UK ward design: Patient dependency, nursing workload, staffing and quality—An observational study
Section snippets
What is already known about the topic?
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Ward design literature concentrates on patients’ needs and staff activity, which generates useful guidance.
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Several important ward design nursing variables, however, remain untested; for example, the ward design's influence on staffing and quality.
What this paper adds
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Nightingale wards, largely defunct, paint an attractive nursing picture and the best characteristics could be emulated in other wards.
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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:
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Evaluation methods (Delon and Smalley, 1970; Harrison, 2003).
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Ward design innovations (Francis and Scher, 1999).
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Nursing activity and staffing (Gadbois et al., 1992; Geden and Begeman, 1981; Hurst, 2005)
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Recruitment and retention (Irvine and Evans, 1995; Leveck and Jones, 1996; Seelye, 1982).
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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.
References (51)
Relationships between patient dependency, nursing workload and quality
International Journal of Nursing Studies
(2005)- et al.
Sources and consequences of satisfaction and dissatisfaction in nursing: findings from a national survey
International Journal of Nursing Studies
(1991) The greying of the UK nursing workforce: implications for employment policy and practice
Journal of Advanced Nursing
(1999)Privacy or help? The use of curtain positioning strategies within maternity ward environment as a means of achieving and maintaining privacy, or as a form of signalling to peers and professionals in an attempt to seek information and support
Journal of Advanced Nursing
(1998)- et al.
Consumer involvement in facilities design
Journal of Nursing Administration
(1994) - et al.
The impact of nursing grade on the quality and outcome of nursing care
Health Economics
(1995) - Commission for Architecture and the Built Environment (CABE), 2004. The Role of Hospital Design in the Recruitment,...
- et al.
Traffic and noise in children's wards
Medical Journal of Australia
(1994) - et al.
The effect of staff nursing on length of stay and mortality
Medical Care
(1998) - et al.
Quantitative methods for evaluating hospital designs
Health Service Research
(1970)
Special report, buildings: castles in the air
Health Service Journal
A volunteer companion-observer intervention reduces falls ion an acute aged care ward
International Journal of Healthcare Quality Assurance
Less is more
Health Service Journal
Fifty Years of Ideas in Healthcare Buildings
Hospital design and the temporal spatial organisation of nursing activity
Work and Stress
Personal space preferences of hospitalised adults
Research in Nursing and Health
Skill mix in nursing: a selective review of the literature
Journal of Advanced Nursing
Luck of the draw
Health Service Journal
Staff views shape hospital design
Nursing Standard
Accidents will happen
Nursing Times
Issues in clinical nursing: consumer perspectives in adolescent ward design
Journal of Clinical Nursing
Job satisfaction and turnover among nurses: integrating research findings across studies
Nursing Research
A facet structure for nurses’ evaluations of ward designs
Journal of Occupational Psychology
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2020, International Journal of Nursing StudiesCitation Excerpt :These descriptive studies illustrate the currency of a range of approaches including professional judgement (Taylor et al., 2015), prototype (Fenton and Casey, 2015; The Shelford Group, 2014) and indicator systems (Fagerström et al., 2014; Kolakowski, 2016), with at least one explicitly combining approaches (Fagerström et al., 2014). Studies demonstrate variation between wards and from day to day and month to month (e.g. Gabbay and Bukchin, 2009; Smith et al., 2009), arising from the number of patients, the numbers of admissions and discharges, individual patient characteristics and their specific needs (e.g. Fagerström et al., 2014; Hurst, 2009; Smith et al., 2009), as well as contextual factors such as the physical arrangement of the ward (Hurst, 2008). While demonstrating that measured demand for nursing care can vary considerably, none of the descriptive studies provided a measure that allowed the variation to be directly quantified in terms of variability in the staff required from day to day.