Luck of the draw

Building design has a crucial effect on staff happiness, performance and choice of workplace, particularly for nurses, says Mary-Louise Harding

The improvement of public building design is fundamental to improving public services. Well-designed healthcare buildings can lead to better health outcomes.

This is the basis for the Commission for Architecture and the Built Environment's healthy hospitals campaign.

It was launched nine months ago to foster radical improvements in design.

CABE's new report, The Role of Hospital Design in The Recruitment, Retention and Performance of NHS Nurses in England, shows that welldesigned hospitals have a significant influence on the performance of nurses in their work and have a positive impact on their recruitment and retention.

It also shows that nurses are acutely aware of the role that hospital design plays in their everyday work and consequently want a greater say in shaping their working environment.

While a number of studies examine the influence of the workplace on office staff, less research has been done on the effect that the healthcare environment has on staff, particularly nurses.Much of the current information about hospital design is focused on patients.

'Nurses constantly see how the design of their working environment impacts on staff and patients, ' says Royal College of Nursing general secretary Dr Beverly Malone.

'Having to walk miles of corridors every day and care for patients in airless, poorly designed wards has a negative impact on healthcare professionals and is not conducive to a quick recovery for patients.'

In compiling its study, CABE commissioned a review of literature on the importance of design and its effect on recruitment, retention and performance. A series of qualitative focus groups was held with nursing staff. And 479 directors and assistant directors of nursing throughout England were surveyed.

Over three-quarters of nursing directors surveyed by CABE said that hospital design impacts on recruitment success. Thirty-nine per cent rate external space, and 37 per cent rate the internal environment as 'very important' in attracting nurses.

Nurses surveyed said the first impression of a hospital's exterior and interior was crucial.A hospital's 'civic value' - how its design impacts on and engages with the community - was important.

Other factors influencing the decision to join included location, quality of staff facilities, parking provision and the availability of public transport, as well as family-friendly facilities.

Overall, the findings show that:

well-designed healthcare buildings improve performance and motivation, leading to better outcomes for patients;

good design is a factor in nurses' choice of hospitals;

a focus on internal design should be a priority - in particular, the organisation of space on wards and units, storage and lighting;

nurses want to be consulted on design and believe they can help improve the design of areas in which they work.

'Often the doctors and consultants grab the juicier rooms and the nurses get what's left, ' says a London nurse.

'The only communal space is in the lift; It is not very communal, ' says another.

A key message from the study indicates that although nurses in the focus groups say they have been consulted about hospital design, many suggest it is carried out so that 'a manager can tick a box to say it has been completed'.

Overwhelmingly, nurses feel that people using specific care units should be consulted about their design before building starts.

The research shows contradictions between opinions of nurses and nursing directors - for example, directors tend to rate provision of staff facilities lower than nurses.

Elements of hospital design that raise community spirit, including banks and crÞches, are particularly important for retention.

And nurses say public spaces that encourage interaction and communication influence retention, particularly those that create an atmosphere in which they feel part of the bigger corporate body rather than just a discrete unit within it.

Factors that would encourage staff to leave a particular unit or hospital include constant alterations to buildings and reallocation of areas for different uses. '[Nurses] will leave if they are. . . moved into smaller and smaller spaces - they will just go to the hospital down the road, ' says a Birmingham nurse.

The organisation of space and equipment is also very important. This can mean anything from too little space to work in and doors too small to allow easy movement of beds, to the location of equipment and insufficient electrical points.

Designing for flexibility is therefore an important consideration given the changing nature of care within the NHS.

The research highlights that seeking to improve design will involve trade-offs. Issues raised by nurses may conflict with other clinical demands. For example, the benefits of daylight and a good view could conflict with having clinical facilities next to each other.

Nurses view flexible working space as highly significant to their performance and say that rooms and wards can be too functional, making them inflexible and only suitable for specific purposes.

Constant exposure to artificial light, in particular fluorescent tube lights, is commonly mentioned by nurses as one of the most draining aspects of working on a ward. The capacity for nurses and patients to control air temperature, rather than rely on hospital air conditioning systems, is seen as important, as is being able to open windows.

Provision of space for confidential discussions with patients and relatives, and between staff members, is also crucial. Often, if a staff room exists, it is the only place available to hand over between shifts and staff are trying to hand over to one another in the same space.

Storage space is seen to have a particular impact on nurses' ability to work efficiently.

The quality of fixtures and fittings is also important, with many nurses highlighting what they consider to be 'cost-cutting' measures that result in inferior quality fittings - 'cheap' door frames and locks, taps that do not encourage infection control and sinks that are not big enough.

'You go into the staff toilets and turn the tap on by hand, but you have to turn it off by hand - You have just washed your hands because they were potentially going to contaminate a patient.

How do you turn it off without recontaminating your hands?' asks a London nurse.