Table 2

Staff advantages and disadvantages of shared patient accommodation and single-room accommodation

Shared patient accommodation in an open ward
AdvantagesStaff interview data
1. Visibility—enhanced surveillance and monitoring
 Visual and aural proximity of staff to patients resulted in three key perceived benefits for staff:
  • (i) Enhanced surveillance and monitoring of patients

  • (ii) Staff ability to monitor and communicate with patients enhanced by the proximity of patients to each other

  • (iii) Staff benefitted from patients acting as an extra pair of eyes on the ward 

“Even when I'm sitting here by the desk [staff base], I can see…By just looking up, you can automatically see that, ‘Oh, I think he's not breathing well,’ or something is going wrong, and you can act immediately.” E6 Nurse, medical (older people) ward “I was on [the postnatal section] the other night in the early hours of the morning and I was seeing somebody and I could hear this baby throwing up, so I dived behind the curtain so I could get it on its side, pat on the back. So, yeah, you can see the patients as you walk down very easily. You hear things.” M3 Midwife, maternity ward “Where I am today it's been absolutely hectic because we've got confused patients. They're all constantly shouting out. And where we are now, we can shout over, ‘I'll be with you in a minute.’ [It helps with] knowing where to go, how to prioritise yourself really” A1 Healthcare assistant, MAU “We've got patients who look out for [other patients]. If a patient next to them sees that they're having trouble doing something they'll ring their bell for them and say, ‘Oh, nurse, she's doing this, she's doing that, I think she's trying to stand up…’ which is really good.” E3 Healthcare assistant, medical (older people) ward
2. Teamwork and communication
  • (i)  Staff valued being easily able to request or provide assistance where needed

  • (ii)  In staff survey, surgical and medical (older people) ward staff had the highest mean scores for the items ‘Obtaining advice from colleagues’, ‘Finding a staff member’ and ‘Knowing when other staff might need a helping hand’ (mean scores >4)

  • (iii) Staff learning from each other and supporting each other highlighted as important. During observation sessions ward managers were frequently observed on the ward ‘floor’, assisting and encouraging or advising their team 

“It's one of the lovely things about the Nightingale wards, at least we [nursing staff] can all see each other… you can go, ‘Do you want some help there?’ E2 Healthcare assistant, medical (older people) ward “Sometimes you are faced with a situation that is difficult to manage on your own and so there's nearly always somebody very close by that you can call. Or if maybe you were struggling a bit in any way …somebody else would probably hear and come to your rescue. Those are big advantages.” S3 Nurse, surgical ward 
3. Facilitation of social contact between patients
  • (i) Staff were positive about patients being able to see, hear and interact with each other in shared open plan areas

  • (ii) Social contact between patients was seen as an aid to staff on busy wards, who might not have time to interact for longer periods with patients

  • (iii) Social contact was perceived to support recovery and relieve boredom on the wards 

“If you have one end of the ward where everybody's quite jolly, it really lifts the spirits of everybody. And it's very distracting. If you're sick in a room on your own and it's quiet and all you've got to think about is your pain, whereas if you've got distractions of people walking around, talking to you, it's a really good therapy.” S6 Nurse, surgical ward “Other patients will give somebody a boost, and they will talk to them [another patient] and they'll say, ‘Oh come on, try and eat a bit more’…that helps people a great deal, if somebody's there talking to them…If we've got two people who are reasonably well and they like a chat…we do try and juggle the beds around so that they're together, so that they can have a talk.” E2 Healthcare assistant, medical (older people) ward
Shared patient accommodation in an open ward
DisadvantagesStaff interview data
4. Inadequate physical space for patients/care
  • (i) Lack of space for staff to provide nursing care to patients emerged as a key constraint

  • (ii) Lack of space in toilets and showers made it difficult for staff to assist patients and created obstacles for patients attempting to mobilise independently

  • (iii) Problems created by lack of space included risk of musculoskeletal injuries, trip hazards and a perceived increase in time required to undertake tasks 

“You're banging into the next patient's chair or locker and stuff like that. It's really tight around the bed space, and .. when trying to get a commode in there you're fighting with everything really.” S4 Nurse, surgical ward When you want to hoist someone…it takes so much time, you've got to move the bed that side, you've got to move the [other furniture], you know. It's so, so much energy doing that, rather than if there was enough space, you just wheel it in, hoist your patient, take them away, and that's it.” E6 Nurse, medical (older people) ward
5. Poor physical spaces/facilities for staff
  • (i) Space at staff bases generally considered inadequate—limited space and poor access to the limited number of PCs and telephones

  • (ii)  Staff break rooms had limited facilities and no kitchen. Often dark, cold and shabby, and multipurpose, serving as meeting rooms as well as staff break rooms

  • (iii) Lack of staff toilets was problematic (particularly maternity and surgical wards), meaning staff often had to go away and return later to use facilities 

“You often have nurses sitting there, then you'll get physios and OT coming along, they might want to sit down and there's only one screen [PC] in the ward and that's really not enough, we need more screens to be effective because you're waiting to use the screen and so it would be useful to have more computer stations.” S1 Nurse, surgical ward “There are no sofas in it [staff room], as you can see [ ] people's bags and coats, and it's usually like a stock room…There's normally stuff piled…It's normally quite cold in here as well, it's got the old window.” M5 Student midwife, maternity ward “Toilet facilities are horrendous, one toilet for all of us, doctors, nurses, domestics—horrendous. So many times you walk up and there's somebody in there. ..[The] changing facilities…[are] totally inadequate, totally.… there's nowhere to change.” S6 Nurse, surgical ward
6. Poor privacy, sleep and rest for patients
  • (i) Staff were looking forward to improved privacy, sleep and rest for patients

  • (ii) Patients in the old accommodation were disturbed, for example, by general ward activity, or by other patients, which could create anxiety 

“On [the antenatal area], because you're doing sort of CTGs the whole time [ ] you can always hear like other peoples’ babies’ heartbeats going on… it's so noisy on there, whatever happens you can hear. Like the other day…someone delivered on the ward [because there wasn't enough time to get her to the Delivery Suite] and…The other women on the ward they were just sort of looking as if to say, ‘Is this really what it's going to be like?’ and so in that sense it's not good.” M5 Student midwife, maternity ward 
100% single rooms
AdvantagesStaff interview data
1. Privacy, dignity and confidentiality: more personalised patient care
Staff compared single rooms favourably with open-plan wards in relation to:
  • (i) Patients having their ‘own space’, including an en-suite bathroom and toilet, where personal care took place away from other patients

  • (ii) Allowing patients to sleep, rest and recuperate without disturbance

  • (iii) They could also better accommodate visitors.

  • (iv) Privacy was particularly valued for patients who were seriously or terminally ill and for their families

  • (v) Staff also reported less likelihood of interruption and distraction 

[I 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.” S16 Nurse, surgical ward “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. […]” 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—dietician “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-Healthcare assistant, MAU
2. Improved room design: improved care delivery
  • (i)  Improved working environment for delivering patient care and rooms described as modern, clean, spacious and safe

  • (ii) The en-suite facilities one of the most positive aspects, allowing nursing staff to more easily assist patients with personal care 

"[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.” S14—Healthcare assistant, surgical ward
3. Improved ward layout and design
  • (i)  Centralised ward support facilities (eg, clean and dirty utility, drug preparation room, kitchen) liked by staff

  • (ii) Secure ward entry system to allow patients and visitors to enter and exit (see also disadvantages)

  • (iii) Dedicated staff break rooms (on surgical ward and the older people ward) 

"The clinical room is a good size, much bigger than at the old hospital […] we've got lots of surface area, whereas before it used to get a little bit cramped, and we'd be getting confused and our drug charts muddled up. Now I think there's much more space to do things quickly and more effectively. S16—Nurse, surgical ward “We've got up to 30 patients, possibly confused, wandering; unless a member of the staff has opened the door, those patients are safe […] that's priceless really.” OP25—junior sister, older people ward “It's much cleaner, much tidier, somewhere to sit down and eat […] you've got access to fresh air which we didn't really have at the old place, so I think the staff areas are much nicer.” S14—Healthcare assistant, surgical ward
4. Perceived reduced risk of infection
  • (i) Staff anticipated that single rooms would reduce infection risk

  • (ii) New wards were perceived by staff to support good hygiene practices, with no-touch clinical hand washbasins in every patient room

  • (iii) Personal protective equipment and alcohol hand gel and antibacterial wipes were 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 

"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 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—Nurse, surgical ward
100% single rooms
DisadvantagesStaff interview data
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
  • MDT, multidisciplinary team.