NIHR Signal One size does not fit all – evaluating the move to a hospital with 100% single rooms

Published on 14 December 2015

This was a well-designed NIHR funded mixed methods evaluation of a move to a new build NHS hospital in England with 100% single inpatient rooms. The study found that while two thirds of patients preferred single rooms, a number reported feeling isolated. There were differences of opinions across groups, for example half of the men interviewed preferred open wards, while all of the women in the postnatal unit preferred single rooms. Only 18% of staff preferred 100% single room wards. Most were concerned that their ability to monitor patients was impeded and that they felt isolated from their colleagues. There was no clear evidence that safety outcomes, such as falls and hospital acquired infections, were impacted by the move. It was estimated that building a hospital with 100% single rooms may cost about 5% more than building one with 50% single rooms. They also had marginally higher housekeeping and cleaning costs.

One size does not fit all – evaluating the move to a hospital with 100% single rooms

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Why was this study needed?

There is an ongoing debate in the NHS on whether hospitals should provide all patients with single rooms. Single rooms arguably increase patient privacy, dignity and comfort and might allow staff more time with individual patients with fewer interruptions. They may also reduce medication errors and hospital infection rates, leading to cost savings because of reduced length of stay. However, potential disadvantages include patient isolation and an increase in falls and other negative outcomes due to less surveillance. Staff may also need to walk further to get to patients and thus actually not be able to spend as much time with them once they get there.

There has been little evidence to date on the impact of single room accommodation on quality and safety in the NHS. This evaluation study explored the impact of 100% single rooms on staff and patient experience, safety outcomes and costs.

What did this study do?

This was an evaluation of a move in 2011 from an NHS hospital that had predominately open wards to a newly built NHS hospital with 100% single inpatient rooms. The approach was a controlled before-after evaluation, using mixed methods, of the impact of this move. Four wards in the new hospital were chosen as case studies: the medical assessment unit, surgical, medical (older people) and maternity. Twenty-four ward staff and 32 patients were interviewed pre and post move. Ward observations, pedometer data, staff surveys and patient outcomes – including falls, medication errors and hospital-acquired infections – were also collected before and after the move. In addition, 20 pre and 21 post move interviews were conducted with senior managers and clinicians from across the trust, architects and staff managing the move.

Two control hospitals were tracked over the same period: one in which no move occurred and one that moved to a new build with an increase in single rooms (but not to 100%). The control hospitals were used to see if similar patterns were observed across two or more hospitals to help test whether any changes could be attributed to the move to 100% single rooms. Change in case-mix was also tracked before and after the move. Cost impact was assessed with an economic model that incorporated data collected on a range of factors including bed occupancy, cleaning costs, nurse staffing, length of stay and building costs.

The results from this before-and-after evaluation are a reliable contribution to the debate about single rooms in the NHS. The controlled design means it is unlikely that observed changes would have happened anyway and could be incorrectly attributed to the move to 100% single rooms.

What did it find?

Patient experiences:

  • Two-thirds of patients expressed a clear preference for single rooms. Single rooms were appreciated for the increased privacy (particularly the en-suite bathrooms), confidentiality and flexibility for visitors. All the women interviewed in the postnatal unit preferred single rooms.
  • A third of patients reported a lack of interaction with other patients as the main disadvantage of a single room.
  • One-fifth of patients, including almost half the men interviewed, said they preferred open wards. Open wards were appreciated for the security of being visible to staff and to other patients, resulting in a sense of camaraderie.
  • Overall, four main themes emerged from patient interviews: comfort, control, connection and isolation.

Staff experiences:

  • Less than one in five staff indicated a preference for 100% single rooms. Most staff said they would prefer a mix of single rooms and open wards.
  • Staff reported that single-rooms impeded their ability to monitor patients, especially those at risk of falls. It was felt that a lack of visibility of patients had contributed to an initial and temporary increase in falls in the new hospital (the investigators suggested that any increase could be explained by changes in case mix).
  • Similar to patients, nurses also sometimes felt isolated in the new setting. Information flow in nurse teams was perceived to be worse than before the move.
  • It was recognised that different strategies were needed to enable staff to divide their time between patients. However, this challenge had been left to individual nurses to resolve, mostly with limited success. This led to a sense of dissatisfaction.

Cost and other outcomes:

  • There was little evidence of any changes in safety outcomes. A temporary increase of falls and medication errors in the medical assessment unit was observed, but was put down to the need to adjust work patterns, rather than the introduction of 100% single rooms.
  • There was no evidence that single rooms reduced infection rates.
  • Staff walking distances increased by about 20% post move.
  • Economic analysis suggested that building a 100% single-room hospital may cost about 5% more than building a 50% single-room hospital. They also had marginally higher housekeeping and cleaning costs (an estimated increase of about 0.14% of annual budget). As no causal link could be made between single-bed rooms and changes in the rate of falls, the cost of falls was not included in the analysis.

What does current guidance say on this issue?

There is no current guidance on single rooms in the English NHS. In Scotland following consultation, the Chief Medical Officer has concluded that hospitals, with rare exception, should be developed with 100% single rooms in future.

Exceptions include existing accommodation which is being refurbished.  Here, the constraints of the existing building can be taken into account, but a minimum of 50% single room accommodation is allowed.  A business case is required for any new developments where there are clinical reasons for not making provision for 100% single rooms.

What are the implications?

While this evaluation did not find a causal link between the move to 100% single rooms and patient safety outcomes, such as falls, it remains possible that some people, such as the elderly, will be at greater risk. It is therefore important that changes in work practices and patient experiences should be monitored before and after any changes.

Managers planning a move to more single rooms should encourage staff to prepare and rehearse for working in their new environment, and review and reinforce infection control procedures and falls policies.

Wards with single rooms need to be designed in a way that can ensure that increased privacy and comfort for patients does not compromise staff’s ability to monitor them. The investigators suggest that a mix of accommodation that can be changed to adapt to patient needs, with sliding glass walls for example, may be a solution.

While two thirds of patients preferred a single room, a number of people preferred open wards. One size, it seems, does not fit all.

Citation

Maben J, Griffiths P, Penfold C, et al. One size fits all? Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience, safety and costs. BMJ Qual Saf 2015. [Epub ahead of print]

This project was funded by the National Institute for Health Research, Health Services and Delivery Research (Project number 10/1013/42).

Bibliography

Health Finance Directorate Scotland, Capital Planning and Asset Management Division. Provision of single room accommodation and bed spacing. Chief Executive Letter. Edinburgh: The Scottish Government; 2010

Pennington H, Isles C. Should hospitals provide all patients with single rooms? BMJ. 2013;347:f5695.

Ramsay AI, Fulop NJ. Why evaluate 'common sense' quality and safety interventions? BMJ Qual Saf. 2015. [Epub ahead of print]

Why was this study needed?

There is an ongoing debate in the NHS on whether hospitals should provide all patients with single rooms. Single rooms arguably increase patient privacy, dignity and comfort and might allow staff more time with individual patients with fewer interruptions. They may also reduce medication errors and hospital infection rates, leading to cost savings because of reduced length of stay. However, potential disadvantages include patient isolation and an increase in falls and other negative outcomes due to less surveillance. Staff may also need to walk further to get to patients and thus actually not be able to spend as much time with them once they get there.

There has been little evidence to date on the impact of single room accommodation on quality and safety in the NHS. This evaluation study explored the impact of 100% single rooms on staff and patient experience, safety outcomes and costs.

What did this study do?

This was an evaluation of a move in 2011 from an NHS hospital that had predominately open wards to a newly built NHS hospital with 100% single inpatient rooms. The approach was a controlled before-after evaluation, using mixed methods, of the impact of this move. Four wards in the new hospital were chosen as case studies: the medical assessment unit, surgical, medical (older people) and maternity. Twenty-four ward staff and 32 patients were interviewed pre and post move. Ward observations, pedometer data, staff surveys and patient outcomes – including falls, medication errors and hospital-acquired infections – were also collected before and after the move. In addition, 20 pre and 21 post move interviews were conducted with senior managers and clinicians from across the trust, architects and staff managing the move.

Two control hospitals were tracked over the same period: one in which no move occurred and one that moved to a new build with an increase in single rooms (but not to 100%). The control hospitals were used to see if similar patterns were observed across two or more hospitals to help test whether any changes could be attributed to the move to 100% single rooms. Change in case-mix was also tracked before and after the move. Cost impact was assessed with an economic model that incorporated data collected on a range of factors including bed occupancy, cleaning costs, nurse staffing, length of stay and building costs.

The results from this before-and-after evaluation are a reliable contribution to the debate about single rooms in the NHS. The controlled design means it is unlikely that observed changes would have happened anyway and could be incorrectly attributed to the move to 100% single rooms.

What did it find?

Patient experiences:

  • Two-thirds of patients expressed a clear preference for single rooms. Single rooms were appreciated for the increased privacy (particularly the en-suite bathrooms), confidentiality and flexibility for visitors. All the women interviewed in the postnatal unit preferred single rooms.
  • A third of patients reported a lack of interaction with other patients as the main disadvantage of a single room.
  • One-fifth of patients, including almost half the men interviewed, said they preferred open wards. Open wards were appreciated for the security of being visible to staff and to other patients, resulting in a sense of camaraderie.
  • Overall, four main themes emerged from patient interviews: comfort, control, connection and isolation.

Staff experiences:

  • Less than one in five staff indicated a preference for 100% single rooms. Most staff said they would prefer a mix of single rooms and open wards.
  • Staff reported that single-rooms impeded their ability to monitor patients, especially those at risk of falls. It was felt that a lack of visibility of patients had contributed to an initial and temporary increase in falls in the new hospital (the investigators suggested that any increase could be explained by changes in case mix).
  • Similar to patients, nurses also sometimes felt isolated in the new setting. Information flow in nurse teams was perceived to be worse than before the move.
  • It was recognised that different strategies were needed to enable staff to divide their time between patients. However, this challenge had been left to individual nurses to resolve, mostly with limited success. This led to a sense of dissatisfaction.

Cost and other outcomes:

  • There was little evidence of any changes in safety outcomes. A temporary increase of falls and medication errors in the medical assessment unit was observed, but was put down to the need to adjust work patterns, rather than the introduction of 100% single rooms.
  • There was no evidence that single rooms reduced infection rates.
  • Staff walking distances increased by about 20% post move.
  • Economic analysis suggested that building a 100% single-room hospital may cost about 5% more than building a 50% single-room hospital. They also had marginally higher housekeeping and cleaning costs (an estimated increase of about 0.14% of annual budget). As no causal link could be made between single-bed rooms and changes in the rate of falls, the cost of falls was not included in the analysis.

What does current guidance say on this issue?

There is no current guidance on single rooms in the English NHS. In Scotland following consultation, the Chief Medical Officer has concluded that hospitals, with rare exception, should be developed with 100% single rooms in future.

Exceptions include existing accommodation which is being refurbished.  Here, the constraints of the existing building can be taken into account, but a minimum of 50% single room accommodation is allowed.  A business case is required for any new developments where there are clinical reasons for not making provision for 100% single rooms.

What are the implications?

While this evaluation did not find a causal link between the move to 100% single rooms and patient safety outcomes, such as falls, it remains possible that some people, such as the elderly, will be at greater risk. It is therefore important that changes in work practices and patient experiences should be monitored before and after any changes.

Managers planning a move to more single rooms should encourage staff to prepare and rehearse for working in their new environment, and review and reinforce infection control procedures and falls policies.

Wards with single rooms need to be designed in a way that can ensure that increased privacy and comfort for patients does not compromise staff’s ability to monitor them. The investigators suggest that a mix of accommodation that can be changed to adapt to patient needs, with sliding glass walls for example, may be a solution.

While two thirds of patients preferred a single room, a number of people preferred open wards. One size, it seems, does not fit all.

Citation

Maben J, Griffiths P, Penfold C, et al. One size fits all? Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience, safety and costs. BMJ Qual Saf 2015. [Epub ahead of print]

This project was funded by the National Institute for Health Research, Health Services and Delivery Research (Project number 10/1013/42).

Bibliography

Health Finance Directorate Scotland, Capital Planning and Asset Management Division. Provision of single room accommodation and bed spacing. Chief Executive Letter. Edinburgh: The Scottish Government; 2010

Pennington H, Isles C. Should hospitals provide all patients with single rooms? BMJ. 2013;347:f5695.

Ramsay AI, Fulop NJ. Why evaluate 'common sense' quality and safety interventions? BMJ Qual Saf. 2015. [Epub ahead of print]

One size fits all? Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience, safety and costs.

Published on 26 September 2015

Jill Maben, Peter Griffiths, Clarissa Penfold, Michael Simon, Janet Anderson, Glenn Robert, Elena Pizzo, Jane Hughes, Trevor Murrells, James Barlow.

BMJ Quality & Safety (previously Quality & Safety in Health Care) , 2015

Background and objectives There is little strong evidence relating to the impact of single-room accommodation on healthcare quality and safety. We explore the impact of all single rooms on staff and patient experience; safety outcomes; and costs. Methods Mixed methods pre/post ‘move’ comparison within four nested case study wards in a single acute hospital with 100% single rooms; quasi-experimental before-and-after study with two control hospitals; analysis of capital and operational costs associated with single rooms. Results Two-thirds of patients expressed a preference for single rooms with comfort and control outweighing any disadvantages (sense of isolation) felt by some. Patients appreciated privacy, confidentiality and flexibility for visitors afforded by single rooms. Staff perceived improvements (patient comfort and confidentiality), but single rooms were worse for visibility, surveillance, teamwork, monitoring and keeping patients safe. Staff walking distances increased significantly post move. A temporary increase of falls and medication errors in one ward was likely to be associated with the need to adjust work patterns rather than associated with single rooms per se. We found no evidence that single rooms reduced infection rates. Building an all single-room hospital can cost 5% more with higher housekeeping and cleaning costs but the difference is marginal over time. Conclusions Staff needed to adapt their working practices significantly and felt unprepared for new ways of working with potentially significant implications for the nature of teamwork in the longer term. Staff preference remained for a mix of single rooms and bays. Patients preferred single rooms

Author commentary

This paper highlights the tensions between staff and patient experiences of 100% single inpatient rooms in an acute hospital. Lack of visibility of patients was of most concern to staff. Architects and designers who have read the research suggest they plan to design for maximum visibility in future builds. NHS readers also recognise the need to manage potential patient and staff isolation and support patients to meet each other. NHS and international managers planning a new build with an increase in single rooms have found the study invaluable regarding planning for increases in nurse staffing and for staff training and development to reinforce key policies such as infection control and to support staff to work differently. Internationally study tools are being used to evaluate similar builds in the Netherlands and Australia.

Professor Jill Maben, Professor of Nursing Research, King’s College London