The effect of ward design on the well-being of post-operative patients

Changes in the design of hospital wards have usually been determined by architects and members of the nursing and medical professions; the views and preferences of patients have seldom been sought directly. The Hospital Anxiety and Depression scale and the Disturbance Due to Hospital Noise questionnaire were administered to 64 female patients on bay and Nightingale wards together with a questionnaire designed for this study. Perceptions of social and physical factors of ward design were examined, and their relationship to psychological well-being and sleep patterns. The results show that the bay ward seemed to offer a more favourable environment for patients but some of the disadvantages of bay wards are balanced by better staffing levels and better and more modern facilities. Visibility to nurses was lower on the bay ward. The Nightingale ward was perceived as significantly noisier than the bay ward and noise levels were significantly correlated to anxiety scores. Paradoxically the increase in noise levels appeared to improve the perceived level of privacy on the Nightingale ward. Seventy-five per cent of patients were found to prefer the bay ward design, and since neither design appears to have major disadvantages their continued introduction should be encouraged. However, recommendations are made concerning the optimizing of patients' well-being within the bay ward setting.

Multifactorial influences on and deviations from medication administration safety and quality in the acute medical/surgical context

Background and Aims: Although numerous factors influence medication administration, our understanding of the interplay of these factors on medication quality and safety is limited. The aim of this study was to explore the multifactorial influences on medication quality and safety in the context of a single checking policy for medication administration in acute care.

Approach: An exploratory/descriptive study using non-participant observation and follow-up interview was used to identify factors influencing medication quality and safety in medication administration episodes (n = 30). Observations focused on nurses’ interactions with patients during medication administration, and the characteristics of the environment in which these took place. Confirmation of observed data occurred on completion of the observation period during short semi-structured interviews with participant nurses.

Findings: Findings showed nurses developed therapeutic relationships with patients in terms of assessing patients before administering medications and educating patients about drugs during medication administration. Nurses experienced more frequent distractions when medications were stored and prepared in a communal drug room according to ward design. Nurses deviated from best-practice guidelines during medication administration.

Implications: Nurses’ abilities and readiness to develop therapeutic relationships with patients increased medication quality and safety, thereby protecting patients from potential adverse events. Deviations from best-practice medication administration had the potential to decrease medication safety. System factors such as ward design determining medication storage areas can be readily addressed to minimise potential error.

Conclusions: Nurses displayed behaviours that increased medication administration quality and safety; however, violations of practice standards were observed. These findings will inform future intervention studies to improve medication quality and safety.

The 'dis-ease' of dying: challenges in nursing care of the dying in the acute hospital setting. A qualitative observational study

BACKGROUND: Changes in health care and an ageing population have meant that more people are dying in the acute hospital setting. While palliative care principles have resulted in quality care for the dying, many patients die in an acute care, still receiving aggressive/resuscitative care. AIMS: The aims were to explore nurses' 'recognition of' and 'responsiveness to' dying patients and to understand the nurses' influence on end-of-life care. DESIGN: A qualitative approach was taken utilising non-participant observation to elicit rich data, followed by focus groups and individual semi-structured interviews for clarification. SETTING/PARTICIPANTS: This study was conducted in two acute medical wards in one health service, identified as having the highest rates of death, once palliative care and critical care areas were excluded. Twenty-five nurses consented to participate, and 20 episodes of observation were conducted. RESULTS: Nurses took a passive role in recognising dying, providing active care until a medical officer's declaration of dying. Ward design, nurse allocation and nurses' attitude to death impacts patient care. End-of-life care in a single room can have negative consequences for the dying. Nurses demonstrated varying degrees of discomfort, indicating that they were underprepared for this role. CONCLUSION: When patients are terminally ill, acknowledgement of dying is essential in providing appropriate care. It should not be assumed that all nurses are adequately prepared to provide dying care. Further work is necessary to investigate how the attitudes of nurses towards caring for dying patients in the acute hospital setting may impact care of the dying patient.

Single-room usage patterns and allocation decision-making in an Australian public hospital: a sequential exploratory study

AIMS AND OBJECTIVES: The aims are to (1) measure occupancy rates of single and shared rooms; (2) compare single room usage patterns and (3) explore the practice, rationale and decision-making processes associated with single rooms; across one Australian public health service.

BACKGROUND: There is a tendency in Australia and internationally to increase the proportion of single patient rooms in hospitals. To date there have been no Australian studies that investigate the use of single rooms in clinical practice.

DESIGN: This study used a sequential exploratory design with data collected in 2014.

METHODS: A descriptive survey was used to measure the use of single rooms across a two-week time frame. Semi-structured interviews were undertaken with occupancy decision-makers to explore the practices, rationale decision-making process associated with single-room allocation.

RESULTS: Total bed occupancy did not fall below 99·4% during the period of data collection. Infection control was the primary reason for patients to be allocated to a single room, however, the patterns varied according to ward type and single-room availability. For occupancy decision-makers, decisions about patient allocation was a complex and challenging process, influenced and complicated by numerous factors including occupancy rates, the infection status of the patient/s, funding and patient/family preference. Bed moves were common resulting from frequent re-evaluation of need.

CONCLUSION: Apart from infection control mandates, there was little tangible evidence to guide decision-making about single-room allocation. Further work is necessary to assist nurses in their decision-making.

RELEVANCE TO CLINICAL PRACTICE: There is a trend towards increasing the proportion of single rooms in new hospital builds. Coupled with the competing clinical demands for single room care, this study highlights the complexity of nursing decision-making about patient allocation to single rooms, an issue urgently requiring further attention.

Ergonomics as authoritarian or libertarian: Learning from colin ward's politics of design

Ergonomics is intrinsically connected to political debates about the good society, about how we should live. This article follows the ideas of Colin Ward by setting the practices of ergonomics and design along a spectrum between more libertarian approaches and more authoritarian. Within Anglo-American ergonomics, more authoritarian approaches tend to prevail, often against the wishes of designers who have had to fight with their employers for best possible design outcomes. The article draws on debates about the design and manufacturing of schoolchildren's furniture. Ergonomics would benefit from embracing these issues to stimulate a broader discourse amongst its practitioners about how to be open to new disciplines, particularly those in the social sciences.

Evaluation of financial incentives as a quality improvement strategy in the public hospital context : clinician attitudes, design variables, and economic costs

In 2008, a three-year pilot ‘pay for performance’ (P4P) program, known as ‘Clinical Practice Improvement Payment’ (CPIP) was introduced into Queensland Health (QHealth). QHealth is a large public health sector provider of acute, community, and public health services in Queensland, Australia. The organisation has recently embarked on a significant reform agenda including a review of existing funding arrangements (Duckett et al., 2008). Partly in response to this reform agenda, a casemix funding model has been implemented to reconnect health care funding with outcomes. CPIP was conceptualised as a performance-based scheme that rewarded quality with financial incentives. This is the first time such a scheme has been implemented into the public health sector in Australia with a focus on rewarding quality, and it is unique in that it has a large state-wide focus and includes 15 Districts. CPIP initially targeted five acute and community clinical areas including Mental Health, Discharge Medication, Emergency Department, Chronic Obstructive Pulmonary Disease, and Stroke. The CPIP scheme was designed around key concepts including the identification of clinical indicators that met the set criteria of: high disease burden, a well defined single diagnostic group or intervention, significant variations in clinical outcomes and/or practices, a good evidence, and clinician control and support (Ward, Daniels, Walker & Duckett, 2007). This evaluative research targeted Phase One of implementation of the CPIP scheme from January 2008 to March 2009. A formative evaluation utilising a mixed methodology and complementarity analysis was undertaken. The research involved three research questions and aimed to determine the knowledge, understanding, and attitudes of clinicians; identify improvements to the design, administration, and monitoring of CPIP; and determine the financial and economic costs of the scheme. Three key studies were undertaken to ascertain responses to the key research questions. Firstly, a survey of clinicians was undertaken to examine levels of knowledge and understanding and their attitudes to the scheme. Secondly, the study sought to apply Statistical Process Control (SPC) to the process indicators to assess if this enhanced the scheme and a third study examined a simple economic cost analysis. The CPIP Survey of clinicians elicited 192 clinician respondents. Over 70% of these respondents were supportive of the continuation of the CPIP scheme. This finding was also supported by the results of a quantitative altitude survey that identified positive attitudes in 6 of the 7 domains-including impact, awareness and understanding and clinical relevance, all being scored positive across the combined respondent group. SPC as a trending tool may play an important role in the early identification of indicator weakness for the CPIP scheme. This evaluative research study supports a previously identified need in the literature for a phased introduction of Pay for Performance (P4P) type programs. It further highlights the value of undertaking a formal risk assessment of clinician, management, and systemic levels of literacy and competency with measurement and monitoring of quality prior to a phased implementation. This phasing can then be guided by a P4P Design Variable Matrix which provides a selection of program design options such as indicator target and payment mechanisms. It became evident that a clear process is required to standardise how clinical indicators evolve over time and direct movement towards more rigorous ‘pay for performance’ targets and the development of an optimal funding model. Use of this matrix will enable the scheme to mature and build the literacy and competency of clinicians and the organisation as implementation progresses. Furthermore, the research identified that CPIP created a spotlight on clinical indicators and incentive payments of over five million from a potential ten million was secured across the five clinical areas in the first 15 months of the scheme. This indicates that quality was rewarded in the new QHealth funding model, and despite issues being identified with the payment mechanism, funding was distributed. The economic model used identified a relative low cost of reporting (under $8,000) as opposed to funds secured of over $300,000 for mental health as an example. Movement to a full cost effectiveness study of CPIP is supported. Overall the introduction of the CPIP scheme into QHealth has been a positive and effective strategy for engaging clinicians in quality and has been the catalyst for the identification and monitoring of valuable clinical process indicators. This research has highlighted that clinicians are supportive of the scheme in general; however, there are some significant risks that include the functioning of the CPIP payment mechanism. Given clinician support for the use of a pay–for-performance methodology in QHealth, the CPIP scheme has the potential to be a powerful addition to a multi-faceted suite of quality improvement initiatives within QHealth.

Included by design : a case for regulation for accessible housing in Australia

Accessible housing is a scarce yet much needed commodity in Australia. A national agreement between industry and advocacy groups to a voluntary approach, called the Livable Design program, aims to provide access features in all new housing by 2020. Through a range of awareness raising initiatives, the program is anticipating increased supply by builders and increased demand by home-buyers. However the people who need accessible housing are the least likely and least able to buy it at the point of new sale and average homebuyers do not consider access features as a priority. This approach has not been successful overseas or in Australia in the past. Regulation with incentives supported by education and awareness has provided the best results, yet, regulation typically comes with controversy and resistance from the housing industry. A study is planned to identify how effective the Livable Design program is likely to be, what is likely to hinder it and why regulation is likely to be needed.

Livable housing design: Is it likely to work?

The need for accessible housing in Australia is acute. Both government and the community service sector recognise the importance of well designed accessible housing to optimise the integration of older people and people with disability, to encourage a prudent use of scarce health and community services and to enhance the liveability of our cities. In 2010, the housing industry, negotiated with the Australian Government and community representatives to adopt a nationally consistent voluntary code (Livable Housing Design) and a strategy to provide minimal level of accessibility in all new housing by 2020. Evidence from the implementation of such programs in the United Kingdom and USA, however, serves to question whether this aspirational goal can be achieved through voluntary codes. Minimal demand at the point of new sale, and problems in the production of housing to the required standards have raised questions regarding the application of program principles in the context of a voluntary code. In addressing the latter issue, this paper presents early findings from the analysis of qualitative interviews conducted with developers, builders and designers in various housing contexts. It identifies their “logics in use” in the production of housing in response to Livable Housing Design’s voluntary code and indicates factors that are likely to assist and impede the attainment of the 2020 aspirational goal.

Design and implementation of a virtual world training simulation of ICU first hour handover processes

Nursing training for an Intensive Care Unit (ICU) is a resource intensive process. High demands are made on staff, students and physical resources. Interactive, 3D computer simulations, known as virtual worlds, are increasingly being used to supplement training regimes in the health sciences; especially in areas such as complex hospital ward processes. Such worlds have been found to be very useful in maximising the utilisation of training resources. Our aim is to design and develop a novel virtual world application for teaching and training Intensive Care nurses in the approach and method for shift handover, to provide an independent, but rigorous approach to teaching these important skills. In this paper we present a virtual world simulator for students to practice key steps in handing over the 24/7 care requirements of intensive care patients during the commencing first hour of a shift. We describe the modelling process to provide a convincing interactive simulation of the handover steps involved. The virtual world provides a practice tool for students to test their analytical skills with scenarios previously provided by simple physical simulations, and live on the job training. Additional educational benefits include facilitation of remote learning, high flexibility in study hours and the automatic recording of a reviewable log from the session. To the best of our knowledge, we believe this is a novel and original application of virtual worlds to an ICU handover process. The major outcome of the work was a virtual world environment for training nurses in the shift handover process, designed and developed for use by postgraduate nurses in training.

Livable Housing Design : Who will take responsibility?

Current housing design and construction practices do not meet the needs of many people with disability and older people, and limits their inclusion and participation in community and family life. In spite of a decade of advocacy for regulation of access within residential environments, the Australian government has opted for a voluntary approach where the housing industry takes responsibility. Housing industry leaders have indicated that they are willing to transform their established practice, if it makes good business to do so, and if there is a demand from home buyers. To date, there has been minimal demand. In 2010, housing industry and community leaders formalised this commitment in an agreement, called Livable Housing Design, to transform housing design and construction practices, with a target of all new housing providing minimal access by 2020. This paper reports on a study which examined the assumption behind Livable Housing Design agreement; that is, individuals in the housing industry will respond voluntarily and take responsibility for the provision of inclusive housing. From interviews with developers, designers and builders in Brisbane, Queensland, the study found a complex picture of competing demands and responsibilities. Instead of changing their design and construction practices voluntarily to meet the future needs of users over the life of housing, they are more likely to focus on their immediate contractual obligations and to maintain the status quo. Contrary to the view of the government and industry leaders, participants identified that an external regulatory framework would be required if Livable Housing Design’s 2020 goal was to be met.

Livable housing design : the voluntary provision of inclusive housing in Australia

This paper reports on a study of the voluntary provision of inclusive housing. The impetus for the study is the Livable Housing Design initiative, an agreement among Australian housing industry and community leaders in 2010 to a national guideline and voluntary strategy with a target to provide minimum access features in all new housing by 2020. Situated in and around Brisbane, Australia, the study problematises the assumption that the housing industry will respond voluntarily; an assumption which this study concludes is unfounded. The Livable Housing Design initiative asks individual agents to consider the needs of people beyond the initial contract, to proceed with objective reasoning and to do the right thing voluntarily. Instead, the study found that interviewees focused on their immediate contractual obligations, were reluctant to change established practices and saw little reason to do more than was legally required of them. This paper argues that the highly-competitive and risk-averse nature of the industry works against a voluntary approach for inclusive housing and, if the 2020 target of the Livable Housing Design initiative is to be reached, a mandated approach through legislation will be necessary. The Livable Housing Design initiative, however, has an important role to play in preparing the Australian housing industry to accept further regulation.

Discharge practices for the intensive care patient : a qualitative exploration in the general ward setting

OBJECTIVE: To explore how registered nurses (RNs) in the general ward perceive discharge processes and practices for patients recently discharged from the intensive care unit (ICU). BACKGROUND: Patients discharged from the ICU environment often require complicated and multifaceted care. The ward-based RN is at the forefront of the care of this fragile patient population, yet their views and perceptions have seldom been explored. DESIGN: A qualitative grounded theory design was used to guide focus group interviews with the RN participants. METHODS: Five semi-structured focus group interviews, including 27 RN participants, were conducted in an Australian metropolitan tertiary referral hospital in 2011. Data analyses of transcripts, field notes and memos used concurrent data generation, constant comparative analysis and theoretical sampling. RESULTS: Results yielded a core category of 'two worlds' stressing the disconnectedness between ICU and the ward setting. This category was divided into sub categories of 'communication disconnect' and 'remember the family'. Properties of 'what we say', 'what we write', 'transfer' and 'information needs' respectively were developed within those sub-categories. CONCLUSION: The discharge process for patients within the ICU setting is complicated and largely underappreciated. There are fundamental, misunderstood differences in prioritisation and care of patients between the areas, with a deep understanding of practice requirements of ward based RNs not being understood. The findings of this research may be used to facilitate inter departmental communications and progress practice development.

The Lymphedema Evaluation in Gynecological cancer Study (LEGS): Design of a prospective, longitudinal, cohort study

Background The Lymphoedema Evaluation in Gynecological cancer Study (LEGS) was a longitudinal, observational, cohort study prospectively evaluating the incidence and risk factors of lower-limb lymphedema after treatment for gynecological cancer. Here we describe the study protocol and characteristics of the sample. Methods Women with a newly diagnosed gynecological cancer between June 1, 2008 and February 28, 2011, aged 18 years or older, and treated at one of six hospitals in Queensland, Australia, were eligible. Lymphedema was assessed by circumference measurements, bioimpedance spectroscopy, and self-reported swelling. LEGS incorporated a cohort of patients requiring surgery for benign gynecological conditions for comparison purposes. Data were collected prior to surgery and at regular intervals thereafter up to 2-years post-diagnosis. Results 546 women participated (408 cancer, 138 benign), with a 24-month retention rate of 78%. Clinical and treatment characteristics of participants were similar to the Queensland gynecological cancer population, except for a higher proportion of early-stage cervical cancers recruited to LEGS compared with Queensland proportions (89% versus 55%, respectively). Discussion Few imbalances were observed between participants with complete and incomplete follow-up data. The prospective design and collection of objective and patient-reported outcome data will allow comprehensive assessment of incidence and risk factors of lower-limb lymphedema.

Feasibility of a stepped wedge cluster RCT and concurrent observational sub-study to evaluate the effects of modified ward night lighting on inpatient fall rates and sleep quality: A protocol for a pilot trial

Background: Falls among hospitalised patients impose a considerable burden on health systems globally and prevention is a priority. Some patient-level interventions have been effective in reducing falls, but others have not. An alternative and promising approach to reducing inpatient falls is through the modification of the hospital physical environment and the night lighting of hospital wards is a leading candidate for investigation. In this pilot trial, we will determine the feasibility of conducting a main trial to evaluate the effects of modified night lighting on inpatient ward level fall rates. We will test also the feasibility of collecting novel forms of patient level data through a concurrent observational sub-study. Methods/design: A stepped wedge, cluster randomised controlled trial will be conducted in six inpatient wards over 14 months in a metropolitan teaching hospital in Brisbane (Australia). The intervention will consist of supplementary night lighting installed across all patient rooms within study wards. The planned placement of luminaires, configurations and spectral characteristics are based on prior published research and pre-trial testing and modification. We will collect data on rates of falls on study wards (falls per 1000 patient days), the proportion of patients who fall once or more, and average length of stay. We will recruit two patients per ward per month to a concurrent observational sub-study aimed at understanding potential impacts on a range of patient sleep and mobility behaviour. The effect on the environment will be monitored with sensors to detect variation in light levels and night-time room activity. We will also collect data on possible patient-level confounders including demographics, pre-admission sleep quality, reported vision, hearing impairment and functional status. Discussion: This pragmatic pilot trial will assess the feasibility of conducting a main trial to investigate the effects of modified night lighting on inpatient fall rates using several new methods previously untested in the context of environmental modifications and patient safety. Pilot data collected through both parts of the trial will be utilised to inform sample size calculations, trial design and final data collection methods for a subsequent main trial.

Healing gardens in the Lady Cilento Children’s Hospital: Reflections on benefits, preferences and design from bench diaries

Background Interest in the use of healing gardens in healthcare settings to provide therapeutic benefits is increasing, however insight is needed to determine whether patients, patient families and friends, and staff who spend time in these gardens use these in the manner for which they were designed, and experience the benefits suggested by broader research in this field. Objective(s) Visitors to four of the LCCH gardens have left comments in ‘bench diaries’ (visitors books). Analysis of these comments yields valuable insights into the use of the gardens, enabling reflection on the design intent and outcomes and guidance regarding how the gardens might be better utilised, as well as a basis for further investigation into the use and value of the gardens. Method(s) Comments have been coded and analysed using a thematic analysis approach to identify patterns relating to the reasons for which people appear to come to the healing gardens; benefits they appear to receive from spending time there; and features and aspects of the gardens that they appear to appreciate in particular. Only comments related to the gardens have been used in this analysis, with all comments being deidentified. Outcome/Conclusion Comments left in the Adventure Garden and Secret Garden bench diaries were used for the analysis, as Staff Garden and Babies Garden bench diary comments did not relate to the garden. There were no negative comments relating to the gardens, other than one comment requesting additional benches. The vast majority of comments expressed gratitude for the space. The four most frequently observed themes from the comments left in the Secret Garden Bench Diary indicated that they were seeking ‘time out’ from their experiences of being at the hospital, a desire for a ‘dose of nature’ (greenery, beautiful garden, etc), and fresh air, and that the garden space provided a restorative experience to them in some manner. Comments in the Adventure Garden Bench Diary related predominately to the view. Analysis of the comments emphasises the importance of gardens providing multi-sensory experiences that significantly differentiate the space from the hospital ward and provide visitors with a sense of being away, of peacefulness, and of familiarity with the outside world. Positioning gardens with prospect, and solar aspect, appears important in these regards, as does the presence of visible greenery. Adequate seating in locations that provide pleasing views appears particularly important for staff and adult visitors. Whilst comments in the Bench Diaries did not indicate direct awareness of the stress and anxiety-reducing effects that research elsewhere has found from viewing plants and nature, however these effects may underpin many of these experiences that visitors did share.