The impact of single occupancy rooms on workforce numbers

By Amina Jina, Laura Wilkes, Beverley Walsh, Gary Cole, Natasha Lewry & Colin Lewry.

Introduction

When designing a new hospital, teams are looking at improving patient care, customer service and efficiency.  These improvements need to be written into a business case if it’s going to get built. There is a long list of improvements that can be made – digital improvements like e-outpatients, internal efficiencies such as shifts to day surgery, movement of delivery out of hospital, etc.

Most of these interventions could be done without a new hospital – but a new build does create a chance to think about system, process, and digital change. Some changes, however, do need new buildings or amended estate: theatre estate redesign, hot & cold site re-organisations – and ward redesigns for example.

One of the ward redesigns that are now standard is the introduction of 100% single occupancy room, whereby patients are given separate private rooms as opposed to open bays with 4 or more patients within an open ward.

But what is the impact of introducing this redesign?  What evidence is there to support or challenge the single occupancy room developments in hospitals.

In this document, we consider the results of a publication review of the potential positives and negatives of single bed occupancy.

Positives

Single bed occupancy can have many positives for patients and staff, including improved infection control, privacy, noise reduction, and better rest.

A positive impact on infection control was seen by Bracco et al., 2007), cited by Kelly, R., Noelle Brown, D., and Mccance, T. (2018). “…reduction in healthcare-associated infections, with infection prevention and control [was] the major driver towards 100% single-room environment.” (2) If patients were separated in the actual environment, then infections across patients would decrease as there is a physical barrier between patients. Even though this would lessen the chances of infections crossing from patient to patient, it wouldn’t completely eradicate infections from passing as nurses and hospital staff could still pass infections from room to room.

Kelly, R., Noelle Brown, D., and Mccance, T. (2018) also found that patients “appreciated the privacy” (2). This led to behaviour changes as the privacy allows them to speak more freely. In turn, patient satisfaction increases due to healthcare staff knowing more about individual patient’s wants and needs. This was also found in an Australian case study by Cusack, L, et al. (2019), “Improving patient sleep and rest was also identified as a physical environment benefit to patients, as was more privacy for patients and their relative’ (1). In this case study, not only did they find single-rooms aided privacy for patients, but also allowed them to rest and sleep better improving patients comfort levels.

Sondergaard, S., Frederiksen, K., and Andersen, A., in “Learning by chance” highlighted that they had a positive impact on the education of student nurses as, ‘The student nurses' conditions for learning in single-room hospital design are associated with the values of the patient room as the patient's home during hospitalisation. It is evident that a hospital design with single-room accommodation influences several parameters for both the patients and staff.’ (3) Essentially a patient-centred approach is subconsciously learnt by students in a single bed occupancy – the environment in which the students are learning affects the outcomes of their education. If the physical environment is patient-centred then it promotes a specific way of working and learning within the workforce. “We conclude that the learning environment in a single-room accommodation setting promotes task-oriented practices where the patient is often a mediator of activities related to nursing care. The learning environment in single-room accommodation places increased demands on the students' ability to reflect on verbal instructions on nursing activities whenever the chance for reflection presents itself.” (5)

Negatives

However, there are negatives when it comes to single bed occupancy.  These including increased time walking between patients, reduced visibility of patients, increase in task-focused care, and a decrease in the visible presence of staff (3). These concerns were also voiced by Cusack, L, et al. (2019), who in an Australian case study raised issues of patient safety due to the decreased visibility between patients and staff. “The ability to see patients and be seen by patients was considered paramount. Nurses preferred working in bays as opposed to the single-rooms as this allowed nurses to continually observe patients.” (1). For some patients it is paramount that they are watched 24/7 due to impairment or risks. A quote from a nurse in an interview stated, “The only concern is about attending the patients because in the six bays it's very easy to look at the patients. Sometimes ... you are going to see one patient, but you can also see the other five patients at the same time, what they are doing or how they look ‐ nobody is having any problems or nobody has a fall.... So that's the only concern about a single room.” (1).

Kelly, R., Noelle Brown, D., and Mccance, T. (2018) found that even though patient satisfaction was increasing, the challenges of “interweaving of engagement, emotional support and the development of therapeutic relationships were still present.” (3) This change in the physical environment will mean that staff need to adapt to the changes and in the short-term this could be time consuming and ineffective. This came as a concern to many nurses, “The vulnerability of staff and patients in relation to systems and processes comes across in several papers (Maben et al., 2015; Nahas et al., 2016). The busy, process-driven environment of acute care can also be a challenging one in which to develop relationships, a key element of PcP (Bradley & Mott, 2013) regardless of the design.” (3) With these new processes that nurses and hospital staff have to adapt to, there is a concern for patient vulnerability and safety as they still need to be getting the same level if not a higher level of care even when this process is being integrated. That also shows that there is a concern for staff vulnerability, as new processes can take time to integrate themselves and staff adapting may take some level of attention off patients or other aspects of their job. (6)

A further study from Kelly, R. et al, revealed that “While there is a significant body of work relating to person‐centredness and the delivery of person‐centred practice, and the impact of the environment on care delivery, there appears to be limited evidence linking person‐centred practice, staff and patient experience and the single‐room environment.” (3)

There is evidence of an increase in costs associated with single occupancy rooms. Maben, J. et al. (2015) highlighted that, “… housekeeping and cleaning costs are higher…” (2)

Conclusion

There is no clear case for single occupancy rooms. There are many arguments supporting and challenging the use of single occupancy rooms in hospitals. Overall, single occupancy rooms do seem to be popular with patients as they receive more privacy and may be more inclined to meet their wants and needs. However, this comes with a cost. To improve the satisfaction of patients there will be a cost involved due to rises in budgets needed to supply these single occupancy rooms.

References

1.     Cusack, L, et al. (2019) ‘ Anticipated advantages and disadvantages of a move to 100% single-room hospital in Australia: A case study’ (Accessed: 23/10/2023)

2.     Health Services and Delivery Research, Vol 3, Iss 3 (2015) (Accessed: 21/10/2023)

3.     Journal of Clinical Nursing Jul2019; 28(13/14): 2369-2385. (17p). ‘The experience of person-centred practice in a 100% single-room environment in acute care settings – A narrative literature’. (Accessed:23/10/2023)

4.     Journal of Clinical Nursing (John Wiley & Sons, Inc.) Oct2022: 31(19/20): 2921-2934. (14p).’Owning the space – person-centred practice in a 100% single-room acute-care environment: an ethnographic study’ (Accessed: 20/10/2023)

5.     Nurse Education in Practice (NURSE EDUC PRACT), Jul2023; 70: N.PAG-N.PAG. (1p) (Accessed: 24/10/2023).

6.     Walker, D. (2019) ‘Challenging the culture of caring of 100 years: the evidence behind single-room provision in hospitals.’ (Accessed: 26/10/2023).