modernising a & e environments - wales
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Modernising A & E Environments
2004
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Modernising A&E environments
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Improving the Patient Experience: Modernising Environments inA&ENHS Estates
Emergency Care Leads, Modern Matrons
24 Mar 2004
Directors of Nursing
This document gathers examples of national best practice in order to show how improvements can be made to the patient's experience of A&E.
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None for information only
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Peter Wearmouth
NHS Estates
0113 254 7000
Trevelyan Square
LS1 6AE
Boar Lane, Leeds
Modernising A&E environments
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First published 2004
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Across the NHS front-line staff are working to improvethe patient’s experience. They are involved in projectsboth large and small which explore ways in whichenvironmental improvements can impact on the patient.
This booklet shows the results of some of that work.Using practical examples it offers useful advice to allthose who wish to make a positive difference to howpatients experience the Accident & Emergencydepartment.
Patients’ feelings about their surroundings can make a significant difference to the way they react to theirexperiences. Where the environment is well cared-forand clean, patients feel valued and respected and theyrespond accordingly. A&E becomes a better place towork, and a better place to be treated.
A&E units face unique difficulties. The range of patientsattending is hugely varied – children, adults, olderpeople – and all have their individual needs andconcerns. The people who attend are often in pain andunder stress. Sometimes their lives or the lives of thosethey care about are threatened; sometimes they aresuffering from confusion or intoxication. The A&Edepartment faces real challenges as it tries to meeteveryone’s needs and provide an equally high-qualityservice to all.
This booklet is an invaluable source of solid andevidence-based guidance on how to make realimprovements to the experience of thousands of staffand millions of patients. We hope you make full use of it.
Foreword
Peter WearmouthChief ExecutiveNHS Estates
Jonathan AsbridgePatient Champion for Accident & EmergencyPresident of the Nursing and Midwifery Council
Introduction page 3
What this document is forHow the document is structuredSources of further information
The importance of the environment page 4
Benefits of improving the environment
Arrival page 6
Reception
Improving seating areas page 8
Positive distractionHeritage and cultureOther distractionsCommunication and informationMeeting specific needsGood practice
Treatment page 16
Viewing
Work already under way page 18
Conclusion page 19
Sources of further information page 20
ContactsOrganisationsWorks referenced in the textSources of supplementary information
Contents
1
WHAT THIS DOCUMENT IS FOR
This document shows some of the creative ways inwhich Accident and Emergency departments across theNHS are meeting the challenges they face. It is notcomprehensive or prescriptive but offers advice basedon the practical experience of NHS staff.
HOW THE DOCUMENT IS STRUCTURED
This document follows the patient s journey as they progress through the Accident & Emergencydepartment. It examines recent research findings,explores the implications for A&E departments and citesexamples of good practice already in use in trusts.
Some of the ideas are from other areas of the hospitalbut they are all relevant to A&E.
While some of the schemes featured here are far largerthan can be accomplished within the allocation, they allcontain elements that can be adapted to meet localneeds. Sometimes very small changes can create asignificant impact on the patient s experience.
SOURCES OF FURTHER INFORMATION
The Sources at the end of the document detail furthersources of information and contact points. It is hopedthat they will provide a useful starting point for thoseinterested in making a positive difference to the patientenvironment in Accident and Emergency departments.
3
Introduction
Recent research evidence shows us that ourenvironment affects us both physically and emotionally.The ideas presented here show how we can use thisknowledge to improve both the patient experience andhealthcare outcomes.
The environment plays a tremendous part in creating a positive first impression, and can help to create arelaxing ambience. We know that patients base theiropinion of the care that they receive on factors that they can understand, and this includes cleanliness anddesign. If a space is dirty, neglected and un-cared for, itsuggests that staff morale is low and leads patients toworry that the care provided may not be of a highquality.
Research shows us that when we are ill and in pain wetend to choose negative interpretations where themessage is ambiguous.1,2
The application of this knowledge to A&E departmentsis clear – spaces should be unambiguously welcomingand supportive.
Drawing upon current research, we can:
• select artwork which is intended to promote positiveemotions;
• use lighting and sound to soothe and calm anxiouspatients;
• use innovative design to challenge preconceivedideas and traditional standards.
Good design can bring significant improvements in arange of issues from staff morale to the reduction ofviolence, but most importantly it can improve the patientexperience and consequently patient outcomes.
MODERNISING ACCIDENT & EMERGENCY ENVIRONMENTS
4
The importance of the environment
1 Ulrich, RS, Emotional Congruence Theory Reflected In
Art Responses In A Psychiatric Ward, 1986.
2 Ulrich, RS, Lunden O and Eltinge, JL, Effects of Exposure to
Nature and Abstract Pictures on Patients Recovering from
Heart Surgery. Paper presented at 33rd meeting of the
Society for Psychophysiological Research, Rottach-Egern,
Germany. Abstract published in Psychophysiology, 30
(Supplement 1), p 7.
Hillingdon Hospital NHS Trust has quite literally embedded thethemes of patient welcome into its hospital, incorporating the
word itself in the flooring in front of the reception desk.
BENEFITS OF IMPROVING THE ENVIRONMENT
Patients have very clear ideas about what they wouldlike to see and how they would like to be treated whenthey come into an A&E department. Market researchhas shown that many visitors feel a poorly-maintainedbuilding is not consistent with high-quality healthcare,and they tell us that improvements in the physicalenvironment make them feel more positive about thecare they are likely to receive.
Patients tell us they would like to see:
• a good standard of cleanliness;
• comfortable seating;
• no graffiti, litter or vandalism;
• appropriate colours on walls;
• adequate lighting;
• practical floor coverings;
• drinks machines available;
• electronic information screens;
• hygienic and safe play areas for children.3
Providing an attractive environment can create avirtuous spiral, and improve the relationship between
patients and staff in a department where this is oftenunder strain. In a clean, tidy, well-decorated and suitablylit space, patients’ perceptions are increasingly positive.
They report:
• feelings of calmness and wellbeing;
• feeling more respected and valued;
• feeling that they are seen as individuals rather than asa mass group;
• receiving better treatment and having a betterexperience;
• feeling less stressed.
It is not only patients who benefit from improvements tothe environment. Staff also report more constructiveemotions about the organisation, patients and theenvironment.
They say they experience:
• improved morale and motivation;
• higher expectations of patients and each other;
• feeling more professional;
• feeling more valued.
THE IMPORTANCE OF THE ENVIRONMENT
5
3 Unpublished MORI research for the Department of Health,
2002
Children’s seating at Great Ormond Street Hospital
Patients come to A&E because they feel that somethingis seriously wrong – they are already under stress.
They must be able to find the help they need as easilyas possible to give them a measure of control over whatis happening to them.
The environment can play a key part in helping them tokeep control. It can help them understand where theyneed to go next. And it should tell them when they havearrived there.
It is not just a question of clear and relevant signage; art and design can also play a significant role in helpingvisitors identify where they are.
Spaces can be distinguished by various means:
• graphic – colours, images (patterns on floor directingto desk for example), artworks/architectural features,text;
• tactile – different finishes in public and privatespaces – for example knurled door knobs;
• audible – announcements, sound clues provided bydifferent surface finishes, running water etc.
West Middlesex Hospitals NHS Trust
The Enhancing the Healing Environment project wasfunded by the King’s Fund to enable hospitals to lookat ways of improving the environment in a patient area. West Middlesex Hospitals undertook arefurbishment of four elderly wards and a bleak linkcorridor, totally changing the look of theaccommodation.
Local artists were commissioned to produce artworksrelating to the local environment, including a tapestryof the Kew pagoda from a local sewing group. Theartwork helps to place the hospital within its localsurroundings and creates landmarks around whichpeople can orient themselves.
Epsom & St Helier NHS Trust
The imaginative use of patterns cut into vinyl flooringand playful decor helps children visiting the A&E findtheir way to the dedicated waiting area.
MODERNISING ACCIDENT & EMERGENCY ENVIRONMENTS
6
Arrival
A patient arriving at Royal Preston Hospital
Epsom and St Helier’s bright andcheerful paediatric area
RECEPTION
Once the patient has arrived at reception, the spacethat they enter should be welcoming and reassuring.Making a good impression is a key factor in the way thatpatients behave while they are in A&E.
This welcoming effect can be achieved in a variety ofways:
• use of light neutral colours;
• inclusion of plants;
• accessibility of staff;
• using a human scale.
The design of the reception desk needs carefulconsideration. It can provide either an open andwelcoming point of contact with staff which reassuresand includes the visitor; or it can be a harsh, divisiveand alienating barrier. Grilles and screens can causegreater stress in patients who are already feelingvulnerable.
However, it is not simply enough to say that a receptiondesk should be open; we need to consider the securityof the staff working at the desk. Their safety should beparamount, and therefore the design should incorporatefeatures that meet these needs.
Purchases do not have to be expensive to make animpact. Sometimes it is the small things that can makea difference. Many of the visitors who arrive at A&Edepartments are brought by relatives, often in a car, andwhere an injury is acute or the patient is frail it can bedifficult to extract them. Funding could be used topurchase an “out of car” kit such as the one used atMid-Yorkshire Hospitals. This simple slide enablespatients to be assisted out of the car with minimum lossof dignity.
Epsom and St Helier NHS Trust
Taking its inspiration from corporate reception areas,the reception desk at Epsom Hospital was designed to be open, but made deep to discourage physicalabuse to staff. This has encouraged the receptioniststo take greater control and responsibility for thetidiness of the waiting area. Staff suggested thatpatients have shown greater respect for theenvironment now that it is more attractive and ordered. Two years on from its installation, the arearemains bright, attractive and un-vandalised.
Royal Wolverhampton Hospitals NHS Trust
At Royal Wolverhampton Hospitals the emergencyteam is ably assisted by the multi-skilled support staffwho form an invaluable part of the emergency team.
ARRIVAL
7
The artwork behind the reception desk at St George'sHealthcare NHS Trust cleverly includes an engraved mirror to deter people from violent behaviour at the desk
Trained in CPR techniques support workersassist in arrest situations, have
responsibility for ensuring that oxygen andair are ready for emergency situations, are
involved in plastering fractured limbs andare part of the team involved in
decontamination after a major incident
There are many initiatives to reduce the amount of timepatients spend in A&E. However, it is possible thatwaiting for treatment will be part of many visitors’experience of A&E. It is during this time that anxiety andstress levels can rise.
Healthcare workers in the UK face a far higher risk ofviolence from patients/clients than that faced by otherservice workers,4 and this risk rises further for staffworking in accident and emergency units. Recentresearch on why patients become violent andaggressive in healthcare settings has looked not only atthe patients themselves but also at the contribution theirsurroundings make.5 Increased levels of humanaggression have all been linked to:
• hot temperatures;
• high humidity;
• extreme cold;
• poor lighting;
• poor air quality;
• high noise levels;
• crowding.6
Put simply, an uncomfortable and stressful environmentmakes patients and visitors stressed and increases thepotential for violence. It follows, therefore, that acomfortable and relaxing environment will reduce thepotential for violence, and that any effort made toimprove the comfort and ambience of the waiting spacewill provide significant benefits across a wide range ofmeasures.
Research has shown that traditional seating plansarranged along the side of the room or in rows acrossthe centre inhibit communication between patients andvisitors. Comfortable, moveable furniture arranged insmall flexible groupings increases the sense of intimacyand levels of interaction and support, reducing stress forpatients and visitors.
MODERNISING ACCIDENT & EMERGENCY ENVIRONMENTS
Improving seating areas
4 Elliot, P (1997), “Violence in Healthcare: What Nurse
Managers Need to Know”, Nursing Management, 28, 12,
pp 38–41.
5 Leather, P, Workplace Violence in the Health Sector:
Scope, Definition and Global Context.
6 Neuman, JH and Baron, RA (1998), “Workplace Violence
and Workplace Aggression: Evidence Concerning Specific
Forms, Potential Causes and Preferred Targets”, Journal of
Management, 24, pp 391–419.
8
Where safety considerations mean that moveableseating is not appropriate it is possible to createrelaxed informal spaces through the use of fixed
seating arranged in smaller intimate groupings usingcurves and softer angles as here
at Hillingdon Hospital
Changes in the design of the A&E seating area atEpsom have seen a significant decrease in the levels of
aggression displayed by clients
POSITIVE DISTRACTION
If patients find the seating area a pleasant andcomfortable place to be, they are less likely to becomeagitated during their visit.
One way in which the waiting experience can beimproved is by providing patients with distractions.Research finds several specific sources of distractionsuch as happy smiling faces, presence of pets orunthreatening animals, and nature elements such astrees, plants and views of nature which have a positiveeffect on patient behaviour and physiology.
These can be provided in a variety of ways:
• representational artworks;
• inclusion of planting as an integral part of the décorof the department;
• use of colours specifically associated with nature,predominantly greens and blues.
Recent research has focused on the capacity of plantsto affect how we see the spaces in which we findourselves. Increasing evidence shows that plants andimages of nature create specific physiological responsessuch as reduced blood pressure and increasedconcentration in those who view them.
Many NHS trusts, realising the therapeutic value ofnature, have created tranquil garden spaces as anintegral part of the landscaping of the hospital. Fewerhave yet explored the potential of significant interiorplanting to any great extent.
However, recent research has suggested that thepresence of plants can positively affect our ability totolerate temporary pain. The implications of this workare significant. Not only can plants contribute to thesense of calm welcome which is so necessary instressful and sensitive situations, but their presence mayalso increase the tolerance of patients suffering mild tomoderate pain.7
IMPROVING SEATING AREAS
9
7 Lohr, VI and Pearson-Mimms, CH (2000), “Physical
Discomfort May be Reduced in the Presence of Interior
Plants”, HortTechnology, 10 (1), pp 53–58.
Local artist John Sirkett transformed a dull and windowlesscorridor at Royal Bolton Hospital into a pleasant waiting space
much appreciated by visitors
Generous planting softens the strong architectural lines in thebridge over the atrium at Thomas Guy House, part of the Guy’s
and St Thomas’ Hospital Trust
HERITAGE AND CULTURE
Art in any form can be a useful means of providingpositive distraction.
However, not all art is appropriate for every space.Research shows us that works based on or depictingnature are most effective as therapeutic tools.
Sensitively selected art can make people feel welcome.It can promote cultural connections by makingreferences to local traditions, landmarks and well-knownlocal figures. It can personalise spaces, creating ahuman dimension and reducing some of the alienaspects of the hospital setting.
By presenting pictorial and written records of thehospital and people associated with it, a display canplace the hospital within the community.
The design and decoration of the space should becareful to reflect the diversity of the clientele.
Art does not have to be a specific work, that is, apainting or sculpture – it can be an imaginative use ofmaterials; for example, stained glass screens can beused to provide privacy to waiting patients but also offera sense of connection to the space outside.
Innovative use of new technology can also be used toenhance the patient experience. Recent work withprojections and digital simulations has shown that theyhave a role to play, creating imaginative effects andoffering the opportunity to create new and imaginativeways of improving the patients’ environment.
OTHER DISTRACTIONS
Not all sources of positive distraction are visual.Research shows that we notice noise more when itsorigin is unfamiliar to us. When we visit the A&Edepartment, many of the sounds are strange anddisturbing to us.
Repeated research tells us that music can play animportant part in the reduction of agitation andaggression. Although few NHS trusts yet utilise this inA&E, there are indications, where it has been used, thatit has an effective role to play in the reduction ofviolence and the improvement of the patients’experience.
Bolton Hospitals NHS Trust
Bolton Hospitals took an innovative approach to thecreation of a soothing yet interesting space in A&E.Drawing upon research that demonstrated theeffectiveness of music in reducing agitation, theyinstalled a digital calming music and messagingsystem. This provides calming background music anddelivers important information in a professional andunobtrusive way. The music is based upon that used in relaxation therapy and is intended to provide aneutral and soothing alternative to silence.8,9,10,11 Thishas been extremely successful. They have experienceda noticeable decrease in the number of violentincidents.
“We are able to impart important information topatients, which assists staff in the day-to-day running of the department. The system is anextremely useful means of calming the more excitable patients, and the relaxing music makes for a more tranquil atmosphere.” Adel Girgis, Consultant, Accident & Emergency,Royal Bolton Hospitals
Other ways to provide positive distraction can be assimple as the provision of reading material and otherforms of entertainment.
MODERNISING ACCIDENT & EMERGENCY ENVIRONMENTS
10
At Royal Bolton Hospitals NHS Trust original stained glass fromthe first Bolton Dispensary has been incorporated into newimages in the main foyer. Continuously illuminated, the imagesprovide a bright and cheerful distraction that refers back to theorigins of the town’s healthcare
8 Tabloski, PA, McKinnon-Howe, L and Remington, R (1995),
“Effects of Calming Music on the Level of Agitation in
Cognitively Impaired Nursing Home Residents”, American
Journal of Alzheimer’s Care and Related Disorders,
Jan/Feb.
9 Austine, P and Hains, AA, “Effect of Music on Ambulatory
Surgery Patients’ Pre-Operative Anxiety”, AORN Journal, Vol
63 No 4, 1996.
10 Denny, A, “Quiet Music: An Intervention for Meal Time
Agitation”, Journal of Gerontological Nursing, Vol 23 No 7,
1997.
11 Cunningham, MF, Monson, B and Bookbinder, M,
“Introducing a Music Programme in the Peri-operative
Area”, AORN Journal, Vol 66 No 4, 1997.
Chelsea & Westminster Hospitals NHS Trust has beenthe host of a recent research study into the effect of liveperformance on staff and patients in the hospital. Thestudy showed that live performances of music inparticular have a beneficial effect upon the morale andstress levels of both patients and staff.12
St George’s Healthcare NHS Trust
At St George’s Healthcare the trust created a genuinesense of community involvement with art projects runat a local primary school and displayed in the waitingarea. To support this sense of community andbelonging, the local Young Offenders Unit wereinvolved in a photographic project. Reflecting currentresearch, the images were of a local scenic river walkwhich many visitors would already know.
The community theme was continued by a partnership with the local museum which provides adisplay of relevant artefacts and documentation that ischanged on a three-monthly basis.
IMPROVING SEATING AREAS
11
12 Staricoff, RL, Duncan, J, Wright, M, Loppert, S and Scott,
J, “A Study of the Effects of the Visual and Performing Arts
in Healthcare”, Hospital Development, Vol 32, June 2000.
Great Ormond Street Hospitals NHS Trust takes illusion a stagefurther: projections of digital images on the ceiling create a
shifting impression of a summertime sky that changes to reflectthe time of day
The display case at St George’s Healthcare
Ealing Hospitals NHS Trust
Ealing Hospitals NHS Trust have used a mezzaninelevel in the main reception to create a reflective galleryspace featuring images of local sites and communityevents. Continuing the theme of involvement, corridors in the main hospital display photographs ofstaff throughout the trust “at work”.
Epsom & St Helier NHS Trust
At Epsom Hospital, staff have experienced fewerincidents of violence and aggression in the newly-refurbished A&E waiting area. It was designed withsoothing colours, mood lighting, and a sense of beingconnected to the outside through the use of decorative glass blocks. Seating in the small spacewas imaginatively arranged, avoiding institutional rowsof seats.
Gateshead Health NHS Trust
Following a suggestion by the newsagent alreadyoperating within the hospital, and in conjunction withlocal newspapers, Gateshead Health has allowed a local newspaper company to install a dispensingmachine. Visitors to the department now have accessto a means of distraction during their wait. Two papers are on offer, and are dispensed on insertion of the required sum. The newsagent maintains themachine, and their contact number is supplied on themachine itself.
MODERNISING ACCIDENT & EMERGENCY ENVIRONMENTS
12
A patient uses the newspaper dispenser at Gateshead Health NHS Trust
The decorative glass blocks at Epsom and St Helier NHS Trust
COMMUNICATION AND INFORMATION
Without adequate information about waiting times andtheir position in the queue, it is easy for patients tobelieve that they have been overlooked. Market researchshows that people feel that being provided with accessto more information would make their visit to A&E better.
The information which patients report that they needfalls into two main categories: that relating to waitingtimes,13 that is,
• initial expected waiting times;
• changes to expected waiting times (particularlyextensions);
• reasons for the changes (for example, intake ofserious Road Traffic Accident);
• their condition and its priority in the queue;
and information on possible treatment:
• minor injuries;
• alternatives to A&E (where could they go instead?);
• what they can expect to happen to them.
Brighton & Sussex University Hospitals NHS Trust
Talking multi-lingual signs relay information in anaudible, verbal format and provide the sameinformation as signs for members of both the non-English-speaking and visually impaired communities.
Brighton and Sussex Hospitals have recently installeda multi-lingual talking sign in the A&E department atthe Royal Sussex County Hospital in Brighton. Thisuses five major European languages, to provide visitors with information on things they need to know. It is programmed with the location of the toilet facilities, where to find refreshments, and how to get to other areas of the hospital, as well as givinginformation on the Patient Advice and Liaison Service(PALS), volunteer activities and the WRVS. It can beset to periodically announce, “I am a talking sign.”
IMPROVING SEATING AREAS
13
13 Hui, MK and Tse, DK, What to Tell Customers in Waits
of Various Lengths: an Integrated Model of Service
Evaluation.
A patient at the Royal Sussex CountyHospital uses the newly installed
system
MEETING SPECIFIC NEEDS
Patients arrive at A&E for many reasons from a simpleminor injury to significant trauma. Different patientgroups do not always mix well. Research showsconsiderable patient support for the provision of discretewaiting areas in which specific types of patient may beaccommodated.14
There has been particular concern about the effects onchildren of late-night visits when the department may bedealing with drunken or drugged patients. As aresponse to this need, many trusts have providedimaginative, well-designed, dedicated paediatric facilitiesin waiting areas.
Typically these projects select a theme which, throughinterior decoration and paintings on the walls and doors,creates an entire fantasy world, and enables stressedand bored children to “escape” from the reality of theirvisit to hospital.
GOOD PRACTICE
Addenbrooke’s NHS Trust
When Addenbrooke’s Hospital undertook a significantrefurbishment of its A&E department it drew on thewishes of local people, the experiences of a trust team who had recently visited America to view similarschemes, and the input of Kay Sowden, a localdesigner who had previously worked with the trust.
The river theme selected picks up on the localfondness for the Cam, with sweeping curves and fishdetails cut into the vinyl flooring. This theme is alsocapable of modification to reflect changes in functionsuch as the dedicated paediatric area which isreached by following “Fergus the frog” along the floor.This surprisingly low-cost option was cut into the vinylflooring by the contractor on site. The area contains six dedicated cubicles each with its own box of toysfor distraction, a segregated waiting area with a rangeof activities, and a play specialist in attendance. Theattention to detail in this area is reflected in the factthat even the signs on the toilet doors have a childlikequality.
MODERNISING ACCIDENT & EMERGENCY ENVIRONMENTS
14
Fergus “guides” children to the dedicated Paediatric area
14 MORI survey
Central Manchester/Manchester Children’sUniversity Hospitals NHS Trust
LIME is an arts in health organisation based at CentralManchester and Manchester Children’s University NHS Trust. Commissioned artists have created animaginative “emergency starship” scheme intended tocreate interest and diversion for children undergoingemergency treatment. Wall, ceiling and floor featuresengage the children, helping to reduce the fear theyhave of the hospital setting, creating talking points fortheir families and staff, and assisting in assessment ofthe child's illness.
Trusts are becoming increasingly aware of theindividual needs of the different groups which attendA&E, for example teenagers. No longer children butnot yet completely adult, teenagers require facilitieswhich provide the different distractions needed.Providing relaxed spaces which incorporate referencesto teenage culture through decor, activities such asgames consoles and relevant health information is oneway to achieve this.
Of course, it is not only different age groups which have specific needs; in some cases the nature of thecondition treated may require a specific environmentwhile the patient waits for treatment.
Many psychiatric patients enter the mental healthsystem via the A&E department, and these patientsrequire quite specific facilities. Assessment roomsshould be well lit, and decorated in quiet, calmingcolours. Any additional decoration provided shouldreflect the need to reduce distraction and over-stimulation for manic and psychotic patients. Indeed,whereas other patient areas benefit from images ofpeople’s faces and pets, these images would be mostunsuitable for a space set aside for psychiatricassessment.
Not all cultures share the same aesthetic, and thevalues of different ethnic groups should be consideredwhen choosing a design or commissioning artwork.
Gateshead Health NHS Trust
Forming links with their local Jewish community(Gateshead has an established and growingcommunity of observant orthodox Jews), the staff atthe A&E department have initiated a unique service.Assisted by Hatzola (a Jewish community first aidorganisation), the A&E staff have a “Sabbath box”containing appropriate kosher foods and religiousequipment for the use of those people who spend anylength of time waiting in the A&E on the Sabbath.
IMPROVING SEATING AREAS
15
St George’s Healthcare NHS Trust hascreated a relaxing assessment room forpsychiatric patients. Using a calmingshade of lilac and simple decor thetrust have created a soothing ambiencethat assists assessment
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As is right in treatment spaces, emphasis is traditionallyplaced on issues of accessibility, functionality andefficiency. Yet it is in this part of the department that the patient can feel at their most vulnerable. Modernhospitals are high-technology places. They are filled withsounds, smells and equipment that are alien to everydayexperience. Even here there is value in considering thevalue of good design, and some trusts are leading theway. Addenbrooke’s preservation of privacy and dignity,the consideration of children’s emotions at RoyalPreston and at Ealing, all show that small, unobtrusivegestures can make a significant difference to theexperience of the patient at a time of great stress.
Addenbrooke’s NHS Trust
One of the ideas brought back to Addenbrooke’s by a trust team who visited America was a simple-to-initiate change to the design of the bay curtains. Byinstalling an overlapping curtain rail, nurses are able toenter and exit the bay without disturbing the curtain.This reduces the risk of inadvertent exposure andprotects the privacy of the patient being treated.
Lancaster Teaching Hospitals NHS Trust
The trust has created a dedicated paediatricresuscitation bay decorated with lions and monkeysdesigned by Blackpool-based artist Suki Carter. Suki,who had previously been involved in work at the RoyalPreston Hospital site, came up with several possiblethemes, and staff in the department selected thejungle theme.
This provides an amusing and reassuring atmospherein a space that would otherwise be quite frightening toa small child.
Bromley Hospitals NHS Trust
Bromley Hospitals NHS Trust has installed a pneumatic tube system which has proved invaluable inensuring prompt delivery of samples from wards anddepartments to the Pathology laboratory.
The average transit time between any of the 17 “tube stations” across the hospital and the pathologydepartment is around 1 minute. Delays in transferringsamples to the lab have been reduced from hours tominutes, allowing patients to be treated moreefficiently.
Ealing Hospital NHS Trust
Aware that many of the children treated in theresuscitation area will be supine, staff at EalingHospital have created a co-ordinated theme thatincludes not only curtain and walls but spreads acrossthe ceiling. It is hoped that familiar nursery-rhymeimages will help to calm distressed and frightenedchildren.
MODERNISING ACCIDENT & EMERGENCY ENVIRONMENTS
16
Feathered friends add reassurance to unfamiliar surroundingsat Preston Hospital
Treatment
VIEWING
On the unfortunate occasions when treatment isunsuccessful and the patient dies, it is important thatthe department is able to provide an appropriate spacefor relatives to receive this information. St George’sHealthcare NHS Trust’s compassion for the newlybereaved is shown by the special facilities they providewhich recognise the importance of spaces wheresensitive interactions take place. The viewing andcounselling room here has been designed to providecomfort and relief. The interior design has involvedcolour schemes for the walls, floors, lighting, furnitureand fittings, modulation of the views from the windowsusing blinds and stained glass, and paintings thatcomplement. This work has had a knock-on effect onthe Trust, which is now reviewing its policy onbereavement.
TREATMENT
17
Relatives have made positive comments about the viewingroom for the way that it expresses a caring and supportiveattitude towards them.
Some modern matrons are already in receipt of the£10,000 allocated, and others have plans in place forwhen they receive the money. In collaboration with avariety of patient groups, they have devised a range ofinteresting and innovative ideas for improving thepatient’s visit to the hospital’s A&E department.
Calderdale & Huddersfield NHS Trust
Julie Dean, Modern Matron, has worked with hospitalnursery nurses and art students at the local universityto design interactive artwork for a new extension to the A&E department housing the paediatric waitingarea.
King’s College Hospital NHS Trust
Lucie Butler, A&E Matron at King’s College Hospital NHS Trust, has an implementation plan in place for her £10,000. She is planning to improve the facilitiesfor children by the use of distraction projectors in themajor treatment room and suture room; better patientinformation using a display screen; and generalimprovements to the environment such as improvedseating and increased positive distractions.
North Cumbria Acute NHS Trust
At Cumberland Infirmary Lynn Anderson has plans to improve the adolescent waiting space, providing decor and entertainment suitable for that age group.As well as a secured games console, the area willcontain suitable books and magazines along withhealthcare information of relevance to teenagers.
Southport & Ormskirk Hospital NHS Trust
Jayne Norbury, the modern matron for Southport &Formby DGH and Ormskirk DGH, has spent part of her allocation on a paging system that allows patientswaiting for the results of tests or for specialistconsultations to leave the A&E (for example, for a mealor snack) and return when required. “We felt thepaging system was an innovative way of allowingpatients the flexibility of leaving the department . . .without compromising their care,” she said.
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Work already under way
Patient and staff with the new paging system at Southport andOrmskirk Hospital NHS Trust
Patients attending A&E departments are likely to bestressed and in pain. Their physical surroundings cannottake away that pain, but they can help to reduce thestress.
We know that making patients feel that their needs arerecognised and that they are valued as individuals cansignificantly decrease the stress they feel, and helps toreduce the number of violent incidents.
The continuous and intensive use that many A&Edepartments face can take its toll on the surroundings,and the design of many A&E facilities is old andoutdated. It is clear that many improvements can bemade which will make the patients’ experience morepleasant.
There is a growing body of research work to whichtrusts can refer when planning changes to the physicalenvironment.
What has already been done shows the potential thatenvironmental changes can have. Where trusts havemade considered alterations, there has been anoticeable effect on patient behaviour and outcomes.
19
Conclusion
West Middlesex Hospitals NHS Trust – before (above) and after (below)
CONTACTS
Within trusts who feature
Addenbrooke’s NHS Trust – Kay Sowden (designer)
Bolton Hospitals NHS Trust – John Flannery
Brighton & Sussex University Hospitals NHS Trust –Andy Wavell
Central Manchester Healthcare NHS Trust – LIME: Brian Chapman
Ealing Hospital NHS Trust – Wendy Capehorn
Epsom & St Helier NHS Trust – Suzan Thompson
Gateshead Health NHS Trust – Ros Beattie
Guys & St Thomas’s Hospital NHS Trust – KarenSorensen
Lancashire Teaching Hospitals NHS Trust – SusanHargreaves
Royal Wolverhampton Hospitals NHS Trust – RomanaJack
St George’s Healthcare NHS Trust – Sue Cooper
West Middlesex University Hospitals NHS Trust – GinaLynn
Within NHS Estates
Centre for Healthcare Architecture & Design – ChrisFarrah, Head of Design
Construction – Peter Woolliscroft, Head of ConstructionServices
Patient Experience – Liz Jones, Head of Policy
Engineering – Darryn Kerr, Head of Engineering
ORGANISATIONS
Commission for Architecture and the Built Environment
Medical Architecture Research Unit, South BankUniversity, London
National Network for Arts in Health
Architects for Health
International Academy for Design & Health (Sweden)
The Center for Health Design (USA)
The Center for Innovation in Health Facilities (USA)
The Academy of Architecture for Health (USA)
Paintings in Hospitals (founded in 1959, Paintings inHospitals is a registered charity that provides works of art on loan to hospitals to enhance the healingenvironment for the benefit of patients, staff and visitors)
Health Development Agency
The Centre for Arts and Humanities in Health andMedicine (CAHHM) at the University of Durham
The Association for Medical Humanities
WORKS REFERENCED IN THE TEXT
Books
Kobus, Richard l et al, Building Type Basics forHealthcare Facilities. New York: John Wiley & Sons,2000.
Healing by Design: Building for Health Care in the21st Century. McGill University Health Centre, 2000.
Verderber, Stephen and Fine, David J, HealthcareArchitecture in an Era of Radical Transformation.New Haven: Yale University Press 2000.
Dilani, Alan (ed), Design and Health: the TherapeuticBenefits of Design. Stockholm: Svensk Byggtjänst,2001.
Dilani, Alan, Design and Care in Hospital Planning.Stockholm: Karolinska Institute, 1999.
Hamilton, D Kirk, Innovations in Planning forHealthcare. Bellaire, Texas: The Centre for Innovation inHealth Facilities, 1999.
Hosking, Sarah and Haggard, Liz, Healing theHospital Environment: Design, Management andMaintenance of Healthcare Premises. New York:E&FN Spon, 1999.
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Sources of further information
SOURCES OF SUPPLEMENTARY INFORMATION
Research in Journals
Noise
Bayo MV, Garcia, MA and Garcia, A, “Noise Levels in anUrban Hospital and Workers’ Response”, Archives ofEnvironmental Health, 50, 1995.
Grumet, GW, “Sounding Board Pandemonium: TheModern Hospital”, The New England Journal ofMedicine, Vol 328 No 6, 1993.
Baker, CF, Garive, BJ, Kennedy, C and Polivka, JB, “TheEffect of Environmental Sound and Communication onCCU Patients’ Heart Rate and Blood Pressure”,Research Nursing Health, Vol 16, 1993.
Light
McDaniel, J, Hunt, A, Hackes, B and Pope, JF, “Impactof Dining Room Environment on Nutritional Intake ofAlzheimer’s Residents: a Case Study”, Journal ofAlzheimer’s Disease and Other Dementias, Vol 16,Sept/Oct 2001.
McColl, SL and Veitch, JA, “A Critical Examination ofPerceptual and Cognitive Effects Attributed to FSFL”,Ergonomics, Vol 44 No 3, February 2001.
Webb, JM, Carlton, F and Geeham, DM, “Delirium in theIntensive Care Unit: Are We Helping the Patient?”,Nursing Quarterly, Vol 22 No 4, 2000.
Partonen, T and JLonqvist, J, “Bright Light ImprovesVitality and Alleviates Distress in Healthy People”,Journal of Affective Disorders, Vol 57, 2000.
Beauchemin, K and Hays, P, “Dying in the Dark;Sunshine, Gender and Outcomes in MyocardialInfarction”, Journal of the Royal Society of Medicine, Vol91, 1998.
Kripe, D, “Light Treatment for Non-Seasonal Depression,Speed, Efficacy and Combined Treatment”, Journal ofAffective Disorders, Vol 49, 1998.
Beauchemin, K and Hays, P, “Sunny Hospital RoomsExpidite Recovery from Severe and RefractoryDepressions”, Journal of Affective Disorders, Vol 40,1998.
Roseman, C and Booker, JM, “Workload andEnvironmental Factors in Hospital Medication Errors”,Nursing Research, Vol 44 No 4, 1995.
Music
Chlan, L, “Effectiveness of a Music Therapy Interventionon Relaxation and Anxiety for Patients ReceivingVentilatory Assistance”, Heart & Lung, Vol 27 No 3.
Cunningham, MF, Monson, B and Bookbinder, M,“Introducing a Music Programme in the Peri-OperativeArea”, AORN Journal, Vol 66 No 4, 1997.
Denney, A, “Quiet Music: An Intervention for Meal TimeAgitation”, Journal of Gerontological Nursing, Vol 23 No7, 1997.
Austine, P and Hains, AA, “Effect of Music onAmbulatory Surgery Patients’ Pre-operative Anxiety”,AORN Journal, Vol 63 No 4, 1996.
Tabloski, PA, McKinnon-Howe, L and Remington, R,“Effects of Calming Music on the Level of Agitation inCognitively Impaired Nursing Home Residents”, TheAmerican Journal of Alzheimer’s Care and RelatedDisorders, Jan/Feb 1995.
Art/performance
Staricoff, RL, Duncan, J, Wright, M, Loppert, S andScott, J, “A Study of the Effects of the Visual andPerforming Arts in Healthcare”, Hospital Development,Vol 32, June 2000.
Odour
Ackerman, BH and Kasbeker, N, “Reviews ofTherapeutics: Disturbances of Taste and Smell Inducedby Drugs”, Pharmacotherapy, Vol 17 No 3, 1997.
Spangenberg, ER, Crowley, AE and Henderson, PW,“Improving the Store Environment: Do Olfactory CuesAffect Evaluations and Behaviours?”, Journal ofMarketing, Vol 60, April 1996.
Ballard, B, “How Odour Affects Performance; AReview”, Proceedings of the Silicon Valley ErgonomicsConference & Exposition (ErgoCon ’95), 1995.
Privacy
Jannssen, PA, Harris, S, Klien, MC and Seymour, LC,“Single Room Maternity Care: The Nursing Response”,Birth, Vol 23, 3 Sept 2001.
Kulik, J, Mahler, H, Moor, IM and PJ, “SocialComparison and Affiliation Under Threat: Effects onRecovery from Major Surgery”, Journal of Personalityand Social Psychology, Vol 71 No 5, 1996.
Pattison, HM and Robertson, CE, “The Effect of WardDesign on the Well-being of Post-operative Patients”,Journal of Advanced Nursing, Vol 23, 1996.
SOURCES OF FURTHER INFORMATION
21
Lawson, B and Phiri, M, “Room for Improvement”, HSJ,Vol 110 (5688), January 2000.
Windows/View
Kaplan, R, “The Nature of View from Home”Environment & Behaviour, Vol 33 No 4, July 2001.
Leather, P, Pygras, M, Beale, D and Lawrence, C,“Windows in the Workplace: Sunlight, View andOccupational Stress”, Environment and Behaviour, Vol30 No 6, 1997.
Tennessen, CM and Cimprich, B, “Views to Nature:Effects on Attention”, Journal of EnvironmentalPsychology, Vol 15, 1995.
Sato, M and Inui, M, “Human Behaviour in WindowlessOffice Spaces”, Journal of Light and Visual Environment,Vol 18 No 1, 1994.
Ulrich, RS, “View from a Window May InfluenceRecovery from Surgery”, Science, 224, pp 420–421,1984.
Waits
Hui, MK and Tse, DK, “What to Tell Consumers in Waitsof Different Lengths; An Integrative Model of ServiceEvaluation”, Journal of Marketing, Vol 60, April 1996.
Violence
Jenkins, MG, Rourke, LG, McNicholl, BP and Highes,DM, “Violence and Verbal Abuse against Staff inAccident and Emergency Departments: a Survey ofConsultants in the UK and the Republic of Ireland”Accident & Emergency Medicine, 15, 1998.
Vittorio di Martino, “Consolidated Report and Guidelineson Violence in the Health Sector”, WHO/ILO, 2002.
Vittorio di Martino, “Relationship between Stress andViolence in the Health Sector”, ILO, 2002.
Richmond, BC, “Preventing Violence in Health Care:First Steps to an Effective Programme”, WorkersCompensation Board of BC.
Wilder and Sorensen, Essentials of AggressionManagement in Healthcare, Prentice-Hall, 2001.
Other publications
NHS Estates produces guidance on all issues ofrelevance to the healthcare estate. A comprehensive listof this guidance is available from NHS Estates, but ofparticular relevance are:
Better by Design
The Design Development Protocol for PFI schemes
The Architectural Healthcare Environment and Its Effectson Patient Health Outcomes
Wayfinding
The Art of Good Health – a Practical Handbook
The Art of Good Health – Using the Visual Arts inHealthcare
Housekeeping – a First Guide to Modern andDependable Ward Housekeeping
National Standards of Cleanliness
Impact of the Built Environment on Care within the A&EDepartment
HFN 01: Design for Patient-focused Care
HFN 05: Design against Crime: a Strategic Approach toHospital Planning
HFN 14: Disability Access
HBN 22: Accident and Emergency Facilities for Adultsand Children
HBN 22 Supplement 1: Trauma and Minor Injury
Websites
http://www.healthyhospitals.org.uk/indexRoyal College of Nurses in conjunction with CABE andNHS Estates
http://www.architectsforhealth.comArchitects for Health
http://www.cabe.org.ukCommission for Architecture and the Built Environment
http://www.designandhealth.comInternational Academy for Design & Health (Sweden)
http://www.lsbu.ac.uk/maru/Medical Architecture Research Unit, South BankUniversity, London
http://www.aia.orgThe Academy of Architecture for Health (USA)
http://www.healthdesign.orgThe Center for Health Design (USA)
http://www.center4innovation.orgThe Center for Innovation in Health Facilities (USA)
http://www.ehca.org.ukExeter HealthCare’s site devoted to the arts in hospital
http://www.dur.ac.uk/cahhm/
MODERNISING ACCIDENT & EMERGENCY ENVIRONMENTS
22
23
The Agency has a dynamic fund of knowledge which ithas acquired over 40 years of working in the field. Ourunique access to estates and facilities data, policy andinformation is shared in guidance delivered in fourprincipal areas:
Design & Building
These documents look at the issues involved inplanning, briefing and designing facilities that reflect thelatest developments and policy around service delivery.They provide current thinking on the best use of space,design and functionality for specific clinical services ornon-clinical activity areas. They may contain schedulesof accommodation. Guidance published under theheadings Health Building Notes (HBNs) and DesignGuides are found in this category.
Examples include:
HBN 54, Facilities for cancer care centresHBN 28, Facilities for cardiac servicesDiagnostic and Treatment Centres: ACAD, CentralMiddlesex Hospital — an evaluationHFN 30, Infection control in the built environment:design and planning
Engineering & Operational (including FacilitiesManagement, Fire, Health & Safety andEnvironment)
These documents provide guidance on the design,installation and running of specialised building servicesystems and also policy guidance and instruction onFire, Health & Safety and Environment issues. HealthTechnical Memoranda (HTMs) and Health GuidanceNotes (HGNs) are included in this category.
Examples include:
HTM 2007, Electrical services supply and distributionHTM 2010, Sterilization: operational management withtesting and validation protocolsHTM 2040, The control of legionellae in healthcarepremises — a code of practiceHTM 82, Fire safety — alarm and detection systems
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These are documents which deal with areas of broadstrategic concern and planning issues, including capitaland procurement.
Examples of titles published under this heading are:
EstatecodeHow to Cost a HospitalDeveloping an Estate StrategySustainable Development in the NHS
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In response to some of the key tasks of the NHS Planand the Modernisation Agenda, NHS Estates hasimplemented, project-managed and monitored severalprogrammes for reform to improve the overall patientexperience. These publications document the projectoutcomes and share best practice and data with thefield.
Examples include:
National standards of cleanliness for the NHSNHS Menu and Recipe BooksSold on Health
The majority of publications are available in hard copyfrom:
The Stationery Office LtdPO Box 29, Norwich NR3 1GNTelephone orders/General enquiries 0870 600 5522Fax orders 0870 600 5533E-mail [email protected]://www.tso.co.uk/bookshop
Publication lists and selected downloadable publicationscan be found on our website:http://www.nhsestates.gov.uk
For further information please contact our InformationCentre:e-mail: [email protected] tel: 0113 254 7070
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