Last month saw the publication by the NIHR of the final report on our study evaluating England’s first 100% single room hospital at Pembury, part of the Maidstone and Tunbridge wells trust, which opened in 2011 (1).
Reflecting on the specific issue of ‘single rooms’ raised many questions and the study highlighted how important the hospital space is to delivering, and experiencing, fundamental care. My own focus on the study was to look for impact on a range of measures that had been identified as potential benefits (or otherwise) of single rooms.
Control of infection had been a major part of the rationale for building the hospital as all single bedrooms. However, we found no evidence of any improvement in infection rates that could be attributed to the new hospital design. The national trend of a rapid decline in hospital associated infections preceding the move was reflected in the data we saw, but no further improvements seemed linked to the move. In fact the only substantive finding was a transient increase if c. difficile infection shortly after the move. While it is not clear that this was directly linked it did illustrate our overall conclusion about infections.
While single rooms clearly play a key role in managing some patients 100% single rooms are neither necessary nor are they sufficient as a solution.
This was amplified by some of our qualitative findings which showed that there was a need to re-emphasise good infection control practice because the single rooms seemed to divert staff attention from basic precautions.
More interesting was the issue of falls. Before our study, it had been argued that the less cluttered space in the rooms might lead to fewer falls although others worried about increased risk because of less surveillance. After the move staff were certainly concerned about their ability to monitor patients and there was an increase in falls that was attributed to the single rooms. However looking in more detail it seemed that the increase in falls in the hospital might have been linked to a significant change in the group of patients cared for. While we saw a temporary increase on one ward other changes seemed consistent with a change in the underlying risk. However, this does not change the fact that staff did feel challenged to provide adequate surveillance for patients at risk of falls and medical deterioration. Certainly, staff had to change their working practices.
From a patient perspective, while most ultimately preferred the single room there was a clear concern about isolation, both from the staff and other patients. Staff too felt disconnected from their colleagues and felt that their ability to work as a team was impaired.
These widespread issues for ‘basic’ nursing care, raised by the issue of single rooms, brings to mind Florence Nightingale’s early preoccupations with hospital design. While much of the work of the CLAHRC on fundamental care focusses on the workforce and immediate interactions between staff and patients, this study was a timely reminder of the complex interactions between fundamental care and the hospital itself.