if they see the other women struggling as well it sort of normalises it for them.” PN36—midwife, postnatal ward “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—Healthcare assistant, MAU |
7. Maintaining teamwork and communication | |
(i) After the move, staff felt that the quality of teamwork had been difficult to recreate (ii) Nurses described seeing less of their colleagues, being unaware of what was happening in other parts of the ward, and sometimes feeling isolated (iii) 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, use of technology to support this was variable (cordless telephones) (iv) Nursing staff worked in small, decentralised teams, caring for patients in a cluster of eight to ten rooms, rather than one large team. Some staff liked this, but others felt that the mutual support they had experienced on multi-bed wards could not always be relied on in the new hospital (v) Single-room wards impacted on the ability to support, train and develop staff as more difficult to supervise junior staff (vi) There were also fewer opportunities for informal learning than on multi-bed wards
| "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—Healthcare assistant, 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—Healthcare assistant, older people ward ”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 “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—Nurse, MAU “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, MAU |