Roundtable: How can healthcare environments adapt to support the wellbeing of staff?

The impact of healthcare environments on people’s wellbeing has been recognised for many years. However, improvements to healthcare buildings and facilities are often focused on creating surroundings that reduce the stress on patients and support the healing process. As panellists at a recent HSJ roundtable in association with Dyson discussed, the experience of staff can be lower down the list of priorities.

They shared concerns that NHS staff are working in buildings that lack natural light, ventilation and connection with the outside world. Some staff are routinely exposed to excessive heat and stale air. One panellist revealed that she had visited a rest area for nurses which was windowless and “boiling”.

Healthcare environments designed to improve the experience of staff as well as patients exist, but they are the exception, not the rule. In some ways, modern hospitals are less friendly to staff than their Victorian predecessors: staff facilities are minimal and when more space is needed for clinical services, it can mean even less is left for staff. The panel reported that improvements made during the initial waves of the covid pandemic – such as the creation of wellbeing spaces for staff – are now being clawed back.

What factors determine whether a healthcare environment is good for those working within it? Are there untapped opportunities for improvement? And what are the benefits of making these changes for staff and organisations? The recent HSJ roundtable, in association with Dyson, brought together experts in NHS estates and capital projects, architecture, air quality and staff wellbeing, to discuss these important issues.

The panel emphasised that the impact of healthcare working environments on staff is often overlooked in the NHS and is a low priority

Last October, Louise Church visited a hospital which left her with a vivid impression of the low priority the NHS gives to facilities for staff. “The rest area for nurses was dark, there was no natural light, and it was boiling. And that’s where nurses were going to have a break!”

The Royal College of Nursing’s health, safety and wellbeing national officer said that staff’s most “basic needs” are often not being met in their working environments. She added that lack of investment in building maintenance meant that some healthcare organisations were not just failing to support wellbeing but falling short of statutory requirements to protect staff from hazards such as asbestos exposure.

The panel agreed that the impact of healthcare working environments on staff is often overlooked in the NHS. Leaders from trusts which are focusing on these issues were represented on the panel, but these panellists acknowledged such focus is not typical. “The biggest issue is that it is such as low priority,” said Alexis Carlyon, deputy head of reconfiguration at Royal Cornwall Hospitals Trust.

It would be easy to assume that the biggest problems are in the oldest buildings, which have developed ad hoc over many years to accommodate modern healthcare services. However, Kevin Fong pointed out that new builds do not necessarily prioritise staff. “In the 21st century we’ve designed hospitals almost without thinking about the staff,” said Professor Fong, a consultant anaesthetist at University College London Hospitals FT and chair of public engagement and innovation at University College London.

The Victorian-built hospitals he trained and worked in, early in his career, were “falling down” but they had staff rooms and social clubs; one had a staff swimming pool. “All of those things disappeared when they got shiny and full of glass on the outside.” The next generation of hospitals should restore some of the things the Victorians got right for staff, he suggested.

Several panellists reported examples of progress during the early waves of the pandemic, including the creation of wellbeing areas for rest and recovery, driven by concern about the extreme pressures on healthcare staff and supported by an influx of extra funding. In some hospitals, these gains are now being lost, said Leslieann Osborne, a former director of wellbeing and engagement at Dartford and Gravesham Trust and now a strategic health and wellness consultant. “We are now using spaces for patients and staff that are inappropriate – there are no showers, no rest areas, and no kitchens.”

Poor conditions for staff may also be the result of an unacknowledged sense that their comfort, and the quality of hospital design, are trivial concerns next to patient care. Architect Jaime Bishop specialises in healthcare settings, but he also has extensive experience in the hospitality and hotel sectors. He insisted it is much harder to deliver a great result in the NHS than for other sectors. Partly, he said, it is due to cumbersome NHS procurement processes (a point reinforced by several panellists) and a lack of “head space” in a service with multiple priorities. “But it is also a reluctance to engage in something that is seen as superficial to what the core business is,” he added.

Many of the problems the panel discussed are tangible and highly visible, and yet, they agreed, paid little heed. Easier still to ignore, said Ken Armstrong, is air quality, both outdoor pollution entering “leaky” buildings and sources of indoor pollution, ranging from solvents in paints and varnishes to people in overcrowded rooms emitting CO2. “Air quality really matters,” said Mr Armstrong, head of research, environmental care at Dyson. “It affects how we feel, it can affect our focus, our cognitive performance and disease transmission risk. There’s so much about air quality that impacts people and their working lives.” He suggested that it should be given the same level of importance as the quality of “the water we drink and the food we eat”.

Malcolm White, a clean air specialist with Global Action Plan, also emphasised that air pollution is a “really good lens” through which to improve NHS estates and staff wellbeing. If cleaner air is the aim it can lead to investment in better physical spaces, improved access to nature, and more room to breathe.

There is a need to challenge the assumption that making healthcare environments better for staff involves taking resources away from patients

“I think we know what good looks like – it’s a quality environment, access to light, good rest areas,” said Martin Duggan, head of capital projects at Royal United Hospitals Bath FT. “It’s just somehow in the translation of that through to the physical end product, it gets lost and we end up with a very basic, generic white painted wall, blue floor sort of place that’s quite sterile.”

The challenge, he suggested, “is to get good baked into standard design. Lots of trusts are [trying to] do that and that’s certainly a journey we are on”.

Mr Duggan emphasised that small changes can deliver big benefits. “We’ve had some really powerful messages from staff recently around just refurbishing what we’ve got. We don’t need to reconfigure the entire department. If you refurbish the rest area – put some new flooring down, paint it – the staff feel incredibly valued and invested in.”

That said, the trust has also created – with the support of the James Dyson Foundation – two carefully curated environments for patients and staff, an award-winning neonatal care centre, and a new cancer centre which opens this year.

Similarly, Maggie’s centres for people with cancer and their families are attached to NHS hospitals but are often a world apart in terms of design and aesthetics: the centres are characterised by light and colour, high quality furnishings, natural materials and connection to nature. There are no separate areas for staff, and no attempt to divide the people who work in the building from patients and their families. “They are both in the space together and are of equal value,” said Laura Lee, Maggie’s chief executive.

Dame Laura emphasised that staff at Maggie’s centres feel nourished and supported by their surroundings. “They talk about the experience of working in a beautiful building that has got access to nature, and that the whole sense of the building is empowering.”

The panel agreed there was a need to challenge the assumption that making healthcare environments better for staff involves taking resources away from patients. Jaime Bishop said there was “something in the system” that tried to deter people from “thinking about design or making things look too nice or caring about the staff space. [It’s as if] you are not adequately focusing on the patient space”.

“The needs of patients and staff are aligned and if we fail to realise that we cannot recover the [health] service,” said Professor Fong, consultant anaesthetist at University College London Hospitals FT and chair of public engagement and innovation at University College London.

At Imperial College Healthcare Trust, patients and staff were brought together at the earliest stage to engage on the major redevelopments of the organisation’s hospitals. The two groups’ interests are “intrinsically linked”, said director of strategy, research and innovation Bob Klaber. “My experience of talking to patients is they are passionate and eloquent about the staff who are looking after them having really good facilities.”

Louise Church, the Royal College of Nursing’s health, safety and wellbeing national officer, added that engagement with staff and their union representatives on the design of healthcare environments could reduce the stressors on patients, such as poor signage. This in turn, makes the environment safer for staff. “If designed properly [the healthcare environment] can reduce violence and aggression. Design has a massive part to play in keeping people safe and healthy at work.”

Improving the healthcare working environment can mean something as simple as painting the walls in the staff room a colour the staff like, and providing them with a fridge, a microwave and “matching cups”, pointed out Leslieann Osborn, a former director of wellbeing and engagement at Dartford and Gravesham Trust and now a strategic health and wellness consultant. Ms Osborn said just about every staff room at Dartford and Gravesham had been upgraded, paid for by funds from NHS charities and local donations. Importantly, the refurbishments reflect the taste of the people who use the rooms. “The staff chose their own colours, so we’ve now got staff rooms in orange, purple, all sorts of colours and designs.”

Several panellists emphasised the need to consider all the different elements that contribute to the “feel” of a building and, as far as possible, give staff control over their working environment and accommodate individuals’ preferences. “Everything interacts. You need to consider this holistically – the light, the temperature, the [air] circulation, the air quality, the acoustics,” said Ken Armstrong. “And the more you can help people to shape their own environments, the better they will feel about where they work.”

Calls for a more ambitious approach were offset by concerns about the need to work within the NHS’s resource limitations and to meet its specific requirements

Some panellists expressed frustration that, in 2023, they were still having to discuss the need for healthcare staff to have access to a kettle or somewhere to park their bike. “It’s ridiculous,” said Professor Fong. “Wellbeing of staff is the priority of the 21st century if we want a sustainable healthcare service for the future.

“It should be intrinsic to the design of future hospitals – and we need to retrofit it to our current hospitals [to take staff wellbeing into account]”.

For Jaime Bishop, the NHS’s tolerance of cramped, shabby working environments is proof of “something fundamentally wrong with the way the system responds to staff spaces”. He called for the bar to be set much higher – and gave as an example of the way forward, a hospital he worked on “on the other side of the world” where the high-quality design was used to attract staff in the global market.

“Smart” buildings could provide data insights on how the healthcare environment is being used and how it is impacting on the health of the people who use it

Calls for a more ambitious approach were offset by concerns about the need to work within the NHS’s resource limitations and to meet its specific requirements, which make it unlike other sectors. “The NHS is very different from an office block,” said Susan Grant, principal architect, NHS National Services, Scotland. But she added: “Can we do better? Yes.”

Phillip Bishop, director for property (health) at Capita, said “smart” buildings could provide data insights on how the healthcare environment is being used and how it is impacting on the health of the people who use it. These insights could then inform interventions to improve the efficiency of the building and boost staff wellbeing.

The discussion also considered the potential benefits of improving outdoor spaces. Ms Osborne revealed that during the early phases of the pandemic, Dartford and Gravesham Trust planted 800-1,000 trees. Donated by NHS Forest, the trees have served to create a “nature space” where staff can go to reflect. The trust also runs “retreats” where staff can experience “forest bathing”, lying under a canopy of trees to reconnect with nature.

Forest bathing may not be an option for many trusts, but the panel was clear that potential improvements are widely available. “I know we are lucky at Maggie’s but I don’t think it is rocket science to shift the lever and empower people in their environments,” said Dame Laura.

Sarah Morley, co-president of the Healthcare People Management Association and executive director of organisations development and workforce, Velindre University Trust, set out the responsibilities for NHS managers. “They need to ask their people: ‘What would make the biggest difference?’ [to your wellbeing in your working environment]. That may mean some quick wins, and it may improve wellbeing.” But as the panel discussion made clear, there is also a need to go further and deeper. She added: “As senior leaders we need to take responsibility for the much more holistic things we’ve talked about today.”