UK ward design: Patient dependency, nursing workload, staffing and quality—An observational study

https://doi.org/10.1016/j.ijnurstu.2006.09.007Get rights and content

Abstract

Background

There are important relationships between ward design, patient welfare and staff activity in the literature but studies seem not to have tested all the variables. Whether ward designs influence nursing structures, processes and outcomes, therefore, has not been fully answered. While studies provide helpful guidance, nursing efficiency and effectiveness implications are speculative.

Objectives

To improve nursing efficiency and effectiveness by capitalising on the best ward design features.

Setting

A database consisting of 375 UK wards, constructed for other research and development purposes, was revisited and reconfigured for the present study. The database was updated between 2003 and 2004.

Participants

Of 390 wards approached, 375 generated usable data.

Method

Patient dependency, nursing activity, workload, nursing quality and staffing data in the original database were obtained using mainly non-participation observation methods. Later, wards were classified in eight ways and differences between ward types examined.

Results

Patient dependency did not stand out in any ward type but as the literature predicted, direct patient care was higher in Nightingale wards. Racetrack ward nursing activity was also close to idyllic. Bay wards, owing to their greater occupancy peaks and troughs, had a propensity to generate heavier workloads. Time-out and down-time were not excessive in any ward type, and it is likely that ward leadership may be compensating for some variables’ negative effects. Racetrack wards were considerably less-well staffed and grade-mix dilute and consequently the cheapest. Quality scores were higher in Nightingale wards—nurses’ greater observation capability was a significant factor. Wards’ central-core configurations also influenced nursing efficiency and effectiveness.

Conclusions

Racetrack wards have an edge over other ward designs. However, replicating Nightingale conditions by, for example, equalising occupancy, throughput and staffing and maximising nurses’ substations, could engender similar outcomes elsewhere.

Section snippets

What is already known about the topic?

  • Ward design literature concentrates on patients’ needs and staff activity, which generates useful guidance.

  • Several important ward design nursing variables, however, remain untested; for example, the ward design's influence on staffing and quality.

What this paper adds

  • Nightingale wards, largely defunct, paint an attractive nursing picture and the best characteristics could be emulated in other wards.

  • The Racetrack design, a close second to Nightingale wards, also raise nursing efficiency and effectiveness.

Introduction, background and context

In addition to her basic ward design principles (natural light, ventilation and cleanliness), Nightingale said that efficient and effective hospital wards brought together all that was needed for patient care in one place; allowed patient-staff allocation based on patient dependency in rooms that facilitated close supervision, day and night (Metcalfe, 1978; Skretkowicz, 1992). Recent studies add the benefits of soothing décor, meaningful and varying stimuli, peaceful sounds; odourless and

Literature review

Wards should provide a safe environment for patients. Nurses, therefore, need to monitor patient and subordinate staff activities (Douglas et al., 2002; Pattison and Roberston, 1996). Other concerns include the adverse effects of ward environment on job satisfaction, staff turnover, patient satisfaction, mortality and readmission rates. Well-designed, well-laid out, spacious and attractively decorated wards significantly influence not only patient welfare but also staff performance (McCusker et

Ward design/layout

Some authors structured their discussion using specific ward designs in which patient and staff issues were sub elements. Several ward layouts were encountered and clearly, each raises distinct staffing and patient issues.

Study aims and objectives

Ward layout, patient and staffing literature is broad. Although important relationships existed between ward design, patient welfare and staff activity, no study tested or controlled all the variables. Whether environments intervened in nursing care therefore, has not been fully answered. Consequently, ward design, patient care and staffing recommendations were sometimes fragile and needed robust empirical work. Fewer studies lead to weak meta-analyses and, therefore, contradictions cannot be

Method

The majority of ward design studies concentrated on several methodological themes and although some were old, valuable insights were offered:

  • 1.

    Evaluation methods (Delon and Smalley, 1970; Harrison, 2003).

  • 2.

    Ward design innovations (Francis and Scher, 1999).

  • 3.

    Nursing activity and staffing (Gadbois et al., 1992; Geden and Begeman, 1981; Hurst, 2005)

  • 4.

    Recruitment and retention (Irvine and Evans, 1995; Leveck and Jones, 1996; Seelye, 1982).

  • 5.

    Patient welfare and outcomes (Kenny and Canter, 1981; Landefeld et

Results

Data from 299,640 inpatient dependency assessments are summarised in Table 2, which shows their distribution according to ward design.

Throughput was calculated in the present study by converting ‘dependency hours’ per bed into patient full-time equivalents (FTEs). That is, the length of time patients stayed was recorded along with their dependency category before dividing the total number of hours in each category by 24. Throughput gives a truer picture of nursing workload because census

Conclusions and recommendations

Ward design, staffing and quality literature, although generating useful insights and pointers to future research, was contradictory. This study, therefore, is timely and important. Two broad themes emerged from ward design literature: patients’ needs and wants; and nursing activity. Although the study's database was tedious and laborious to construct, and ward classification data not easy to obtain (because ward-type data were collected retrospectively and managers had to be traced) most wards

Acknowledgements

NHS Estates commissioned the study; however the discussion, conclusions and recommendations are the author's alone.

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