Thought Leadership

Thoughts on the Inpatient Environment

For Pete’s sake – will you please keep the noise down!  

Damn it, I’d really hoped that I wouldn’t lose my temper but I guess I’ve been pushed too far. It’s been almost a week since I had any meaningful sleep and exhaustion has got the better of my mood turning me into a difficult customer! 

This is a quote taken directly from a personal diary I kept during a recent hospital stay. The quote refers to one specific issue relating to the inpatient environment – acoustic privacy and noise management. It was one of several issues I was able to observe first-hand during several separate  three-week stays in a major acute hospital where I was an inpatient in a single room.  

It’s not often that an architect who claims to have experience and expertise in healthcare design has an opportunity to obtain extensive insight into the workings of a specialist environment. It’s true, my treatment for leukaemia was the priority but, as an experienced healthcare architect, I also considered this a valuable opportunity to observe and learn about the realities of being an inpatient. Here was a chance to go ‘deep-cover’ and to consider inpatient ward design from a different perspective, to challenge some assumptions and to widen the debate about patient-focused design. 

You might expect my observations to focus on architectural aspects such as ergonomics, form, colour or spatial planning but the issues I experienced were far simpler and rooted in basic human experience. The key issues I noted relate to environmental sensory factors and, having reviewed a number of publications and research papers, have been identified as common themes in hospital environments for many years. They are perhaps best summarised by considering three topics: noise, control and connection. 

Noise

Noise

 Firstly some interesting facts for context: 

 World Health Organisation guidelines suggest average noise levels in inpatient wards should not exceed 30dB (peak level 40dB). 

  • The average noise level in a car travelling at 60mph is 70dB 
  • A 2008 study carried out at the Queen’s Medical Centre, Nottingham* recorded noise levels across five inpatient wards frequently exceeded 80dB. 

Noise, and in particular the impact on sleep, was the primary issue that affected me as an inpatient. Equipment alarms, banging doors, crashing bin-lids, trolleys, paper-towel dispensers were the cause of frequent noise throughout day and night time activities on the ward. Speech privacy was generally compromised through poor partition/door performance and there was a proliferation of reflective surfaces, amplifying noise through excessive reverberation.  

Poor sleep quality in hospital has been established as a key factor in poor recovery via a number of published studies. Sleep disturbance has been shown to have a deleterious effect on immunological function as well as a cause of confusion, delirium and reduced cognitive function. Alarmingly, there is also growing evidence of increased prescription of medication to aid sleep on the ward. Ensuring there are measures in place to combat sleep disturbance would seem an obvious strategy but, for some reason, other issues are typically given higher priority. 

*’Noise Pollution on an Acute Surgical Ward’ – Emma McLaren, Charles Maxwell-Armstrong 2008

Control

Control

A further frustration was the lack of control to adjust the environment within my room. Most inpatients’ physiological response to their environment varies – everyone is different. Patients will experience temperature changes, air quality, odour response and light sensitivity to varying degrees depending on a large number of factors.  

As an inpatient, there were occasions when my treatment caused bouts of shivering and, even with extra blankets, I wanted the room to be warmer. Sometimes, mainly due to excessive solar gain via poorly designed window treatments, I wanted my room to be cooler.  

The ability to tailor the room environmental qualities to suit my specific needs was not available to me – such controls were located centrally, providing a uniform environment throughout the ward. I did have control over the room lighting but vision panels in the door, necessary to ensure a degree of nursing-observation, contributed to the issues affecting sleep quality due to light spillage from the corridor. 

It seemed that some basic elements of environmental control, routinely available at home and now also possible through the use of smart-phone and digital devices, had been unnecessarily removed. The inpatient room environment was not helping me to recover it seemed. 

Connection

Connection

During an extended period as an inpatient, feelings of isolation can often be amplified. It’s true to state that there are some circumstances where isolation is a clinical necessity due to infection risk (as it was for me for some of my time as a patient). Generally however, an inpatient craves a degree of connection with the world outside yet the ability to form that connection is often denied. The simple act of opening the window, to not only admit some fresh air, but also to be able to hear external activities such as birdsong or even traffic, is typically unavailable.  

During my inpatient stay I craved some connection with the outside. External sound, fresh air, odour control (a common feature of inpatient care not always managed by mechanical ventilation systems) would have improved my wellbeing but issues relating to safety (potential falls from height) and infection control prevented this.  

It’s important to emphasise that not all inpatients feel unwell for the entire duration of their stay. There are periods where an inpatient, though still in recovery mode, is well enough, under controlled circumstances, to benefit from some time outdoors. One is reminded of the iconic images of tuberculosis patients being wheeled onto the roof terrace at the revered Paimio Sanitorium in 1930’s Finland. Is it time to return to these practices? 

The benefits to patient wellbeing in terms of environmental change, access to vitamin D and fresh air are clear. I craved the ability to spend some time outdoors as an inpatient but this was just not possible. 

The Inpatient Experience

The Inpatient Experience

My experience seems to endorse the findings of countless studies and academic papers which consider the effect of the inpatient environment upon wellbeing. It seems clear that the room environment is a major contributor to the inpatient experience and has been frequently identified as having a negative impact on healing, recovery and wellbeing.  

 

So if the room environment can have such a marked effect upon the inpatient experience, surely it would be possible to reverse the trend and enhance healing? I began to consider the design of the inpatient room as an opportunity to supplement treatment, to boost care delivery and improve recovery. Would it not be better to reconsider the inpatient environment and begin to view the space not as a room but as a mechanism for healing? 

An Alternative Approach

An Alternative Approach

Couldn’t the inpatient room be considered as another piece of specialist medical equipment? The provision of sophisticated equipment like an MRI scanner, supplied by global organisations with reputations for product quality born out of extensive research and development, prototyping and manufacturing techniques are commonplace in hospitals. Why couldn’t the same approach be applied to the inpatient environment?  

Feeling groggy from yet another poor night’s sleep, I pondered a scenario where the design team convened for a new hospital project included design input from perhaps non-traditional fields such as the automotive or aviation sectors. The introduction of new thinking from designers who are experts in not only ergonomics but also in the provision of bespoke environments where comfort, control and performance are priority factors would surely offer improvements. What if the interior of an inpatient room felt more like the interior of a high-performance sports car, I wondered? 

Of course as an architect the temptation to reach for a pen and start sketching solutions is too great. I’ve therefore sketched some ideas as to how some of the core issues I experienced as a patient might be addressed. Clearly, these do not represent fully resolved propositions but would hopefully be useful in progressing the debate about inpatient care and perhaps provide a catalyst for improvement. 

The idea considers the provision of a completely pre-fabricated ‘healing-module’, taking full advantage of off-site manufacturing and production regimes with quality the primary factor rather than speed of delivery.  

The provision of separate units, together with the use of automatic sliding doors and carefully selected interior finishes, are all proposed to counter the acoustic and noise problems which have become the norm. Each unit is treated as an autonomous module, offering maximum user control to tailor environmental conditions to individual patient needs. The addition of a small terrace space, allowing access to external space and some biophilia completes the patient-centred approach without compromising safety or comfort. 

What does the Inpatient Want?

What does the Inpatient Want?

What does the Inpatient want?

What does the Inpatient want?

Our core needs are quite basic and, one would hope, easy to deliver. Yet the evidence, reinforced by my own experience, suggests these simple measures remain problematic. As patients, we just want… 

Quiet.
An environment with less noise will benefit all users – both staff and patients.  A new focus needs to be placed on acoustic design. This needs to include the specification of materials, components and fittings as well as consideration of how all occupants behave, especially during night time hours. It is now commonplace for hospitals to employ staff with a singular responsibility to monitor and implement infection control regimes. Why not expand the role to include matters relating to acoustic control? 

Control.
Decentralisation of environmental controls plus the introduction of smart technology, already available in the home, is needed to ensure each inpatient regains more control over their environment. 

Connection.
We want the option to connect physically with the world outside our room. It should be possible to regain the simple joys of being able to open a window or spend a few minutes outside 

 

Final Words

Final Words

And finally, what do patients want of healthcare designers, architects, constructors and care-providers? 

We must not forget to focus on the human experience which will result from our design propositions. Our thinking must continue beyond the physical and should also consider how it feels to dwell within these spaces.  

We must elevate the status of the inpatient environment above conventional considerations of space/form to something seen as a critical component in any patient’s journey to wellness… …a healing module perhaps?

Author:
Date Published: 14 July 2021
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DB3 Healthcare

DB3 Healthcare

Our work in the healthcare sector encompasses the design and management of buildings for acute and specialist care to primary care and mental health.

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