The Use of Single Patient Rooms vs. Multiple Occupancy Rooms in Acute Care Environments

The Use of Single Patient Rooms vs. Multiple Occupancy Rooms in Acute Care Environments
The Use of
Single Patient Rooms
versus Multiple
Occupancy Rooms
in Acute Care Environments
Contents
1. Preamble
2. Executive Summary
3. A Review and Analysis of the Literature
4. Comparative First Cost Assessment of
Single and Multiple Occupancy Rooms
5. Pilot Study on Comparative Assessment of
Patient Care Issues in Single and Multiple
Occupancy Patient Rooms
6. Appendices
a. Literature Review Charts
b. Literature Review Annotations
c. Bibliography
d. Floor Plans
Principal
Investigators:
Habib Chaudhury
Atiya Mahmood
and Maria Valente
Simon Fraser University
2004
Coalition for Health
Environments Research (CHER)
www.CHEResearch.org
e. BTY Comparative Cost Study
The Use of Single Patient Rooms versus Multiple Occupancy Rooms
in Acute Care Environments
Principal Researchers:
Habib Chaudhury, Ph.D.
Atiya Mahmood, Ph.D
Maria Valente
Simon Fraser University, Vancouver, BC, Canada
CHER Members 2005
Organizational Members
AIA Academy of Architecture
for Health
American College of
Healthcare Architecture
American Society of Interior
Designers (ASID)
Center for Health Center for
Health Design (CHD)
International Interior Design
Association (IIDA)
Sustaining Members
American Art Resources
Collins & Aikman
HKS, Inc., Architects
Herman Miller, Inc.
Hughes Supply
Lees Carpets
Mannington Commercial
Watkins Hamilton Ross
Architects
Wellness, LLC
Provider Council
Advocate Health Care
Oakbrook, IL
Cottonwood Hospital
Murray, UT
Intermountain Health Care
Salt Lake City, UT
MedStar Health, Columbia,
MD
The Methodist Hospital
Houston, TX
Porter Adventist Hospital
Denver, CO
St. Charles Medical Center
Bend, OR
Stamford Hospital Health
System Stamford, CT
Stanford University Medical
Center, Stanford, CA
Sutter Health, Sacramento,
CA
Sponsor:
Facility Guidelines Institute
Special Thanks:
Special appreciation is given to the Facility Guidelines Institute (FGI)
who identified a critical need for information not currently available and
funded this study. The FGI is a 501[c] 3 tax-exempt organization
established in 2001 for the primary purpose of funding significant
research work in health facility design. FGI has agreed to make the
study available free of charge to the public by placing it on two web sites.
We are also indebted to Habib Chaudhury, Ph.D., Atiya Mahmood, Ph.D,
and Maria Valente. Their time, dedication and commitment to creating
this landmark document has contributed to making this report a
significant contribution to the decision making process of healthcare
providers and the design professionals who advise them.
We also wish to thank the Academy of Architecture for Health
Foundation for their generous support in assisting with the dissemination
of this study.
This CD edition will be distributed at no cost to all AIA Academy of
Architecture for Health members (while supplies last) as a result of the
funding provided by the Foundation and will be available for sale at a
modest cost through the Coalition of Health Environments Research
(CHER) web site (www.CHEResearch.org) for others who desire a CD
version.
Although the current market trends are leaning strongly toward a single
occupancy acute care bed rooms, there is a huge inventory of double
occupancy bed rooms still functioning and playing a vital role in the delivery of
the nation’s healthcare. This report raises questions as to whether double
occupancy bed rooms are detrimental to patient care and staff morale. It should
be emphasized that, although this document is based on a comprehensive
literature search, the remaining components of the study are a pilot sampling
only. Ideally, a more comprehensive follow-on survey could be funded and
would add to the validity and impact of the findings.
Coalition
for Health
Environments
Research
www.CHERresearch.org
The Coalition for Health Environments Research (CHER) is a 501(c)(3) not for
profit organization dedicated to “promote, fund, and disseminate research into
humane, effective and efficient environments through multidisciplinary
collaboration dedicated to quality healthcare for all.”
January 2005
Published in the United States of America
ISBN No. 0-9743763-2-9
Coalition
for Health
Environments
Research
www.CHERresearch.org
CHER Board Members
CHER Research Council Members
W. H. (Tib) Tusler, FAIA, FACHA,
President
Uriel Cohen, M. Arch, Arch D., FGSA,
Research Council Chair
Frank Weinberg, Executive Director
David Allison, AIA, ACHA
Roger B. Call, AIA, ACHA, Secretary /
Treasurer
Debra D. Harris, Ph.D.
Uriel Cohen, M. Arch, Arch D., FGSA
Mardelle McCuskey Shepley, Arch. D
H. Bart Franey
Teri Oelrich, RN, BSN, MBA
D. Kirk Hamilton, FAIA, FACHA,
Kathy Hathorn
Roger Leib, AIA, ACHA
Jane Rohde, AIA
Jennie Selden
Jean Young, ASID
The Use of Single Patient Rooms versus Multiple Occupancy Rooms
in Acute Care Environments
Executive Summary
A. Review and Analysis of the Literature
An extensive review of literature in the areas of healthcare design, construction and
operating cost, hospital management, staff efficiency, infection control and patient
outcomes was conducted in order to identify advantages and disadvantages of single
versus multiple occupancy patient rooms. The literature search revealed that many
articles on the relationship of design to healing and innovations in hospital design are
dated 1980 and later, so this timeframe was chosen for the systematic journal searches.
However, relevant articles dealing with room occupancy and patient care issues, and
dated earlier than 1980 were also included in the review.
The research questions that guided the literature review were:
1. What are the differences in first cost, operating cost, energy costs and
efficiency of management and care delivery in single and double occupancy
patient rooms in acute care settings?
2. What are the advantages and disadvantages in disease control and falls
prevention in single versus double occupancy rooms in acute care settings?
3. What are the therapeutic impacts (socio-behavioral issues of patient privacy,
social interaction and daily functioning) of single versus double occupancy
hospital rooms?
The articles, book chapters and reports reviewed were initially divided into four
categories: a) First and operating cost of hospitals; b) Health care facility management
and hospital design; c) Disease control and falls prevention; and d) Relationship
between healing and environment. An in-depth review of the literature revealed that
articles in the “Healthcare facility management and hospital design” and the “Therapeutic
impacts: Relationship between healing and environment” categories had a significant
overlap of foci and issues. Consequently, findings in these two categories were
combined. The final three categories [i.e., a) cost, b) infection control and falls, and c)
hospital design and therapeutic impacts] were utilized as a framework to analyze the
literature, which is presented in the integrated summary document, “A Review and
Analysis of the Literature.” The findings from the literature review are also presented in a
chart format in order to provide information in a concise manner. In addition, an
annotated bibliography providing a summary of key issues from each article or chapter
was developed. Based on the feedback from CHER Research Council on the interim
report, several additional pertinent articles have been included in this review and
analysis since the time of submission of the interim report. Moreover, sections of the
document have been reorganized and/or fine-tuned based on the council’s comments.
The following chart illustrates the number of empirical and non-empirical articles or book
chapters (total number: 222) reviewed in each of the three final categories:
Single and Multiple Occupancy Patient Room Study
1
120
108
100
80
60
Empirical Articles
Non Empirical Articles
50
40
14
20
22
19
9
0
First &
Operating Costs
Design &
Therapeutic
Impacts
Disease Control
& Falls
Prevention
FIGURE 1: The number of empirical and non-empirical articles reviewed under
specified categories
Key Findings:
Private rooms are the trend in hospital planning and design. The advantages of singleoccupancy rooms are cited as improvements in patient care, a reduction in the risk of
cross infection, and greater flexibility in operation. However, it is important to view and
interpret the benefits of single-occupancy rooms within the context of patient care
issues, other environmental changes and management policy changes in order to bring
about desired and sustainable outcomes.
First and operating costs
-
-
-
Literature focusing on comparative first costs for single and multi-occupancy
rooms is scarce. The limited number of articles exploring the relationship
between first costs and operating costs indicates that operating costs are
proportionately more than the capital cost of hospitals, and this is true even for
cost estimates within the first three years of construction.
Operating costs are reduced in single patient rooms compared with multioccupancy rooms due to reduction in transfer cost, higher bed occupancy rates
and reduction in labor cost. However, this cost reduction can be better achieved
when conversion to single room is paired with other healing environment design
principles. Cost savings because of reduction in transfers is particularly
applicable with acuity-adaptable rooms (Hill-Rom, 2002; Ulrich, 2003).
Even with higher first or unit costs of construction, furniture, maintenance,
housekeeping, energy (e.g., heating and ventilation) and nursing, single
occupancy can match the per diem cost of multi-bed rooms because of the
higher occupancy rates (Bobrow & Thomas, 2000; Delon & Smalley, 1970).
Single and Multiple Occupancy Patient Room Study
2
-
-
A patient’s length of stay is associated with hospital costs. Research
demonstrates that patients’ length of stay in private rooms is shorter, which
in turn reduces costs (Anonymous, 2000; Hill-Rom, 2002).
In comparison to multi-occupancy rooms, medication errors are reduced in
single-occupancy rooms, resulting in reduced costs (Anonymous, 2000; Bilchik,
2002; Bobrow & Thomas, 2000; Hill-Rom, 2002; Morrissey, 1994).
Infection Control and Falls Prevention
Infection Control
Infected patients or patients highly susceptible to infections need to be isolated in
private rooms with proper ventilation systems and barrier protections in order to
stop infection from spreading or to reduce the possibility of development of new
infections. (Anderson et al., 1985; Muto et al. 2000; O’Connell & Humphreys, 2000;
Sehulster & Chinn, 2003).
Prolonged hospitalization is a risk factor for hospital-acquired infections.
Additionally, intra-hospital spread of infection may result from patients being
transferred to more than one ICU or more than one floor during their hospitalization.
Patients length of stay in hospitals and cost is increased due to nosocomial infection
(Zhan & Miller, 2003; Press Ganey Associates, 2003; Pittet, Tarara & Wenzel,
1994). Ongoing research is demonstrating that nosocomial infection rates are low
in private rooms with proper design and ventilation systems (The Center for Health
Design, 2003).
Caution must be used when interpreting results from infection control literature,
because the findings and recommendations are often based on retrospective
investigations of infection outbreaks in particular settings and are tailored towards
those settings. They may or may not be applicable to other settings.
Patient Falls
Patients who require constant supervision (as in the case of frail and/or delirious
patients) are more likely to fall in hospitals; multi-occupancy patient rooms with
increased surveillance may be more appropriate for these patients (Jones &
Simpson, 1991; Sutton, 1994; Tutuarima et al., 1997).
Most falls occur in patient rooms, among elderly patients, and when patients are
alone or while attempting to go to the bathroom. (Hendrich et al., 1995; Langer,
1996; Pullen, Heikaus, & Fusgen, 1999). However, if provision is made for family
members in patient rooms, falls may be reduced due to assistance from family. It is
easier to accommodate family in private rooms than in semi-private rooms (Ulrich,
2003).
Health care Facility Management, Hospital Design and Therapeutic Impacts
-
-
Single-occupancy rooms increase patients’ privacy, which provides patients with
control over personal information, an opportunity to rest, and an opportunity to
discuss their needs with family members and friends. The number of patients in a
room, the presence of visual screening devices, the location of the bathroom, and
the placement of the patient’s bed all impact privacy (Bobrow & Thomas, 1994;
Burden, 1998; Morgan & Stewart, 1999).
The influence of room occupancy on type of pain medication usage is mixed. Some
researchers discovered that patients in private rooms were more likely to use
narcotics than were similar patients in semi-private rooms. This may be due to
Single and Multiple Occupancy Patient Room Study
3
-
-
-
-
-
-
decreased environmental stimuli in private rooms. Whereas, others have
demonstrated that pain medication intake is less in single occupancy rooms.
(Dolce et al., 1985;Lawson & Phiri, 2000).
It is claimed that health care professionals have more private, and in many cases,
more thorough consultation with patients in single rooms than with patients in
multi-occupancy units (Ulrich, 2003). Research in this area of patient confidentiality
and patient consultation is limited.
Mixed results were obtained in studies and surveys of patients’ preferences for
room design. The majority of patients prefer single rooms because of greater
privacy, reduced noise, reduced embarrassment, improved quality of sleep,
opportunity for family members to stay, and avoidance of upsetting other patients
(Douglas, Steele, Todd, & Douglas, 2002; Kirk, 2002; Pease & Finlay, 2002; Reed
& Feeley, 1973).
Patient stress can be reduced if preoperative patients are assigned to rooms with
postoperative or non-surgical patients (Kulik, Moore, & Mahler, 1993). Multiple
occupancy rooms are associated with lack of privacy, higher noise level and sleep
disturbance (Hilton, 1985, Ulrich, 2003).
Universal rooms or acuity adaptable rooms are a current trend in design,
especially in hospitals that are promoting patient-centered care and family
participation in the patient’s healing program. These rooms are all private rooms.
Results from a limited number of studies have indicated that medication errors,
patient falls and procedural problems may be reduced in acuity adaptable rooms
(Bobrow & Thomas, 2000; Gallant & Lanning, 2001; Hill-Rom, 2002; Spear, 1997).
However, these results may be specific to the particular institutions studied. More
detailed study with examples from multiple hospitals is required before drawing
specific conclusions.
Sources of stress for patients are: perceived lack of control, lack of privacy, noise,
and crowding (Shumaker & Pequegnat, 1989). Excess noise can lead to increased
anxiety and pain perception, loss of sleep, and prolonged convalescence (Baker,
Garvin, Kennedy, & Polivka, 1993; Cys, 1999; Hilton, 1985). Single rooms often
afford more privacy, reduction of noise and less crowding. Control is greater in
private rooms, as patients can adjust settings according to their needs (Shumaker
& Reizensten, 1982).
Music can also help reduce patients’ stress. Patients can listen to music in private
rooms without disturbing their roommates (Cabrera & Lee, 2000).
Crowding can contribute to higher blood pressure. The use of private rooms often
minimizes the patients’ sense of crowding (Baum & Davis, 1980; D’Atri, 1975).
These key findings are summarized in Table 1:
Single and Multiple Occupancy Patient Room Study
4
TABLE 1: Categories, issues, and findings related to single versus multiple
Category
Room Occupancy
Single-Occupancy Room
COST
Issues & Findings
Operating costs ↓
First costs ↑
Occupancy rates ↑
Length of stay ↓
Medication errors & costs ↓
Multi-Occupancy Room
Operating costs (inconclusive)
First costs ↓
Occupancy rates ↓
Length of stay ↑
Medication errors & costs ↑
Single-Occupancy Room
Rate of nosocomial infection↓
Patient transfers ↓
Patient length of stay ↓
Infections in burn patients ↓
HCV transmission between patients ↓
Transmission of hospital-acquired
diarrhea↓
Falls in patients requiring supervision ↑
Falls in elderly when provisions are taken ↓
Multi-Occupancy Room
Isolation for infected patients (inconclusive)
Infections when patients are transferred ↑
Transmission of hospital-acquired
diarrhea↑
Patient length of stay ↑
Access to bathrooms ↓
Falls in patients requiring supervision ↓
Falls in elderly when provisions are taken ↓
INFECTION
CONTROL AND
FALLS
occupancy
patient rooms based on the literature review
Single and Multiple Occupancy Patient Room Study
5
Category
Room Occupancy
Single-Occupancy Room
HOSPITAL
DESIGN
&
THERAPEUTIC
IMPACTS
Multi-Occupancy Room
Issues & Findings
Privacy ↑
Pain medication (inconclusive)
Patient consultation with physician
(inconclusive)
Patient preference for room design
(inconclusive)
Noise level ↓
Sleep disturbances ↓
Acuity-Adaptable rooms (inconclusive)
Patient satisfaction ↑
Patient control ↑
Crowding ↑
Stress reduction through music ↑
Privacy ↓
Pain medication (inconclusive)
Patient consultation with physician
(inconclusive)
Patient preference for room design
(inconclusive)
Benefit of roommates (inconclusive)
Noise level ↑
Sleep disturbances ↑
Patient satisfaction ↓
Patient control ↓
Crowding ↑
Stress reduction through music ↓
TABLE 1(Cont’d): Categories, issues, and findings in regards to single versus multiple
patient rooms based on the literature review
Single and Multiple Occupancy Patient Room Study
6
B. Comparative Assessment of “First Costs” of Single versus Double
Occupancy Residents’ Rooms
Based on consultations with Mahlum Architects and Davis Langdon Adamson
(Construction Cost Planning and Management firm), the focus of first costs comparison
has been expanded from patient rooms and adjacent corridors to include the associated
support service areas in the nursing units. Mahlum Architects has assisted us in
identifying several nursing unit floor plans with various configurations. However, most of
these plans reflect either all single patient rooms or a mix of single and double rooms in
the nursing units. Based on the analysis by Davis Langdon Adamson on multiple nursing
unit floor plans of various configurations, it is evident that gross area per patient is
significantly larger for single patient rooms than for double patient rooms. Most of the
other building components correlate to area, rather than patient count. This leads to the
conclusion that for the purpose of this study, single patient rooms can be reasonably
evaluated based on area per patient.
A dual approach has been taken in comparative first cost assessment between single
and double occupancy rooms. The first approach is an overall comparative estimation
completed by Davis Langdon Adamson based on ten nursing unit floor plans. Because
none of the nursing units consisted of only double patient rooms, the grossing factor was
calculated for single patient room floors and for mixed (double and single) room floors.
Gross floor area per bed was calculated by multiplying the square footage of the room
by the grossing factor for that floor plan type (either single patient or mixed). Based on
the analysis of the nursing floor plan samples, gross area per bed can be considered a
reasonable indicator of cost per patient for building construction. The cost for
construction of a typical patient nursing tower, based on cost analysis of these and other
recently built hospitals, is about $285 per square foot for both types of floor plan.
Two additional floor plans have been analyzed, resulting in a total of ten nursing unit
floor plans included in this final cost model. The overall conclusion was not significantly
altered by addition of the two hospitals. Using the construction cost and the values for
gross floor area per patient calculated, the cost per patient for the two floor plan types
(based on ten different nursing units) was as follows:
•
•
$182,400 per patient – single patient room floor plans
$122,550 per patient – mixed room floor plans
Typical Cost Models for Hospital Nursing Tower Construction for single and double
rooms are provided in document “Comparative First Cost Assessment.”
The second approach provides a cost model that replaces the single rooms of a nursing
unit with double rooms. This analysis was done by the quantity surveyor firm, BTY
Group, based on one particular nursing unit plan (Swedish Medical Center, Seattle). In
this approach, it was assumed that the total patient room areas and half of the corridor
areas immediately adjacent to those patient rooms would be reduced by 20%, with the
assumption that core services would remain same as that required for the one-bed
option in the floor plan. However, in reality these services may require additional spaces
in double-occupancy conversion. This cost model includes all direct and indirect building
construction costs, and excludes items such as legal fees, professional fees and
disbursement, site work, etc. This approach (based on one example) yielded the
following cost comparison:
Single and Multiple Occupancy Patient Room Study
7
$153,000 – single patient room option
$134,000 – double patient room option
Nursing unit floor plans analyzed in this cost modelling are as follows:
•
•
•
•
•
•
•
•
•
•
Evergreen Hospital, Kirkland. East Wing, 5th floor
University of Washington Medical Center, Seattle. Wing EC/EB, 4th floor
Swedish Medical Center, Seattle. Southeast Tower, 9th floor
Providence Newberg, Oregon. 2nd floor
Evergreen Hospital, Kirkland. unidentified floor
San Joaquin General Hospital, California. Med Surg, 2nd floor
VA Menlo Park, California. Psychogeriatric floor
University of California at Davis Medical Center, Davis. Davis Tower, 14th floor
St Luke’s Medical Center, Milwaukee, Wisconsin.
Valley Presbyterian, Van Nuys, California.
C. Pilot Study on Comparative Assessment of Operational Costs and Patient Care
Issues in Single and Multiple Occupancy Patient Rooms
This empirical component of the research documented, comparatively analyzed and
synthesized information on use, efficiency and suitability of single and double occupancy
med-surgical patient rooms in four hospitals in the Pacific Northwest. We conducted
structured interviews with administrators and staff in the following four hospitals:
Evergreen Hospital Medical Center, Kirkland, Washington; Swedish Medical Center-First
Hill, Seattle, Washington; University of Washington Medical Center, Seattle,
Washington; and Providence Medical Center, Portland, Oregon.
Brief descriptions of the hospitals:
Swedish Medical Center-First Hill: Swedish Hospital is the Northwest's largest, most
comprehensive medical center, with three campuses: Seattle's First Hill, Swedish
Medical Center/Providence and Swedish Medical Center/Ballard. Swedish Medical
Center-First Hill is the flagship campus, with 697 beds.
Evergreen Hospital Medical Center: Evergreen Healthcare is a community-based health
care organization serving more than 400,000 people in the Northwest. Evergreen
Hospital Medical Center is a 244-bed acute care hospital in Kirkland, Washington.
University of Washington Medical Center: The University of Washington Medical Center
is a comprehensive medical care facility. It is rated among the top dozen medical centers
in the United States. Number of beds is 450. Inpatient admission in 2002 was 16,517,
and total operating expenses were more than $436 million.
Single and Multiple Occupancy Patient Room Study
8
Providence Portland Medical Center: The Providence Portland Medical Center is located
in the Portland metro area, with 483 beds and admissions of 22,646 in 2000.
Data Collection
We developed two questionnaires to gather data on staffing, patient care issues and
operational costs. The first questionnaire focused on hospital background information,
staffing patterns in nursing units, comparative assessment of single versus double
patient rooms and some operating cost issues. This was used with an appropriate
administrative staff member in each of the four hospitals. The second questionnaire
focused primarily on comparative assessment of single versus double patient rooms in
terms of patient care and staff efficiency. This questionnaire was used with frontline
nursing staff (e.g. nurse managers, charge nurses, nurse aides and other health care
personnel) at each hospital. There is some overlap of the questions on the two
questionnaires. We believed that it was important to gather multiple viewpoints (from
both administration and nursing unit staff members) on certain issues of advantages and
disadvantages of single versus double patient rooms.
In order to identify relevant issues and variables for a comparative assessment of
operating costs with an emphasis on staffing and maintenance costs, we consulted with
several administrative and nursing staff members at those four hospitals either in person
or over the telephone. It became apparent that there is no systematic built-in mechanism
for documenting staff efficiency and patient care factors, and their associated operating
cost figures in these four hospitals. For example, although anecdotal experience
indicates that considerable time is spent on patient transfers, there is no existing data on
the actual time spent on the related tasks at the hospitals. Given the scope in time and
financial resources of this current study, we gathered experience-based data on these
issues. We believe that in order to fully examine the factors that have relevance for
operational costs associated with single and multi-occupancy rooms (e.g., reduced
transfers, effect of single rooms on infection rates, easier surveillance), an expanded
study with a specific focus on these issues should be considered in the future.
Key Findings
Data from the semi-structured questionnaires was analyzed using SPSS for Windows
software. Descriptive statistical analysis was performed on the quantitative data to
provide comparative assessment on single versus double patient rooms. Participants
represent various levels of nursing staff. The findings need to be viewed within the
context of the limited sample size of this pilot study (Nursing staff N=73; Administrative
staff N=4). In comparing single- versus double-occupancy rooms, it is evident that
nurses clearly favored single-occupancy rooms. Most of the participants responded
more favorably for single rooms than for double rooms on the majority of the fifteen
categories in the comparison questions. The most noticeable categories of positive
assessment for single rooms include: flexibility for accommodating family, suitability for
examination of patients by health care personnel, patient comfort level, patient recovery
rate, less probability of medication errors, and less probability of diet mix-ups.
-
Single and Multiple Occupancy Patient Room Study
9
-
-
-
-
-
-
The respondents rated many environmental characteristics of single patient rooms
as helpful. These included the layout of the room (47 percent), the availability of
space in rooms (49 percent), the arrangement of furniture (47 percent), privacy (89
percent), and space for family members (51 percent).
Double-occupancy rooms were thought to be somewhat helpful in terms of walking
distance from the nursing station (41 percent) and visibility of the patients for
monitoring purposes (40 percent)
Surveillance of patients was considered somewhat problematic in both single- (40
percent) and double-occupancy rooms (34 percent).
The most common reason given for a transfer request was privacy (52 percent),
followed by patient behavior issues (36 percent) and infection control (27 percent).
Future studies may rely on multi-method data collection, such as observation and
log entries, as well as respondent surveys, in order to gain more accurate
information on the tasks, time and cost involved in patient transfer.
Staff efficiency is greater in single-occupancy rooms, according to more than half of
the study participants (53 percent), and 58 percent of nurses noted that patients use
less medication in single-occupancy rooms.
Respondents felt that single-occupancy rooms have better access to bathing
facilities (93 percent), more space for storage and equipment (86 percent), and are
better suited for different ethno-cultural groups and family members (96 percent)
compared to double or multi-occupancy rooms.
Eighty-four (84) percent of the respondents rated room flexibility as high or very high
in single-occupancy rooms, whereas only 40 percent of nurses felt doubleoccupancy rooms are moderately flexible.
Single-occupancy rooms were chosen as most appropriate for patient examination
(85 percent) and collection of a patient’s history (82 percent) compared to less than
half of the respondents rating double-occupancy rooms as low in their suitability for
patient examination and collection of a patient’s history.
Fifty-seven percent of the respondents stated that the rate of acquiring a nosocomial
infection is either low or very low in single-occupancy rooms, compared to 11
percent respondents stating that the rate is high or very high in single rooms. As for
double rooms, 10 percent respondents felt that the rate of acquiring a nosocomial
infection is either low or very low, compared to 46 percent respondents stating that
the rate is high or very high in double rooms.
The incidence of patient falls was considered moderate in both types of rooms (48
percent). Similarly, the rate of taking pain reducing or sleep inducing medicine was
considered moderate in both types of room (37 percent in single-occupancy rooms;
33 percent in double-occupancy rooms).
The primary objectives of this pilot study were to gather an experience-based
assessment from hospital staff in regard to single versus double patient rooms and to
examine the validity and relevance of the two survey questionnaires. The results
generally support the positive aspects of single rooms from a patient care perspective,
as suggested by the literature. The limitations of this study include limited sample size
and limited data on operating costs. Findings need to be interpreted with these
limitations in mind. Future studies need to examine carefully the implications for
operating costs of the positive assessments of patient care issues associated with single
rooms. An in-depth case study approach using multiple methods (e.g., systematic
observations, information from data logs, qualitative interviews) can provide more useful
Single and Multiple Occupancy Patient Room Study
10
data in regard to the complex relationships among patient care issues, operating cost
variables, patient outcomes, and staff efficiency, as well as subjective evaluations by
patients and family members. See the document Pilot Study on Comparative
Assessment for full report.
Issues for Future Research:
It is evident from this research project that in order to better understand the advantages
and disadvantages of single versus double rooms, future research needs to examine the
effects of design of patient rooms and nursing units, staffing, care procedures and
practices on operating costs. Although cost of construction is an important factor in the
consideration of single versus multi-occupancy rooms, room area and design of patient
rooms, nursing unit configurations, etc., it is relatively insignificant over the lifetime of the
building. Eventually, the operating costs become the truly relevant factors in terms of
seeking out efficient and meaningful strategies in design, staffing and care delivery that
can positively impact cost containment and reduction.
In this study, we provided comparative first cost analysis of single and double occupancy
patient rooms. However, issues related to operational cost was only covered through
some experiential data provided by the frontline staff at the four study hospitals. We
believe that future studies could be designed with an in-depth methodology by collecting
concrete data with direct staff input over a period of time, and focusing primarily on
specific patient care tasks/activities and their relevance to operating costs. Multi-method
of data collection including observation, information from data logs and interviews is
required to gain more detailed information. However, in order to have a meaningful
understanding of the associated issues, measurement of operating cost with variables
such as staff travel time, paperwork, maintenance, infection control, transfer, etc., need
to be conducted along with the variables of a therapeutic environment. It is important to
recognize the apparently intangible benefits of a patient-focused and positive
environment on patient satisfaction, morale and self-efficacy.
Single and Multiple Occupancy Patient Room Study
11
The Use of Single Patient Rooms vs. Multiple
Occupancy Rooms in Acute Care Environments
A Review and Analysis of the Literature
Habib Chaudhury, Atiya Mahmood and Maria Valente
Simon Fraser University
The Use of Single Patient Rooms vs. Multiple Occupancy Rooms
in Acute Care Environments: Review and Analysis of the Literature
Overview
Aging of the population in the United States has resulted in increased prevalence of chronic and
acute conditions that require hospitalization and this will play a central role in driving the future
demand of inpatient care (Ulrich, 1992). Demographic changes (e.g., the aging baby boom
generation, increasing life expectancy and continued immigration) could result in a 46 percent
increase in acute care bed demand by 2027 (Solucient, 2003). One effect of increased acuity in
patients is that hospitals are designing inpatient care units much more like critical care units.
Nursing stations are being designed to allow for closer proximity of nurses to the patients and to
other nurses. According to Burmahl (2000), built-in flexibility in design is becoming more crucial,
mainly because technology is quickly obsolete and patient populations are constantly changing.
Today’s patient room may be tomorrow’s intensive care unit, so flexibility is essential. However,
the trend is also to design therapeutic environments --wellness-oriented, healing environments –
that incorporate family-centered care and include organic elements like natural light, plants,
water, color and texture in their design schemes. In recent years, health care designers and
administrators have become more aware of the need to create patient centered and
psychologically supportive acute care environments (Gerteis et al., 1993; Ulrich, 1999). The
challenge is to design patient rooms to be more like intensive care rooms, yet achieve a better
healing environment. How does the need to address increased acuity, as well as the need to
promote therapeutic outcomes affect patient density issues in patient room design?
Single patient rooms have become the industry standard in new construction of acute care
facilities in the United States. Healthcare design professionals and planners argue that private
patient rooms reduce the possibilities for infection, facilitate nurses and healthcare workers’
ability to do their jobs efficiently, provide adequate spaces for family members to participate in
the healing process of the patients, and afford a greater measure of privacy for the delivery of
bedside treatments and for sensitive discussions with health-care personnel (e.g., Bobrow &
Thomas, 2000; Gallant & Lanning, 2001; Hill-Rom, 2002; Hohenstein, 2001; Solovy, 2002,
Ulrich, 2003). Additionally, they claim that this type of room design reduces noise levels and
traffic in and out of patient rooms and contributes to a reduction in patient stress levels, which in
turn results in faster healing time for the patient (e.g., Bacon, 1920; Cabrera & Lee, 2000; Tate,
1980). However, are these claims supported by empirical evidence?
Review and Analysis of the Literature
1
An extensive review of literature in the area of healthcare design, construction and operating
cost, hospital management, staff efficiency, infection control and patient outcomes was
conducted to identify advantages and disadvantages of single versus double occupancy patient
rooms. The research questions that guided this review are:
1) What are the differences in first cost, operating cost, energy costs and efficiency of
management and care delivery in single and double occupancy patient rooms in acute
care settings?
2) What are the advantages and disadvantages in disease control and falls prevention in
single versus double occupancy rooms in acute care settings?
3) What are the therapeutic impacts (socio-behavioral issues of patient privacy, social
interaction and daily functioning) of single versus double occupancy hospital rooms?
To address the study research questions and facilitate the review and analysis process, the
articles and chapters reviewed were divided into four categories. Additionally, the articles in
each category were subdivided into empirical and non-empirical articles. Articles that presented
primary data and findings from a research project were grouped under the “empirical” subcategory. Articles and chapters that were either reviews of other studies or prescriptive in
nature, or that covered general descriptive information were grouped under the “non-empirical”
sub-category. The four general categories of the literature review are as follows:
i)
First and operating cost of hospitals
The review included articles that discussed issues that affect first and operational costs of
acute care settings. Most of the articles in this section were non-empirical in nature and
provided a general overview of cost factor in acute care settings. An extensive literature
search revealed a limited number of articles that addressed cost factors relative to room
occupancy.
ii) Health care facility management and hospital design
In this section, literature on current hospital design trends and the reasons behind these
trends were reviewed. Additionally, some literature on hospital management was reviewed.
The literature searches were also conducted on nursing unit layout, room occupancy rates,
patient transfers, efficiency related to medical procedures and staff walking distance. There
were more non-empirical articles in this section.
iii) Disease control and falls prevention
The review of literature in this category included articles on nosocomial infections in
hospitals and their relationship to environmental factors. Articles on falls in hospitals were
also reviewed to identify any linkages to the built environment and design.
Review and Analysis of the Literature
2
iv) Therapeutic impacts: Relationship between healing and environment
This section mainly dealt with articles and chapters that discussed the contribution of
environmental factors to the healing process. It covered issues of room size, acoustics,
room location, ambient characteristics, privacy, confidentiality and stress reduction. Many of
the articles in this section were empirical in nature and provided useful information on health
outcomes as they relate to built environmental factors.
The articles in the “Healthcare facility management and hospital design” and the “Therapeutic
impacts: Relationship between healing and environment” categories are interrelated and have
overlapping ideas and issues. Though these two categories are separate in the annotations and
summary charts (see Appendices A and B), highlights from the findings in these two categories
are combined later in this summary section due to their interrelated nature.
Literature review methods
Several strategies were used to identify potential studies/articles for the review. First, a keyword
search of relevant databases was conducted. The databases searched were: Medline, EBSCO
Host, ABI/Inform, Ageline, Clinical Reference Systems, Digital Dissertations, Healthsource:
Nursing and Academic, JSTOR, PsycINFO, Science Direct, EMBASE, Pubmed, World Cat,
Social Sciences Citation Index, Simon Fraser University and affiliated libraries’ catalogues.
Second, potential studies were identified by a systematic review of issues of relevant
journals/magazines in the area of healthcare design, management and infection control.1
The literature search demonstrated that many articles on the relationship of design to healing
and innovations in hospital design are dated 1980 and later, so this timeframe was chosen for
the systematic journal searches. However, relevant articles dealing with room occupancy and
1
Journals/magazines/newsletters searched for relevant articles:
•
Architecture and design – Journal of Healthcare Design, Hospital Design, Journal of Healthcare Interior
Design, Journal of Architectural and Planning Research.
•
Hospital and healthcare - Journal of Healthcare Management, Managed Healthcare Executive, Health
Facilities Management, Hospitals, Hospital and Healthcare Network, Modern Healthcare, Healthcare
Forum Journal, American Journal of Infection Control, Journal of Hospital Infection, American Journal of
Critical Care, American Journal of Nursing, Facilities Design and Management, Health Services
Management, Nursing Times, Critical Care Nursing Quarterly, Healthcare Financial Management.
•
Social, Psychological and Behavioral issues- Social Science and Medicine, Journal of Environmental
Psychology, Environment and Behavior, Behavior Research and Therapy, Health Psychology, Journal of
Personality and Social Psychology.
•
Others: The Gerontologist, Canadian Journal of Aging, Journal of Gerontology (Psychological and Social
Sciences), Journal of Gerontological Nursing, Journal of the American Geriatrics Society.
Review and Analysis of the Literature
3
patient issues and dating earlier than 1980 were also included in the review. Finally, the
reference lists for included articles that dealt directly with room occupancy issues were
inspected. In each case, articles and chapters that were potentially relevant were collected and
assessed for appropriateness.
Keyword searches included: hospital design, healthcare facility design, acute care, hospital
planning, hospital management, single occupancy rooms, private rooms, semi-private rooms,
multiple occupancy rooms, double occupancy rooms, patient rooms, ward design, isolation and
infection control, cost analysis in hospitals, first cost, energy cost, operating cost of hospitals,
falls incidence and prevention, patient occupancy rates, patient transfer, design and well-being,
patient-centered care, cooperative care, health and environment, social interaction, privacy,
nursing efficiency in hospitals, etc.
The formats of the charts for empirical and non-empirical articles are as follows:
Chart format for empirical studies:
Study
Focus of study Research
Design
Sample
information and
site
Findings
Chart format for non-empirical articles and chapters:
Article
Focus of
Type of healthcare
Recommendations
article
facility
for healthcare
settings
Relationship of
findings to room
occupancy
Relationship of
recommendation to
room occupancy
The following graph (Figure 1) provides the number of empirical and non-empirical articles
reviewed under each category of the literature review. It illustrates to the reader the type and
quantity of the articles reviewed.
Review and Analysis of the Literature
4
120
108
100
80
60
40
20
Empirical Articles
Non Empirical Articles
50
14
22
19
9
0
First & Operating
Costs
Design &
Therapeutic
Impacts
Disease Control
& Falls
Prevention
FIGURE 1: The number of empirical and non-empirical articles reviewed under
specified categories
The next section provides an historical overview of hospital development and patient room
design. This is followed by highlights from the review and analysis of literature.
Historical Overview and Context
The healthful environment it provides for patients, the amount of privacy it allows
patients, the extent to which it exercises supervision and control over patients,
and the efficiency with which it can be operated. These we call the four elements
of ward design.
Thompson & Golden, 1975, p. xxviii
Today [in the United States] the patient room is seen as a place of sanctuary,
privacy and safety—the place where the patient and the family are in control of
their lives and environment. The patient room can now house the family, if
necessary, and can be designed as an extension of the daily life of the patient,
with total access to the world.
-- Bobrow & Thomas 2000, p. 132
As background for the review of literature, this section provides a brief overview of the
development of the hospital as it relates to patient room issues. The hospital, as it is known
today, has undergone various changes throughout past centuries. Verderber & Fine (2000)
identified six periods in history through which hospital design has evolved. These include the
Ancient era, the Medieval period, the Renaissance, the Nightingale era, the Minimalist
Review and Analysis of the Literature
5
Megahospital and the Virtual Healthscape. Among the first four periods, the Nightingale era is
most relevant in terms of room layout and occupancy.
Based on her nursing work during the Crimean War, Florence Nightingale wrote two seminal
books, Notes on nursing (1858) and Notes on hospitals (1859), in which she spelled out her
theories on nursing practice, hospital planning and design.2 She was a strong proponent for
large multi-occupancy wards (over 30 patients), favoring them over private rooms and smallscale wards because she wanted to improve the work environment for the nursing staff (Jones,
1995). Nightingale argued from the point of view of staff efficiency, and highlighted the ease of
supervision and better quality of care, as well as the spaciousness in large multi-occupancy
wards compared to private rooms. She indicated that benefits of staff efficiency and increased
health status (as in multi-occupancy wards) outweighed the need for individual privacy (as in
single-occupancy rooms) (Seymer, 1954). Nightingale’s reforms, as well as advancement in
medicine, resulted in hospitals that were places of healing rather than places of dying. This in
turn resulted in hospitals being used not only by the poor, but also by the wealthy. People from
the upper income groups wanted privacy during their healing process, so they created a
demand for single-occupancy rooms. Gradually, private and semi-rooms replaced multi-bed
large wards in hospitals and, by the mid-twentieth century, the Nightingale ward was a dying
template (Miller & Swensson, 1995). However, in the 1950s and 1960s, many hospitals still
favored open smaller wards over private rooms because of the staff efficiency issue. Even in the
early 1970s, advocates of multi-occupancy rooms were stating that patient privacy (in single
occupancy rooms) meant a sacrifice of continuous supervision. They attributed the trend
towards single rooms in hospitals to the general movement towards privacy in all aspects of 20th
century life (Thompson & Golden, 1975). The all-private-room argument was waged mainly as a
reflection of societal progress rather than on the basis of strictly rationalized medical justification
(Verderber & Fine, 2000).3
2
Her guidelines for hospital reform addressed the maximum allowable width and length of a ward, the size of
windows and their placement in relation to the bed, the overall ambience, the heating and ventilation systems, and
the use of specific materials and colors. St Thomas Hospital in London, which opened in 1871, was the first hospital
that used her guidelines in the planning of its wards (Verderber & Fine, 2000).
3
Countries that have some form of universal healthcare coverage (e.g., Britain, Canada), patients pay more for
private rooms, thus a majority of the hospitals have more small scale wards (four to six patients) and double
occupancy rooms than single patient rooms. These types of multi-occupancy patient rooms continue to find medical,
religious, economic and social justification in many developed and developing countries.
Review and Analysis of the Literature
6
According to Verderber and Fine (2000), the United States was one of the first countries to
reject the multi-bed ward concept. This shift began after the Second World War and was nearly
complete by the early 1970s (with the exception of some urban charity hospitals and large staterun institutions). Although the trend was to develop all private rooms in hospitals, such inpatient
facilities often compounded the patient’s sense of alienation, dislocation and fear that is part and
parcel of the hospitalization process (Verderber & Fine, 2000). By the 1970s some hospital
designers began to lobby for hospitals that offer several variants of the medical-surgical units,
consisting of a mixture of private rooms, double occupancy rooms, and small wards of up to six
beds (Verderber & Fine, 2000). In the past two decades, hospitals in the United States have
tended to build more private patient rooms and most renovations done or planned for the future
have also favored maximizing single-bed rooms.
Though private patient rooms gained popularity in the latter half of the twentieth century,
advocates like A. Bacon, Superintendent of Chicago’s Presbyterian Hospital, were
recommending them from the early part of the 20th century. Bacon (1920) argued that this type
of room design not only provided patients more privacy and comfort, but also addressed the
hospital’s goal of maximum occupancy. Recent publications (e.g., Bobrow & Thomas, 2000)
have provided support for his claim by stating that almost 100 percent occupancy can be
achieved in single occupancy rooms versus 80 percent occupancy in double or multi-occupancy
rooms. Bacon (1920) also mentioned that hospital-acquired infections were reduced in single
rooms and that medical personnel were better able to examine patients and to collect more
complete medical histories due to the privacy afforded in this type of rooms. Recent studies on
infection control (e.g., Kappstein & Daschner, 1991; Muto et al. 2003; Shirani, et al. 1986)
support his claim on mitigation of contagion. Ulrich (2003), in his presentation on evidencebased design, stated that a significant number of studies demonstrate that nosocomial infection
rates are reduced in single versus multiple occupancy patient rooms, even when controlling for
hand washing practices and air quality (the two other key factors affecting control of nosocomial
infection).
Preliminary results from ongoing studies (Rich, 2002) support the examination and patient
history part of Bacon’s (1920) claim. Additionally, in their study of maternity rooms, Janssen, et
al. (2001) discovered that nurses were better able to respond to the needs of patients in singleoccupancy maternity rooms, equipment was easily accessed, and privacy was increased.
Nguyen, et al. (2002) mention that in their study on patients’ satisfaction with their hospital stay
Review and Analysis of the Literature
7
and care, patients in private rooms were more satisfied with the hospital environment, the staff,
and the overall quality of care. Present studies verify that there is merit to Bacon’s early 20th
century claims about the benefits of private rooms.
In “Building type Basics: Healthcare facilities,” Bobrow & Thomas have highlighted different
advantages of private patient rooms. According to them,
[In single patient rooms] the patient can rest undisturbed by a roommate’s
activities. A patient can become ambulatory earlier when the toilet and shower
are in the room, and such rooms can be used for many types of isolation.
Because patients in single-bed rooms are rarely moved, medication errors are
greatly reduced [There is a reduction of patient transfer cost for the institution]….
In units with multi-bed rooms the number of daily moves has averaged six to nine
per day, at a significant cost in added paperwork, housekeeping, patient
transport, medication instructions, etc.
-- Bobrow & Thomas, 2000, p. 145
The efficiency and effectiveness of patient room design is tied to a large extent to the nursing
unit design. As patient rooms gradually shifted from multi-occupancy to single occupancy units
in the United States, the design of the nursing units also evolved. Staff work efficiency, walking
distance to rooms and monitoring capacity are all related to nursing unit design and this is true
for both multi- and single occupancy patient rooms. Designers and administrators should
evaluate the benefits and shortcomings of single versus multi-occupancy patient rooms within
the context of the different types of nursing unit layout and design.
The Hill-Burton Program that started in 1947 and remained in operation into the early 1970s
gave rise to many of the hospitals built in the suburbs to support the housing constructed during
that time (Jones, 1995). Thus, many of the current hospitals in the United States are
approximately 40 to 50 years old. Because of the changing demographics, increase in
ambulatory care, advancement of technology and increase in patient acuity during admission,
medical care is very different than it was in the 1950s and 1960s. Hospital and patient room
design and renovation in the 21st century need to address these changing needs and
demographics. 4 Thus, the type of density in patient rooms needs to be guided by design
4
The Planetree movement, originated by Theriot in 1978, has tried to address some of these issues and has impacted
hospital design by creating an emphasis on patient-centered care. After her negative experience in a hospital,
Theriot “founded a nonprofit organization to provide health and medical information aimed at improving the quality
of patient care” (Miller & Swensson, 1995, p. 177). The Planetree guidelines place an emphasis on creating a
comfortable, soothing, and homelike environment for the patient (Martin et al., 1998). New models of patient
care rooms--mainly private rooms--such as acuity-adaptable rooms and universal or family-oriented rooms are being
Review and Analysis of the Literature
8
principles that are patient focused, have therapeutic impacts, reduce inefficiencies and increase
staff productivity.
This section provided some background information about the evolution of multi- and single
patient rooms in hospitals in the United States. The following sections provide a summary of the
findings from literature on the four themes mentioned earlier.
Highlights from the Literature Review
While a number of issues and patterns were discovered about the cost, patient care,
management, disease control and therapeutic impact of environmental factors, highlighted
below are some of the more pertinent and prominent findings related to cost issues.
First and Operating Costs of Hospitals
Even though staff costs account for around 70 percent of the running costs of
hospitals, hospitals are still being built and modernized, not with smooth care
processes or savings in operational costs in mind, but in accordance with ageold space and operational models seeking to minimize building costs.
-- Paatela, 2000, p. 2
Healthcare construction cost expenditures have gradually increased over the years. In the
United States, this amount has risen from 11.6 billion in 1997 to 18 billion in 2001, and it is
expected to rise to 27 billion by 2010 (Coile, 2001; Crosswall, 2001 & 1999). According to Coile
(2001), the rise in healthcare facility construction will be driven by the aging of the Baby Boom
generation and the expansion of the population to 300 million by this decade. Hospital cost
covers a significant portion of the national healthcare expenditure in the United States.5 Though
there are not many articles exploring the relationship between first costs and operating costs,
the consensus among the few that compare these two cost factors is that operating costs are
proportionately more than the capital cost of hospitals and this is true even for cost estimates
within the first five years of construction.
The review of literature on hospital costs revealed that there are very few articles that address
the relationship between hospital’s first or operating costs and room occupancy. Most articles
designed to address some of the current patient and staff needs. Description of these types of patient rooms is
provided in a following section.
5
In 1998, hospital care expenditure was 383.2 billion dollars (33.4 percent of the total health care expenditure) and
it is expected to be 649.4 billion dollars in 2007 (30.4 percent of the total healthcare expenditure) (Inglehart, 1999).
Review and Analysis of the Literature
9
on hospital expenditure (e.g., Bachelor & Esmond, 1989; Smet, 2003; Yafchak, 2000) dealt with
overall capital or operating cost and methods of cost reduction in hospitals. Some articles (e.g.,
Berry, 1974; Li & Rosenman, 2001; Hoppszallern, 2003; Woodlander & Himmelstein, 1997)
provided comparative cost information in different types of hospitals; others discussed methods
of evaluating hospital costs accurately (e.g., Baker, 1998; Doyle et al., 1996; Udpa, 1996, etc.).
However, hardly any research addresses how patient room density affects hospital expenditure
in terms of first costs. The following discussion focuses on hospital design and operational cost.
Even within this category the literature is limited.
Operational costs in hospitals
There are several non-empirical articles/book chapters that mentioned that, in general,
operating costs account for over 70 percent of the hospital’s overall cost and are usually the
same as capital cost within the first three years of construction (Bobrow & Thomas, 2000;
Paatela, 2000). Berry (1974), in studying factors that affect hospital costs, determined that
wage rate was the most significant factor in explaining average costs; construction costs of the
facility did not contribute to the explanation.
Drake (2001), in his article on hospital management and cost, stated that capital improvements
(first cost) on a healthcare campus typically account for no more than 10 percent of the total
cost of providing care, but efficient designs can lower overall operating costs and enable
healthcare providers to administer innovative care in the most convenient, professional and
cost-effective environment possible. He further mentioned that patient-focused care has
brought about as much as a 10 percent reduction in staff cost without compromising care quality
or patient satisfaction.
Paatela (2000) argued that the operational costs of a new hospital or modernized section are as
high as the capital (investment) costs within 3 years, and that there is a tendency in the Western
world to build hospitals to increase “productivity” and the number of patients treated per staff
unit. This requires space arrangements that enable the smooth running of care processes, the
delivery of patient-centered care, and the appropriate placement of procedures and treatment,
while minimizing the movement of patients and all the unnecessary waiting, reporting and errors
this movement entails.
Some authors stated that operating costs are reduced in single patient rooms compared with
multi-occupancy rooms due to reduction in transfer and labor cost and higher bed occupancy
Review and Analysis of the Literature
10
rates. Bobrow & Thomas (2000) mentioned that operational costs of hospitals are reduced in
single occupancy patient rooms compared to multi-occupancy rooms. They argued that, even
with higher first or unit costs of construction, furniture, maintenance, housekeeping, energy
costs (e.g., heating and ventilation) and nursing costs, single occupancy can match the per
diem cost of multibed rooms because of the higher occupancy rates.6 This enables the hospital
to take care of the same size population with fewer beds.
In an earlier book on hospital design, Thomas and Goldin (1975) argued that, economically,
multiple-occupancy rooms are the most efficient. In these types of rooms, patients can be
placed along one corridor, facilitating the supervision of patients and reducing the amount of
time nurses spend traveling. Thomas and Goldin proposed a six-bed room, with three beds on
each side of the room, as the most economical configuration. Costs associated with nurses’
travel time are reduced in multi-occupancy rooms compared to single occupancy rooms. Traffic
costs/nurses’ travel time costs are higher in private rooms, and this increases proportionately as
the number of patients in rooms decreases (Delon & Smalley, 1970). However, staff travel time
is only one variable under consideration when designing patient room layout and density. Often
the advantages of single-occupancy rooms--for example, improvements in patient care, a
reduction in the risk of cross infection, and greater flexibility in operation--may outweigh the
greater travel distances (and the related cost values) associated with private rooms.
Berry, Colle, et al. (as cited in Ulrich, 2003) argued that hospitals can reduce costs through
reducing density in patient rooms. Their estimates for a hypothetical hospital, Fable Hospital,
demonstrated over $3 million savings in patient transfers cost, over $80,000 dollars savings
through a reduction in nosocomial infections, and over $3 million savings through a reduction in
patient falls and drug costs through upgrading of multi-occupancy rooms to large single
occupancy rooms and acuity-adaptable rooms.
Overhead and Administrative Costs
Overhead costs affect overall hospital costs. The volume of patients, bed availability, and the
complexity and costs of services influence overhead costs (Smet, 2002). Due to a trend
towards greater outpatient care and lower occupancy levels, hospitals are experiencing greater
overhead costs (Yafchak, 2000). Woodlander, Himmelstein & Lewontin (1993), in their
6
Occupancy of multi-bed rooms can reach up to a maximum of 80-85 percent, whereas single rooms have the
potential to reach 100 percent occupancy.
Review and Analysis of the Literature
11
evaluation of administrative costs in U.S. hospitals, discovered that administration cost
accounted for an average of 24.8 percent of each hospital’s expenditure in 1990.
Transfer costs
In terms of transfer cost, Bobrow and Thomas (2000) indicated that hospitals save money by
reducing patient moves in single occupancy rooms. “In units with multibed rooms the number of
daily moves has averaged six to nine per day, at a significant higher cost in added paper work,
housekeeping, patient transport medication instructions, etc.” (Bobrow & Thomas, p. 145).
In Bronson Methodist Hospital’s new 348 private room facility, there was a reduction in transfer
costs compared to their older multi-bed facility, as demonstrated by initial findings during
ongoing research at the hospital. In the old facility, the hospital spent around $500,000 per year
in patient transfers due to problems with roommates or infection-control issues; these problems
have been greatly reduced according to the hospital’s chief executive (Rich, 2002). Bronson
Methodist Hospital, upon adopting all single-occupancy rooms, saved $500,000 per year in
transfer costs, while Clarian Methodist Hospital saved $5 million per year by building acuityadaptable rooms (Ulrich, 2003). Patient transfers at the latter facility have decreased by ninety
percent and medication errors have also declined (Hendrich, Fay, & Sorrells, 2002). Gallant &
Lanning (2001), in their article on acuity adaptable rooms, demonstrated that the less a patient
is moved, the greater the reduction in cost. The research they quoted in their article
demonstrated that the transfer time from a critical care room to a patient room is approximately
seven labor hours. Thus, by keeping a patient in a private acuity adaptable room, the hospital
cuts down on the salary cost associated with seven labor hours required for patient transfer.
Berry, Colle, et al. (as cited in Ulrich, 2003) generated some estimates of cost reduction in
hospitals through upgrades of multi-occupancy rooms to private rooms, including oversized
single-occupancy rooms and variable acuity rooms. They calculated cost reduction estimates
for a hypothetical hospital, Fable Hospital, and demonstrated that this hospital could save over
three million dollars in patient transfers alone, by upgrading to single occupancy rooms from
multi-occupancy rooms.
Length of Stay
A patient’s length of stay is associated with hospital costs. The first days of hospitalization are
generally the most expensive, regardless of the type of illness (Berry, 1974) and, by decreasing
Review and Analysis of the Literature
12
the patients’ length of stay, hospitals can become cost-efficient (Smet, 2002). Gallant &
Lanning (2001) stated that patients remaining in one private acuity adaptable room throughout
their stay tended to recover faster. Their article illustrated that patient stay was reduced from 9.5
days to 5.4 days in five diagnostic related groups (DRGs) in private acuity adaptable rooms in
Linda Loma hospital in California.
According to Jones (1995), patients change their room assignments on average four times
during a typical admission. Approximately 40 percent of nursing hours are used to manage
patient logistics, time taken away from patient care issues. Studies (e.g., Hill-Rom, 2000)
demonstrate that there are more patient transfers from multi-occupancy rooms than from private
rooms. Thus, from the perspective of patient transfer issues, private rooms seem to be the more
suitable choice than multi-occupancy rooms (more discussion on this issue follows).
Healing Design and Cost
According to some advocates of healing design, hospital designs that address therapeutic goals
also help to reduce hospital expenses. Aspects of healing design that lead to cost reduction are
as follows:
-
Shorter length of stay;
-
Lower cost per case;
-
Reduced use of stronger drugs;
-
Reduced nurse hours per patient;
-
Reduced turnover (due to improved staff morale) and reduced costs for recruitment
(Coile, 2001b, p.12).
Recent ongoing studies on hospital rooms are demonstrating that using private rooms as part of
the healing design process has the potential of reducing length of patient stay in hospitals and
thus of reducing pain medication intake in private rooms. Private room design that supports the
presence of family members reduces patients’ falls incidence (Ulrich, 2003) and may reduce the
requirement of nurse hours per patient, because family members are participating in the
caregiving process.
Parker (1991) estimated the cost savings in a 300-bed (private rooms) hospital environment that
was designed to address patient needs. As a result of shorter patient stays, drug intake
reduction and reduction of labor cost, the cost savings in that hospital was 10 million dollars per
Review and Analysis of the Literature
13
year in the early 1990s. Parker argued that the savings in staffing cost alone would justify
building a healing hospital. His estimates for 1991demonstrated that the cost of recruiting a
nurse was $20,000 in the United States. Thus, by reducing the nursing labor requirement the
hospital could accrue significant savings. In recent years, the average nurse recruiting cost is
between 72,000 and 87,000 dollars a year or $42-$50 per hour (O’ Neill, 2001 as cited in Coile,
2001b). Based on current expenses and labor cost, Parker’s 10 million dollar estimate could
mean 15-20 million dollars in savings at present.
The articles/chapters that directly or indirectly related cost to room occupancy demonstrated
that multi-occupancy rooms may be cost effective in terms of patient monitoring and staff
walking distance. However, private rooms, when they are a part of a healing design process,
often reduce operational costs in hospitals through shorter patient stays, a lower nursing labor
requirement and drug intake reduction. Additionally, cost may be reduced in private rooms due
to a lower falls incidence and better infection control. These latter two aspects are discussed in
more detail in the following section.
B. Infection Control and Falls
Infection Control
Since March 28 [2003], SARS [Severe Acute Respiratory Syndrome] has been the
focus of my professional life…The epicenter of the [second] outbreak [in the
Greater Toronto Area] is my hospital… My hospital will be extensively studied by
Health Canada and the CDC[The Centers for Disease Control] to answer why this
happened. There is no doubt that the answer will relate to environmental issues.
Part of the answer is going to be simple. The standard for healthcare is going to be
private rooms for every patient. Many of our rooms have 2 to 4 patients. Tell me if
you would check into a hotel where you shared a bedroom with strangers and
shared a toilet with strangers and had to walk down the hall for a shower. Why do
we accept this standard in hospitals? We have had VRE [vancomycin-resistant
Enterococcus], MRSA [methicillin-resistant S. aureus], and now SARS. I may be a
surgeon, but some things are obvious. I encourage all surgeons to ask their
administrators about plans to create this new type of standard.
-- Feinberg, 20037
The reality is that risk of potential exposure is greater in a double room or open
ward than in a private room. This is not necessarily from VRE & MRSA, which can
spread by surface contact of things, if the room is not thoroughly cleaned but
7
Dr Stan Feinberg, shared this information through an internet listserv. He is currently the Chief of Surgery at the
North York General Hospital, Toronto, Ontario.
Review and Analysis of the Literature
14
certainly for anything respiratory (ex. cold, flu, SARS, pertusis/whooping cough)….
Cleaning and scrubbing are critical for controlling infection but it is the same for
both single- and double-occupancy rooms.
-- Shelton, 2003
Antibiotic-resistant pathogens are an important and growing threat in the hospital environment.
More than 70 percent of the bacteria that cause hospital-acquired infections are resistant to at
least one of the drugs most commonly used to treat these infections (Muto et al., 2003).8
Among the various methods recommended for infection control in hospitals, two important
environmental factors are isolation and ventilation. Infected patients or patients highly
susceptible to infections need to be isolated in private rooms with proper ventilation systems in
order to stop infection from spreading and to reduce the possibility of the development of new
infections. Rates of nosocomial infection are affected by handwashing practices, air quality, and
single- versus multiple-occupancy rooms. In particular, single-occupancy rooms appear to have
lower rates of infection than double-occupancy rooms (Ulrich, 2003). Larger-sized, singleoccupancy rooms are recommended for infection control as they can accommodate equipment,
sinks, and storage (Ognibene, 2000). Preliminary findings at Bronson Methodist Hospital in
Michigan demonstrate that private rooms, location of sinks and air-flow design have resulted in
a 10 to 11 percent decline in overall nosocomial infections rates (The Center for Health Design,
2003). These findings at Bronson Methodist Hospital indicates that private rooms in conjunction
with other design modifications can reduce infection rates in hospitals. However, additional
research in multiple hospitals, using similar precautions is required to understand fully the
relationship between room layout, air-flow design, fixture placement, patient density and
infection control.
Additionally, studies have demonstrated that prolonged hospitalization and intra-hospital patient
transfer may increase the probability of infection (Tornieporth, et al., 1996, Wakefield et al.,
1987). It was mentioned earlier that private rooms help to reduce patients’ hospital stays,
8
Nosocomial infections occur in more than two million hospitalizations each year (Haley, R. W. et al., 1985). The
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) cited federal statistics that 2 million
people in the United States acquire an infection each year while being treated in a hospital for other reasons and
90,000 die as a result. Due to this high incidence of hospital related infection, JAHCO is issuing new standards that
go into effect in January 2005. Under the new standards, hospitals will be required to make an infection-control
program a major component of safety and performance improvement programs and to perform ongoing assessments
to identify risks for transmission and acquisition of infectious agents. (Morrissey, 2003)
Review and Analysis of the Literature
15
thereby reducing their probability of acquiring nosocomial infections, as well as cost associated
with such hospitalization.
Isolation
Isolation of patients is one of the recommended precautions to prevent the occurrence of
infection and isolation can only be possible through confinement of the patient in a private room,
often with specialized ventilation systems. Kappstein & Daschner (1991) suggested that private
rooms are needed for patients suffering from staphylococcal pneumonia, skin lesions, or
methicillin-resistant S. aureus (MRSA), as these patients carry organisms that can lead to
environmental contamination, and MRSA has the potential to become widespread. Since
proximity to an un-isolated patient with vancomycin-resistant Enterococcus (VRE) can lead to
the spread of this infection, patients suffering from VRE also need to be kept in isolation,
according to the Society of Healthcare and Epidemiology of America (SHEA) guidelines (Muto
et al., 2003). However, some experts in the area of hospital epidemiology have critiqued the
SHEA guidelines for being based on evidence that is still inconclusive (Eickhoff, 2003). Thus,
caution should be used when interpreting the SHEA guidelines.
Research by Byers et al. (2001) demonstrated that the most important risk factor for acquiring
VRE during an outbreak was proximity to unisolated patients who became culture positive
during the preceding seven days. Montecalvo et al. (2001) illustrated that the implementation
of an active surveillance and isolation program for VRE terminated an outbreak at Westchester
County Medical Center. Additionally, this program was cost-effective, with reported annual cost
savings of $189,318. However, these results were based on findings from single outbreaks and
may not be applicable to all healthcare delivery sites.
In a study on the transmission of the Hepatitis C virus (HCV) in a hematology ward, Silini et al.
(2002) discovered that there was patient-to-patient nosocomial HCV transmission. After having
analyzed possible routes of transmission, the researchers recommended several preventive
measures that included isolation of patients during neutropenic phases. Allander et al. (1995)
also discovered that HCV was frequently transferred from one patient to another in a
Hematology ward, and their findings highlighted the need for isolation of patients to reduce the
spread of HCV. In another study (Korpela et al., 1995) on hospital-acquired diarrhea, it was
discovered that nosocomial transfer of Shigell spp. occurred between patients sharing rooms
Review and Analysis of the Literature
16
and toilets. The researchers highlighted the importance of the isolation of patients with diarrhea
in a hospital setting.
Most studies discussing the relationship between infection control and the built environment
recommended isolation to reduce the spread of infection. However, a recent study (Stelfox,
Bates, & Redelmeier, 2003) explored care issues of patients in isolation. The researchers of this
study discovered that when patients were in isolation due to infection control, the quality of care
they received differed from that of patients who were not in isolation. Stelfox, Bates, &
Redelmeier (2003) noted that isolated patients were twice as likely as control patients (patients
not isolated) to experience an adverse event during their hospital stay. Supportive care failures,
such as falls and peptic ulcers, were more likely among isolated patients, as were incomplete
recordings of their vital signs. Hospital stays were also longer for isolated patients and their
dissatisfaction with their treatment was greater than that of control patients. The findings from
this study were contrary to the findings of other studies that demonstrated that private rooms are
beneficial to the patient’s recovery process. Additional studies are needed to examine the
relationship between infection control, private rooms and patient satisfaction to determine the
quality of patient care for isolated patients, as well as the need for isolation for different types of
disease.
Ventilation
Ventilation is also critical in the control of airborne pathogens for both protective (burns) and
infectious (respiratory) isolation (Marier, 1996). For protective isolation and special procedures,
the movement of air relative to adjacent areas must be positive and for infectious isolation, it
must be negative (AIA/CAH, 1992, pp.52-54). In particular, patients suspected of having an
airborne infectious disease should be placed in negative pressure rooms that receive numerous
air changes per hour (Sehulster & Chinn, 2003). During an outbreak of airborne infection, whole
units of single rooms may need to be converted to negative pressure rooms in order to minimize
transfer to other parts of the hospital.
Centralized, filtered, unrecirculating air handling systems with an efficient preventive
maintenance program should keep airborne organisms at a minimum in hospital rooms used for
isolating patients (du Moulin, 1989). Du Moulin (1989) argued that the single patient cubicle
should be mandatory in the design of intensive care units. Physical separation not only
Review and Analysis of the Literature
17
contributes to a decrease in the spread of endogenous flora, but also serves as a constant
reminder and barrier to cross-contamination by unit personnel. In their study on the effects of
negative pressure ventilation on the spread of nosocomial infection, Anderson et al. (1985)
discovered that, in wards with this ventilation system, secondary spread of Varicella zoster did
not occur. The rooms on these wards were single-occupancy, as patients were in isolation.
Various isolation strategies are used to prevent infection during bone marrow transplantation. A
study by Passweg et al. (1998) examined whether patients treated in high efficiency particulate
air filtration (HEPA) and/or laminar airflow (LAF) private rooms had decreased transplant-related
mortality (TRM) in the first year after allogeneic transplantation compared to conventional
isolation units. Their findings demonstrated that the use of HEPA and/or LAF to prevent
infections decreased TRM and increased survival after bone marrow transplants for leukemia.
This finding illustrated that the isolation of patients in private rooms, in conjunction with effective
environmental controls (like the use of a proper filtration system or a ventilation system) helps in
infection control and reduces patient mortality.
Hospital Stay and Intrahospital Transfer
A study conducted by Tornieporth et al. (1996) demonstrated that prolonged hospitalization is a
risk factor for Vancomycin-resistant Enterococcus faecium (VREF). Additionally, the researchers
discovered that intrahospital spread of VREF may have been facilitated by patients who were
transferred to more than one ICU or more than one floor during their hospitalization. These
patients had a two to threefold higher risk of acquiring VREF. We know from other studies that
hospital stay is reduced if patients stay in single occupancy rooms, and there is less need for
transfer in these types of rooms.
Wakefield et al. (1988) assessed the extra costs due to serious S. Aureus nosocomial infection
and discovered that 77 percent of the cost was related to per diem costs for extra days spent in
hospitals, 21 percent was due to anti-microbials for treating the infections and 2 percent was
due to laboratory costs. In a recent research, Zhan & Miller (2003) discovered that infection due
to medical care was associated with the increase of 9.58 days in hospital stay, 38,656 dollars in
excess charges and 4.31 percent attributable mortality. Another study (Pittet, Tarara, &
Wenzel, 1994) on the relationship between nosocomial infection in surgical patients, length of
stay, costs and mortality rates demonstrated that the surgical intensive care unit stay doubled
for patients with infection (their median hospital days was also 24 days longer than patients
Review and Analysis of the Literature
18
without infection) and extra cost attributable to infection averaged 40,000 dollars per patient. It is
well known that nosocomial infection is a serious patient safety issue and it is also an economic
cost burden (Press Ganey Associates, 2003; Stone, Larson & Kawar, 2002). Recent ongoing
studies have demonstrated that nosocomial infection rates go down in single patients rooms
with proper design and ventilation systems (The Center for Health Design, 2003). Thus,
hospitals may save in operational costs associated with nosocomial infection if patients are
isolated in private rooms that have proper ventilation and other infection control protocols in
place. Additional research is required to understand the relationship between private rooms,
patient length of stay, costs and hospital-acquired infection.
Burn Victims and Immuno-suppressed Patients
Burn victims require added precautions in infection control due to their heightened susceptibility
to infections. Shirani et al. (1986) studied burn victims in terms of the spread of infection and
mortality. Burn patients in nursing units with a majority of single rooms, with each room
containing a sink for hand washing, were less likely to acquire an infection than those in an
open ward. Because of this factor, mortality was significantly lower on the closed ward.
Researchers have stated that Immuno-comprised patients may need to be placed in private
rooms where positive pressure is maintained. Furthermore, time spent outside their rooms
should be minimized, and these patients should be provided with respiratory protection
(Sehulster & Chinn, 2003). Due to their suppressed immune systems, HIV patients are more
susceptible to infections than are non-HIV patients with similar patient characteristics. These
types of patients when hospitalized may require isolation in rooms with proper ventilation, in
order to reduce the probability of contracting hospital-related infections (Muto, 2003).
Multiple studies have demonstrated that private rooms with proper ventilation (when required)
often optimize the use of appropriate precautions and may facilitate infection control in
hospitals.9 Private rooms do provide more flexibility in changing from positive to negative
pressure ventilation and may be more useful than multi-occupancy rooms for airborne disease
outbreaks. However, one factor that should be kept in mind when reviewing infection control
9
One has to keep in mind that private rooms by themselves may not be very effective in infection control without
proper precautions such as handwashing and use of protective gear. For example, during the recent SARS outbreak
in Toronto, transmission problems continued after isolation of patients. The key to curbing the SARS transmission
was staff awareness and behavior change. When it is not possible to provide private rooms for all patients, the use
of barrier precautions in semi-private room can help reduce transmission.
Review and Analysis of the Literature
19
literature is that findings and recommendations often apply to specific institutions (as the studies
are often retrospective investigations of infection outbreaks in particular settings) and may or
may not be applicable to other settings; thus, caution must be used in interpreting these results.
Patient Falls
Patient Characteristics
Patient characteristics are critical in determining the occurrence of falls. Older patients and
males are more likely to experience an adverse event, as are patients with longer lengths of
stay.10 These adverse events are associated with higher hospital costs (Jones, Simpson, &
Pieroni, 1991; Sutton, Standen, & Wallace, 1994). A recent study (Solomon, 2003; Flaherty et
al., 2003) on delirious elderly patients (who are highly susceptible to falling) demonstrated that
these types of patients were better cared for in a multi-occupancy delirium room rather than in a
private room. For patients who require constant supervision (as in the case of frail and/or
delirious patients), and who are more likely to fall in hospitals, multi-occupancy patient rooms
with increased surveillance may be more appropriate than private rooms.
Patient Rooms
Consistent within the literature is the implication that most patient accidents occur in patient
rooms. Hendrich, et al. (1995), for instance, conducted a study at a Midwest teaching institution.
They discovered that most falls occurred in patient rooms, in particular when patients were
alone and attempting to get to the bathroom. Similarly, in a geriatric facility where the majority of
rooms were multiple-occupancy, most falls occurred when patients were in their rooms, alone or
with other patients. Seventy-four of the 444 falls occurring in patient rooms took place when
patients were alone in the bathroom (Pullen, Heikaus, & Fusgen, 1999). Langer (1996) also
noted that most accidents on a surgical and urological unit in Durban happened while patients
were on their way to the bathroom. The majority of falls occurred during the day, while patients
were in their rooms, and during visits to the bathrooms.
Since the majority of falls occurred when the patients were alone in their rooms, one may argue
that shared occupancy is beneficial, as patients can assist each other and call for help when
necessary. Interventions, such as greater monitoring by staff members, can also reduce the
number of falls that occur (Hendrich et al., 1995). Recent studies (as cited in Ulrich, 2003)
10
As we have noted elsewhere that single occupancy rooms often reduce a patient’s length of stay in the hospital,
room occupancy can be shown to have some relevance to patient falls.
Review and Analysis of the Literature
20
demonstrated that patient falls may be reduced in private rooms that have provisions for family
members. The presence of a relative to assist the patient to move around the space may result
in a reduction in falls. This finding highlights the need to examine patient room design and
layout in a holistic manner and to take into consideration different healing design principles, as
well as room density issues. The following sections deal with these aspects of hospital design
as they relate to patient room occupancy.
C. Healthcare Facility Management and Hospital Design/Therapeutic Impacts
This section of the summary combines information from articles reviewed in both the “Hospital
Design and Management” section and the “Therapeutic Impacts of Design” section (see
Appendices A & B for summary charts and annotations). The “Hospital Design and
Management” section provides insight into innovations in facility design and suggests
improvements and additions that are critical to patient care and comfort. The articles reviewed
here are usually prescriptive in nature and often do not provide evidence of patient outcomes.
Articles included in the “Therapeutic Impacts of Design” section primarily address the effect of
supportive design innovations on patients’ health outcomes. These articles are more empirically
based and evaluate the impact of the physical environmental factors. As these two sections are
interrelated and have overlapping ideas and issues, we decided to combine the information from
the annotations of the two categories in this summary. This summary covers nursing unit and
patient room design, patient-centered care as it relates to design (including use of the Planetree
model in hospitals), and patient room density as it relates to health outcomes, as well as some
general physical environmental elements that have a therapeutic impact on patients.
Patient-centered care and design
Hospital design impacts patient care and, recently, has taken a patient-centered approach
(Horsburgh, 1995). This approach creates a homelike environment that is functionally efficient
(Martin, 2000). The goal of a patient-centered care hospital is decentralization, which brings
services nearer to the patient. Rooms should be humane and provide the patient with privacy,
dignity, security, and cleanliness (Miller & Swensson, 1995). This type of care structure strongly
promotes single-occupancy rooms in acute care settings.
Review and Analysis of the Literature
21
Planetree model
The Planetree model is patient-centered. It focuses on the spiritual, mental, and emotional
needs of patients. Emphasis is placed on patient participation and education (Martin, et al.,
1998). Patients are urged to read their own medical charts and to learn more about their illness
and treatment through the use of a medical reference library (Weber, 1995). Rooms in
Planetree facilities are generally private and large enough to accommodate the patient’s
caregiver (Leibrock, 2000). Patients are in control of their settings, including lighting,
temperature, and the television. The environment is also made more homelike through the use
of soothing colors and artwork, as well as the ability of patients to bring their personal
possessions to the hospital (Voelker, 1994). Nursing stations are decentralized into pods
serving three to four patients (Leibrock, 2000).
Various facilities in England, and Griffin Hospital in Connecticut, utilized the Planetree model
with double-occupancy rooms. An “L”-shaped room design was intended to give patients a
sense of their own space (McTaggart, 1996; Weisman, 1994). At Griffin Hospital, satellitenursing stations and service clusters of three to four patient rooms were used (Weisman, 1994).
Martin et al. (1998) conducted a study comparing patients on a Planetree ward to those on
regular medical units. Planetree patients were significantly more satisfied with their hospital
stay and with the unit’s environment. Planetree patients also had a greater opportunity to
interact with other patients, family members, and friends, and they were more satisfied with the
involvement of nurses and with the education they received.
Patient room/nursing unit design and their impact on patient satisfaction and nursing activity
From a nursing standpoint, it’s better when patients are closer together. With single
rooms, patients are spread out and nurses don’t have a line of vision with patients.
Nurses don’t want to restrain patients and if patients are wandering at night, it is nice to
have them grouped closer together when the nurses aren’t with them … From a staff
perspective, single rooms may require more staffing. When there are two patients in a
room, there is less floor space to clean than if all the patients were in single
rooms…From infection control perspective it is nice to have a private room…Time
savings are incurred with single rooms as transfers go down….From the patients’
perspective, single rooms are better. Many prefer privacy. Confidentiality is an issue-in
semi-private rooms, even though you can pull the curtain, the patient next to you and
family members of that patient can hear what is being said and the patient knows this.
-- Will Shelton (2003)
Review and Analysis of the Literature
22
An optimal mix of single and multiple occupancy rooms depends on medical, social, and
economical factors. In their book on hospital design, Thompson & Goldin (1975) suggested that
a minimum of 25 percent of the rooms in hospitals should be single-occupancy. Occupancy
rates of 80 percent were considered ideal with this type of room density. Service failures were
reduced at this level and the majority of patients requesting admission were accommodated
(Thompson & Goldin, 1975). Bobrow and Thomas (2000) stated that near 100 percent
occupancy rates could be achieved in private rooms. Thus, from an occupancy standpoint,
private rooms are more efficient than multi-occupancy rooms.
As mentioned earlier, the nursing unit design is an important aspect of patient room design and
layout. Patient rooms cannot be considered in isolation and they need to be evaluated in the
context of nursing unit layout. Nursing unit/ward design is vital to the work performed by health
personnel. Over the years, different nursing unit and ward designs have evolved, each having
distinct features. Florence Nightingale inspired one of the earliest ward designs. The
Nightingale ward is a basic long and narrow open ward with beds arranged down each side
(Hosking & Haggard, 1999; Tradewell, 1993; Jones, 1985). The goal of this design is to have
clear visibility of all patients on the ward. An average of thirty to thirty-two beds are located on
this type of ward, with the nursing station is located at one end and the convalescent bay at the
opposite end of the ward (Hosking & Haggard, 1999,Tradewell, 1993). Newer designs include
the bay ward. This type of design subdivides wards into four-, six-, or eight-bed bays (Hosking
& Haggard, 1999).
Various articles have compared the advantages and disadvantages, as well as patient
preferences, of the bay and Nightingale wards. Hosking & Haggard (1999) noted, for instance,
that Nightingale wards do not enable patients to have their need for privacy met. While bay
wards offer more flexibility, privacy, and intimacy, patients have only a limited view of nurses.
Anxiety may result if patients are attempting to contact their nurse who, unknown to them, may
be unavailable. Other negative aspects of the bay ward include the patient’s sense of
confinement and increased noise due to the use of more equipment. In a study conducted in
Scotland, patients made the transition from open wards to bay wards. Positive aspects of the
bay ward included privacy and isolation in the single-rooms. However, nurses found it difficult
to track patients. The open ward, on the other hand, offered patients greater opportunity to
interact with each other (Rainey, 1990).
Review and Analysis of the Literature
23
Interestingly, Pattison & Robertson (1996) found the majority of gynecological patients preferred
the bay ward to the Nightingale ward. Patients on the Nightingale ward thought privacy and
contact with nurses was adequate, but noise levels were higher and sleep disturbances were
greater than on the bay ward. Those on the bay ward were concerned both with a lack of
information regarding the whereabouts of nurses and with the activity on the rest of the ward.
Patients also mentioned they felt a lack of auditory privacy.
Evidence from these studies does not clearly support the use of one ward over the other. Each
has its advantages and disadvantages, such as lack of privacy and increased noise. Patients,
however, at least in the case of Pattison & Robertson (1996), preferred to stay on the bay ward
despite its limitations. Thus even studies on patients demonstrated that they prefer reduced
social density in their recovery spaces.
The efficiency of a nursing unit is determined by its design more than by its size. In particular,
circulation design schemes, such as the double-corridor, circular, and square plans, are the
most efficient designs, especially if the unit has more than thirty beds (Thompson & Goldin,
1975). Double-corridor designs, followed by the circular and the single-corridor designs, also
appear to be the least costly, and costs increase as the number of square feet per bed
increases, since construction costs are higher. Traffic costs are lower on smaller units, as travel
distances are shorter (Delon & Smalley, 1970).
In terms of unit size, the optimum has been suggested to be between twenty-five and thirty-five
beds. Larger units are arguably more efficient, since better staffing patterns are achieved and
fewer medicine units and linen rooms are required. Smaller units are advantageous because
supervision of patients is better than on the larger units (Delon & Smalley, 1970).
Trites et al. (1968, 1970) studied the impact of nursing unit design on nursing activity. In
particular, the nursing units examined were radial, single-, and double-corridor designs.11 The
radial design was superior to the other designs in terms of nurses’ traveling time. With the
reduction in time spent traveling, nurses were able to spend more time with patients. Nurses
11
In single and double-corridor patterns of ward design, patient rooms are located along one or both sides of the
corridor, respectively, and rooms contain four to six beds. A central nursing station is utilized and support spaces
are used to supply the unit (Tradewell, 1993). The radial design, on the other hand, centralizes patient care and
provides immediate access to the patient (Stichler, 2001).
Review and Analysis of the Literature
24
also had fewer accidents and the lowest rate of absenteeism on the radial design unit. Finally,
the majority of nurses preferred to work on the radial design unit. The radial design, however,
does have some disadvantages. In particular, lateral expansion of this unit is difficult, and this
type of design is not able to accommodate an adequate number of private rooms without
wasting core space (Cawood, 1993). This type of nursing unit design in not used much anymore
because of its inherent staff inefficiencies, awkward leftover spaces in the center, and the
irregular shapes of patient rooms (Verderber & Fine, 2000).
A square nursing unit design is another alternative. This design was effectively utilized in a
Georgia nursing home. Patient rooms are located along the perimeter of the design and within
forty-five feet of the nurse’s station. With bathrooms located along the exterior walls, nurses are
better able to observe patients without entering the patient room. Since use of space is
maximized, nurses spend less time walking. In turn, morale is high and turnover is low among
registered nurses (Fisher, 1982). This type of design is suitable for single-occupancy rooms.
The cluster design encompasses mainly single patient rooms around nursing substations. One
nursing station is dedicated as the central one (Tradewell, 1993). This design helps reduce
patient travel and the number of people associated with patient care (Jones, 1995).
Visualization of patients is increased, and more patient rooms can be located around building
peripheries. This design does have disadvantages, though, in that care is decentralized and the
social needs of nurses are not met (Stichler, 2001).
The triangular design provides for a maximum number of patient rooms to be located on one
floor. This type of design is suitable for single patient rooms. It also reduces travel distance
from the nursing station to the patient room. Multiple nursing stations are possible and storage
space is centralized. Many current new medical-surgical unit designs are using this type of
layout for their nursing units. Negative aspects of this design include limited visibility of patients
in remote corners, and difficulty of unit expansion (Stichler, 2001).
The rectilinear design is another possibility for a nursing units. It contains a centralized storage
location and is less costly to build than other designs. It has various disadvantages, though,
including increased travel distances by nurses (especially when single occupancy rooms
comprise the majority of patient rooms), minimal visualization of patients in remote rooms, and a
greater space requirement for patient rooms.
Review and Analysis of the Literature
25
According to Burmahl (2000), flexibility in design is important in the design of patient care
environments. Flexible design may include decentralization of the nurses’ station to allow subcharting stations to be near the patient’s bedside, and to allow for changes to a floor layout
within the nursing unit.
Private and semi-private patient rooms
Patient privacy is necessary for the treatment of patients. Privacy gives patients control over
personal information, an opportunity to rest, and an opportunity to discuss their needs with
family members and friends. The number of patients in a room, the presence of visual
screening devices, the location of the bathroom, and the placement of the patient’s bed all
impact privacy (Shumaker & Reizemstein, 1982).
Single-occupancy rooms increase a patient’s privacy (Bobrow & Thomas, 1994, 2000; Solovy,
2002). In addition, Verderber & Fine (2000) noted that, in the 1970s, the U.S. General
Accounting Office deemed single-occupancy rooms to be the most cost efficient “in terms of
day-to-day operations and initial construction costs” (p. 198). Various hospitals have used
private rooms in their designs. For instance, Children’s Hospital in Omaha, Nebraska designed
private rooms to look like children’s bedrooms, with enough space to accommodate family
members. Privacy is ensured, and the risk of infection is reduced (Hohenstein, 2001). Bobrow
& Thomas (2000) also note that single-occupancy rooms can be used for isolation purposes,
thus reducing the possibility of acquiring an infection.
Bacon (1920) foresaw the use of private rooms. Early in the 20th century, he noted that private
rooms increased flexibility and enabled hospitals to reach maximum bed capacity. He also
suggested that private rooms provided patients with more comfort, as better examinations could
take place and the patients could control temperatures based on their needs. Visitation could
also be scheduled based on the condition of the patients.
Single-occupancy rooms are cost-efficient. In comparison to multiple-occupancy rooms,
medication errors and patient transfers are reduced. For instance, in multiple-occupancy
rooms, patient transfers can average from six to nine per day. Also, whereas in multipleoccupancy rooms occupancy reaches an average of eighty to eighty-five percent, in single-
Review and Analysis of the Literature
26
occupancy rooms occupancy can reach one hundred percent. These factors all contribute to
increased savings for the hospital (Bobrow & Thomas, 2000).
Administrators at William Beaumont Hospital in Royal Oak, Michigan noted that while the
majority of patients request private rooms, the hospital usually does not have any to offer
patients. The semi-private rooms in this facility typically have a ten percent lower occupancy
rate than the private rooms. This fact, combined with a savings in transfer costs, makes private
rooms more viable. Thus, the hospital is converting seventy to eighty percent of its beds into
private rooms (Anonymous, 2000).
The ideal patient room at Providence Portland Medical Center is single-occupancy. “Paired
rooms,” with sufficient accommodation for family members and friends were created from one or
two rooms on each ward containing connecting doors. These rooms also have the ability to be
converted into intensive care units, with enough space to accommodate necessary equipment.
Within these rooms, staff have their own area, which includes the tools necessary to treat
patients. Families were also included in the room design, and space was allotted for family
members to stay and be secondary caregivers.
Private rooms may not be a feasible design in all cases. Mader (2002) suggested that although
private rooms help control the spread of infectious diseases, provide a safer, more efficient
layout, and increase patient usage, semi-private rooms are advantageous when patient volume
is high. Semi-private rooms require less square footage per patient, but issues, such as those
relating to gender and the spread of infections, arise in patient placement.
In Fromhart’s (1995) look at long-term facilities, administrators from various facilities had
differing opinions on the benefits of private rooms. For one executive in New York, private
rooms were seen as the best design because roommate problems are avoided and family
members can visit freely and personalize the patient’s room. An administrator in Virginia felt
that semi-private rooms are more cost-effective, while a director in Texas felt that sharedoccupancy in an apartment type setting is more cost-effective.
Nurses in England questioned the use of private rooms. Orr, Farrell, and Portman (2002)
believed that patients who need constant monitoring would be worse off in private rooms, as
monitoring is made more difficult. Staffing would need to be increased and bed capacity would
Review and Analysis of the Literature
27
be reduced. Another author, in referring to NHS hospitals, suggested that the open ward is best
because of increased patient supervision and greater privacy than on bay wards, and costefficiency (Anonymous, 1991).
The research results on the influence of room occupancy or type on pain medication usage
were mixed. In a comparative study (Dolce et al., 1985) of narcotic use among back pain
patients undertaken to explore whether room type was a predictive variable in narcotic
utilization, researchers discovered that patients in private rooms were more likely to use
intramuscular request-contingent narcotics than were similar patients in semi-private rooms.
This may be due to decreased environmental stimuli in private rooms, combined with patient
personality variables and medical staff characteristics. The researchers concluded that type of
room might not be the only factor affecting pain medication intake; patients’ own characteristics,
along with staff behavior, may also affect medication intake. Other research (e.g., Vernon &
McGill, 1961; Zubek, 1969) demonstrated that there is a relationship between decreased
environmental stimuli and increased sensitivity to pain. However, other recent studies (e.g., HillRom, 2002) demonstrated that medication intake is less in single occupancy rooms.
More
research needs to be done in this area to better analyze the relationship between room density
and frequency of patients’ narcotics/pain medication usage.
In the year 2000, the Center for Health Design, launched a series of research projects in 10
hospitals that had recently built or renovated facilities according to the Pebble principles.12 The
preliminary results from some of these projects demonstrated the influence of design on patient
outcome. Methodist Hospital in Indianapolis and Bronson Methodist Hospital in Michigan are
two examples of facilities that are part of this research program and have used the Pebble
principles. Clarion Health Partners Inc. renovated the Indianapolis Methodist Hospital’s cardiac
wing and redesigned its rooms to be acuity adaptable single patient rooms so that the patients
would not have to move from critical care units to medical-surgical units. In these rooms the
patients can control both the temperature and lighting within the space. Visibility of patients (by
the staff) is increased through the use of an interior window, as is privacy, because the window
can be made opaque when needed. Falls and transfers have also decreased substantially. 13
12
The pebble project utilizes research to document the impact of the hospital environment on patients, family
members and staff. An emphasis is placed on identifying the best hospital practices, as well as continuous
improvements in design (McMorrow, 2001).
13
The number of patient falls dropped 60 percent in these newly renovated units (Rich, 2002).
Review and Analysis of the Literature
28
Bronson Methodist Hospital similarly built a facility with 348 private rooms. The preliminary
results from the research conducted in this facility demonstrated a greater reduction in hospitalacquired infections than in previous units. Health care professionals have more private and, in
many cases, more thorough consultation with patients in single rooms than with patients in
multi-occupancy units. In the old facility, the hospital spent around 500,000 dollars per year in
patient transfers due to problems with roommates or infection-control issues; this amount has
been greatly reduced according to the hospital’s chief executive (Bilchick, 2002; Rich, 2002).
The Barbara Ann Karmanos Cancer Institute was renovated to provide patients with a more
pleasant and patient-centered environment. Rooms were made private and larger in size, and
lighting and acoustics emphasized. Medication errors and the use of pain medication have
been reduced in this facility, thus reducing hospital costs (Bilchik, 2002; Rich, 2002). Though
conversion to private rooms did facilitate some of the patient care issues, it was a combination
of multiple patient-centered design changes that helped to bring about the above mentioned
outcomes. Thus, patient room density needs to be considered in conjunction with other patientfocused design changes in order to achieve therapeutic and cost efficiency goals. Conversion to
private rooms (from multi-occupancy rooms) by itself may not provide the desired outcomes.
Saint Louis University Hospital recently introduced a Delirium Room to treat patients
suffering from delirium.14 This room is part of the acute care for elderly unit, and key to
its existence is the provision of a safe environment. Typically, elderly delirious patients
who are agitated are cared for in private or semi-private rooms, isolated from others.
They may be placed in physical restraints for protection and given calming
medications. However, this new environment is a four-bed room, where 24-hour
intensive nursing care is provided without the use of physical restraints and medication
to quiet patients is the last-choice treatment. The geriatricians in the hospital found that
the elderly patients with delirium do better if they are placed together and cared for in
the Delirium Room (Solomon, 2003). Mortality on the unit was zero and patient’s fall
rate near zero during a one-year study period, and the use of medications was
comparable to or lower than those found in previous studies on delirious patients. Less
than ten percent of patients used sedatives (Flaherty et al., 2003). This study
demonstrated that in some specific instances where constant supervision is required
14
Between 15 and 20 percent of older patients are delirious when they are admitted to a hospital and up to 30
percent become delirious while they are in the hospital (Flaherty, as cited in Solomon, 2003).
Review and Analysis of the Literature
29
and patient safety is critical, multi-occupancy rooms may be preferable to single
occupancy rooms.
Variations in single-occupancy rooms
Universal Rooms / Acuity Adaptable Rooms: Within the hospital environment, universal rooms
are a current trend in design, especially in hospitals that are promoting patient-centered care
and family participation patient healing programs. These rooms are single-occupancy, and their
goal is to support the level of care needed by all patients. In other words, any one patient can
be placed in any one hospital room and receive the required treatment (Spear, 1997). These
rooms are larger than typical hospital rooms, enabling bedside treatment to occur more
efficiently. Since patients undergo most of the required procedures in their room, the need to
transfer patients is reduced, thus reducing transfer costs (Gallant & Lanning, 2001). Space is
also provided for family members to stay, thus incorporating them in patient care (Spear, 1997).
Flexibility in these rooms is increased through the use of disabled-access bathrooms. This
enables constant patient use of the room (Miller & Swensson, 1995). When these rooms are
incorporated into a cluster ward design, the nursing team can readily supervise patients.
Mercy Hospital and Medical Center in San Diego, California is an example of a facility that has
incorporated the use of larger rooms. Family members and friends are accommodated in
patient rooms and are involved in the care of the patients. The nursing station is decentralized
to make monitoring of patients more efficient (Lumsdon, 1993).
Another term for universal rooms is acuity adaptable rooms. As the name suggests these single
patient rooms serve people at different levels of acuity. The proponents of this type of room
argue that, with more and more patients coming to the hospital with a higher level of acuity, this
type of room is more suitable to address their varying needs. These rooms are singleoccupancy and have enough space to accommodate patients as well as family members.
Space is also provided for critical care equipment, and the majority of procedures take place in
the room, reducing the need for patient transfers. This, in turn, reduces hospital costs. If
bathrooms are located on the exterior wall, space is further increased in rooms, allowing for
efficient organization of the room (Gallant & Lanning, 2001).
Acuity adaptable rooms are ideal for the changing trends in hospitals. As the aging population
increases, those requiring acute hospitalization will increase as well. The proportion of patients
Review and Analysis of the Literature
30
needing intensive care will become larger, and thus services in the Intensive Care Unit will
become critical to the hospital (Hamilton, 1999). Acuity adaptable rooms enable patients to
receive the critical care needed without being transferred to other units throughout their various
phases of treatment. Waiting times transfers are also reduced or eliminated, as they are no
longer necessary (Hill-Rom, 2002). One study claimed that medication errors, patient falls,
procedural problems, and lab problems are also reduced in acuity adaptable rooms (Hill-Rom,
2002). However, these types of outcomes may be relevant only to the hospital under study and
may not be applicable to other settings. More studies on acuity adaptable rooms are required
before proposing similar outcomes for other hospitals. When beds are clustered into smaller
units (six to nine beds) with decentralized nursing stations, it is expected that visibility of patients
will improve and staff will be in close proximity to patients (Hamilton, 1999).
Patient Preference of Room Type
Mixed results were obtained in studies and surveys of patients’ preferences for room design.
Kirk (2002), for instance, interviewed hospice patients in Leeds, England, in regards to their
room preference. The majority of patients preferred a single room because of the greater
privacy offered, reduced noise, reduced embarrassment, and improved quality of sleep, and
because of being able to have family members stay, and to avoid upsetting other patients.
Those preferring a shared room did so because they enjoyed the company and sharing their
experiences. Similarly, in the United States, a survey conducted on assisted living facilities
resulted in eighty-two percent of those surveyed preferring a private room. Only four percent of
people surveyed preferred a shared room. The remaining people did not know or did not have a
preference. Of those surveyed, women and those from the western United States were more
likely to prefer a private room (Contemporary Long Term Care, 1997).
Other researchers, on the other hand, found results favoring shared occupancy. Of the
oncology patients surveyed in a British hospital by Pease and Finlay (2002), thirty-four percent
preferred a four-bed bay, while only twenty percent preferred a single-occupancy room. The
main factor in selecting the shared room was the wish to avoid isolation. Similar results were
found by Reid & Feeley (1973), who conducted a study in the United States. If given the choice,
fewer than half the patients surveyed preferred a private room. Double-occupancy rooms were
favored because patients had someone to talk to and they felt help was available, if needed,
from their roommates. Negative aspects of these rooms mentioned included lack of privacy and
high noise levels, especially when patients had visitors.
Review and Analysis of the Literature
31
Previous experience in a hospital influences a patient’s room preference. Spaeth & Angell
(1968) found that ophthalmic patients with previous experience in hospitals were nine times
more likely to prefer a multi-bed room to a single-occupancy room. Those without previous
experience were more likely to prefer a single-occupancy room, but only by a small margin.
After being discharged, significantly more patients stated they would prefer multi-bed rooms.
The number of patients in a room can impact patient behaviors. For instance, in one study,
patients in single-occupancy rooms were more likely to experience loneliness and separation
anxiety. Those on open wards experienced higher levels of shame anxiety, but were able to
express their hostility to a greater extent (Leigh et al., 1972). When a dormitory style ward was
divided into two-bed sections by partitions, patients had more positive attitudes toward the
environment and engaged in more social and less passive behavior (Holahan & Seagert, 1973).
Ittleson, Proshansky, & Rivlin (1970) also noted that smaller, private rooms gave patients
greater freedom in regards to behaviors and activities chosen in their rooms. Roommate
assignment can impact patient anxiety and stress. Kulik, Moore, & Mahler (1993) discovered
that patient stress can be reduced if preoperative patients are assigned to rooms with
postoperative or non-surgical patients, rather than with other anxious, preoperative patients.
Patient Satisfaction
Evaluations made by patients in regards to their hospital rooms affect their satisfaction with their
hospital stay. Positive evaluations of their rooms, and of the nursing care received, led to
greater hospital stay satisfaction (Gotlieb 2000, 2002). Patients staying in private rooms in a
hospital in France were more satisfied with the hospital environment and staff, the information
they received, and the quality of care they received (Nguyen et al., 2002).
In a study by Harris et al. (2002), satisfaction with the hospital environment, including the patient
room, impacted overall satisfaction. Satisfied patients had larger rooms, windows with a nice
view, and easily accessible bathrooms. Their privacy was also protected, and enough space
was provided to accommodate family members. In a study by Lawson & Phiri (2000),
conducted in England, patients were moved from conventional psychiatric and orthopedic wards
to refurbished wards that were mainly composed of single-occupancy rooms. Patients rated
their experience and treatment higher on the refurbished wards and were more satisfied with the
Review and Analysis of the Literature
32
appearance, layout, and overall design of the unit. Psychiatric patients also stayed for shorter
periods of time, while orthopedic patients required lower levels of analgesia.
Morgan and Stewart (1999) studied dementia patients moved from an older, high-density
special care unit to a new, low-density special care unit with private rooms. The family
members of the residents were pleased with the private rooms because they were able to
personalize the rooms and the patients had greater privacy. Due to less stimulation, disruptive
behaviors also decreased on the new unit. Some patients did prefer the old ward due to the
proximity between patients and staff, as well as the busy atmosphere. Alzheimer’s patients also
appear to benefit from the reduced stimulation environment offered by private rooms. Patients
in a retirement residence in Iowa were calmer and less agitated when moved to a reduced
stimulation unit (Cleary et al., 1988).
Patients appear to prefer single-occupancy rooms. Kaldenberg (1999), for instance, discovered
that patients in private rooms were more satisfied with their hospital stay, including their
communication with staff members, than patients staying in multiple-occupancy rooms. Patients
who had roommates were less satisfied with the noise, cleanliness, and temperature of the
room.
When roommates are incompatible, hospitals are likely to incur increased transfer costs.
Roommates can also be a source of stress for patients. Specifically, roommates who are
unfriendly, have too many visitors, and are seriously ill can have negative effects on other
patients (Ulrich, 2003). Patients in single-occupancy rooms large enough to accommodate
family members fare better. Social contact reduces stress and improves patient health. Patient
falls are also lower in family-centered rooms since patients are likely to have assistance if they
need to get up from their beds (Ulrich, 2003).
Ambient Features of Room Design
A sense of control over their setting is important to patients during their hospital stay is. The
environment should foster the patients’ well being, and it should be convenient and accessible
(Lowers, 1999). Poor building design contributes to patient stress. Patients experience a loss
of control when their privacy is reduced, when they are not given adequate information, and
when they are unable to adjust the lighting and temperature in their rooms (Ulrich, 1999).
Environments that are not sensitive to their needs do not enable patients to cope effectively with
their stress. This, in turn, can manifest in negative patient outcomes, such as problems with
Review and Analysis of the Literature
33
sleeping and noncompliance with medication (Ulrich, 1997). The design of the patient room
communicates to patients the attitude of hospital management toward their needs. Patient
satisfaction is increased when the environment is pleasant, comfortable, and relaxing (Baker &
Lamb, 1992). Sources of patient stress are perceived lack of control, lack of privacy, noise, and
crowding (Shumaker & Pequegnat, 1989). Positive patient outcomes are achieved when the
hospital environment incorporates natural light, elements of nature, soothing colors, pleasant
sounds, and the ability to control one’s environment (Murphy, 2000; Stichler, 2001). The
pervasive theme through these articles is the need for a sense of control and reduction of stress
for the patient. Single patient rooms provide people with more control over the lighting, HVAC,
sound and privacy.
Bed placement is critical in terms of giving patients access to windows in semi-private rooms.
Brown (1994) suggested that a problem with semi-private rooms is that both beds are placed on
the same wall, thus permitting only one person to be placed next to the window. A solution to
this problem is to place the beds on opposite walls or to turn both beds toward the window. A
number of researchers (e.g., Beauchemin & Hays, 1996; Neumann & Ruga 1995;Verderber,
1986; Ulrich, 1984) demonstrated the beneficial effects of a natural view and lighting for hospital
patients through the decrease of anxiety, reduction of blood pressure and muscle tension,
accelerated recovery time, and minimization of length of stay. Another suggestion was for the
room to include two windows, so both patients have equal access to the outside (Anonymous,
1971). Although equal access to a window is not an issue in private rooms, Cys (1999)
suggested that beds should have an angular placement so that patients can focus on the view
outside rather than on what is taking place in the corridor.
Noise in the hospital environment can heighten patient stress. Tolerance of noise is low during
illness, and control of noise is important for the recovery of patients (Hosking & Haggard,
1999b). Excess noise can lead to increased amounts of anxiety, pain perception, loss of sleep,
and prolonged convalescence. High noise levels can also impact staff members and increase
their burnout levels (Cabrera & Lee, 2000). Hilton (1985) noted that patients recovering in large
rooms containing two to eight beds found the noise levels unacceptable. Single-occupancy
rooms, on the other hand, had acceptable sound levels. Excess noise can be reduced through
the use of sound-absorbing ceilings and floor coverings (Ulrich, 2003). Private rooms aid in the
reduction of noise. With fewer patients in one room, the amount of noise produced is lower.
Duffin (2002) noted that less exposure to noise can facilitate a patient’s recovery. Music can
Review and Analysis of the Literature
34
also help reduce patient stress, and patients should be encouraged to listen to music when
possible (Lowers, 1999; Ulrich, 1997; Weber, 1995).
Patients can listen to music in private rooms without disturbing their roommates, as would be
the case in semi-private rooms. Empirical research has addressed the issue of noise production
in hospital rooms. Hilton (1985) conducted a study at three hospitals in a large metropolitan
area in Canada. He discovered that noise levels were lower in single-occupancy rooms,
whereas rooms consisting of two to eight patients produced unacceptable sound levels. Baker
et al. (1993) studied the various types of sounds on a critical care unit. They found that sound
levels were highest during room conversation and lowest for background sound. There is a
greater tendency to conversation if the room is semi-private or multi-occupancy. Other sources
of noise included hall conversation, furniture moving, alarms, and toilet flushing. Two of these
four sources are more prevalent in multi-occupancy rooms.
Crowding
Crowding can contribute to higher blood pressure. In a study of inmates, those staying in higher
occupancy cells were more likely to have high blood pressure than those in lower occupancy
cells (D’Atri, 1975). Crowding also impacts socialization. In a study conducted in a college
dormitory with short and long corridors, those on the long corridor with more residents were
more likely to perceive dormitory life as hectic and less controllable. They also found it difficult to
develop small groups (Baum & Davis, 1980). The elderly living in long term care institutions
need enough space to have their needs for privacy and territoriality met. If their needs are not
met, patients often exhibit a sense of loss of personal control and a weakened personal identity.
The use of private rooms and social lounges often minimizes the patients’ sense of crowding
(Tate, 1980).
These studies on crowding in other types of environment have implications for inpatient
hospitals, where people’s physical and/or mental health status may make them more sensitive
to issues of crowding. These studies imply that private rooms are beneficial to patients. In
private rooms, patients are not subject to others, and thus have a greater opportunity to control
their environment such that its negative effects, such as high blood pressure and a loss of
personal identity, are greatly reduced.
Other Features of the Environment
Review and Analysis of the Literature
35
As mentioned previously, a patient’s sense of control is crucial to recovery. Control can be
exercised through various means. For instance, patients can be in control of lighting in the room
through the use of bedside dimmers, and they have more flexibility in controlling the light and
sound level in their room if they are in single occupancy rooms. Patients should be able to
control the temperature in their rooms, since temperatures that are incongruent with the
patients’ needs may result in stress (Shumaker & Reizemstein, 1982; Williams, 2001). Other
controls that can be added in patient rooms are bedside window shades and television controls
(Murphy, 2000). Control is greater in private rooms, as patients can adjust settings according to
their needs, without having to be concerned about the needs of others. Ulrich (1999) suggests
the use of a healing garden, which includes elements of nature such as green vegetation,
flowers, and water, may aid in the reduction of stress experienced by patients during their
hospital stay.
CONCLUSION
Private rooms are the trend in hospital design. The advantages of single-occupancy rooms are
cited as improvements in patient care, a reduction in the risk of cross infection, and greater
flexibility in operation. However, the above discussion of hospital costs, infection control, falls
reduction, and therapeutic impacts as they relate to room occupancy demonstrates that a
simple consideration of room occupancy does not provide a complete picture of patient care,
cost or infection reduction issues. Room occupancy issues need to be considered along with
other patient care issues, other environmental changes or changes in management policy in
order to bring about desired outcomes. A summary of the above discussion is presented in brief
bulleted format below followed by a summary chart (see Table 1) illustrating issues that are
related to room density.
First and Operating Costs of Hospitals
Literature focusing on comparative first costs for single and multi-occupancy rooms is
scarce. There are a few articles that address operating costs in patient rooms in relation
to transfer costs/patient stay (Cho, Ketefian, Barkauskas, & Smith, 2003; Smet, 2002).
In general, the literature addressing cost issues addresses the health care delivery
process and methods of accurate cost estimates (Dexter & Macario, 2001; Cleverley,
2002; Garattini, Giuliani, & Pagano, 1999; Li & Rosenman, 2001; Thompson & Goldin,
1975).
Review and Analysis of the Literature
36
The limited number of articles exploring the relationship between first costs and
operating costs indicates that operating costs are proportionately more than the capital
cost of hospitals and this is true even for cost estimates within the first three years of
construction.
Operating costs are reduced in single patient rooms compared with multi-occupancy
rooms due to reduction in transfer cost (Hill-Rom, 2002; Ulrich, 2003), higher bed
occupancy rates (Bobrow & Thomas, 2000) and reduction in labor cost. However, this
reduction in cost can only be achieved when conversion to single rooms is paired with
other healing environment design principles.
Even with higher first or unit costs of construction, furniture, maintenance,
housekeeping, energy (e.g., heating and ventilation) and nursing, single occupancy can
match the per diem cost of multi-bed rooms because of the higher occupancy rates
(Bobrow & Thomas, 2000; Delon & Smalley, 1970). In multiple-occupancy rooms,
occupancy reaches an average of eighty to eighty-five percent, whereas in singleoccupancy rooms, occupancy has the ability to reach one hundred percent. This
contributes to increased savings in operations costs (Bobrow & Thomas, 2000).
A patient’s length of stay is associated with hospital costs. Research demonstrates that
patients’ length of stay in private rooms is less, which in turn reduces costs (Anonymous,
2000; Hill-Rom, 2002).
In comparison to multi-occupancy rooms, medication errors are reduced in singleoccupancy rooms, resulting in reduced costs (Anonymous, 2000; Bilchik, 2002; Bobrow
& Thomas, 2000; Hill-Rom, 2002; Morrissey, 1994).
Infection Control and Falls Prevention
Infected patients or patients highly susceptible to infections need to be isolated in private
rooms with proper ventilation systems and barrier protections to stop infection from
spreading or reduce the possible development of new infections (Anderson, Bonner,
Scheifele & Schneider, 1985; Muto et al. 2000; O’Connell & Humphreys, 2000; Sehulster
& Chinn, 2003).
Caution must be used when interpreting results from infection control literature, because
the findings and recommendations are often based on retrospective investigations of
infection outbreaks in particular settings, and are tailored towards those settings. They
may or may not be applicable to other settings.
Review and Analysis of the Literature
37
Prolonged hospitalization is a risk factor for hospital-acquired infections. Additionally,
intra-hospital spread of infection may result from transferring patients to more than one
ICU or more than one floor during their hospitalization. We know from other studies that
hospital stay is reduced if patients stay in single occupancy rooms, and there is less
need for transfer in these types of rooms (Mulin et al., 1997).
Patients length of stay in hospitals and cost is increased due to nosocomial infection
(Zhan & Miller, 2003; Press Ganey Associates, 2003; Pittet, Tarara & Wenzel, 1994).
Ongoing research is demonstrating that nosocomial infection rates are low in private
rooms with proper design and ventilation systems (The Center for Health Design, 2003).
Burn patients in nursing units with a majority of single-occupancy rooms are less likely to
acquire an infection than those in an open wards (Shirani, McManus,Vaughan, Pruitt, &
Mason, 1986).
Studies have demonstrated that Hepatitis C virus is often transferred from one patient to
another, especially in Hematology wards when patients with the virus are not isolated.
The researchers emphasized the need for isolation of patients to reduce spread of HCV
in hospitals (Allander et al., 1995, Silini, et al., 2002).
Studies have demonstrated that hospital-acquired diarrhea may transmit between
patients sharing rooms and toilets. It is often recommended that patients with diarrhea
be isolated (Korpela et al., 1995).
A recent research demonstrated some negative consequences of isolation. Isolated
patients were twice as likely as non-isolated patients to experience an adverse event
during their hospital stay. For instance, supportive care failures, such as falls and peptic
ulcers, were more likely among them as were incomplete recordings of their vital signs.
Hospital stays were also longer for isolated patients and their dissatisfaction with their
treatment was greater than non-isolated patients (Stelfox, Bates, & Redelmeier, 2003).
This study points to the need of more in-depth research on the relationship between
patient care issues and patient isolation.
Patients who require constant supervision (as in the case of frail and/or delirious
patients) are more likely to fall in hospitals; multi-occupancy patient rooms with
increased surveillance may be more appropriate for these patients (Jones & Simpson,
1991; Sutton, 1994; Tutuarima, van der Meulen, de Haan, van Straten, & Limburg,
1997).
Most falls occur in patient rooms, among elderly patients, when patients are alone and
while patients are attempting to go to the bathroom (Hendrich, Nyhuis, Kippenbrock, &
Review and Analysis of the Literature
38
Soja, 1995; Langer, 1996; Pullen, Heikaus, & Fusgen, 1999). However, if provision is
made for family members in patient rooms, falls may be reduced due to assistance from
family (Ulrich, 2003).
Although patients in double rooms can assist each other in the event of falls, double
rooms also pose a greater challenge for one of the two patients in accessing the
bathroom (Pullen, Heikaus, & Fusgen, 1999).
Health care Facility Management and Hospital Design and Therapeutic Impacts
Single-occupancy rooms increase patients’ privacy. Privacy gives patients control over
personal information, an opportunity to rest, and an opportunity to discuss their needs
with family members and friends. The number of patients in a room, the presence of
visual screening devices, the location of the bathroom, and the placement of the
patient’s bed all impact privacy (Bobrow & Thomas, 1994; Burden, 1998; Morgan &
Stewart, 1999).
Research indicates that the influence of room occupancy or type on pain medication
usage is mixed. Some researchers discovered that patients in private rooms were more
likely to use narcotics than were similar patients in semi-private rooms. This may be due
to decreased environmental stimuli in private rooms. On the other hand, other research
demonstrated that pain medication intake is less in single occupancy rooms (Dolce,
Doleys, Raczynski, & Crocker, 1985; Lawson & Phiri, 2000).
It is claimed that health care professionals have more private and, in many cases, more
thorough consultations with patients in single rooms than with patients in multioccupancy units (Ulrich, 2003). Research in this area of patient confidentiality and
patient consultation is limited. More research is required before providing more definitive
recommendations.
Mixed results were obtained in studies and surveys of patients’ preferences for room
design. A majority of patients prefer single rooms because they offer greater privacy,
reduced noise, reduced embarrassment, improved quality of sleep, an opportunity for
family members to stay, and less likelihood of upsetting other patients (Douglas, Steele,
Todd, & Douglas, 2002; Kirk, 2002; Pease & Finlay, 2002; Reed & Feeley, 1973).
Some patients prefer shared rooms because they enjoy the company and sharing of
experiences, as well as the potential for help from roommates, if needed. Patients in
single-occupancy rooms are more likely to experience loneliness and separation anxiety,
Review and Analysis of the Literature
39
whereas patients in open wards experience higher levels of shame and anxiety (Leigh,
Hofer, Cooper, & Reiser, 1972).
Patient stress can be reduced if preoperative patients are assigned to postoperative or
non-surgical roommates (Kulik, Moore, & Mahler, 1993).
Multiple occupancy rooms are associated with lack of privacy, higher noise level and
sleep disturbance (Hilton, 1985, Ulrich, 2003).
Universal rooms or acuity adaptable rooms are a current trend in design, especially in
hospitals that are promoting patient-centered care and family participation in the
patient’s healing program. These rooms are single-occupancy, and their goal is to
support the level of care needed by all patients. Waiting times for patient transfer are
reduced or eliminated, as transfers are no longer necessary. Space is also provided for
family members to stay, incorporating them in patient care. Results from a limited
number of studies have indicated that medication errors, patient falls and procedural
problems may be reduced in acuity adaptable rooms (Bobrow & Thomas, 2000; Gallant
& Lanning, 2001; Hill-Rom, 2002; Spear, 1997). However, these results may be specific
to the particular institutions studied. Acuity adaptable rooms are a fairly new
development in the area of hospital room designs. More detailed study with examples
from multiple hospitals is required before drawing specific conclusions.
Studies on the patient satisfaction issue demonstrated that patients in private rooms
were more satisfied with their hospital stay, including their communication with staff
members, than patients staying in multiple-occupancy rooms. Patients who had
roommates were less satisfied with the noise, cleanliness, and temperature of the room
(Kaldenberg, 1999, Ulrich, 2003).
Patient satisfaction is increased when the environment is pleasant, comfortable, and
relaxing. Sources of stress for patients are: perceived lack of control, lack of privacy,
noise, and crowding (Shumaker & Pequegnat, 1989). Single rooms often afford more
privacy, reduction of noise and less crowding. Control is greater in private rooms, as
patients can adjust settings according to their needs (Shumaker & Reizensten, 1982).
One problem that may arise in semi-private rooms is that both beds may be placed on
the same wall, thus permitting only one person to be placed next to the window (Brown,
1994).
Less exposure to noise in private rooms can facilitate a patient’s recovery. Excess noise
can lead to increased amounts of anxiety, increased pain perception, loss of sleep, and
Review and Analysis of the Literature
40
prolonged convalescence (Baker, Garvin, Kennedy, & Polivka, 1993; Cys, 1999; Hilton,
1985).
Music can also help reduce patients’ stress. Patients can listen to music in private rooms
without disturbing their roommates, as would be the case in semi-private rooms
(Cabrera & Lee, 2000).
Crowding can contribute to higher blood pressure. The use of private rooms and social
lounges often minimizes the patients’ sense of crowding (Baum & Davis, 1980; D’Atri,
1975).
Review and Analysis of the Literature
41
Category
Room Occupancy
Single-Occupancy Room
COST
Multi-Occupancy Room
Issues & Findings
Operating costs ↓
First costs ↑
Occupancy rates ↑
Length of stay ↓
Medication errors & costs ↓
Operating costs (inconclusive)
First costs ↓
Occupancy rates ↓
Length of stay ↑
Medication errors & costs ↑
Single-Occupancy Room
Rate of nosocomial infection ↓
Patient transfers ↓
Patient length of stay ↓
Infections in burn patients ↓
HCV transmission between patients ↓
Transmission of hospital-acquired
diarrhea↓
Falls in patients requiring supervision ↑
Falls in elderly when provisions are taken ↓
Multi-Occupancy Room
Isolation for infected patients (inconclusive)
Infections when patients are transferred ↑
Transmission of hospital-acquired
diarrhea↑
Patient length of stay ↑
Access to bathrooms ↓
Falls in patients requiring supervision ↓
Falls in elderly when provisions are taken ↓
INFECTION
CONTROL AND
FALLS
TABLE 1: Categories, issues, and findings related to single vs. multiple occupancy patient
rooms based on the literature review
Review and Analysis of the Literature
42
Category
Room Occupancy
Single-Occupancy Room
HOSPITAL
DESIGN &
THERAPEUTIC
IMPACTS
Multi-Occupancy Room
Issues & Findings
Privacy ↑
Pain medication (inconclusive)
Patient consultation with physician
(inconclusive)
Patient preference for room design
(inconclusive)
Noise level ↓
Sleep disturbances ↓
Acuity-Adaptable rooms (inconclusive)
Patient satisfaction ↑
Patient control ↑
Crowding ↑
Stress reduction through music ↑
Privacy ↓
Pain medication (inconclusive)
Patient consultation with physician
(inconclusive)
Patient preference for room design
(inconclusive)
Benefit of roommates (inconclusive)
Noise level ↑
Sleep disturbances ↑
Patient satisfaction ↓
Patient control ↓
Crowding ↑
Stress reduction through music ↓
TABLE 1(Cont’d): Categories, issues, and findings in regards to single vs. multiple patient
rooms based on the literature review
Review and Analysis of the Literature
43
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Comparative First Cost Assessment of
Single and Multiple Occupancy Patient Rooms
Developed by
Davis Langdon Adamson
Construction Cost Planning and Management
Context:
Based on consultations with Mahlum Architects and Davis Langdon Adamson
(Construction Cost Planning and Management firm), the focus of first costs comparison
was expanded from patient rooms and adjacent corridors to include the associated
support service areas in the nursing units. Mahlum Architects assisted us in identifying
several nursing unit floor plans with various configurations. However, most of those
plans reflected either all single patient rooms or a mix of single and double rooms in the
nursing units. Based on the analysis by Davis Langdon Adamson on multiple nursing
unit floor plans of various configurations, it was evident that gross area per patient is
significantly larger for single patient rooms than for double patient rooms. Most of the
other building components correlate to area, rather than patient count. This led to the
conclusion that for the purpose of this study, single patient rooms could be reasonably
evaluated based on area per patient.
A dual approach was taken in comparative first cost assessment between single and
double occupancy rooms. The first approach was an overall comparative estimation
completed by Davis Langdon Adamson based on ten nursing unit floor plans. Because
none of the nursing units consisted of only double patient rooms, the grossing factor was
calculated for single patient room floors and for mixed (double and single) room floors.
Gross floor area per bed was calculated by multiplying the square footage of the room
by the grossing factor for that floor plan type (either single patient or mixed). Based on
the analysis of the nursing floor plan samples, gross area per bed could be considered a
reasonable indicator of cost per patient for building construction. The cost for
construction of a typical patient nursing tower, based on cost analysis of these and other
recently built hospitals, is about $285 per square foot for both types of floor plan.
The second approach, complementing the first, provided a cost model that replaced the
single rooms of a nursing unit with double rooms. This analysis was done by the quantity
surveyor firm, BTY Group, based on one particular nursing unit plan (Swedish Medical
Center, Seattle). In this approach, it was assumed that the total patient room areas and
half of the corridor areas immediately adjacent to those patient rooms would be reduced
by 20% with the assumption that core services would remain same. However, in reality
these services may require additional spaces in double-occupancy conversion. This cost
model includes all direct and indirect building construction costs, and excludes items
such as legal fees, professional fees and disbursement, site work, etc.
Summary
The purpose of the study was to establish a reasonable cost of construction per patient
for both single and double occupancy rooms, in support of the overall analysis of the
cost and benefits of single versus double patient care. From analysis of ten floor plans of
recently constructed patient towers we established the gross floor area per patient bed
by taking into account all floor area required for support of patient rooms as well as the
area of the rooms themselves. Based on this analysis we recommended using gross
area per patient bed to establish cost of construction, since this addressed the core
demand of both types of patient room configurations.
Analysis
Single and Multiple Occupancy Patient Room Study
1
To establish baseline quantities and costs for single and double patient rooms, we
reviewed floor plans for ten recently built nursing floors. These included plans with only
single rooms, and plans with a mix of both double and single rooms on the same floor.
Mixed plans included double rooms for about 50% of the patients, providing a ratio of
about one-third double rooms and two-thirds single rooms. Room area per patient bed
for all floor plans is shown in the graph below.
Room Area per Patient
Double
Single
0 SF
100 SF
200 SF
EEW
UW
SMC
PN
EH
SJ
SLM
Average
EH
SJ
VAMP
UCD
VP
Average
300 SF
400 SF
267
159
During the analysis it became quite evident that there are significant differences in room
size, as determined by the nature of the room. The largest rooms were those for LDRP,
closely followed by those designated for Med/Surg. Square foot area ranged from 209 to
342 in the single patient rooms reviewed, while double patient rooms ranged from 141 to
192. However, an average room size could still be calculated despite the noted
variations. From these floor plans we were able to establish an average room size for
both types of patient care:
Single – 267 square feet
Double – 159 square feet
While the room area per patient includes bathroom area, it does not take into account
the square footage of all non-patient room areas required for maintaining the nursing
floors such as nursing desks, laundry and janitorial facilities, and so on. To incorporate
these factors we established the typical grossing factor. Because none of the nursing
floor models were made of only double patient rooms, grossing factor was calculated for
single patient room floors and for mixed (double and single) room floors instead.
The grossing factor was calculated by determining the area of all non-patient rooms
necessary for support of the nursing floor, and then dividing that value by the number of
patients those non-patient facilities support.
Np = Total area of non-patient support facilities
Single and Multiple Occupancy Patient Room Study
2
P = Total number of patients supported by A
Grossing Factor = Np / P
Using this logic, the average grossing factor for each type of floor plan was calculated:
Single – 2.41
Mixed – 2.71
From these calculations we found that the mixed floors typically have a higher grossing
factor than do single patient floors. This is to be expected since some of the core
functions are proportional to patient count rather than simply room count.
The grossing factor was generated in order to calculate the gross floor area necessary in
a nursing floor plan for each bed, beyond the area of the room itself. Gross floor area per
bed is calculated by multiplying the square footage of the room by the grossing factor for
that floor play type (either single patient or mixed).
Gf = Grossing Factor
Rm = Room area per patient bed
Gross Floor Area per Patient = Gf * Rm
Using the average room area and grossing factor calculated above, the average gross
floor area per patient bed for the two floor plan types is
Single – 640 square feet
Mixed – 430 square feet
Based on the analysis of the nursing floor plan samples, gross area per bed can be
considered a reasonable indicator of cost per patient for building construction. This is
based on the assumption that the cost per square foot for construction of a nursing floor
is irrelevant to floor plan type. Cost per patient for construction can thus be considered
equivalent to the average cost per square foot multiplied by the gross area per patient
bed.
Gfp = Gross floor area per patient bed
Csf = Construction cost per square foot
Cost Per Patient = Gfp * Csf
The cost for construction of a typical patient nursing tower, based on cost analysis of
these and other recently built hospitals, is about $285 per square foot for both types of
floor plans (see the Nursing Tower Typical Cost Models in Appendix II of this report).
Using this construction cost and the values for gross floor area per patient calculated
above, the cost per patient for the two floor plan types is as follows:
$182,400 per patient – single patient room floor plans
$122,550 per patient – mixed room floor plans
Single and Multiple Occupancy Patient Room Study
3
During the analysis it became quite evident that there are significant differences in room
size, as determined by the nature of the room. This variation in room size should be
taken into consideration when planning budgets, as it did become meaningful in the
analysis. Following the calculations discussed above, larger room sizes for either type of
room could result in an increased cost per patient to build, while smaller room sizes
could decrease the cost per patient. Additionally, the use of smaller rooms and thus an
increase in the number of patients served in an area could impact the square footage
required for support facilities such as laundry rooms, janitorial facilities, and nursing
stations. These factors should all be considered when estimating the average cost per
patient for new nursing floor construction.
Single and Multiple Occupancy Patient Room Study
4
List of Hospital Floor Plans Analyzed
Plans for nursing floors analyzed in this study are listed below.
Evergreen Hospital, East Wing, 5th floor
University of Washington Medical Center, Wing EC/EB, 4th floor
Swedish Medical Center, Southeast Tower, 9th floor
Providence Newberg, 2nd floor **
Evergreen Hospital, unidentified floor
San Joaquin General Hospital, Med Surg, 2nd floor
VA Menlo Park, Psychogeriatric floor
University of California at Davis Medical Center, Davis Tower, 14th floor
St Luke’s Medical Center, in Milwaukee, Wisconsin
Valley Presbyterian, in Van Nuys, California
** While the information from the Providence Newberg floor plan was used to calculate
the square foot area of the individual patient rooms, this floor plan was not used when
calculating the grossing factor, due to the inclusion of a surgical delivery room and a
corridor of offices. All other floor plans included only patient rooms or those spaces
required for support of patient rooms such as laundry and janitorial facilities, and nursing
stations.
Single and Multiple Occupancy Patient Room Study
5
Appendix II – Typical Cost Models for Hospital Nursing Tower Construction
Nursing Tower Typical Cost Model
Single Patient Room
COMPONENT SUMMARY
Gross Area,
Single Room:
640 SF
$/SF
9.00
18.00
27.00
35.00
$x1,000
6
12
17
22
6.00
4
95.00
61
21.00
15.00
13
10
36.00
23
20.00
7.00
13
4
27.00
17
22.00
14
38.00
24
28.00
5.00
18
3
Mechanical & Electrical (10-13)
93.00
60
Total Building Construction (1-13)
251.00
161
1.
2.
3.
4.
5.
Foundations
Vertical Structure
Floor & Roof Structures
Exterior Cladding
Roofing, Waterproofing &
Skylights
Shell (1-5)
6.
7.
Interior Partitions, Doors &
Glazing
Floor, Wall & Ceiling Finishes
Interiors (6-7)
8.
9.
Function Equipment & Specialties
Stairs & Vertical Transportation
Equipment & Vertical Transportation (8-9)
10.
11.
12.
13.
14.
15.
16.
Plumbing Systems
Heating, Ventilating & Air
Conditioning
Electric Lighting, Power &
Communications
Fire Protection Systems
Site Preparation & Demolition
Site Paving, Structures &
Landscaping
Utilities on Site
Single and Multiple Occupancy Patient Room Study
Excluded
Excluded
Excluded
6
Total Site Construction (14-16)
0.00
0
TOTAL BUILDING & SITE (1-16)
251.00
161
9.00%
23.00
15
4.00%
11.00
7
March 2005
285.00
182
General Conditions
Contractor's Overhead & Profit or
Fee
RECOMMENDED BUDGET
Single and Multiple Occupancy Patient Room Study
7
Nursing Tower Typical Cost Model
Double Patient Room
COMPONENT SUMMARY
Gross Area,
Double
Room:
430 SF
$/SF
$x1,000
9.00
18.00
27.00
35.00
6.00
4
8
12
15
3
95.00
41
21.00
9
15.00
6
36.00
15
20.00
9
7.00
3
27.00
12
22.00
9
38.00
16
28.00
5.00
12
2
Mechanical & Electrical (10-13)
93.00
40
Total Building Construction (1-13)
251.00
108
1.
2.
3.
4.
5.
Foundations
Vertical Structure
Floor & Roof Structures
Exterior Cladding
Roofing, Waterproofing & Skylights
Shell (1-5)
6.
7.
Interior Partitions, Doors &
Glazing
Floor, Wall & Ceiling
Finishes
Interiors (6-7)
8.
9.
Function Equipment &
Specialties
Stairs & Vertical
Transportation
Equipment & Vertical Transportation (8-9)
10.
11.
12.
13.
14.
15.
Plumbing Systems
Heating, Ventilating & Air
Conditioning
Electric Lighting, Power &
Communications
Fire Protection Systems
Site Preparation &
Demolition
Site Paving, Structures &
Single and Multiple Occupancy Patient Room Study
Excluded
Excluded
8
Landscaping
16.
Utilities on Site
Excluded
Total Site Construction (14-16)
0.00
0
TOTAL BUILDING & SITE (1-16)
251.00
108
9.00%
22.00
10
4.00%
12.00
5
March 2005
285.00
123
General Conditions
Contractor's Overhead
& Profit or Fee
RECOMMENDED BUDGET
Single and Multiple Occupancy Patient Room Study
9
Pilot Study on Comparative Assessment of Patient Care
Issues in Single and Multiple Occupancy Patient Rooms
Habib Chaudhury, Atiya Mahmood and Maria Valente
Simon Fraser University
Introduction
This empirical component of this research documents analyzes and synthesizes information on
the use, cost, efficiency and suitability of single and double occupancy patient rooms in specific
hospitals. Our research team conducted cross-sectional surveys and semi-structured interviews
in four hospitals in the Seattle area and in Oregon. These hospitals are:
Evergreen Hospital Medical Center (Seattle Area)
University of Washington Medical Center (Seattle Area)
Swedish Hospital Medical Center (Seattle Area)
Providence Health System (Oregon)
First costs of the single and double occupancy rooms in these hospitals are considered in the
first cost analysis section. In this section we report on the findings of the survey conducted at
the four hospitals. Data were collected from both the hospital administrative staff and the
frontline staff (e.g., nurse managers, charge nurses, etc.). Data on hospital management,
history, capacity, operational costs and patient care issues were collected from one
administrative staff member in each hospital. Structured interviews were conducted with
nurses and other health personnel taking care of patients in both single and double occupancy
rooms. The variables examined in these interviews include: interaction with patients, patient
contact hours, staff walking distances, ability to accommodate patients from different ethnocultural groups, efficiency of medical procedures and patient’s daily functioning, and
advantages/disadvantages related to privacy and confidentiality (see Appendices VI and VII for
examples of survey questionnaires).
Methods
Participants
Participants in this study included both administrative and nursing staff from three hospitals in
Seattle, Washington, and one hospital in Oregon. In total, 77 respondents participated in the
study (73 nursing staff members and four administrative staff members). The Seattle area
hospitals were Evergreen Hospital, from which 14 nurses participated, Swedish hospital, from
which 25 nurses participated, and University of Washington Hospital, from which 16 nurses
participated. Providence Hospital participated from Oregon, with 18 nurses completing the
Single and Multiple Occupancy Patient Room Study
1
questionnaires. For each hospital, one administrative staff member also completed a
questionnaire dealing with executive information.
Procedures
Participants were given short questionnaires, which took between 30 and 45 minutes to
complete (questionnaires for the study are included in Appendices VI and VII). For the three
Seattle area hospitals, researchers met with groups of nursing staff and were present while
participants filled out the questionnaires. Respondents were told about the purpose of the study
and were also given the opportunity to provide verbal feedback on their experiential evaluation
regarding single- and double-occupancy rooms. Additional participants who were not able to
complete the questionnaires in the allocated times were able to complete them on their own
time and mail them back to the researchers.
Questionnaires were mailed out to participants at Providence Hospital in Oregon. Upon
completion, the questionnaires were returned to the researchers. One representative from the
administrative staff of each hospital was also solicited to fill out a short questionnaire. After the
questionnaires were completed, they were sent back to the researchers. All the participants in
this study were remunerated with a ten-dollar Starbucks gift card.
Measures
The nursing staff and administrative staff completed similar questionnaires, but the
administrative questionnaire included additional questions pertaining to historical and
operational information. This included the history of the hospital, the operating budget of the
hospital, staffing information, and occupancy information. Administrative staff members were
not required to fill out one portion of the questionnaire (dealing with the environmental
characteristics of single- and double-occupancy rooms) that was filled out by nursing staff.
Demographic Information
Participants were asked to provide their gender and age. They were also asked to select their
job designation from a variety of choices including nurse manager, charge nurse, nurse aide,
clerk, and other. The participants were requested to specify the amount of time they had
worked at their current hospital and the number of years experience they had in their profession.
Single and Multiple Occupancy Patient Room Study
2
Nursing Units
Four questions were asked pertaining to the nursing unit design. Nurses had to select the most
common nursing unit layouts in their hospital and specify whether the units were centralized or
decentralized. Choices included triangle, circular, linear, box, staggered, double loaded, and
horseshoe design. The respondents were also able to draw out a design if they felt their layout
was not represented in the choices provided. Questions also determined what type of
medical/surgical unit the respondents worked on, the ratio of staff members to patients on the
unit, and how many patients were assigned to the unit.
Patient Rooms
Various scales were used to measure the design of patient rooms. Respondents were asked to
clarify whether they had experience working in both single- and double-occupancy rooms or
solely in one type of room. Once this was established, respondents were asked eight
questions, using a 5-point likert-type scale, regarding which type of room is more beneficial (See
Appendix I). Choices included single-occupancy rooms, double occupancy rooms, four-bed
wards, same in all types of rooms, or don’t know. One question pertaining to the cleaning of
rooms asked participants how often single- and double-occupancy rooms were cleaned and
how long it took.
To address specific features of single- and double-occupancy rooms, 15 questions were asked
using a 5-point likert-type scale, ranging from very low, low, moderate, high, and very high (See
Appendix II). Items included aspects such as flexibility of room usage, probability of medication
error, and quality of patient monitoring. To investigate environmental characteristics in singleand double-occupancy rooms, 19 questions were asked, using a scale ranging from helpful and
somewhat helpful to somewhat problematic and problematic. Items included the layout of the
room, storage space, and heating and cooling (See Appendix III). Space was also provided in
the questionnaires for respondents to make qualitative comments qualifying their responses.
DESCRIPTION OF THE HOSPITALS
Evergreen Hospital Medical Center, Kirkland, Washington
Evergreen Hospital Medical Center was established in 1972. The oldest patient bed unit was
constructed in 1972, and the newest in 2002. There are a total of five buildings in the main
hospital complex, with a total square footage of 719,009. Approximately seven percent of
square footage, or 52,202 square feet, is dedicated to patient care units. The total number of
Single and Multiple Occupancy Patient Room Study
3
acute care beds in this facility is 155; there are also an additional 13 pediatric beds in private
rooms. Evergreen Hospital contains 125 single-occupancy rooms, 11 double-occupancy rooms,
and two four-bed rooms in the medical/surgical units. Additionally, the obstetrics department
holds 49 single-occupancy rooms. Acuity adaptable rooms are available at this hospital, and
were built to further the growth of the facility and to offer flexibility to patients.
Swedish Medical Center, Seattle, Washington
Swedish Medical Center was established in 1910, when the oldest patient unit was constructed.
The newest unit was constructed in 2000. There are five buildings in the main complex, with a
total square footage of over one million. Approximately 13,000-18,000 square feet are allocated
to patient care units. The hospital includes 697 acute care beds. In the medical/surgical unit,
there are 152 single-occupancy rooms and 52 double-occupancy rooms. The cardiovascular
unit contains 20 single-occupancy and 20 double-occupancy rooms. The hospital does have
acuity adaptable rooms in certain areas, such as obstetrics, which are more family oriented.
University of Washington Medical Center, Seattle, Washington
The University of Washington Medical Center is a comprehensive medical care facility. It is
rated among the top dozen medical centers in the United States. Number of beds is 450.
Inpatient admission in 2002 was 16,517, and total operating expenses were more than $436
million.
Providence Saint Vincent Hospital, Portland, Oregon
Providence Saint Vincent Hospital was established in 1971. The newest patient bed unit was
constructed in 2003. The main hospital complex is made up of two buildings, of which 80
percent of the total square footage, or 182,000 square feet, is dedicated to patient care units
(total square footage is 225,000 square feet). There are a total of 450 acute care beds in the
facility, and all but four of the rooms on the medical/surgical units are single-occupancy.
Obstetrics is another department that contains all single-occupancy rooms, while the
cardiovascular department includes one double-occupancy room, with the rest being singleoccupancy. Acuity adaptable rooms are available at Providence. According to the viewpoint of
administration, these rooms were built because they offer greater flexibility. Patient satisfaction
and occupancy rates are better in these rooms than in traditional models, and patient safety is
increased, since there are fewer transfers.
Single and Multiple Occupancy Patient Room Study
4
In the following section information on the findings for the survey is presented. The sample size
for this study is small, as it is a pilot project and the data is mainly experiential in nature (that is,
based on the experiences of the health care personnel), and the findings should be interpreted
within that context. The data are combined for the four hospitals in the following results section.
(The comparative data for the four hospitals are provided in Appendix IV).
RESULTS
Demographic Information
A majority of the respondents (88 percent) were females. In terms of their age, most participants
(89 percent) were between the ages of 26 and 55 years (see Table 1). One participant chose
not to respond to the question pertaining to age. The respondents were mainly charge nurses,
registered nurses and nurse managers. One respondent was a nurse’s aide. Several
respondents did not state their job designation.
Demographic characteristics
of respondents
Gender
Age
Designation
Value
Female:
88 %
Male:
12 %
18-25 years:
4%
26-35 years:
32 %
36-45 years:
34 %
46-55 years:
23 %
56-65 years:
6%
Charge Nurses:
34 %
Registered Nurses: 27%
Nurse Managers: 25 %
Nurse’s aide:
1%
TABLE 1: Respondents’ demographic characteristics.
Nursing Unit
In addressing the layout of the nursing unit, approximately one-third of the respondents
identified the triangle design as the most common unit design, followed by the inverted triangle,
box, double loaded and linear respectively (see Figure 1).
Single and Multiple Occupancy Patient Room Study
5
Triangle (30 %)
Inverted Triangle (15 %)
NS
NS
Box (12%)
NS
Double loaded (11%)
Linear (11%)
NS
NS
FIGURE 1: Nursing unit layout in study hospitals.
In hospitals with more than one type of layout, respondents identified the linear design as the
second most common design. Other designs in this category include the box design and the
circular design. When asked whether the nursing unit was centralized or decentralized, 38
percent of respondents stated their unit was decentralized, while 30 percent of nurses asserted
their unit was centralized. Data were missing for 20 participants. Most nurses worked on an
oncology unit (22 percent) or a telemetry unit (15 percent).
The number of patients per unit ranged between 5 and 30. Patient to staff ratios varied in
different units. Throughout the day, patient to staff ratios ranged from 3:1 to 6:1, with 4:1 being
the most frequent (30 percent). During the evening, patient to staff ratios ranged from 3:1 to
7:1, with 5:1 being the most common (27 percent). Overnight, the patient to staff ratios varied
from 3:1 to 9:1. The most frequent ratio was 5-6 patients per staff member (38 percent).
Patient Rooms
Over three-fourth of the respondents (75 percent) had experience working in both single and
multi-occupancy rooms and, in most cases, single-occupancy rooms were preferred over double
Single and Multiple Occupancy Patient Room Study
6
or multi-occupancy rooms. For instance, a large portion of respondents (86 percent) stated that
fewer transfers occur in single-occupancy rooms (Figure 2).
Room with Fewer Patient Transfers
don't know
8.2%
same in all rooms
1.4%
double-occupancy
4.1%
single-occupancy
86.3%
FIGURE 2: Comparison of rooms in terms of patient transfer.
Respondents also felt that single-occupancy rooms have better access to bathing facilities (93
percent), more space for storage and equipment (86 percent), and are better suited for different
ethno-cultural groups and family members (96 percent) compared to double or multi-occupancy
rooms (Figure 3).
Single and Multiple Occupancy Patient Room Study
7
Room Better Suited for Ethno-cultural Groups & Family
don't know
2.7%
same in all rooms
1.4%
single-occupancy
95.9%
Figure 3: Comparison of rooms in terms of suitability for family and people from different ethnocultural groups.
Staff efficiency is greater in single-occupancy rooms, according to more than half of the study
participants (53 percent), and 58 percent of nurses noted that patients use less medication in
single-occupancy rooms (Figure 4).
Room Increasing Staff Efficiency
50
40
30
20
Count
10
0
Missing
double
single
same in all rooms
four-bed wards
don't know
Room increasing staff efficiency
Figure 4: Comparison of rooms in terms of staff efficiency.
Single and Multiple Occupancy Patient Room Study
8
Approximately one-third of the respondents (30 percent) felt that walking distances are the
same in single- and double-occupancy rooms and 4-bed wards, while 29 percent of nurses felt
double-occupancy rooms required the least amount of walking by staff members (Figure 5). It
seems that, in terms of the nurses’ walking distance, the layout of the nursing unit, more than
patient density in rooms, is a determining factor.
Room Requiring the Least Amount of Walking by Staff
Missing
don't know
11.0%
1.4%
single-occupancy
16.4%
same in all rooms
30.1%
double-occupancy
28.8%
four-bed wards
12.3%
FIGURE 5: Comparison of rooms in terms of staff walking time
A little less than half (43 percent) of the respondents did not know the maintenance and upkeep
costs of different types of patient rooms. However, approximately 23 percent of the
respondents (out of a N=41) who knew about maintenance costs identified single-occupancy
rooms as the least costly in terms of cleaning. Similarly, a significant percentage of
respondents did not know the room cleaning frequency for patient rooms. Of those that did
respond in the affirmative for this question, 63.0 percent (N=49) thought single-occupancy
rooms are cleaned once daily, while 50.7 percent (N=40) of nurses stated that doubleoccupancy rooms are cleaned once daily. A small portion of nurses (four percent) stated that
both types of rooms are cleaned twice daily.
The results were similar for the time taken to clean patient rooms. Around half of the
respondents were unaware of the time it takes to clean the rooms, commenting that they are not
responsible for the cleaning itself. Of those (N=39) who responded to the room cleaning time
question, 26 percent stated that single-occupancy rooms require between 10 and 19 minutes to
Single and Multiple Occupancy Patient Room Study
9
clean. Twelve percent of those responding (N=29) stated that double-occupancy rooms are
cleaned within 20 to 29 minutes, while 11 percent stated that it takes between 10 and 19
minutes to clean these rooms. Variation in times for room cleaning could be due to differences
between regular or daily room cleaning and cleaning a room after a patient has been
discharged. The latter takes longer as it is a more thorough cleaning. The findings on room
cleaning frequency, time and cost are inconclusive as many of the respondents did not respond
to this question. Nursing staff may not be the appropriate personnel to answer cleaning related
questions. In future studies, janitorial or environmental maintenance staff should be interviewed
to get more accurate information in this category.
Comparison of single- versus double- occupancy rooms
In comparing single- versus double-occupancy rooms, it is evident that nurses clearly favor
single-occupancy rooms, as demonstrated by data in Table 2 and Table 3. Most of the
participants responded to a majority of the categories in the comparison questions. However,
there were a few categories where all the participants did not respond. Thus, the frequency (that
is, the number of respondents) across the different categories is not the same. However, even
with the missing responses the findings demonstrate that the nursing staff from all four hospitals
prefer private rooms over multi-occupancy rooms. For instance, 84 percent of the respondents
rated room flexibility as high or very high in single-occupancy rooms, whereas only 40 percent
of nurses felt double-occupancy rooms are moderately flexible. In terms of flexibility in private
rooms, one respondent stated that, “lots of room, private conversations in person and on phone,
stay in room.” Interaction with family members and flexibility for accommodating family
members both got high scores (high or very high) in private rooms, whereas in doubleoccupancy rooms, interaction with family members was considered low (33 percent) or
moderate (47 percent) and flexibility for accommodating family members was considered low
(48 percent).
Although interaction with family members is greater in single-occupancy rooms, interaction with
other patients is greater in double-occupancy rooms. Specifically, 56 percent of the
respondents stated that interaction was high in double-occupancy rooms, while 37 percent of
nurses responded that interaction was low in single-occupancy rooms.
Single and Multiple Occupancy Patient Room Study
10
Flexibility of room usage
Scope for interaction among
patients
Scope of interaction with
family members and family
participation in care
72
68
Percentages
Very
High
High
47.9
35.6
12.3
13.7
72
52.1
43.8
1.4
0.0
0.0
1.4
Flexibility for accommodating
family
Suitability for patient
examination
Quality of patient monitoring
Suitability for collection of
patient history
Patient comfort level
Patient recovery rate
Scope for patient surveillance
Probability of medication error
Rate of nosocomial infection
Probability of dietary mix-up
Falls incidence
Rate of pain reduction /sleep
inducing medication taken
73
69.9
24.7
4.1
1.4
0.0
0.0
73
84.9
15.1
0.0
0.0
0.0
0.0
73
73
37.0
82.2
45.2
17.8
15.1
0.0
0.0
0.0
0.0
0.0
2.7
0.0
73
64
71
73
69
73
67
66
68.5
26.0
20.5
6.8
6.8
8.2
4.1
13.7
31.5
38.4
37.0
2.7
4.1
2.7
5.5
11.0
0.0
11.0
31.5
13.7
13.7
9.6
47.9
37.0
0.0
0.0
4.1
42.5
47.9
54.8
21.9
21.9
0.0
0.0
2.7
31.5
19.2
24.7
2.7
0.0
0.0
12.3
1.4
2.7
2.7
0.0
9.6
6.8
Item
Total
N
Moderate
Low
0.0
37.0
Very
Low
1.4
13.7
Not
Applicable
2.7
2.7
11.0
13.7
TABLE 2: Features of Single-Occupancy Rooms
Single and Multiple Occupancy Patient Room Study
11
ITEM
Flexibility of room usage
Scope for interaction among
patients
Scope of interaction with
family members and family
participation in care
Flexibility for accommodating
family
Suitability for patient
examination
Quality of patient monitoring
Suitability for collection of
patient history
Patient comfort level
Patient recovery rate
Scope for patient surveillance
Probability of medication error
Rate of nosocomial infection
Probability of dietary mix-up
Falls incidence
Rate of pain reduction /sleep
inducing medication taken
Total
N
70
70
Percentages
Very
High
High
1.4
9.6
5.5
56.2
Moderate
Low
26.0
11.0
Very
Low
11.0
0.0
Not
Applicable
8.2
4.1
39.7
19.2
72
2.7
12.3
46.6
32.9
0.0
4.1
72
0.0
2.7
15.1
47.9
27.4
5.5
72
0.0
6.8
28.8
46.6
12.3
4.1
71
72
1.4
0.0
26.0
1.4
57.5
27.4
6.8
45.2
0.0
20.5
5.5
4.1
71
62
71
71
66
71
65
64
0.0
0.0
1.4
11.0
9.6
8.2
0.0
4.1
1.4
11.0
20.5
28.8
35.6
34.2
12.3
31.5
34.2
43.8
52.1
39.7
30.1
35.6
47.9
32.9
38.4
6.8
16.4
8.2
5.5
13.7
17.8
6.8
19.2
1.4
0.0
2.7
1.4
1.4
1.4
2.7
4.1
21.9
6.8
6.8
8.2
4.1
9.6
9.6
TABLE 3: Features of Double-Occupancy Rooms
Single-occupancy rooms were chosen as most appropriate for patient examination (85 percent)
and collection of a patient’s history (82 percent). However, less than half of the respondents
rated double-occupancy rooms as low in their suitability for patient examination and collection of
a patient’s history. According to one respondent, single rooms are more helpful as there is
“more privacy, room for ambulation within room.” According to another respondent, “my opinion
is that I am totally focused on one patient without interruptions [when noting patient history].”
One respondent stated, “can’t assure confidentiality if there’s another patient in the same room.”
Other factors such as the quality of patient monitoring, patient’s comfort level, patient’s recovery
rate, and scope for patient surveillance were all rated higher in private rooms compared to
double occupancy rooms. One respondent stated that “[patient recovery rate] could be impacted
Single and Multiple Occupancy Patient Room Study
12
by loss of sleep due to noisy/sick roommate.” On the issue of surveillance one respondent
stated, “100% focus on 1 patient is better than one eye on one patient another eye on other
patient.” Medication errors were considered low in single-occupancy rooms (43 percent) and
moderate in double-occupancy rooms (40 percent). Double-occupancy rooms were selected in
the high (34 percent) to moderate (36 percent) category for dietary mix-ups. Thus, the findings
demonstrate that in both types of room there is little scope for medication error; however,
double-occupancy rooms have a slightly greater chance of dietary mix-ups.
Fifty-seven percent of the respondents stated that the rate of acquiring a nosocomial infection is
either low or very low in single-occupancy rooms (versus 10 percent respondents in case of
double rooms), compared to 11 percent respondents stating that the rate is high or very high in
single rooms (versus 46 percent stating the same for double rooms). The incidence of patient
falls was considered moderate in both types of rooms (48 percent). Similarly, the rate of taking
pain reducing or sleep inducing medicine was considered moderate in both types of room (37
percent in single occupancy rooms; 33 percent in double-occupancy rooms).
Environmental characteristics in single- and double-occupancy rooms
The respondents were asked to rate the environmental characteristics of single- and doubleoccupancy rooms based on their experiences at their present work setting (See Table 4 & Table
5). The respondents rated many of the environmental characteristics of single patient rooms as
helpful. These included the layout of the room (47 percent), the availability of space in rooms
(49 percent), the arrangement of furniture (47 percent), privacy (89 percent), and space for
family members (51 percent). Double-occupancy rooms were thought to be somewhat helpful
in terms of walking distance from the nursing station (41 percent) and visibility of the patients for
monitoring purpose (40 percent).
Single and Multiple Occupancy Patient Room Study
13
ITEM
Layout
Availability of space in room
Arrangement of furniture in room
Privacy
Walking distance from nursing
station
Visibility
Degree of surveillance capability
Storage space for clean supplies
Storage space for dirty supplies
Location of storage area (clean &
dirty)
Sink location
Bathroom location
Door location
Window location
Space for family members
Noise level/Acoustics
Lighting in space
Heating and cooling
Other = Bathroom size and
wheelchair accessibility
Total
N
68
Percentages
Helpful Somewhat Somewhat
Problematic
Helpful
Problematic
46.6
23.3
16.4
4.1
72
71
72
68
49.3
46.6
89.0
16.4
27.4
21.9
9.6
27.4
11.0
23.3
0.0
41.1
9.6
4.1
0.0
6.8
68
70
71
70
70
13.7
17.8
32.9
24.7
19.2
30.1
31.5
32.9
32.9
41.1
39.7
39.7
20.5
24.7
24.7
8.2
5.5
11.0
13.7
9.6
71
71
71
71
72
71
71
72
1
63.0
65.8
67.1
72.6
50.7
39.7
53.4
47.9
1.4
20.5
21.9
19.2
21.9
21.9
39.7
28.8
21.9
0.0
6.8
4.1
9.6
2.7
20.5
8.2
12.3
20.5
0.0
5.5
2.7
0.0
0.0
2.7
8.2
2.7
8.2
0.0
TABLE 4: Environmental Characteristics in Single-Occupancy Rooms.
Single and Multiple Occupancy Patient Room Study
14
ITEM
Layout
Availability of space in room
Arrangement of furniture in room
Privacy
Walking distance from nursing
station
Visibility
Degree of surveillance capability
Storage space for clean supplies
Storage space for dirty supplies
Location of storage area (clean &
dirty)
Sink location
Bathroom location
Door location
Window location
Space for family members
Noise level/Acoustics
Lighting in space
Heating and cooling
Other
Total
N
64
Percentages
Helpful Somewhat Somewhat
Problematic
Helpful
Problematic
9.6
26.0
43.8
6.8
65
65
65
62
5.5
6.8
2.7
15.1
8.2
12.3
1.4
41.1
50.7
52.1
28.8
20.5
21.9
16.4
56.2
6.8
64
62
64
64
62
6.8
8.2
5.5
4.1
8.2
39.7
32.9
9.6
15.1
30.1
34.2
34.2
58.9
49.3
32.9
5.5
8.2
13.7
19.2
12.3
64
65
63
63
65
65
63
65
0
13.7
5.5
13.7
13.7
4.1
2.7
9.6
9.6
0.0
34.2
27.4
41.1
39.7
4.1
2.7
23.3
12.3
0.0
28.8
38.4
28.8
27.4
35.6
35.6
39.7
37.0
0.0
9.6
16.4
2.7
5.5
45.2
47.9
13.7
30.1
0.0
TABLE 5: Environmental Characteristics in Double-Occupancy Rooms.
Surveillance of patients was considered somewhat problematic in both single- (40 percent) and
double-occupancy rooms (34 percent). Storage for clean and dirty supplies was considered
somewhat helpful in single-occupancy rooms (33 percent), but in double-occupancy rooms,
storage was considered somewhat problematic (59 percent for clean supplies; 54 percent for
dirty supplies).
The location of the sink, bathroom, door, and window in the single-occupancy rooms were all
rated as helpful by a large majority of respondents (63 percent; 66 percent; 67 percent; and 73
percent respectively). Similarly, in double-occupancy rooms, the location of the sink, door, and
window were considered somewhat helpful (34 percent; 41 percent; and 40 percent
respectively). The bathroom location, on the other hand, was thought to be somewhat
problematic (38 percent).
Single and Multiple Occupancy Patient Room Study
15
Data in Tables 5 and 6 demonstrate that lighting, temperature control, and noise levels were
considered helpful in single-occupancy rooms, but these features were felt to be somewhat
problematic or problematic in double-occupancy rooms.
Samples of open-ended comments comparing single- and multi-occupancy rooms:
University of Washington Medical Center
Single patient rooms are always preferred over double. There is almost no reason to transfer
patients – critically ill, or dying patients don’t have to be moved, single rooms can accommodate
families.
Single occupancy rooms provide a more private and quiet environment for patient, which is very
important when it comes to a patient’s healing and well-being. I also believe patients are at
much less risk of nosocomial infections, especially when they are sharing bathrooms &
showers-this puts patients at a much greater risk of passing germs to one another.
For single rooms, some of the rooms are very far from the nurses’ station.
Our private rooms are fairly quiet. They are not close to the nursing station so they aren’t within
hearing distance of people working. However, it’s concerning not to see any rooms from the
front desk.
Evergreen Hospital
Because one can only place patients of the same sex in a double occupancy room, patient
placement can become somewhat problematic.
The benefit of private, long, and narrow patient rooms for family members. Rooms that have
provision for family members need to have bathrooms with a shower, enough room for
equipment storage, a sink by the door, and a window.
Universal care rooms can help reduce operational costs.
[Nursing units] that are in open areas and provide good visibility of registered nurses and of
patients in their rooms can help to decrease operation cost.
If rooms are narrower and closer together, staff walking distances can also be reduced.
Swedish Medical Center
In my experience, the majority of patients don’t want a lot of interaction with other patients.
On the oncology floor, private rooms provide opportunities for families and friends to be at
patient’s bedside during time of need (not usually the case in double rooms).
Single and Multiple Occupancy Patient Room Study
16
About 80-90 percent of all patients admitted to double rooms really want a private room, so we
are constantly shuffling people around.
I’m unable to tell you what impact being in a private room versus double rooms has on these
things. We should be just as vigilant in either room.
I’ve listed most things as both helpful and problematic. On our unit it depends on where your
room is in the floor layout. Some rooms are bigger, some are close to, others far away from the
nursing station which impacts noise levels, etc.
The double rooms are big but here we have a pillar in one of the three rooms, which causes
much frustration. Families love having more space but this works only if the other bed is not
occupied.
One cannot ascertain privacy when two patients share a room, particularly pt information.
Maintaining clean linens & prevention of cross contamination is problematic in two shared area.
Noise level is aggravated with more people in room. Also consider differences in individual
preferences relating to noise/lighting and heating.
Many of our private rooms are not the same with layout or square footage so some of these
answers really depend on what room.
Providence health system
The bathrooms are challenging in all rooms.
Every time we place a patient in a double or triple room [there is request for transfer].
Every patient is so different and likes different things, especially, temperature of room, noise
level, etc. Single rooms are the only way to go.
We have a high level of confused patients, which would make double occupancy rooms
problematic.
Patients interact with other patients more in a double room.
The patients in our “high acuity rooms” have very little space when patient has equipment in
room-such as ventilator, special chair, special beds, family cots, BSC, etc. A room with no
equipment is just barely enough room for the bed, chair, and bedside table.
The double rooms have very limited space to move in and patients are ambulating in tight
areas. If patient’s share a bathroom-nurses have trouble monitoring outputs. Alsoconfidentiality is almost impossible when two patient’s are in the same room. The double rooms
can be very crowded and can increase the risk to fall due to the lack of space (equipment in
small spaces).
We try not to use the double rooms unless we don’t have any private rooms.
Single and Multiple Occupancy Patient Room Study
17
The data on environmental features in single and double room demonstrate that single rooms
have more helpful features than multi-occupancy rooms. However, one must keep in mind that
environmental features of particular patient rooms are tied to the room layout, size, design and
nursing unit layout. Thus, the helpful or problematic aspects of environmental features may
vary from hospital to hospital.
Conclusion
This empirical component of this project was a pilot study on nursing staff’s comparative
assessment of patient care issues between single and double-occupancy rooms. Participants
represent various levels of nursing staff. The findings need to be viewed within the context of
the limited sample size of this pilot study (Nursing staff N=73; Administrative staff N=4). In
comparing single- versus double-occupancy rooms, it is evident that nurses clearly favor singleoccupancy rooms. Most of the participants responded more favorably for single rooms than for
double rooms on the majority of the fifteen categories in the comparison questions. The most
noticeable categories of positive assessment for single rooms include: flexibility for
accommodating family, suitability for examination of patients by health care personnel, patient
comfort level, patient recovery rate, less probability of medication errors, and less probability of
diet mix-ups (see Tables 2 and 3, Appendix IV for more detailed information).
The respondents rated many environmental characteristics of single patient rooms as helpful.
These included the layout of the room (47 percent), the availability of space in rooms (49
percent), the arrangement of furniture (47 percent), privacy (89 percent), and space for family
members (51 percent). Double-occupancy rooms were thought to be somewhat helpful in terms
of walking distance from the nursing station (41 percent) and visibility of the patients for
monitoring purposes (40 percent). Surveillance of patients was considered somewhat
problematic in both single- (40 percent) and double-occupancy rooms (34 percent). Due to
disproportionate missing data in the transfer related question section, we have not reported that
data. Future studies may want to rely on multi-method data collection, such as observation and
log entries, as well as respondent surveys, in order to gain more accurate information on the
tasks, time and cost involved in patient transfer.
The primary objectives of this pilot study were to gather an experience-based assessment from
hospital staff in regard to single versus double patient rooms and to examine the validity and
Single and Multiple Occupancy Patient Room Study
18
relevance of the two survey questionnaires. The results generally support the positive aspects
of single rooms from a patient care perspective, as suggested by the literature. The limitations
of this study include limited sample size and limited data on operating costs. Findings need to
be interpreted with these limitations in mind. Future studies need to examine carefully the
implications for operating costs of the positive assessments of patient care issues associated
with single rooms. An in-depth case study approach using multiple methods (e.g., systematic
observations, information from data logs, qualitative interviews) can provide more useful data in
regard to the complex relationships among patient care issues, operating cost variables, patient
outcomes, and staff efficiency, as well as subjective evaluations by patients and family
members.
Single and Multiple Occupancy Patient Room Study
19
APPENDIX I
Which type of room has fewer patient transfers (for infection control and psycho-social needs)?
Which type of room provides better access to bathing and toilet facilities?
Which type of room enables staff to walk lesser distance per work shift or day?
Which type of room increases staff efficiency and productivity?
Which type of room provides more space for placement of equipment and for storage?
Which type of room is less costly for maintenance and upkeep?
Room cleaning cost (please complete for the types of rooms present in your facility)
Room cleaning frequency in a single-occupancy room
Approximate time taken to clean a single-occupancy room
Room cleaning frequency in a double-occupancy room
Approximate time taken to clean a double occupancy room
In which type of room do patients tend to use less pain and/or sleep medication?
Which type of rooms are better suited for people from different ethno-cultural groups and their
family members?
Single and Multiple Occupancy Patient Room Study
20
APPENDIX II
Flexibility of room usage
Scope for interaction among patients
Scope of interaction with family members and family participation in care
Flexibility for accommodating family
Suitability for patient examination
Quality of patient monitoring
Suitability for collection of patient history
Patient comfort level (resting undisturbed, sleeping, etc.)
Patient recovery rate
Scope for patient surveillance
Probability of medication error
Rate of nosocomial infection
Probability of dietary mix-up
Falls incidence
Rate of pain reduction /sleep inducing medication taken
Single and Multiple Occupancy Patient Room Study
21
APPENDIX III
Layout
Availability of space in room
Arrangement of furniture in room
Privacy
Walking distance from nursing station
Visibility
Degree of surveillance capability
Storage space for clean supplies
Storage space for dirty supplies
Location of storage area (clean & dirty)
Sink location
Bathroom location
Door location
Window location
Space for family members
Noise level/Acoustics
Lighting in space
Heating and cooling
Other
Single and Multiple Occupancy Patient Room Study
22
APPENDIX IV
Comparison of data across single and double occupancy rooms in four study hospitals
To address specific features of single- and double-occupancy rooms, 15 questions were asked
using a 5-point likert scale, ranging from very low, low, moderate, high, and high. The mean
value for each of these variables (question) across the four hospitals (for both single and double
occupancy patient rooms) is displayed in the graphs below. The graphs for both single and
double occupancy rooms are displayed side-by-side for ease of comparison. These graphs
demonstrate the consistency of findings across the four hospitals, as well as the findings for the
combined data.
Flexibility of room usage
Flexibility of Room Usage in Double-Occupancy Rooms
5.0
5.0
4.7
4.0
3.0
2.0
1.0
0.0
Evergreen Hospital
4.0
4.3
4.1
3.9
Mean flexibility of room usage
Mean Flexibility of single-occupancy rooms
Flexibility of Single-Occupancy Rooms
3.0
2.8
1.8
1.0
0.0
Evergreen Hospital
U. of Washington
Swedish Hospital
2.5
2.4
2.0
U. of Washington
Swedish Hospital
Providence Hospital
Providence Hospital
Name of Hospital
Name of Hospital
Scope of interaction among patients
Scope for Interaction Among Patients in Double-Occupancy Rooms
Mean scope for interaction among patients
4.0
3.0
2.9
2.9
2.5
2.5
2.0
1.0
0.0
Evergreen Hospital
U.of Washington
Swedish Hospital
Mean scope for interaction among patients
Scope for Interaction Among Patients in Single-Occupancy Rooms
5.0
5.0
4.0
4.0
3.0
3.1
2.8
2.0
1.0
0.0
Evergreen Hospital
U. of Washington
Swedish Hospital
Providence Hospital
Name of Hospital
3.8
Providence Hospital
Name of Hospital
Scope of interaction with family
Single and Multiple Occupancy Patient Room Study
23
5.0
4.9
4.5
4.3
4.3
4.0
3.0
2.0
1.0
0.0
Evergreen Hospital
Mean scope for interaction with family members
Mean scope for interaction with family members
Scope for Interaction with Family in Double-Occupancy Rooms
Scope for Interaction with Family In Single-Occupancy Rooms
5.0
4.0
3.0
2.5
2.4
2.0
1.0
0.0
Evergreen Hospital
U. of Washington
Swedish Hospital
3.0
2.9
U. of Washington
Swedish Hospital
Providence Hospital
Providence Hospital
Name of Hospital
Name of Hospital
Flexibility for accommodating family
Flexibility for Accomodating Family in Double-Occupancy Rooms
Flexibility for Accomodating Family in Single-Occupancy Rooms
5.0
4.9
4.8
4.8
4.0
Mean flexibility of accomodating family
Mean flexibility for accomodating family
5.0
4.1
3.0
2.0
1.0
0.0
Evergreen Hospital
4.0
3.0
2.0
2.0
1.7
1.6
1.0
0.0
Evergreen Hospital
U. of Washington
Swedish Hospital
2.0
U. of Washington
Swedish Hospital
Providence Hospital
Providence Hospital
Name of Hospital
Name of Hospital
Suitability for examination of patients by health care personnel
Suitability for Patient Exams in Single-Occupancy Rooms
Suitability for Patient Exams in Double-Occupancy Rooms
5.00
5.0
4.88
4.84
4.83
4.00
Mean suitability for patient exams
Mean suitability for patient exams
4.86
3.00
2.00
1.00
0.00
Evergreen Hospital
U. of Washington
Swedish Hospital
4.0
3.0
2.0
2.4
2.2
2.0
1.0
0.0
Evergreen Hospital
Providence Hospital
Name of Hospital
2.3
U. of Washington
Swedish Hospital
Providence Hospital
Name of Hospital
Quality of patient monitoring
Single and Multiple Occupancy Patient Room Study
24
Quality of Patient Monitoring in Single-Occupancy Rooms
5.0
4.0
4.1
4.1
4.0
Mean quality of patient monitoring
Mean quality of patient monitoring
Quality of Patient Monitoring in Double-Occupancy Rooms
5.0
4.3
3.0
2.0
1.0
0.0
Evergreen Hospital
U. of Washington
Swedish Hospital
Providence Hospital
Name of Hospital
4.0
3.4
3.0
3.2
3.1
2.5
2.0
1.0
0.0
Evergreen Hospital
U. of Washington
Swedish Hospital
Providence Hospital
Name of Hospital
Suitability for collecting patient history by health care personnel
Mean suitability for collecting patient history
Suitability for Collecting Patient History in Single-Occupancy Rooms
5.0
4.9
4.8
4.9
4.7
4.0
3.0
2.0
1.0
0.0
Evergreen Hospital
U. of Washington
Swedish Hospital
Providence Hospital
Name of Hospital
Mean suitability for collecting patient history
Suitability for Collecting Patient History in Double-Occupancy Rooms
5.0
4.0
3.0
2.0
2.4
2.1
1.8
1.8
1.0
0.0
Evergreen Hospital
Swedish Hospital
U. of Washington
Providence Hospital
Name of Hospital
Single and Multiple Occupancy Patient Room Study
25
Patient comfort level
4.8
4.8
4.7
4.5
4.0
3.0
2.0
1.0
0.0
Evergreen Hospital
Patient Comfort Level in Double-Occupancy Rooms
Mean patient comfort level in double rooms
Mean patient comfort level in single rooms
Patient Comfort Levels in Single-Occupancy Rooms
5.0
5.0
4.0
3.0
2.0
2.2
1.9
1.0
0.0
U. of Washington
Swedish Hospital
2.3
2.1
Evergreen Hospital
Providence Hospital
U. of Washington
Swedish Hospital
Name of Hospital
Providence Hospital
Name of Hospital
Patient recovery rate
Patient Recovery Rate in Double-Occupancy Rooms
Mean patient recovery rate in double rooms
Mean patient recovery rate in single rooms
Patient Recovery Rate in Single-Occupancy Rooms
5.0
4.0
3.9
3.8
3.6
3.0
3.1
2.0
1.0
0.0
Evergreen Hospital
U. of Washington
Swedish Hospital
5.0
4.0
3.0
2.6
2.0
2.4
2.1
1.8
1.0
0.0
Evergreen Hospital
Providence Hospital
U. of Washington
Swedish Hospital
Name of Hospital
Providence Hospital
Name of Hospital
Scope for patient surveillance
Scope for Patient Surveillance In Single-Occupancy Rooms
Scope for Patient Surveillance in Double-Occupancy Rooms
5.0
4.0
3.8
3.6
3.5
3.6
3.0
2.0
1.0
0.0
Evergreen Hospital
U. of Washington
Swedish Hospital
Mean scope for patient surveillance
Mean scope for patient surveillance
5.0
4.0
3.0
2.9
2.7
2.0
1.0
0.0
Evergreen Hospital
Providence Hospital
Name of Hospital
2.9
2.9
U. of Washington
Swedish Hospital
Providence Hospital
Name of Hospital
Probability of medication errors
Single and Multiple Occupancy Patient Room Study
26
Probability of Medication Errors in Single-Occupancy Rooms
Probability of Medication Errors in Double-Occupancy Rooms
5.0
4.0
Mean probability of medication errors
Mean probability of medication errors
5.0
3.0
2.0
2.2
2.2
2.0
1.8
1.0
0.0
Evergreen Hospital
4.0
3.0
2.0
1.0
0.0
U. of Washington
Swedish Hospital
Evergreen Hospital
Providence Hospital
U. of Washington
Swedish Hospital
Name of Hospital
Providence Hospital
Name of Hospital
Probability of diet mix-ups
Probability of Diet Mix-ups in Single-Occupancy Rooms
Probability of Diet Mix-ups in Double-Occupancy Rooms
5.0
5.0
4.0
Mean probability of diet mix-up
Mean probability of diet mix-up
4.0
3.0
2.0
2.2
2.3
2.2
1.9
1.0
0.0
Evergreen Hospital
3.6
3.2
3.0
2.0
1.0
0.0
U. of Washington
Swedish Hospital
3.1
3.1
Evergreen Hospital
Providence Hospital
U. of Washington
Swedish Hospital
Name of Hospital
Providence Hospital
Name of Hospital
Rate of nosocomial infection
Rate of Nosocomial Infections in Single-Occupancy Rooms
Rate of Nosocomial Infections in Double-Occupancy Rooms
5.0
4.0
3.0
2.6
2.0
2.1
2.1
1.9
1.0
0.0
Evergreen Hospital
U. of Washington
Swedish Hospital
Mean rate of nosocomial infections
Mean rate of nosocomial infections
5.0
4.0
3.0
2.0
1.0
0.0
Evergreen Hospital
Providence Hospital
Name of Hospital
Single and Multiple Occupancy Patient Room Study
U. of Washington
Swedish Hospital
Providence Hospital
Name of Hospital
27
Falls incidence
Incidences of Falls in Single-Occupancy Rooms
Incidences of Falls in Double-Occupancy Rooms
5.0
4.0
Mean falls incidence in double rooms
Mean falls incidence in single rooms
5.0
3.0
2.8
2.8
2.4
2.0
2.3
1.0
0.0
Evergreen Hospital
U. of Washington
Swedish Hospital
4.0
3.0
2.9
2.8
2.4
2.0
2.1
1.0
0.0
Evergreen Hospital
Providence Hospital
U. of Washington
Swedish Hospital
Name of Hospital
Providence Hospital
Name of Hospital
Rate of pain reducing and sleep inducing medication taken
Rate of Pain Reducing & Sleep Inducing Medication Taken
Rate of Pain Reducing & Sleep Inducing Medication Taken
in Single-Occupancy Rooms
in Double-Occupancy Rooms
5.0
4.0
3.0
3.2
3.1
3.0
2.6
2.0
1.0
0.0
Evergreen Hospital
U. of Washington
Swedish Hospital
Mean rate of medication taken
Mean rate of medication taken
5.0
4.0
3.4
3.0
Single and Multiple Occupancy Patient Room Study
2.5
2.0
1.0
0.0
Evergreen Hospital
Providence Hospital
Name of Hospital
3.2
2.6
U. of Washington
Swedish Hospital
Providence Hospital
Name of Hospital
28
Empirical Articles
First and Operating Cost of Hospitals
Study
Ashby, J. L. Jr. &
Lisk, C. K. (1992,
Summer)
Focus of Study
To determine how general and
medical inflation and intensity
determine the hospital cost per
case
Research Design
Conceptual model
used which breaks
down change in
hospital operating
costs per adjusted
admission into
seven components
and four ratios
Sample
Information and
Site
Site & Sample:
Data on FTE
employees,
admissions, total
charges, and total
operating expenses
were obtained from
the AHA annual
hospital survey
from 1985-1989
Patient complexity
change measured
using Prospective
Payment
Assessment
Commission
(ProPAC)
methodology
Findings
Largest single
contribution to increase
in hospital operating
costs was inflation in
the general economy;
this accounted for 40%
of average total
increase
Price inflation specific
to hospital industry
accounted for about
17% of annual increase
in hospital expenses
Patient complexity
changes continue to be
quite large and account
for 21% of annual
increase in costs per
adjusted admission
during analysis period
2% of total annual cost
increase due to changes
in quantity and quality
of labor and non-labor
inputs
Although total
operating costs increase
rising during 19851989, portion of
increase that partially
subject to hospital
control reduced
Expenditures on supply
upgrades decreased
Relationship of
findings to room
occupancy
Cost controlling efforts
should focus on
controlling increases in
intensity of services and
lower wage and salary
increases
Study
Berry, R. E. Jr.
(1974, Summer)
Focus of Study
To identify and measure the
effects of factors that
significantly impact the cost and
efficiency of short-term general
hospitals in the U.S.
Research Design
Analysis of data
utilized a model
which measured
hospital cost as a
function of the
level of output, the
quality of services
provided, the scope
of services
provided, factor
prices, and relative
efficiency
Sample
Information and
Site
Sample & Site:
approximately
6000 short-term
hospitals in the U.S
for the years 1965,
1966, & 1967
Findings
Hospital services are
produced subject to
decreasing costs
initially and increasing
costs eventually
Average cost curves are
‘U” shaped and
shallow; magnitudes of
the economies of scale
are insignificant
Empty beds lead to
higher average costs for
voluntary hospitals and
lower average costs for
proprietary and
government hospitals
Higher-quality hospital
services cost more to
produce than lowerquality services
Costs are higher in
hospitals that are
involved in medical
education
More complex inpatient
services and provision
of community medical
services are significant
factors affecting
hospital costs
Differences in wages
across hospitals explain
significant part of
differences in average
costs across hospitals
Relationship of
findings to room
occupancy
Several variables
impact the costs
incurred by hospitals
No mention made in
regards to room
occupancy
Study
Cho, S., Ketefian, S.,
Barkauskas, V. H., &
Smith, D. G. (2003,
March/April)
Focus of Study
To examine the effects of nurse
staffing on adverse events,
morbidity, mortality, and
medical costs
Research Design
2 existing
databases used to
retrieve data:
Hospital Financial
Data and the State
Inpatient Databases
(SID) California1997
Databases from
three fiscal years
(1996-1997, 19971998, and 19981999) were used to
estimate nursing
hours and patient
days during 1997
Items measured
were hospital
characteristics,
nurse staffing,
patient
characteristics,
adverse events,
morbidity and
mortality, and costs
Multilevel analyses
were used to
analyze the data
Sample
Information and
Site
Site: 232 acute
care California
hospitals
Sample: 124,204
patients in 20
surgical diagnosisrelated groups
Findings
On average, patients
were provided with 6.3
hours of RN staffing
per patient day; total
hours incurred by
nurses per patient day
was 8.9
Adverse events rarely
occurred; patient
characteristics such as
age and sex were
significantly related to
adverse events
Occurrence of adverse
events related to longer
length of stay; patient
characteristics were
related to longer length
of stay but hospital
characteristics were not
related
Adverse events
associated with
increased costs
Relationship of
findings to room
occupancy
Having appropriate
nurse staffing levels
aids in the prevention of
adverse events in
hospitals; operational
costs could then be
reduced
No mention made in
regards to room
occupancy
Study
Delon, G. L. &
Smalley, H. E.
(1970, April 1)
Focus of Study
To evaluate nursing unit designs
in terms of traffic patterns and
costs
Research Design
A list of existing
inpatient nursing
unit designs was
compiled
A representative
collection of
designs was
selected and
evaluated in terms
of costs
Designs evaluated
were singlecorridor, doublecorridor, circular,
and angular
Sample
Information and
Site
Site & Sample:
U.S. hospitals
Findings
Double-corridor
designs are least costly
followed by the circular
design, single-corridor
design, and angular
design
As the number of
square feet per bed
increases, construction
costs rise, resulting in
higher overall costs
Private rooms increase
traffic costs; multipatient rooms tend to
have fewer square feet
per bed, reducing
construction costs
Smaller unit sizes result
in shorter distances
traveled, resulting in
lower traffic costs
Advantages of doublecorridor designs
include: patients are
not likely to see into
each other’s rooms, the
nurses’ station is
centrally located, &
staffing patterns are
easily divided
Advantages of the
single-corridor unit
include: simple
circulation patterns,
good control from the
nurses’ station, & less
space tied up in
corridors
Advantages of the
circular unit include:
centrally located
nurses’ station &
shorter distances
Relationship of
findings to room
occupancy
Unit design is more
important than unit size
in terms of evaluating
the efficiency of the
unit
The double-corridor
design appears to be the
most efficient design
Multiple-occupancy
rooms appear to be
more efficient than
private rooms
between functional
points; disadvantages
include: higher
construction costs,
complicated patterns,
limited size, & lack of
control from the nurses’
station
Advantages of the
angular unit include:
centrally located
nurses’ station &
shorter distances
between functional
points; disadvantages
include: most costly
design, complicated
patterns, & poor control
from the nurses’ station
Designs with
compound circulation
(double-corridor,
circular) tend to be less
costly than those with
simple circulation
(single-corridor,
angular)
Study
Dexter, F. &
Macario, A. (2001,
March)
Focus of Study
To describe how analyzing
patient arrival and discharge data
can help to determine the
optimal number of staffed
obstetrical beds to minimize
labour costs
Research Design
Data was obtained
from patients
admitted and
discharged from an
obstetrical unit
An average census
was calculated and
combined with the
Poisson
distribution, an
optimal number of
staffed beds needed
was estimated
Sample
Information and
Site
Site: Stanford
University Medical
Center
Sample: 777
successive patients
cared for at the
obstetrical unit
Findings
The Poisson
distribution fit the data
for the weekdays and
weekends 6 am to 6 pm
and 6 pm to 6 am
The amount of beds
necessary are 15 staffed
beds weekdays from 6
am to 6 pm, 12 staffed
beds weekdays from 6
pm to 6 am, 12 staffed
beds weekends 6 am to
6 pm and 10 staffed
beds weekends from 6
pm to 6 am; these
figures encompass a 5%
risk that the hospital is
willing to accept a
patient without having
enough staff to care for
another patient
Relationship of
findings to room
occupancy
Using statistical
methods to determine
the optimal number of
staffed beds in an
obstetrical unit can help
a number of hospitals to
keep the save money by
not having excess staff
No mention made in
terms of room
occupancy
Study
Eastaugh, S. R.
(2002, Fall)
Focus of Study
To present results regarding
factors that impact nurse
productivity
Research Design
Nurse output data
acquired from
Atlas MediQual,
the largest
proprietary vendor
of nurse workload
and nurse
scheduling systems
Use of production
function analysis to
determine nurse
productivity
Five inputs studied:
Nurse extenders
(NE); registered
nurses (RN);
house-staff
residents and
interns performing
some nursing
activity; clerks,
licensed practical
nurses (LPN) and
nurse aids; and
capital
Nursing output is
specified by a
point-scoring
system
Sample
Information and
Site
Sample & Site:
Data was collected
for 37 hospitals in
the U.S. between
1997-2000
Findings
As RN labor becomes
more costly, the labor
of NE is used less
extensively in place of
RNs; NEs and RNs are
complementary team
members
As house-staff labor
becomes more costly,
NE labor is used more
extensively in place of
residents
In 2000, nursing
departments were
realizing only 81% of
their technical
efficiency
Hospitals with the
worst productivity
employed no NE
technicians and
operated at 100% RN
primary care nursing
Hospitals with highest
productivity made
heavy use of NEs
Shortage of nurses did
not reduce productivity
levels
Relationship of
findings to room
occupancy
Primary care nursing is
most productive when a
combination of RNs
and NEs is used as NEs
help enhance
productivity and reduce
wasted labor
Study
Garattini, L.,
Giuliani, G., &
Pagano, E. (1999)
Focus of Study
To present a cost analysis
method, which would enable an
understanding of the distribution
of resources among departments
Research Design
A step-down
allocation was used
to assess costs
Department costs,
wards and costs per
stay for each ward
were identified
Costs were
allocated based on
the following
categories:
Overheads, direct
costs, and indirect
costs
Sample
Information and
Site
Site: Bolognini
Hospital in Seriate,
Italy
Sample: 87,476
days of stay in the
hospital
Findings
30 cost and revenue
centers were identified
Most expensive wards
were the Intensive
Cardio-Coronary Unit
and ophthalmology;
least expensive ward
was general medicine
Average bed day cost
depends on the
occupancy rate, the
fixed costs inversely
related to the number of
hospital beds used
Cardiology and
pediatrics show highest
variance for bed day
costs
Relationship of
findings to room
occupancy
No mention was made
in regards to room
occupancy
Study
Li, T. & Rosenman,
R. (2001)
Focus of Study
To use the stochastic frontier
approach to analyze the cost
efficiency of Washington
hospitals
Research Design
Data was obtained
from the year-end
report of financial
data and activities
of the State
Department of
Health during
1988-1993
Outputs measured
were total number
of patient days and
total number of
outpatient visits
Input prices used
were labor, capital,
and an aggregate of
other costs
Analyses were
conducted using
the stochastic
frontier approach
Sample
Information and
Site
Site & Sample: 84
not-for profit
hospitals and 6 forprofit hospitals in
Washington State
Findings
Not-for-profit hospitals
are larger in terms of
outputs and number of
beds
For-profit hospitals do
greater share of
inpatient business
For profit hospitals pay
less for most types of
labor
Capital and other costs
were lower for not-forprofit hospitals
Outpatient business
increased for both types
of hospitals, but the
increase was greater for
not-for profit hospitals
Increases in costs and
labor were twice as
much at not-for-profit
hospitals
Hospitals with higher
casemix indices or
more beds are less
efficient; severity of
Relationship of
findings to room
occupancy
Study
Morey, R. C., Fine,
D. J., Loree, S. W.,
Retzlaff-Roberts, D.
L., & Tsubakitani, S.
(1992, August)
Focus of Study
To estimate the impact on
hospital-wide costs if levels of
quality of care are varied
Research Design
Quality of care was
measured as a ratio
of actual to riskadjusted predicted
inpatient
mortalities in the
hospital for a given
year
Nine aggregated
hospital-specific
measurements were
used to measure
service output
Nine descriptors of
the hospital
environment and
level of resource
expenditures were
used
Cost estimates
were based on
costs expended by
hospitals
Information was
extracted from the
American Hospital
Association
regarding number
of staffed beds,
outpatient activity,
and expenses on
medical education
Sample
Information and
Site
Site & Sample:
300 hospitals
drawn from CPHA
database
Findings
Hospital total cost
highly correlated with
number of beds and
number of caseseverity-weighed
discharges
Non-teaching hospitals
were relatively efficient
hospitals
Larger hospitals had
larger estimated
marginal costs and
larger average costs per
death deferred
Average additional cost
for deferring one death
is approximately
$29,000
Relationship of
findings to room
occupancy
No mention made in
regards to room
occupancy
Study
Thompson, J. D. &
Goldin, G. (1975)
Focus of Study
To determine the efficiency of
various nursing unit plans
Research Design
Trips taken by
nurses were used as
the unit of
measurement
Traffic patterns
were measured in
four nursing units,
two surgical units,
and two medical
units; one of each
unit contained 30
beds and the other
contained 48 beds
Information was
recorded by
observers
positioned at the
nursing station
Information
included who made
the trip, where the
person left from
and the destination
of that person, and
when the person
went
Data was collected
over 15 shifts
during a six-month
period
Sample
Information and
Site
Site: Yale-New
Haven Hospital,
New York
Sample: Nurses at
Yale-New Haven
Hospital
Findings
Two variables, the
distance between areas
and the number of times
this distance was
crossed, were used to
develop the Yale
Traffic Index
Redundant circulation
schemes, such as the
double-corridor,
circular, and square
plans were found to be
more efficient,
especially if the unit
contained more than 30
beds
The design of the
inpatient unit is most
critical factor in
determining the unit’s
efficiency
The size of the unit and
the degree of privacy
offered do not dictate
the efficiency of the
unit
Relationship of
findings to room
occupancy
The efficiency of the
unit is determined by
the design of the
inpatient unit
Room occupancy is not
related to the unit’s
efficiency
Study
Thompson, J. D. &
Goldin, G. (1975)
Focus of Study
To determine if occupancy rates
are increased with all singleoccupancy rates
To determine if the increase in
occupancy rates offsets the
increased investment and
operating costs of singleoccupancy rooms
Research Design
Rooms were
simulated using a
computer program
Groups of patients
were generated
based on
characteristics such
as sex, desire for a
particular type of
room, or need for a
single-occupancy
room
Patients are then
randomly admitted
to the hospital and,
if possible, to
hospital beds;
length of stay is
used to determine
occupancy rates
The program was
run to explore three
different
occupancy rates:
25,869, 29,465 and
33,172 patients and
to account for
various room
occupancy levels
Sample
Information and
Site
Site & Sample:
Computer
simulations were
used
Findings
When all patients could
be admitted in the five
different room
arrangements, the
difference in average
occupancy between
arrangements that
allowed 4.6% of single
rooms to arrangements
that enabled 100%
single-occupancy
rooms was only 0.370.39%
On average, only 45
patients days would be
gained in an all singleoccupancy room unit
An 80% occupancy
level is ideal; less
service failures
occurred and most
patients requesting
admission were
accommodated
Operational costs
appear lower in
multiple-bed units
Relationship of
findings to room
occupancy
The optimal mix of
single- and multipleoccupancy rooms
depends on medical,
social, and economical
factors
It is recommended that
a minimum of 25% of
the beds should be
single-occupancy
Study
Thompson, J. D. &
Goldin, G. (1975)
Focus of Study
To demonstrate that the size of
the obstetrical unit affects the
average occupancy of the unit
To illustrate the effect that unit
size has on investment and
operational costs
Research Design
The hospitals were
divided into 3
groups based on
the number of
obstetrical
discharges
Data was collected
from the hospitals
in terms of their
discharge rate in
the obstetrical unit
Analyses were
conducted to
determine the
impact that unit
size has on
operational costs
Sample
Information and
Site
Site: 33
Connecticut
hospitals
Sample:
Obstetrical units in
the hospitals
Findings
Bed investment costs
rise higher as
admissions decrease;
costs level off at 4,000
admissions
Direct costs per day are
higher for maternity
suites serving small
populations
Swing units are an
alternative if beds are
needed for nonmaternity patients; they
can be made bigger or
smaller based on the
number of maternity
patients; they require
the separation of staff
involved and of the
ancillary areas
Relationship of
findings to room
occupancy
No mention was made
in regards to room
occupancy
Study
Yafchak, R. (2000,
Fall)
Focus of Study
To determine whether or not
large hospitals have lower longrun average costs per bed than
small hospitals
Research Design
Data was extracted
from the Medicare
Cost Report
from1989-1997
Cross-sectional
regressions were
completed by year
from 1989 to 1997
to assess the
changes in the cost
curve
Unit of interest in
the analyses was
number of
operating beds in
the hospital
A Cobb-Douglas
production function
was modified and
used to incorporate
case mix into the
analyses
Sample
Information and
Site
Sample & Site:
The primary data
categories
evaluated were
non-profit versus
for-profit hospitals
and teaching versus
non-teaching
hospitals in the
U. S.
Findings
The average size of
hospitals is relatively
constant over time
Average length of stay
has decreased by 17%
Shift towards more
outpatient care;
inpatient activity is
more severe
Revenue for hospitals is
decreasing because
units of service
provided are decreasing
High overhead costs
incurred because
occupancy is relatively
low
Profit margins are
increasing
Overall number of
hospitals in the U. S.
has declined by 18%
from 1989-1997
Teaching hospitals are
larger and serve sicker
patients, have higher
average revenues and
costs, have more
inpatient activity, and
have slightly lower
return on assets
Larger hospitals have
lower costs per bed;
cost per bed higher in
teaching hospitals
Relationship of
findings to room
occupancy
Hospital revenues are
declining as a shift is
being made towards
outpatient care
No mention made in
regards to room
occupancy
Study
Zwanziger, J.,
Anderson, G. M.,
Haber, S.G., Thorpe,
K. E., & Newhouse,
J. P. (1993, Summer)
Focus of Study
To compare hospital spending in
two U. S. states with spending in
two Canadian provinces to better
understand the differences in
spending between the two
countries
Research Design
Admission rates
and average
lengths-of-stay
were calculated
using hospital
discharge data
from each region
Data was chosen
for 1981 and 1985
Specialty hospitals
were excluded
Sample
Information and
Site
Site: Hospitals in
New York,
California, Ontario,
and British
Columbia
Sample: Patients
admitted and
discharged in the
years 1981 and
1985
Findings
Canadian hospitals, on
average, provide far
higher proportion of
low-cost sub-acute days
of care; U.S. hospitals
provide far higher
proportion of high-cost
intensive care days
Costs are higher in
California and lowest in
Canada for majority of
inpatient outputs
Canadian hospitals have
lower unit costs
because each output
produced at a lower
cost
Rate of increase in unit
costs is lower in
Canadian hospitals than
U.S. hospitals
Canadian hospitals
combine lower
treatment intensity with
longer patient stays
Average incremental
costs of an outpatient
visit were essentially
identical in 1985
Relationship of
findings to room
occupancy
It appears that hospital
costs are lower in
Canada than in the U.S.
No mention made in
terms of room
occupancy
Non Empirical Articles First and Operating Costs of Hospitals
Study
Anonymous (2003)
Focus of Article
To describe characteristics of
the top 100 hospitals in the
U.S.
Type of Healthcare
Facility
Hospitals in the U.S.
Recommendations for
Healthcare Settings
Hospitals that demonstrate
superiority in quality and
operational efficiency are also
most profitable
Teaching hospitals have the
most complex mix of patients
while small community hospitals
have the least complex mix
Benchmark hospitals had median
total profit margin of 8.81%
while peer hospitals had a
margin of just 3.69%
Between 1996 and 2000, peer
hospitals saw an increase of 13%
in their adjusted expenses, while
the top 100 hospitals had an
increase of only 4%
Top hospitals had a case flow of
51.4 admissions per bed while
peer hospitals had a case flow of
44.4 admissions per bed
Top hospitals continued to
increase salary and benefit
packages and consistently spent
more than peers on overhead
costs
Hospitals in the Northeast are
emerging as leaders
Relationship of findings to room
occupancy
The top hospitals provide high quality
care while reducing expenses
No mention was made in terms of room
occupancy
Study
Focus of Article
Type of Healthcare
Facility
Anonymous (2003,
February)
To describe how hospitals are
achieving greater operating
efficiency
U. S. Hospitals
Anonymous (1981,
NovemberDecember)
To discuss results from a study
conducted by the accounting
firm of Ernst & Whinney in
regards to the assumption that
excess hospital beds are costly
8 Acute hospitals in
Orange County,
California
Recommendations for
Healthcare Settings
Challenges faced by hospitals in
2003 are rising costs, declining
payments, and increasing patient
volumes, especially among the
aging population
Trend in U. S. hospitals is
toward greater efficiency
Hospitals with 150-299 beds had
highest operating margin in
second quarter of 2002
Average daily census has
increased steadily since 1997
and costs per adjusted discharge
have also risen
Extra or excess beds in hospitals
are one of the least important
factors contributing to rise in
healthcare costs
The total cost per bed is $8.60
per patient day or 2% of total
hospital costs
Hospital utilization is growing
and the number of excess beds
are decreasing
100% occupancy in hospitals is
impossible because of the
handling of different patients
with different needs and patient
mix factors
Relationship of findings to room
occupancy
It appears that hospitals in the U. S. are
moving towards greater efficiency
No mention made in regards to room
occupancy
Excess beds do not contribute to rising
hospital costs in Orange County
No mention was made in regards to room
occupancy
Study
Focus of Article
Type of Healthcare
Facility
Batchelor, G. J. &
Esmond, T. H. Jr.
(1989)
To demonstrate high quality
care costs less than poor
quality care
U. S. Hospitals
Bennett, M. (2002,
June)
To describe ways that can help
healthcare leaders make nonroutine decisions
U.S. Hospitals
Recommendations for
Healthcare Settings
Quality of patient care can be
improved without increasing
overall expenditures
Hospital costs can be reduced by
eliminating ineffective or
unnecessary treatments
Underutilized facilities should be
closed; duplicated services
should be reduced
Over utilization of tests affects
quality of care and treatment
Patient-centered care focuses on
time spent by workers talking to
the patients, physical
attractiveness of hospital rooms,
physical comfort, and
convenient parking facilities
Multiple non-routine decisions
usually made within same time
period making it difficult to
determine the impact of any
individual decision on financial
performance
Leaders making decisions should
use cost analysis to make
decisions regarding all possible
options; goal is to show how
financial results will differ for
each alternative and make most
viable decision
Relationship of findings to room
occupancy
Meeting patient-related quality criteria
saves hospitals money by reducing
number of hours spent in dealing with
patient complaints
No direct reference was made in regards
to room occupancy
Non-routine decisions may have large
impacts on the financial resources of
hospitals, and thus careful analysis should
be conducted before making a decision
No mention made in regards to room
occupancy
Study
Focus of Article
Type of Healthcare
Facility
Benton, P. (1998,
January-February)
To comment on the financial
positions of Pennsylvania
hospitals
Hospitals in Pennsylvania
Cleverley, W. C.
(2002, July)
To describe the Hospital Cost
Index (HCI), an effective
measure of cost efficiency in
hospitals
U.S. Hospitals
Recommendations for
Healthcare Settings
Through collecting and reporting
hospital financial and utilization
data, 3 key areas of interest have
emerged: timeliness,
comparability, and flexibility
To gain cooperation from all
facilities, the ability to report the
most current data available is
important; gives incentive for
hospitals to participate in
reporting data
Comparability enables
comparisons between facilities
with the same core business
operating in the same geographic
area
Ability to be flexible enhances
cooperation from hospitals and
helps produce the best report
possible
The HCI weighs 2 measures:
the Medicare cost per discharge
(MCPD) adjusted for case mix
and wage index and the
Medicare cost per outpatient
claim (MCPC) adjusted for
relative-value unit and wage
index
The MCPD deals with inpatient
costs
The MCPC assesses costs of
outpatient services
Both measures have a
disadvantage in that they are a
measure of Medicaid patients,
and the costs for non-Medicare
patients are not reflected
Relationship of findings to room
occupancy
No mention was made in relation to room
occupancy
The HCI is a reliable measure of costefficiency in hospitals
No mention made in regards to room
occupancy
Study
Gardner, E. (1992,
June 22)
Focus of Article
To discuss how hospitals
could save money by
eliminating inefficiencies
Type of Healthcare
Facility
U. S. Hospitals
Recommendations for
Healthcare Settings
Hospitals waste 1/3rd of time
overcoming organizational
inefficiencies
Hospitals could save as much as
$60 billion each year by
streamlining organizations,
redesigning jobs, and improving
communication and cooperation
among departments
Hospitals, on average, spend $53
on clerical and communication
tasks and $25 on administration
for every $100 spent on direct
patient care; better-run hospitals
spend $21 to $42 on clerical and
communication costs and $8 to
$15 on administrative costs for
every $100 spent on direct
patient care
Hospital employees suggest that
almost 60% of time wasted came
from unnecessary paperwork and
poor communication between
departments; another 20% of
wasted time is due to inefficient
methods of operating; remainder
due to variety of factors such as
outdated materials
Eliminating clerical tasks not
related to patient care could
increase nurses’ efficiency and
productivity
Relationship of findings to room
occupancy
By reorganizing and eliminating
unnecessary tasks as well as improving
communicating between departments,
hospitals could save a great deal of
money
No direct reference was made in regards
to room occupancy
Study
Goe, S. (2002, June)
Focus of Article
To discuss Scenario facility
planning (SFP), a pre-design
process that looks at planning
managed care for the future
Type of Healthcare
Facility
U. S. Hospitals
Recommendations for
Healthcare Settings
Hospitals now receiving over
60% of revenue from outpatient
care
SFP is a pre-design process that
brings managed care executives
and hospital administrators
together; engage in “what if “
thinking for the future
Anticipate needs of future based
on possible trends of the future,
not on the trends of the past
One goal is to ensure hospitals
will have sufficient number of
beds to meet future needs
Trends of future: aging
population, population growth,
and cultural shifts; must also
consider unpredictable factors
such as major epidemics
Uncertainty in government
reimbursement for hospitals
Relationship of findings to room
occupancy
Hospital executives should base hospital
plans on possible trends of the future
rather than on past experiences
No direct reference was made in regards
to room occupancy
Study
Focus of Article
Type of Healthcare
Facility
Hoppszallern, S.
(2003)
To describe the financial
performance of hospitals
U. S. Hospitals
Kirtane, M. (1999,
April)
To discuss why hospitals are
losing money
Hospitals in the U.S.
Recommendations for
Healthcare Settings
Department performance varies
by bed size; larger hospitals treat
patients with higher acuity,
longer stays, and greater
resource consumption
Tertiary care and teaching
hospitals offer more complex
and costly care
Costs of inpatient nursing
expenses higher
Total margins declined for all
hospitals in 2001; hospitals high
in managed care outperforming
counterparts in profitability
measures
Once financially strong hospitals
are being downsized to reduce
expenses
In the early 1990’s, hospitals had
reduced their costs and became
efficient
Physicians and hospitals then
tried to neutralize the dominance
of the managed care industry by
using the Integrated Delivery
system (IDS) which combined a
hospital network, a physician
network, HMO’s, home care
services, and assisted living
communities
Productivity of physicians
decreases and expenses
increased; Balanced Budget Act
of 1997 reduced Medicare
reimbursement for hospital and
home care services
Majority of hospital-sponsored
HMO’s were terminated or sold
Relationship of findings to room
occupancy
No mention was made in relation to room
occupancy
No mention made in regards to room
occupancy
Study
Komiske, B. K.
(1995)
Focus of Article
To describe the Cooperative
Care Center in Providence,
Rhode Island
Type of Healthcare
Facility
Cooperative Care Center,
Providence, Rhode Island
Recommendations for
Healthcare Settings
Mission of Cooperative Care
Center is to provide high quality
care in hospital where healthcare
professionals join patient and
care partner to treat and manage
patient’s illness; emphasis is on
educating patient
No nurse stations on patient
floors
Setting is home-like and care is
high-quality and lower-cost
Patients have to require inpatient
care, must be mobile, and must
have a care partner
No charge for room and board of
care partner
Privacy is important; patient
rooms are locked
Cost to build: less than
$128/square foot
Cost per room: $380/night.;
includes both patient and care
partner; costs at other Rhode
Island hospitals range from $440
to $630 for a private room
Relationship of findings to room
occupancy
Patients can receive care in a home-like
setting for lower costs than other
hospitals in Rhode Island, provided they
have a care partner to aid in the treatment
Rooms in this facility are private
Study
Moore, J. (1999,
December)
Focus of Article
To discuss shared occupancy
and its costs for seniors
Type of Healthcare
Facility
Assisted living facilities
in the U. S.
Recommendations for
Healthcare Settings
Only about 25% of seniors can
afford current monthly rate of
$2500 for assisted living (private
rooms)
Alternative is shared living
arrangements for unrelated
individuals
Shared occupancy can reduce
monthly service fee for resident
from $2500 to $1650; shared
occupancy monthly service fee
likely to be 60% to 70% of
private occupancy fee
3 types of designs: studio; a
modified one-bedroom space so
each resident has individual
living and sleeping space; twobedroom unit with 2 equivalent
sleeping areas and larger shared
living space
Roommates must be compatible
Relationship of findings to room
occupancy
Shared occupancy can be lest costly for
seniors in assisted living facilities
Study
Morrissey, J. (1994,
September 19)
Focus of Article
To describe a non-traditional
method of acute-care at Rhode
Island Hospital
Type of Healthcare
Facility
Cooperative Care Center
at Rhode Island Hospital,
Providence, R.I.
Recommendations for
Healthcare Settings
Acute-care hospitals are being
asked to keep staffing levels
under control while at the same
time handling more complex
cases and getting patients
discharged faster
Cooperative Care Center (74-bed
facility) has eliminated
traditional hospital structure
from plan and provides acute
care at 30% lower cost while
providing education to patient to
deal with life after discharge
Uses family members and
friends of patients to administer
routine care of patient
Predict that this type of care will
lead to lower readmission rates,
improved patient outcome,
shorter length of stay, fewer
medication errors and enhanced
satisfaction scores
Care Center built for $13.3
million-1/3less than comparable
facility built to traditional acutecare standards: mechanical
systems simpler, no nursing
stations required, oxygen supply
provided to only 14 rooms, &
overhead paging replaced by
patient/partner beepers
Cost per square foot is $125;
rooms equipped with hotel beds
($300), not standard hospital
beds ($6000)
Daily charge $140 less than
traditional care at Rhode Island
Hospital
Relationship of findings to room
occupancy
By creating a hotel-like environment and
including family and friends in acute
patient care, hospitals can care for
patients in a non-traditional manner and
save money
Patient rooms include beds for both the
patient and care partner and thus are
private rooms
Study
Priselac, T. (2000,
July 17)
Focus of Article
To discuss factors that need to
be considered in funding
healthcare systems in terms of
mitigating losses suffered by
the Balanced Budget Act of
1997
Type of Healthcare
Facility
U. S. Hospitals
Recommendations for
Healthcare Settings
Foundation for successful
hospital begins with strategic,
financial, and operational
planning based on constant
vigilance and ongoing
reassessment
Factors that should be assessed are:
Quality improvement
fundamental in attracting
patients, physicians and best
employees
Program development/strategic
review: hospitals must eliminate
and/or modify recent and
longstanding programs
Marketing the hospital is
essential
Managed care: hospitals should
develop contracting and pricing
policies based on present needs
and those of the future
Effective treasury management
can help in times of uncertainty
resulting from shifts in public
policy
Fundraising is essential for notfor-profit hospitals
Productivity/supply chain
management: productivity
management most important
consideration
Information and Internet
technology enhance
communication and data
utilization
Relationship of findings to room
occupancy
In light of governmental policies,
hospitals can take steps to manage their
finances through ongoing evaluations of
factors that influence their operation
No direct reference was made in regards
to room occupancy
Study
Smet, M. (2002)
Focus of Article
To gain insight into the
literature on cost structure of
hospitals
Type of Healthcare
Facility
U.S. Hospitals
Recommendations for
Healthcare Settings
Over 85% of all hospital costs
are paid through 3rd party
insurers; their reimbursement
policies create cost-minimizing
pressures on hospital
management
Hospitals don’t operate at longrun efficient position because
they over-invest in capacity and
equipment
Larger, more specialized
hospitals may be more costeffective
Cost savings can be
accomplished through reduction
in length of stay; day costs
account for 60-70% of a 7-day
stay
Hospitals with large part of staff
under 45 years of age were more
costly
Hospital overhead costs are
driven by volume, capacity, and
complexity
Relationship of findings to room
occupancy
In general, hospitals over-invest in capital
No mention was made in regards to room
occupancy
Study
Focus of Article
Type of Healthcare
Facility
Solucient. (2003)
To discuss changing trends in
healthcare demographics and
its impact on hospital usage
U. S. hospitals
Terry, K. (2003,
January 10)
To give perspective as to why
health care costs are
increasing
U. S. Hospitals
Recommendations for
Healthcare Settings
Inpatient volume will increase
over next 25 years due to aging
baby boom generation,
increasing life expectancy, rising
fertility rates, and continued
immigration
Rapid growth in inpatient
changes will be due to projected
85% growth of senior population
Bed demand will grow to 2
percent annually by 2012
Markets with highest levels of
migration (South and West) or
large baby boomer population
(Midwest and Northeast) will
experience greatest change
Anticipated growth of inpatient
care for seniors will place
increasing financial burden on
Medicare
In 2001, hospital outpatient
spending rose 16.3% and more
than half the total growth in
healthcare spending came from
inpatient and outpatient
expenditures
Primary care doctors are not
benefiting from rising inpatient
expenditures but specialists are
HMO profit margins close to
zero for past few years
Technology is increasing cost of
care
Hospital rates rose and use of
services increased because of
reduced authorization
requirements for tests and the
consolidation of hospitals into
bigger systems
Insurance costs continue to rise
Relationship of findings to room
occupancy
Inpatient volume will increase drastically
over the next 25 years mainly because of
aging baby boom generation
No mention was made in relation to room
occupancy
Hospitals and specialists are benefiting
from the increase in inpatient and
outpatient care while primary care
physicians are not seeing any increase in
wages
No mention made in regards to room
occupancy
Study
Thompson, J. D. &
Goldin, G. (1975)
Focus of Article
To discuss future trends in
hospital planning, design,
operation, and management
Type of Healthcare
Facility
All hospitals
Recommendations for
Healthcare Settings
A shift should occur from
thinking in terms of a
progressive patient care hospital
to planning a progressive
patient-centered system
Hospitalizations should be used
to cure the patient and to educate
the patient to prevent relapses;
single-occupancy rooms are not
beneficial because patients
should be trained in groups
Milieu therapy can be used to
combine professional support
and patient interaction; a better
outcome is achieved with this
system
Two problems in hospitals are
the increased costs of new
programs and searching for an
institution that is large enough to
meet the needs of patients and
communities
To decrease hospital costs,
patient stays can be decreased;
inpatient days can be reduced
through staff monitoring of the
patient to determine whether it is
necessary for the patient to
remain in hospital; patients stays
can also by promoting
comprehensive care outside the
hospital
Increased hospital costs are due
in part to newly discovered
scientific technology; the
machinery used and nursing
skills applied are expensive
Relationship of findings to room
occupancy
Room occupancy was mentioned in terms
of training patients to prevent relapses;
multiple-occupancy rooms are preferred
in this instance
Empirical Articles
Healthcare Facility Management and Hospital Design
Study
Delon, G. L. &
Smalley, H. E.
(1970, April 1)
Focus of Study
To develop methodology for
evaluating nursing units
Research Design
Qualitative
checklists were
developed for
nursing unit design
The model was
applied to existing
nursing units to
determine its
usefulness
Traffic costs and
construction costs
were measured as
were controllable
and uncontrollable
costs
Sample
Information and
Site
Site & Sample:
U.S. hospitals
Findings
Seven areas within the
nursing unit serve as
the beginning and end
points for the majority
of trips made by nurses
These areas include the
nurse station, patient
rooms, clean supply
rooms, laundry,
kitchen, bedpan rooms,
and the elevator
Ten areas account for
80% of the trips
originating or destined
for the nursing station:
dietary department,
surgical suite, central
supply, radiology
department,
housekeeping,
laboratory, laundry,
pharmacy, emergency,
and other nursing units
Larger units with more
beds are advantageous
because better staffing
patterns are achieved,
the need for tall
buildings is eliminated
saving costs in
elevators and plumbing,
and the number of
medicine units, linen
rooms, and nursing
stations needed is lower
Smaller units are better
for supervising patients
Trend towards singleoccupancy rooms in
hospitals; advantages
Relationship of
findings to room
occupancy
Although arguments are
made in favor of both
larger and smaller
nursing units as well as
single-occupancy
rooms, neither design is
clearly favored
Douglas, C., Steele,
A., Todd, S. , &
Douglas, M. (2002,
October 17)
To investigate how hospital
design helps patients recover
Interviews
conducted with and
questionnaires sent
to patients who had
stayed in the
hospital for more
than 5 days
Groups set up with
people from the
community and
experts to discuss
patient-centered
environment
Site: Salford Royal
Hospitals
Sample: 785
people who
returned
questionnaires and
50 inpatients who
were interviewed;
community group
are higher occupancy
rates, improved patient
care, greater flexibility
of operation, and
reduced possibility of
cross-infection
Nursing stations should
provide for a head nurse
office, charting area,
medication unit, and
work space for the ward
clerk
Community group
suggested hospital
should have good
signage, good lighting,
privacy for patients,
reduced noise levels,
temperature controls,
access to natural
environment,
accommodation for
visitors, and safety
Those interviewed
suggested enough space
for privacy, welcoming
environment,
provisions for visitors,
views of nature, and
design that facilitates
communication
Questionnaires
suggested that patients
least satisfied with lack
of privacy and mixedsex wards; patients who
stayed in single rooms
and on small bays
clustered around a
nursing station were
most satisfied
Patients suggested more
pleasing and welcoming
environment
Patients preferred single
rooms or small bay
wards clustered around
a nursing station
Study
Gadbois, C.,
Bourgeois, P., GoehAkue-Gad, M. M.,
Guillamine, J., &
Urbain, M. A. (1992)
Focus of Study
To analyze the spatial and
temporal organization of nurses’
work in medical and surgical
units of French hospitals
Research Design
Nursing activity
was observed and
recorded in terms
of sequence of
areas visited, tasks
executed, reasons
for travel, and
times of entry and
exit for each area
Observations
covered the whole
working period of
the day shift; data
collection spread
over 6 months
Sample
Information and
Site
Site: Private
hospital in Paris
Sample: Nurses in
the medical and
surgical units of the
hospital
Findings
Nursing activities are
divided into several acts
distributed through time
and space
Two thirds of activities
on the medical and
surgical wards lasted
less than 2 minutes
Large number of
activities performed in
rooms isolated
Large number of work
areas devoted to
different activities on
ward; includes patients’
room, nurses’ area, the
corridor, and other
specialized areas
U-shaped layout made
visibility of individuals
difficult
Relationship of
findings to room
occupancy
No mention made in
regards to room
occupancy
Study
Kirk (2002)
Focus of Study
To look at hospice patients’
preferences for single or shared
bedrooms
To investigate factors that might
lead to a change in preference
Research Design
Structured
interviews were
conducted with 24
patients (12 in each
of 2 hospices) in
regards to their
previous and
current experiences
of single and
shared rooms
Sample
Information and
Site
Site: 2 hospices in
Leeds
Sample: 24
patients (12 in each
hospice); 6 male
and 6 female
patients were
interviewed from
each hospice
3 men and 3
women occupied
single rooms & the
other patients
occupied shared
rooms
19 of the 24
patients had
previously stayed
in a single room;
23 patients had
some experience in
a shared room
Findings
18 patients preferred to
be cared for in single
rooms; 5 preferred
shared rooms; 1 had no
strong view
Reasons given for
preference of single room:
Privacy
Quiet
Avoiding upsetting
other patients
Reduce embarrassment
Improve quality of
sleep
Having family member
stay
Reasons given for
preference of shared room:
Company
Able to share
experiences
Relationship of
findings to room
occupancy
The majority of patients
preferred single rooms
over shared rooms,
especially if they had
distressing symptoms
Patients with previous
experience in a single
room were more likely
to prefer a single room
Study
Focus of Study
Research Design
Sample
Information and
Site
Pease, N. J. F. &
Finlay, I. G. (2002)
To determine if patients and
their family members prefer
single or shared occupancy
rooms on an oncology ward
Questionnaires
were given to
patients and their
next of kin to
ascertain
preference for
place of care
Site: 17-bed
oncology ward in
England
Sample: 50
oncology patients
that were
consecutively
admitted; 17 died
during admission;
36 relatives of
patients
Reid, E. A. & Feeley,
E. M. (1973,
January)
To determine the perceptions of
patients relating to factors
involved in sharing a two-person
room
Questionnaires
were mailed to
patients who had
recently been
discharged from
the hospital and
who had stayed in
a doubleoccupancy room
Patients were asked
background
information and to
rate their
experiences with
their roommates
Site: Large
community
hospital in the U.S.
Sample: 51 patients
who stayed in a
double-occupancy
room
Findings
Only 20% of patients
preferred a single room;
68% wanted to be in an
open area; 12% stated
no preference
28% of relatives
preferred their relative
to be in a single room
Wishes of patients and
relatives agreed in only
50% of the cases
Main reason given for
remaining in 4-bed bay
was to avoid isolation
Fewer than half of the
patients surveyed
would opt for a private
room if given the
choice
Roommates were good
to have someone to talk
to and roommates could
help each other
Privacy was an issue
and roommates with too
many visitors were
annoying; noise was
also an annoying factor
Ill roommates were
undesirable as was a
large age difference
between roommates
Relationship of
findings to room
occupancy
Ward design on an
oncology ward should
include some single
cubicles as well as open
areas, as the majority of
patients prefer to stay in
multiple occupancy
rooms
Overall, patients
preferred a doubleoccupancy room to a
single-occupancy room
Study
Focus of Study
Research Design
Sample
Information and
Site
Shepley, M. M.
(2002)
To provide data on behavioral
issues associated with the design
of neonatal intensive care units
Multimethod
approach was used
involving
behavioral
mapping,
interviews,
questionnaires, and
calibrated measures
of walking, noise,
and temperature
Site: Predesign
research was
conducted on the
existing neonatal
intensive care unit;
post occupancy
evaluation was
conducted in new
facility
Sample: Nursing
staff on the units
Trites, D. K.,
Galbraith, F. D. Jr.,
Sturdavant, M., &
Leckwart, J. F.
(1970, December)
To investigate the impact of
radial, single-corridor, and
double-corridor nursing unit
designs on the activities and
feelings of nurses working on
these units
4 nursing units of
radial design,
single-corridor
design, and doublecorridor design
were examined on
day, evening, and
night shifts
Work sampling
was used and
questionnaires
were given to staff
members over 82
days
Site: Rochester
Methodist Hospital
Sample: 590 staff
members
Findings
New unit is open and
divided into bays of six
baby stations each
Nurses spent most time
in active baby care,
followed by walking,
conversations, passive
baby care, and charting
Nurses spent more time
working with babies on
new unit
New unit was perceived
as comforting, clean,
but less secure than
previous unit
Family-centered spaces
were perceived as
supportive
In terms of activities
and their locations,
radial design was best,
followed by the doublecorridor design; the
single-corridor design
was the worst
Nurse absenteeism is
greatest on the singlecorridor design and
lowest on radial design
More accidents occur
on single-corridor
design
Nurses preferred to
work on the radial
design
Relationship of
findings to room
occupancy
For the most part, the
new unit was rated
positively; nurses were
able to move at a
greater velocity in the
new unit and they spent
more time with the
infants
The radial design was
preferred as nurses
spent less time in travel
than those on the other
units and spent more
time with patients
Study
Trites, D. K.,
Galbraith, F. D. Jr., &
Leckwart, J. F.
(1967. December)
Focus of Study
To investigate which design of
nursing units, radial, singlecorridor, or double-corridor, is
most efficient
Research Design
4 nursing units of
radial design,
single-corridor
design, and doublecorridor design
were examined on
day, evening, and
night shifts; radial
units had 1 private
room; linear units
had 4 to 10 private
units
Information on
nursing staff
activities was
collected by
randomized work
sampling method
Subjective feelings
of nursing staff
obtained from
questionnaires
completed by staff
immediately before
and after every
shift
Sample
Information and
Site
Site: Rochester
Methodist Hospital
Sample: 590 staff
members
Findings
Radial design was
superior to the other 2
designs on all shifts
Nursing staff spent
significantly less time
walking on the radial
units
Average distance from
the center of the radial
nursing unit to the
patient’s bedside is 34
feet; in the doublecorridor design the
distance is 48 feet; on
the single-corridor
design the distance is
71 feet
Preference by nurses
for radial unit; less time
spent traveling and
more time spent with
patients
Fewer absences of staff
and fewer accidents
occurred on the radial
unit
Fewer complaints made
by patients, relatives,
and physicians on radial
unit
Relationship of
findings to room
occupancy
The radial design was
preferred because
nurses were able to
spend more time with
patients and less time
traveling
No reference was made
in terms of room design
and its impact on
nursing efficiency
Study
Veatch, R. M. &
Veatch, L. L. (1994,
Winter)
Focus of Study
To present information regarding
the impact that roommates have
on one another
Research Design
Case study
Patient was
interviewed at
home in regards to
his experiences
with hospital
roommates
Sample
Information and
Site
Patient was a 72year old man with
metastasized
cancer, a herniated
diaphragm,
trigeminal
neualgia, a partially
paralyzed leg, and
diverticulitis
Findings
Quality of patient’s care
influenced by
interactions with
roommates
Roommates created
anxiety and confusion
in terms of
responsibility towards
roommate
Experiences of
roommates aroused
concerns in patient in
regards to pain
experience and
medication
Nurses should be made
responsible for
assessing impact of
roommate assignment;
should talk to patients
and address their
concerns
Relationship of
findings to room
occupancy
If patients are in
multiple-occupancy
rooms, care should be
taken in assigning them
a roommate
Study
Whitehead, C. C.,
Polsky, R. H.,
Crookshank, C., &
Fik, E.
Focus of Study
To describe and evaluate the
redesign of a psychiatric unit
which used a
psychoenvironmental model
Research Design
Patients were
moved from a ward
which was shaped
in a cross, with
large open
dormitories to a
ward which breaks
up the ling corridor
and adds flexibility
to day room areas
Patients behavior
was observed on
the original ward
and then again
eight weeks after
moving to the
redesigned ward
using the
Behavioral
Environment
Assessment
Technique
Sample
Information and
Site
Site: 30-bed
psychiatric facility
Sample: Patients
who were veterans
Findings
In the old design,
socially related
behaviors occurred in
the hallways and hall
intersection; after the
redesign, these
behaviors were more
common in the visiting
room, cafeteria, and day
room
Increase in frequency of
staff observed in the
day room after the
redesign
Visiting area was used
more often after the
redesign
Staff and patients
responded positively to
the changes; patients
were more affected by
the redesign than staff
Relationship of
findings to room
occupancy
The subjective
experience of patients
was improved as was
staff behavior after the
ward was redesigned
Rooms were in a
dormitory
Non Empirical Studies: Healthcare Facility Management and Hospital Design
Study
Focus of Article
Type of Healthcare
Facility
Aldridge, E., Smith,
L. D., & Sperling, L.
A. (1991)
To describe the design of VIP
suites in hospitals
Camellia Pavilion at the
University of Alabama
Hospital
Anonymous (2001,
March)
To describe the features of a
new six-story tower at United
Medical Center in Cheyenne,
Wyoming
United Medical Center in
Cheyenne, Wyoming
Recommendations for
Healthcare Settings
Unit contains 20 beds
Patient rooms are a minimum of
390 to 400 square feet; armoires
conceal television and VCRs;
computers are available;
bathrooms consist of full baths
with a tub and shower
Patients able to use this facility
are non-acute
Ratio of nurses to patients is one
to four
Georgian style décor used for
design
Cost of staying in room is
slightly greater than cost of
semiprivate room
Non-profit hospital with 195
beds
Private patient rooms with clean,
modern look and comfortable
feel
Patients able to control lights
and blinds from the bed
Sleeper sofa available for family
members when staying overnight
In-room nurses’ station; provides
a separate area for nurses and
clinical staff to work so don’t
have to use the patient’s private
bathroom
Use of easy-to-clean floor and
wall coverings and curved
surfaces for safety, ease of
maintenance, and maneuvering
of equipment
Relationship of findings to room
occupancy
The VIP suites consist of private
rooms
Private rooms are used, although no
financial or empirical reasons
provided
Study
Focus of Article
Type of Healthcare
Facility
Anonymous (2000,
March)
To discuss patient rooms of
the future
TriStar Health System’s
Centennial Medical
Center, Nashville
Anonymous (2000,
January)
To describe why 2 facilities
are converting semi-private
rooms into private rooms
Northwestern Memorial
Hospital, Chicago
William Beaumont
Hospital, Royal Oak,
Michigan
Recommendations for
Healthcare Settings
Patient room of the future will
be larger
Rooms should be holistic in
nature: flowing, curved
surfaces, soothing colors, inroom nursing stations, and easy
to clean floor and wall coverings
should be used
Rooms should actively promote
healing and staff efficiency and
should allow increased
flexibility to adapt to
technological innovations
Northwestern Memorial Hospital
Made decision to go with private
rooms because determined that
privacy was critical for patients’
physical comfort
Rooms have a window seat with
pull-out bed to accommodate
overnight visitor
William Beaumont Hospital
90% of the patients request
private rooms
Benefits of private rooms:
Shortened lengths of stay
Costs cut
Reduce risk of hospital-acquired
infection
Lowered risk of medication
errors
Semi-private rooms typically
have 10% lower occupancy rate
than private rooms do
Relationship of findings to room
occupancy
No mention made of preference for
single or multiple room occupancy
Both hospitals prefer private rooms
Study
Focus of Article
Type of Healthcare
Facility
Anonymous (1998,
October)
To describe the remodeling of
the telemetry and intensive
care units at Methodist
Hospital
Methodist Hospital, St.
Louis Park, Minnesota
Anonymous (1991a)
To discuss how hospitals
should be designed in the
future
Hospitals in England
Anonymous (1991b)
To describe aspects of a
patient-centered hospital
Hospitals in England
Recommendations for
Healthcare Settings
Goal to improve working
conditions and efficiency
Number of private rooms
increased; if demand for beds
exceeds supply, patients are
placed in and eight-bed swing
area
Central nursing station
eliminated; alcoves spread along
corridors and furnished with
work surface, seating, storage,
and lighting
Infrared technology used to track
staff when needed
Design of departments can affect
running and staffing needs
Hospitals should be pleasing for
patients
Case for single rooms exists
Case against single rooms: cost
and difficulty of nursing
supervision
Argument made that open ward
is best for supervision and more
private than bays of four or six
patients
Trend is towards patient-focused
hospitals where services are
decentralized and brought nearer
to the patient
Decentralization requires
appropriate equipment,
appropriate staffing, and
appropriate size unit
Optimal size is about 130 beds
Main costs are running costs and
patient-focused hospitals are less
expensive to build than
traditional hospitals
Relationship of findings to room
occupancy
Number of private rooms increased
and ability to accommodate patients
increased as 8-bed unit available
when needed
Single rooms are the norm in
independent hospitals and private
wings in the NHS, but they are costly
in terms of building and staff, and
supervision by nurses is difficult
Open ward may be best for
supervision
Patient-focused hospitals are a viable
alternative to traditional hospitals
No mention made in regards to room
occupancy
Study
Anonymous (1971)
Focus of Article
To describe a newly devised
semi-private room that offers
private space to both
occupants
Type of Healthcare
Facility
Carlisle Hospital, Pa.
Recommendations for
Healthcare Settings
Design makes it possible for 1
patient to converse with visitors
without inconveniencing or
disturbing roommate
Staff able to provide treatment
and services to 1 patient without
disturbing the other patient
Both patients have equal access
to toilet & wardrobe facilities
Both patients have equal access
to view of outside through 2
windows in room
Pillow speakers enable each
patient to select and enjoy radio
or television programs without
creating distractions for other
patient
Standard fabric curtain used to
separate patient areas
Windows indented 6ft from
building façade providing sun
and weather protection
Patient room is 351 sq feet
Color schemes different for each
patient room off the same
corridor
Rooms are carpeted
Bright colors used throughout
nursing units
Nursing units designed with
conventional structural system
Relationship of findings to room
occupancy
Through this design, semi-private
rooms can offer the patient privacy
Study
Focus of Article
Type of Healthcare
Facility
Bacon, A. S. (1920)
To describe the ward design of
an efficient hospital
U. S. Hospitals
Baker, J. & Lamb,
C.W. (1992)
To highlight the importance of
managing the physical
environment in hospitals
To explore the role of physical
environment in hospital
marketing
U.S Hospitals
Recommendations for
Healthcare Settings
Ideal efficient hospital serves
people in moderate
circumstances and gives them all
the conveniences of the most
exclusive institutions
Maximum capacity of wards
seldom reached because
flexibility of beds is small due to
gender differences and diseases
that are epidemics
Private rooms provide comfort
and eliminate issues with bed
assignment
In private rooms, temperature
can be adjusted for the patients,
better examinations can be
made, and visiting hours can be
regulated based on the patient
Private rooms allow hospitals to
achieve maximum bed capacity
Centralized control is needed as
it provides a systematic system
of checking up
Four roles of hospital facilities:
communication, contributions to
psychological welfare of patient,
contributions to overall service
quality perceptions, & market
segmentation, targeting, and
positioning
Appearance of patients’ rooms
conveys attitude and concern of
hospital towards needs of
patients
Relationship of findings to room
occupancy
Private rooms are desired to
maximize bed occupancy and to
provide patients with a more
comfortable environment
Incorporating needs of physicians,
staff, and patients into hospital
design can improve staff morale and
productivity and make stay less
traumatic for patients
No mention made in regards to room
occupancy
Study
Focus of Article
Type of Healthcare
Facility
Barista, D. (2000,
November)
To describe changes made to
Baptist Memorial Hospital to
make the environment more
pleasant for patients
Baptist Memorial
Hospital, Collierville,
Tennessee
Bilchik, G. S. (2002,
July-August)
To describe various facilities
incorporating the pebble
project which is trying to
evaluate impacts of healthcare
design
Children’s Hospital in
San Diego
Methodist
Hospital/Clarian Health
Partners in Indianapolis
Bronson Methodist
Hospital in Michigan
Barbara Ann Karmanos
Cancer Institute in
Michigan
Study
Bobrow, M. &
Thomas, J. (2000)
Focus of Article
To describe efficient designs
of patient rooms and nursing
units
Type of Healthcare
Facility
All Hospitals
Recommendations for
Healthcare Settings
Larger, more accommodating
patient rooms built; able to
integrate equipment and house
family members
Changes made due to increased
competition and changes in
healthcare delivery
Design based on medical mall
concept; integrates departments
into layout of retail mall; allows
for smooth outpatient-traffic
flow
Children’s Hospital: building
new convalescent care hospital
to provide long-term care to
permanently disabled children;
design includes storage for
wheelchair, private spaces
outside patients’ rooms, and
enhance air ventilation
Methodist Hospital/Clarian
Health Partners: 56-bed
cardiovascular critical care unit;
private rooms used with patients
in control of light and
temperature
Bronson Methodist Hospital:
Private patient rooms used and
access provided to nature;
positive distractions used
Barbara Ann Karmanos Cancer
Institute: Medication rooms are
larger with the focus placed on
lighting and acoustics
Recommendations for
Healthcare Settings
Patient room seen as place of
sanctuary, privacy, and safety
Nursing unit provides a family
support system
Primary goal of nursing unit
design is to minimize the
average distance as well as the
Relationship of findings to room
occupancy
The design incorporates more private
rooms that are large enough to
accommodate family members as
well as integrate necessary
equipment
Rooms in most of these hospitals are
private based on the needs of the
patients
Relationship of findings to room
occupancy
Efficient hospital design includes
clusters of single-occupancy patient
rooms and nursing substations to
serve these clusters
range of distance traveled by
nurses
Efficient designs include
groupings of concentric pods
and use of bedside computers
Hospitals have progressively
moved from open wards to
double- and single-occupancy
rooms
Advantages of single room:
patient can rest undisturbed, the
rooms can be used for isolation,
medication errors are reduced,
and patient transfers are reduced
thereby reducing hospital costs
Occupancy of multi-bed rooms
reaches an average of 80-85%;
occupancy of single-occupancy
rooms can reach 100%
occupancy
Design should be flexible so
room can be converted from
general acute care to critical care
Patients prefer single-occupancy
rooms because of the privacy
offered, the ability to control the
environment, and room for
accommodating family members
Universal rooms are large
enough to accommodate
complex bedside treatments
Maximum utilization of patient
beds can be achieved by creating
generic patient units, providing
patient beds that can be used for
a range of acuity levels, and
providing sufficient numbers of
single and isolation patient beds
to accommodate increasing
patient acuity
Patient care units should be
decentralized into smaller
clusters which contain
decentralized nursing
substations, provide increased
visibility of patient beds and
reduced congestion
Nurse server should be provided
adjacent to or within patient
rooms to provide immediate
access
Traffic on the unit should be
reduced through used of waiting
areas, larger patient rooms, and
holding areas adjacent to service
elevators
Space should be provided on
units for frequently utilized
ancillary and support services
Each patient care floor should consist
of two to three patient units;
support that can be shared by all
units on the floor should be
provided
Study
Focus of Article
Type of Healthcare
Facility
Bobrow, M. &
Thomas, J. (1994,
November 21)
To describe trends in
designing hospitals
U.S. hospitals
Brown, P. &
Taquino, L. T.
(2001, June)
To outline the design and
outcomes of a neonatal
intensive care design project
Neonatal Intensive Care
Unit at Children’s
Hospital and Regional
Medical Center, Seattle,
Washington
Recommendations for
Healthcare Settings
Many hospitals need to redesign
facilities to reflect requirements
of changing market;
environment needs to be less
institutional and more consumerfriendly
Multibed units will be replaced
by larger patient rooms with
fiber-optic capabilities and space
to house equipment as well as
family members
Clusters of small nursing
stations responsible for pods of
four to eight beds; computerized
patient records and tracking
systems permit more efficient
staffing in single room model
Flexibility of private rooms
outweigh costs; rooms more
comfortable and have increased
privacy
All rooms single occupancy;
clusters arranged around central
nursing station
Variable lighting, decreased
sound and individualizing
patient spaces more easily
achieved in single rooms
Family-centered care enhanced
in single occupancy rooms and
privacy is increased
Relationship of findings to room
occupancy
Rooms of the future should be larger
and should be single occupancy to
increase patient comfort as well as
increase privacy and accommodate
family members
Rooms on the neonatal intensive care
unit are all private; design benefits
patients, family members, and staff
Study
Brown, W. J. (1994)
Focus of Article
To describe how a patient’s
space should be personalized
Type of Healthcare
Facility
U. S. Extended care
facility
Recommendations for
Healthcare Settings
Beds: Should be placed on
opposite walls or direct both
beds toward window in semiprivate room
Paint: Use variety of compatible
colors and textures
Emphasis wall: Adds color and
visual interest
Windows: Use blinds curtains to
provide privacy
Doors: Use compatible but
contrasting color from walls
Corridors: Give each corridor
unique character to allow for
visual differentiation; use singlecolor carpet
Nurse’s station: should invite
interaction
Sitting rooms: small groupings
of chairs and sofas to encourage
interaction
Use of artwork, plants, and
appropriate lighting
Relationship of findings to room
occupancy
Semi-private rooms can be designed
to promote home-like environment;
allows patient interaction while
enabling each resident to have own
unique space
Renovations cost efficient (less than
$5000 to refurbish) ; enhance
resident’s quality of life; make
facility more marketable
Study
Focus of Article
Type of Healthcare
Facility
Burmhal, B. (2000)
To describe trends in
healthcare
U. S. Hospitals
Carpman. J. (1992)
To describe how research can
aid in design strategies
U.S. Hospitals
Recommendations for
Healthcare Settings
Healthcare trend is towards
greater outpatient services
Number of short-stay hospitals is
increasing; offer from several
hours of observation to 72-hour
stays
Hospitals more likely to build
more critical care beds and to
make rooms larger and more
private due to increase in
seriously ill inpatients
Nursing stations are
decentralized to make work
more efficient
Patient rooms are larger to
accommodate family members
Design seen as marketing tool
that can attract or repel patients
Design can have effect on
patient and visitor well-being
Design can help prevent illness
and injury
Spaces are needed for visitors to
have some privacy and escape
Universal design emphasizes
independence, safety, and
adaptability over time
Design should be pragmatic,
based on needs of the users,
reviewed and evaluated
Relationship of findings to room
occupancy
Trend is towards larger private rooms
to accommodate increasing number
of seriously ill inpatients
No mention made in regards to room
occupancy
Study
Che, P. (2002)
Focus of Article
To present results of a study
conducted by Solucient on
hospital needs in the U.S.
Type of Healthcare
Facility
U. S. Hospitals
Recommendations for
Healthcare Settings
Demand for beds projected to
increase as much as 46% in the
next 25 years
Age of baby boom generation,
increased life expectancy, rising
fertility rates, & continued
immigration likely to contribute
growth in inpatient care
Demand expected to grow
fastest in Western & Southern
states and more slowly in
Midwestern and Northeastern
regions
Relationship of findings to room
occupancy
No mention of preference for single
or multiple room occupancy
Study
Focus of Article
Type of Healthcare
Facility
Coile, R. Jr. (1997)
To discuss changes that are
occurring in the healthcare
industry
U. S. Hospitals
Contemporary
Longterm Care
(1997, August)
To present the results of a
survey conducted by the
American Association of
Retired Persons in regards to
private and shared occupancy
rooms
Assisted living facilities
in the U.S.
Cys, J. (1999, March
29)
To review design factors that
can help improve patient
outcome
Hospitals in the U.S.
Recommendations for
Healthcare Settings
Capital investment is shifting
from inpatient care to
ambulatory care and non-acute
facilities
Economic message of managing
care, managing cost, and
managing clinical efficiency
Community health information
networks will be universal
82% of people surveyed prefer a
private room; 4% would rather
share a room; 14% didn’t know
or didn’t care
Women and people from the
western U.S. were most likely to
want their own room
Good environmental design in
hospitals can improve patient
outcomes
Noise can elevate patients’ blood
pressure and heart rate and can
result in sleep loss; carpeting can
help reduce noise levels as can
using varied ceiling heights
Sunlight exposure can help
reduce depression
Nature scenes, outside spaces,
plants, indoor atriums, and
windows are positive
distractions
Beds in private rooms should be
on an angle and face the outside
Seniors walk better and faster on
carpeted floors
Relationship of findings to room
occupancy
Healthcare is shifting from inpatient
care to continuum-care services
No mention made in regards to room
occupancy
Most people would prefer to stay in a
private room in an assisted living
facility
Environmental factors can impact the
outcome of patients
In private rooms, beds should be
located on an angle and face the
outside so that the patient does not
have to view the corridor
Study
Downing, K. (2002)
Focus of Article
To provide information on the
Planetree organization
Type of Healthcare
Facility
Planetree based hospitals
in the U.S.
Recommendations for
Healthcare Settings
Since 1998, Planetree has
established 40 new affiliates; in
1998, only 15 Planetree facilities
existed
Model includes architecture and
design of rooms; double rooms
set up to allow window views
for both patients; soothing
artwork on walls; shelves hold
photographs; room controls
installed by beds
Planetree has tried to make
affiliation cost-neutral
Relationship of findings to room
occupancy
Double-occupancy rooms mentioned,
but no reason given for this
preference
Study
Focus of Article
Type of Healthcare
Facility
Duffin, C. (2002,
June 4)
To discuss the preference of
architects for single occupancy
patient rooms
Hospitals in England
Edgman-Levitan, S.
(1997)
To describe elements the
Picker Institute found critical
to patient satisfaction with
care
Picker Institute, Boston
Recommendations for
Healthcare Settings
Architects suggest that all rooms
should be en suite single rooms
monitored by nursing substations
Patients would recover more
quickly in own rooms because
exposed to less noise, sleep
better, and have greater privacy
Patients would receive most
treatments in their rooms; space
around beds should be larger to
accommodate equipment
Monitoring of patients not
difficult if rooms designed in
clusters with glass fronts
Physical barrier between patients
helps prevent infection
Mission is to promote quality
assessment and improvement
strategies to address needs and
concerns of patients and family
Patients want to be involved in
decision-making process and
want their cultural and religious
views respected
Most important for patients’
overall satisfaction are physical
comfort, information and
education, and respect for
patients’ preferences
Physical design should
incorporate features such as
wayfinding, emotional support,
gardens and plants, private areas,
music, physical comfort, and
places for alternative therapies
Education can be achieved
through use of computers,
patient learning centers, tape
recorders, and space for family
members
Relationship of findings to room
occupancy
Recommendation is for single rooms
because of benefits to patients
Patients’ satisfaction is dependent
upon their level of physical comfort,
the information and education
received, and respect for the patients’
preferences
No mention made in regards to room
occupancy
Study
Focus of Article
Type of Healthcare
Facility
Fishback, B. W. &
Krewson, C. (1981,
February 16)
To describe the design of
Vanderbilt University Medical
Center
Vanderbilt University
Medical Center,
Nashville, Texas
Fisher, S. (1982)
To discuss the design of a
nursing home
Christian City
Convalescent Center,
Union City, Georgia
Recommendations for
Healthcare Settings
Patient rooms were painted offwhite and floors were carpeted
Layout modified octagonal;
patient rooms located along
periphery
Nurse stations contained within
service core
Two frequent complaints of
nurses in nursing homes are tired
feet and the tendency of patients
to gather around their work areas
The Convalescent Center is
square in structure and rooms are
arranged around the perimeter
Patient rooms are located on
exterior walls; nurses can
observe each bed without
entering the room
Design maximizes space use,
increases the intensity of patient
care, and feels less institutional
Less walking is required to get
anywhere in the building due to
the compact design
High morale and low turnover
among registered nurses; partly
due to decreased walking
Relationship of findings to room
occupancy
No mention made in regards to room
occupancy
Compact design reduces amount of
walking by nurses
No mention made in regards to room
occupancy
Study
Focus of Article
Type of Healthcare
Facility
Forman, A. D.,
Stoller, J. K. &
Horsburgh, C. R. Jr.
(1996, February 1)
To comment on the article
written by Horsburgh (1995)
U. S. Hospitals
Francis, S. (2002,
March)
To describe future trends in
designing hospitals
Hospitals in England
Recommendations for
Healthcare Settings
Forman: Medical economic
pressures are influencing design;
hospitals are spending money on
extravagant design while cutting
back staff; skilled and laborintensive care most important
Stoller: design should optimize
coordination among health care
providers; alcoves in hallways
enable private conversations;
horizontal spaces should
encourage face-to-face
interaction among health care
providers
Horsburgh: Health care
providers should be included in
the design to help prevent
misguided expenditures in
design
Hospital design has addressed
functional requirements for
clinical practice but environment
not comforting or inspiring
Shift in emphasis to patientcentered care
New buildings include healthy
living centers, information
kiosks, and social and advice
centers; will accommodate
multidisciplinary teams
Distinctive characteristics
created for public, social, and
private spaces
Design can reduce stress for staff
and reduce anxiety for patients
Relationship of findings to room
occupancy
No mention was made in regards to
room occupancy
No mention made in regards to room
occupancy though private spaces are
recommended for consultations and
treatments
Study
Fromhart, S. G.
(1995)
Focus of Article
To compare private versus
shared rooms in long-term
care facilities
Type of Healthcare
Facility
Schoellkopf Health
Center, Niagara Falls,
New York
Beth Sholom Home of
Eastern Virginia, Virginia
Beach, Virginia
Capital Senior Living,
Dallas, Texas
Recommendations for
Healthcare Settings
New York:
Private rooms only
No “roommate problems”
Family members can visit freely
and decorate loved one’s room
Increased costs justified by
improved quality of life
Virginia:
Single rooms are for private
paying residents
Until government funding
improves, semi-private room
cost-effective standard
If given choice, almost all those
in a nursing facility would
choose private rooms
Texas:
Shared living arrangements costeffective
Alternative to facility is low cost
2 bedroom apartment-type
situation; share common room
and have separate walled
bedrooms
Smaller facilities can benefit
from having fewer units to
control costs
Relationship of findings to room
occupancy
In all 3 cases, it appears that privacy
is key; most patients would prefer a
private room over a shared room
For cost-effective purposes, shared
rooms are the norm
Study
Focus of Article
Type of Healthcare
Facility
Gallant, D. &
Lanning, K. (2001)
To describe the design of an
acuity-adaptable room
U.S. Hospitals
Garber, K. (1999,
February)
To describe revisions made by
the Joint Commission
(JCAHO) to its hospital
accreditation manual
Hospitals in the U. S.
Recommendations for
Healthcare Settings
Acuity-adaptable room support
complete range of care required
by patients
Rooms are private and must be
large enough to support clinical
care equipment, staff,
procedures, and family members
Bathroom should be located
along exterior side of room
Hospitals should create
welcoming environments that
support patient dignity and raise
awareness among staff
Hospitals should use visual clues
and signs to help people get
around; can help reduce anxiety
and increase attention span and
treatment compliance
Elements of nature such as
flowers help brighten rooms and
make patients feel better
Relationship of findings to room
occupancy
Rooms are private and are adaptable
based on the needs of the patients
Hospitals should be patient-friendly
No mention made in regards to room
occupancy
Study
Gilpin, L. (1996)
Focus of Article
To describe how healthcare is
moving from the Industrial
Age to the Information Age
Type of Healthcare
Facility
U. S. Hospitals
Recommendations for
Healthcare Settings
Goal of the Information Age is
not information, but knowledgethe integration of information to
create health
Patients becoming partners and
taking personal responsibility for
their health and making
decisions about the treatment
process
People (patients, families, and
staff) will always be more
important than information
Planetree developed techniques
to encourage creativity among
healthcare providers and design
professionals
Social support needs to be
encouraged
The best use must be made of
treatments and preventative care
that requires less technology and
expenses
The opportunity for learning
should be created
Every person should feel valued
and nurtured despite cultural and
ethnic differences
Relationship of findings to room
occupancy
No mention of preference for single
or multiple room occupancy
Study
Focus of Article
Type of Healthcare
Facility
Glanville, R. (1996,
November)
To describe the design of a
Swedish hospital ward
Norrtalje Sjukhus,
Sweden
Graven, S. N. (1997)
To describe design factors of
neonatal intensive care units
Neonatal Intensive Care
Units
Hahn, J. E., Jones, M.
R., & Waszkiewicz,
M. (1995, March)
To discuss the renovations
made to two semi-private
rooms in a geriatric unit
Geriatric Rehabilitation
Unit in the Johnston R.
Bowman Health Center
for the Elderly at RushPresbyterian-St. Luke’s
Medical Center
Recommendations for
Healthcare Settings
Patients are encouraged to
progress from a quiet and fairly
private bed space through a
series of areas that provide
opportunities for social activity
as part of the healing process
24 bed groups were designed,
arranged in 3 subgroups of 8
Subgroups consist of a 3-bed
room, a 2-bed room, and 3 single
bed rooms; each has its own en
suite bathroom facilities
Folding screens are provided for
each bed to give the patient
privacy and each patient has a
view from the bed
Staff facilities are provided and
staff are expected to take breaks
while on the ward
Controlled lighting for all infants
Noise levels should be kept low
Primary functions of patient
room are patient care, nursing
care, medical treatment, and
therapies; activities of daily
living; examinations;
socializing; sleeping; and
cleaning and repair
Rooms were modified to
maximize diminishing visual
abilities of elderly and to provide
warm, homelike environment;
closets were also reconfigured
Surveys suggest that patient
satisfaction has improved
Relationship of findings to room
occupancy
Though a variety of occupancy
rooms are used, patients are given
their own space to ensure they have
privacy
Environmental factors, such as light
and noise, can be adapted to the
infants’ needs
No mention made in regards to room
occupancy
Semi-private patient rooms were
successfully modified to create a
more aesthetically pleasing
environment for patients
Study
Hendrich, A., Fay, J.,
Sorrells, A. (2002)
Focus of Article
To describe the design of the
Critical Care Unit at
Methodist Hospital
Type of Healthcare
Facility
Comprehensive Cardiac
Critical Care Unit in
Methodist Hospital of
Clarian Health Partners in
Indianapolis
Recommendations for
Healthcare Settings
Based on data from a time-andmotion video study, it was noted
that patients moved 3 to 6 times
during their stay as their acuity
levels changed; tasks performed
by caregivers were duplicated &
an increased error factor was
introduced due to multiple
caregivers; nurse traveled
several miles each shift to find
supplies
Private room was created to
support changing levels of acuity
Rooms are 400 sq. feet designed
with a family zone, a patient
zone, & a caregiver zone
Patients can control lighting,
temperature, and privacy as
condition improves
Nursing stations are
decentralized
Unit-to-unit transfers have
decreased by 90% and the
overall number of patient days
per bed has increased; decrease
has also occurred in patient falls
and medication errors
Relationship of findings to room
occupancy
The acuity adaptable rooms have
helped improve clinical outcomes,
cost and operational efficiency, and
staff and patient satisfaction
Study
Hewitt, T. &
McFarlane, J. (1997,
August)
Focus of Article
To describe the ward of Leeds
General Infirmary (Phase One)
Type of Healthcare
Facility
Leeds General Infirmary,
England
Recommendations for
Healthcare Settings
Maximum ward size is 28 beds
with four bedded bays being the
maximum
Each ward can accommodate
both sexes and have exclusive
use of a shower and a toilet
Most wards have 4 single rooms
and some of these have ensuite
facilities
Rooms incorporate large
windows which are set at a low
level to enable patients to see
outside
Incorporate a clean and dirty
hold area on each floor to
minimize congestion on
corridors
Day spaces smaller and more
friendly
Relationship of findings to room
occupancy
The design incorporates both single
and multiple bed rooms and no
preference for either is suggested
Study
Hill-Rom
Focus of Article
To describe the benefits of the
acuity adaptable room
Type of Healthcare
Facility
U. S. Hospitals
Recommendations for
Healthcare Settings
Changing trends in healthcare
with the aging patient population
requiring higher acuity care
Patients are transferred various
times from emergency to critical
care to the medical-surgical
rooms
Acuity adaptable rooms reduce
the need for patient transfers; the
patient can receive all the care
needed in one room, regardless
of acuity
Room size is increased, the
patient is visible from the
corridor, and there is space to
accommodate visitors
Medication errors, patient falls,
phlebitis, and procedural and lab
problems are reduced
Average length of stay is
reduced
Relationship of findings to room
occupancy
The acuity adaptable room is singleoccupancy and reduces the need for
patient transfers
Study
Hohenstein, J.
(December, 2001)
Focus of Article
To describe the successful
construction of Children’s
Hospital in Omaha, Nebraska
Type of Healthcare
Facility
Children’s Hospital,
Omaha, Nebraska
Recommendations for
Healthcare Settings
Colors used are inviting and
uplifting (colors used on the
exterior are peach, beige, and
gray brick)
130-bed facility
On each floor, the themes are
drawn form the environment of
Nebraska
Diversion and entertainment
important: game rooms on every
patient floor, artwork created by
kids on the walls
Curved patient floors divide
nursing duties into six-room
pods; equipment is centralized in
inner nursing area of pod
Outside patient room, each pod
has table where staff and family
can talk
All patient rooms on the medical
and surgical floors are single
occupancy, allowing family
privacy; each room includes a
parent bed
Natural light used extensively
Relationship of findings to room
occupancy
Preference towards single occupancy
rooms to allow families privacy
Study
Horsburgh, C. R. Jr.
(1995, September 14)
Focus of Article
To describe current trends in
hospital design that focus on
the patients and their families
Type of Healthcare
Facility
U. S. Hospitals
Recommendations for
Healthcare Settings
Four qualities characterize good
architecture: orientation,
connection, scale, and symbolic
meaning
Orientation: use of signs, visual
cues, and landmarks to help
patients locate destinations and
reducing their spatial confusion
Connection: quality of
interaction between people and
their environment; use of open
lobbies, alcoves in hallways for
confidential discussions,
windows with views of nature,
and social spaces
Scale: should provide variety,
should accent changes in
function & ambience, help
define progression from private
to public space
Symbolic Meaning: atmosphere
of security, cleanliness, and
physical comfort should be
conveyed
Relationship of findings to room
occupancy
Hospitals should be a combination of
successful function and good
architecture
No mention made in regards to room
occupancy
Study
Hosking, S. &
Haggard L. (1999)
Focus of Article
To describe the advantages
and disadvantages of the
Nightingale and Bay wards
Type of Healthcare
Facility
All Hospitals
Recommendations for
Healthcare Settings
In the Nightingale ward, beds
are arranged down each side of a
long, narrow ward; nursing
station is at one end and a
convalescent bay is at the other
end
Nightingale wards became
unpopular because they failed to
meet the needs of privacy of
patients
Newer wards are designed in
four-, six-, or eight-bed bays
Bay designs offer more
flexibility and greater privacy
and intimacy; patients can be
clustered according to illness or
sex
Disadvantages of the bay ward
are the patient’s view of nurses
is diminished, which can
increase anxiety; patients feel
confined to their bay and find it
difficult to approach others; it is
harder for staff to be vigilant
over noise and new sources of
noise are introduced
Relationship of findings to room
occupancy
Both the bay and nightingale wards
have advantages and disadvantages
Rooms on these wards are multiple
occupancy
Study
Focus of Article
Type of Healthcare
Facility
Jones, W. J. (1992)
To discuss emerging trends in
healthcare facilities
All hospitals
Kaldenberg, D. O.
(1999,
January/February)
To discuss the impact that
having a roommate has on
patient satisfaction
U. S. Hospitals
Kennedy, S. P.
(1994, March 21)
To describe how design
should change to meet
changing needs in healthcare
U. S. Hospitals
Recommendations for
Healthcare Settings
Old hospital forms offered
shelter, food, and some
cleanliness
Florence Nightingale inspired
wards which were long, and
open corridors with windows on
both sides; the central elevator
determined the size of the
nursing units
Hospitals are now designed in
the form of bed clusters to
reduce patient travel as well as
the number of people associated
with patient care
Flexibility and adaptability are
key to design; larger patient
rooms in separable suites will be
used to provide patient care
Hospitals with more private
rooms tend to have higher
patient satisfaction
Patients without roommates
were more satisfied with their
stay than those with roommates
Female patients with roommates
were less satisfied than males;
females without roommates were
more satisfied than males
Patients with roommates were
least satisfied with the noise,
pleasantness, cleanliness, and
temperature in the room
Shift to outpatient services left
inpatient facilities struggling to
survive
Buildings should be designed for
short-term, but design should
accommodate changes in long
term
Facilities should be flexible to
permit change with minimum
inconvenience and cost
Relationship of findings to room
occupancy
Larger patient rooms will be used in
future-oriented hospital to provide
patient-care
Patients’ satisfaction with their
hospital stay is greater for those who
do not have roommates
No mention made in regards to room
occupancy
Study
Focus of Article
Type of Healthcare
Facility
Larson, L. (2003,
February)
To describe the design for a
new hospital whose focus is
patient safety
St Joseph’s Community
Hospital, West Bend,
Wisconsin
Leccese, M. (1992)
To describe the features, and
in particular, the landscape of
St. Michael’s Hospital
St. Michael’s Hospital,
Texas
Recommendations for
Healthcare Settings
All rooms in this facility will be
private
Rooms will be wired to use
cameras with the patient’s
permission to monitor the patient
without disrupting them
Rooms will have cabinets
containing medicine locked up
in boxes for the patient and other
supplies needed to care for the
patient
Bedside computers used to
double-check treatments and
allow patients to see their
records
Hallways are shorter to
minimize employee fatigue
A small alcove adjacent to the
room will enable nurses to
observe patients through a
window without disturbing them
Patients have views of nature
through floor-to-ceiling
windows in rooms
Landscape includes jogging
paths, fountains, lake, and trees
Large courtyards include
seasonal plants
Relationship of findings to room
occupancy
Rooms in this hospital are private,
though no specific reason is given as
to why this is the case
No mention made in regards to room
occupancy
Study
Focus of Article
Type of Healthcare
Facility
Leibrock, C. A.
(2000)
To describe the design of
hospitals
U. S. Hospitals
Lippman, H. (1991,
July)
To describe the design at
Irvine Medical Center
Irvine Medical Center,
California
Recommendations for
Healthcare Settings
Hospitals are moving away from
general hospital delivery to
ambulatory care
In tertiary care hospitals, patients
and family members are
expected to take an active role in
treatment
Planetree model empowers
patients with research; patient
rooms are private and the
patient’s care partner stays with
the patient in the room; the
nursing station is decentralized
into a series of pods that serves
three to four patients
A well-maintained garden
provides sensory stimulation
Art can stimulate the
consciousness of the viewer
ADA requirements must be met
in facilities
Stress can be reduced with
wayfinding and nature scenes;
sound can be a positive
distraction
Patients should have a sense of
control over their personal space
Philosophy is patient-centered
with business orientation
Rooms are all private and are
divided into pods containing
four rooms
One nursing alcove exists for
two pods; alcoves serve as mininursing stations where staff can
discuss patients, print records,
replenish supplies, and reach
patients quickly
Relationship of findings to room
occupancy
Patient-centered care gives the
patients a sense of control as they are
active participants in their care
Room occupancy is mentioned for
the Planetree facilities; rooms are
private and are large enough to
accommodate the patient and the
caregiver
Rooms in this facility are private,
though reasons for this choice are not
stated
Study
Lowers, J. (1999)
Focus of Article
To describe how hospital
design can incorporate the
needs of patients
Type of Healthcare
Facility
Patient-centered hospitals
in the U.S.
Recommendations for
Healthcare Settings
Patients want safety,
confidentiality, and sense of
control
Environment should provide
connection to staff, be conducive
to sense of well-being, be
accessible, have private rooms to
increase privacy and
confidentiality, provide space for
families, be safe and secure, and
should provide connection to
outside world
Indirect lighting diffuses light
and creates more natural effect
Carpeted hallways keep noise to
a minimum
Temperature controls in rooms
allow patients to adjust the
temperature as needed
Senses should be engaged
through use of gardens, artwork,
furniture, and lobbies
Nursing stations should be
accessible to patients; mininursing stations can eliminate
central gathering point; staff
need lounges to rest
Relationship of findings to room
occupancy
Private patient rooms are preferred to
increase privacy and confidentiality
as well as to enable family members
to spend the night
Study
Focus of Article
Type of Healthcare
Facility
Lumsdon, K. (1996,
November 5)
To discuss changes made to
West Allis Memorial Hospital
based on patient satisfaction
surveys
West Allis Memorial
Hospital, Wisconsin
Lumsdon, K. (1993,
February 5)
To describe the design of
patient-centered Mercy
Hospital and Medical Center
Mercy Hospital and
Medical Center, San
Diego
Recommendations for
Healthcare Settings
Patient surveys suggested that
patients did not want to share a
semiprivate room with a
stranger; not enough space in
rooms for family member to
spend the night; remedy is to
incorporate private rooms
Centralized nursing station
removed and smaller satellite
pods created to serve seven to
nine patients
Patient care associates, a new
staff category, handle support
tasks formerly done by nurses
Inpatient rooms transformed to
lower patient stress levels and
give them more control over
surroundings
Rooms larger to accommodate
family and friends
Artwork, paint, and wall
coverings chosen are sensitive to
patients’ conditions
Patient server, a cabinet of
drawers and shelves, located in
patient rooms
Nursing areas decentralized and
located at smaller pods
throughout patient unit
Addition of activity rooms,
dining areas, and reference
libraries
Relationship of findings to room
occupancy
Private rooms will be created to
improve patient care
Rooms in this facility are large and
accommodate family members,
though it is not specified if the rooms
are private
Study
Focus of Article
Type of Healthcare
Facility
McMorrow, E (2001,
March)
To describe The Center for
Health Design Pebble Project
San Diego Children’s
Hospital and Health
Center
McTaggart, R. (1996,
June)
To discuss the issues relevant
to designing hospital ward
with attention to staff bases
Private rooms in a U. K.
facility
Recommendations for
Healthcare Settings
The Center for Health Design
focuses on 5 core areas:
Environmental standards,
education/information, technical
assistance, research, and
partnerships with selected
healthcare organizations
2 components to pebble project:
emphasis on understanding how
organizational behavior changes
as a result of the planning and
design process; development of
a standardized evaluation
methodology
Staff base central to ward
management
Increased unit size for costreduction
Less dependence on multi-bed
rooms
Core ward support services
closer to all beds
Improved visibility of entrance
points and beds from staff bases
Design includes 34 bed wards;
patients in groups of 12; mainly
single and 4 bed rooms; nursing
teams are local to the group and
have own staff base
Relationship of findings to room
occupancy
No mention of preference for single
or multiple room occupancy
Ward designs should include 30-50%
of patients in single rooms
Study
McTaggart, R.
(1996, May)
Focus of Article
To assess British ward design
Type of Healthcare
Facility
Hospitals in England
Recommendations for
Healthcare Settings
Ward design should incorporate
patient-focused care; use of
Planetree model
Non-clinical spaces should be
included such as quiet lounges
and rooms for counseling
Patients should be given option
to move from unwelcome
neighbors, their own personal
space, and room to escape
Increases provisions for single
rooms
2-bed room design with “L” shape enables patients to have a
sense of their own space; rooms
should have en suite bathrooms
Bed space should be adequate
for bedside procedures
Sexes should have own wards
Relationship of findings to room
occupancy
2-bed “L”-shaped rooms can be
economical and give patients a sense
of their own space
Increased provision for single rooms
exists as marketing asset and for
infection control
Study
Mader, B. (2002)
Focus of Article
To discuss why private rooms
are becoming the norm in
Milwaukee hospitals
Type of Healthcare
Facility
Hospitals in Milwaukee
Recommendations for
Healthcare Settings
Healthcare consumers expect
and demand private rooms when
they have a hospital stay; costs
are increasing because of
individual expectations
Advantages of private room:
Patients sicker now than in past;
require more intensive care and
privacy
Helps with infection control
More efficient layout
For same number of beds,
hospitals can achieve 15%
improvement in room usage
Ultimate cost savings from
improved efficiencies
Advantages of semi-private room
Hard to justify private room
creation in existing facility if
volume high
Entail less square footage per
patient than private room
Disadvantages of semi-private room
Flexibility not as great as in
private room
Limitations to roommate pairing
due to gender and infectious
disease issues
Relationship of findings to room
occupancy
Patients prefer private rooms
HMO’s believe private rooms too
costly
Hospital administrators see private
rooms as being cost-effective and
prefer private rooms to semi-private
rooms
Study
Focus of Article
Martin, C. (2000)
To evaluate the 2nd
International Conference on
Health & Design in
Stockholm, Sweden
Miller, R. L. &
Swensson, E. S.
(1995)
To describe trends in the
design of hospitals
Type of Healthcare
Facility
Hospitals in general
U.S. Hospitals
Recommendations for
Healthcare Settings
Stress is scientific starting point
for understanding how design
affects medical outcome
Design of healthcare facilities
should be human centered,
functionally efficient, and should
benefit patients, families, and
staff
Patient-focused room design
given momentum by Planetree
design
Open ward made obsolete by the
team approach to care and
technological developments
Patient-focused facilities will
feature larger, single-occupancy
rooms
Flexibility of larger room
reduced need of transporting
patients
Larger rooms are economically
feasible in long-run as their
flexibility allows them to be
adapted for other uses such as
rehabilitation and elderly
housing
Flexibility is also enhanced
through uses of disabledaccessible bathrooms; all
patients can use the room at all
times; bathrooms should be
located on outside wall
Cluster of beds supervised by a
nursing team recommended;
easily managed to accommodate
fluctuating patient census
Bedside computers allow for
more detailed and frequent
updating of charts
Relationship of findings to room
occupancy
No mention of preference for single
or multiple room occupancy
Patient-focused care incorporates
single-occupancy rooms which
provide for increased flexibility and
adaptability
Study
Focus of Article
Type of Healthcare
Facility
Moore, J. P. (1974,
February 1)
To discuss the renovations and
expansions that occurred at
Methodist Hospital
Methodist Hospital,
Lubbock, Texas
Morrissey, J. (1998)
To discuss the acquisition of
the Planetree organization by
Griffin Health Services
Corporation
Planetree based hospitals
in the U.S.
Recommendations for
Healthcare Settings
Problems with old facility:
majority of rooms were
semiprivate or four-bed rooms
New tower includes 5 floors of
patient rooms; 190 new singlecare rooms
Planetree has been acquired by
Griffin Health Services Corp.
Only 15 facilities have been
converted since 1986
Trouble demonstrating ongoing
benefit of paying $15,000
licensing fee
Planetree can’t guarantee
reduction in costs and greater
operating efficiency
Relationship of findings to room
occupancy
New facility includes large number
of single occupancy rooms, though
reasons are not given for preference
of these rooms
No mention made of preference for
single or multiple room occupancy
Study
Focus of Article
Type of Healthcare
Facility
Murphy, E. (2000,
May)
To describe the patient rooms
of the future which are
designed to promote healing
U. S. Hospitals
Napthine, R.
(1997/1998)
To describe the layout of a
patient’s room
All hospitals
Recommendations for
Healthcare Settings
Light, color, nature, and ability
to control one’s environment
have healing effect
Patient rooms will be larger to
enhance comfort and include
space for family members;
comfortable seating, guest
sleeping, and storage important
Natural light should be used
where possible; soothing and
invigorating hues should be used
Nurses need adequate working
space
Space around patient’s bed
inefficiently laid out
Service outlets behind the
patients’ bed-head often
inaccessible; solution is to
increase the number of wallmounted services so they are
readily accessible
Towels behind bed-head or
beside bedside lockers
inefficient because nurses cannot
reach these towels
Other inefficiencies include
shallow wardrobes, narrow
shelves and doorways, and
shallow hand basins
Inefficiencies impact nurses;
they may take longer to
complete tasks or they may
injure themselves in attempting
to complete the task
Relationship of findings to room
occupancy
No mention made in regards to room
occupancy, though implication is that
rooms are single occupancy as space
is included for family members
No mention made in regards to room
occupancy
Study
Neumann, T. &
Ruga, W. (1995,
April)
Focus of Article
To give suggestions, based on
experience, on how to improve
a nursing unit’s environment
Type of Healthcare
Facility
St. Luke’s Episcopal
Hospital, Houston, Texas
Recommendations for
Healthcare Settings
Viewing nature scenes can shift
feelings to a more positive state,
increase activity levels, decrease
anxiety, reduce blood pressure
and muscle tension, and
minimize length of stay
Natural images that can be seen
or chosen by the patient are best
Plants are useful
Aquariums shown to decrease
anxiety and discomfort and
increase patient compliance
Unnecessary noise should be
minimized
Patients should be encouraged to
listen to music
Soft blankets can help provide a
good night sleep
Ambient temperature should be
assessed
Negative odors should be
eliminated and clean, therapeutic
aromas should be used
Comfortable seating should be
provided for visitors and family
members
Relationship of findings to room
occupancy
No mention of preference for single
or multiple room occupancy
Study
Focus of Article
Type of Healthcare
Facility
Noakes, T. & Glynis,
M. (1998, October)
To describe the proposed ward
design for the Millennium
Hospital in New South Wales
Millennium Hospital,
King’s Cross, New South
Wales
Orr, S., Farrell, J., &
Portman, F. (2002,
August)
To discuss the viability of
private rooms based on the
opinions of nurses
Hospitals in England
Recommendations for
Healthcare Settings
Wards will contain continuous
bands of at least 200 beds per
floor
Clusters of eight beds: one fourbed and four single rooms; each
cluster has own associated nurse
station
Each patient room has own drug
cupboard for prescriptions
Beds should be widely spaced to
accommodate bedside care
Increase in single rooms to help
control hospital-acquired
infection
Orr: Not viable for all patients
to have single room; acutely ill
patients need constant
monitoring and single room may
be hazardous
Farrell: Concern with safety and
security of patients in single
room since harder to monitor;
single rooms will reduce overall
bed capacity; single rooms
impractical
Portman: Cost of single rooms
huge; patients can become
invisible; patients said they
would rather be on a ward where
psycho-social needs are met
through contact with other
patients
Relationship of findings to room
occupancy
Hospital ward design will include
combination of single and multiple
occupancy rooms; Larger number of
single occupancy rooms needed to
help reduce risk of acquiring
infection
From the perspective of nurses,
single rooms are not ideal since the
safety of patients may be jeopardized
Study
Focus of Article
Type of Healthcare
Facility
Patterson, M. (1999,
July)
To describe the features of the
Cardiac comprehensive care
unit at Methodist Hospital
Cardiac Comprehensive
Care Unit at Methodist
Hospital, Indianapolis
Rainey, J. B. (1990,
May 19)
To describe the effects of
moving from an open ward to
a bay ward
Hospital in Scotland
Recommendations for
Healthcare Settings
Computers outside patient rooms
for nurses to input patient
information; windows in patient
rooms are angled so nurses have
visual access of 3 rooms
simultaneously
Patients have shelves by their
bedside to keep personal
materials
Families have their own space
within the patient room to
encourage their participation as
well as a retreat area outside the
patient rooms
Patient rooms are private
Move was made from open ward
to six-bed bays and single rooms
New ward difficult to adjust to
as patients were moved around;
large amounts of time spent
tracking down patients
Counseling patients in sixbedded bays impossible; privacy
greater on open ward
Patients in single rooms can feel
lonely and isolated; open ward
offered patient chance to interact
with others
Relationship of findings to room
occupancy
Private rooms are used in this design
and these rooms are large enough to
accommodate family members who
participate in the care of the patient
Preference is for open ward as
privacy is greater and patients are
able to interact with one another
Study
Focus of Article
Type of Healthcare
Facility
Shumaker, S. A. &
Pequegnat W. (1989)
To discuss elements of design
that can influence patient
stress
All hospitals
Solovy, A. (2002,
December)
To describe the change in
room design in hospitals
U.S. Hospitals
Recommendations for
Healthcare Settings
Poor design and organization
can directly affect health by
hampering effective and timely
delivery and receipt of
healthcare; health can be
affected indirectly by creating a
stressful environment
Sources of stress are factors that
contribute to perceptions of
inadequate control, lack of
sufficient privacy, multiple and
competing stimuli, and
competing role demands
Ambient stressors include noise,
inadequate privacy,
uncomfortable temperatures, and
crowding
Changes in technology
associated with diagnosis and
treatment influence patient care
and hospital design; equipment
demands large spaces
Trend toward use of light,
materials, and color to liven up
human qualities of the
environment
Pattern of design of nursing unit
may influence nurses’
satisfaction and their delivery of
health care
Larger private rooms with more
family space have been driven
by consumerism and view of
family’s role in treatment
Rooms include foldout beds,
desks, internet access, and
greater control of lighting
Privacy is increased
Relationship of findings to room
occupancy
No mention was made in regards to
room occupancy
Trend towards large private rooms to
accommodate family members and to
increase privacy
Study
Spear, M. (1997)
Focus of Article
To describe how the universal
patient care room should be
designed
Type of Healthcare
Facility
Massachusetts General
Hospital, Boston
Recommendations for
Healthcare Settings
Problem: most patient rooms
fail to acknowledge family
participation and there are too
many double rooms; these rooms
don’t comply with ADA
standards and medical
equipment does not fit
Recommendations: a universal
patient room that is single
occupancy; the hospital should
be able to put any patient in any
room; family members and
others are included in the
patient’s care; want to reduce the
number and frequency of patient
transfers
4 functional processes go into
patient’s room: activities of
daily living; communication
among staff, visitors, families,
patients, and students;
interactions with the
environment; therapies and
diagnostic services
Relationship of findings to room
occupancy
Patient room should be single
occupancy to enable better care of
the patient
Study
Stichler, J. F. (2001,
November)
Focus of Article
To describe how the critical
care unit can be designed to
enhance the healing process of
patients
Type of Healthcare
Facility
Critical Care Units in U.S.
Hospitals
Recommendations for
Healthcare Settings
Patients experience a positive
outcome in environment that
incorporates natural light,
elements of nature, soothing
colors and pleasant sounds
Trend toward use of universal
rooms; provide more space for
patient care, equipment, and
family members
Placing bathroom in each patient
room or between patient rooms
increases flexibility and
adaptability of unit
Visibility into and out of the
room is critical; patients should
have access to outside window
too
Optimal design would include a
mini-nursing station between
every two patient rooms
Nursing station should be
located centrally to allow
visibility to all patient rooms
Family waiting area should be
large enough to accommodate
visitors and should be adjacent
to the critical care unit
Staff lounge should be
comfortable and should be
located in an area that enables
staff to return quickly to the unit
Optimal size of patient unit is
multiples of four beds
Circular design - adv:
centralization of care and
immediate access to patient;
disadv: noisy, storage area is
reduced, & patient privacy
minimized
Triangular design – adv:
reduces travel distance to patient
rooms, maximized number of
rooms designed, and allows for
multiple nursing stations; disadv:
Relationship of findings to room
occupancy
Trend towards universal rooms
increases patients’ comfort
Various ward designs have both
advantages and disadvantages
minimizes visualization of
patients in remote corners and
design is difficult to expand
Clustered design – adv: allow
more patient rooms to be located
on periphery, facilitate nurses’
visualization, allows for use of
mini nursing stations; disadv:
decentralized approach to care
and social needs of nurses not
always met
Rectilinear design: adv: cost,
centralized location for supplies,
and improved way-finding;
disadv: distance traveled by
nurses, visualization of patients
decreased, and space required
for patient rooms
Study
Thompson, J. D. &
Goldin, G. (1975)
Focus of Article
To discuss ward design in
British hospitals
Type of Healthcare
Facility
British hospitals
Recommendations for
Healthcare Settings
Hospitals in Britain place an
emphasis on supervision and
economy rather than privacy of
patients
Important for nurses is the
ability to see their patients, to
respond quickly to an
emergency, and to reach a
patient in the shortest amount of
time possible
The Nightingale ward was
designed as an open ward with
beds in two rows; 2 toilets were
available for every 25-30 beds
Private rooms were available for
those who were extremely ill or
dying and for those who had an
infectious disease
Nuffield studies determined that
nurses could handle 8 patients
during peak periods and double
that during non-peak periods;
wards were designed in
multiples of 8 beds with 32 beds
being the average unit
The use of artificial ventilation
to reduce the risk of infection
changed the design of wards
Relationship of findings to room
occupancy
Hospitals in Britain tend to favor the
use of multiple-occupancy rooms to
facilitate supervision of patients,
though there are some proponents of
single-occupancy rooms
Study
Thompson, J. D. &
Goldin, G. (1975)
Focus of Article
To discuss the issue of privacy
in hospitals in relation to room
occupancy
Type of Healthcare
Facility
U. S. Hospitals
Recommendations for
Healthcare Settings
Desire for privacy affected by
social class; those of poorer
classes generally resent being
left alone in a hospital room
Florence Nightingale was
against private rooms and
instead favored a ward design
that facilitated the nurses’
supervision of patients
Private rooms were used for
medical reasons and for social
reasons, usually by those who
could afford them
A Bacon suggests that private
rooms are more efficient; they
allow for maximum ward
capacity and patients do not need
to be moved, reducing the risk of
infections; better examinations
can be made and room
temperature can be adjusted to
suit the needs of the patient
After World War II, the benefit
of private rooms was increased
as it was noted that private
bathrooms enabled patients to
recover faster
Economically, multi-bed rooms
had an advantage as more
patients could be placed along
the same corridor; nurses also
had to walk less to tend to
patients
Relationship of findings to room
occupancy
Private rooms are favored among
patients of the upper social classes,
while patients in lower social classes
prefer shared rooms
Study
Tidwell C., &
Sowman, J. (2002)
Focus of Article
To demonstrate how effective
healing environments have
proven to produce quantifiable
effects on patient experience
Type of Healthcare
Facility
Recommendations for
Healthcare Settings
Relationship of findings to room
occupancy
Florida Hospital
Heartland Medical Center
(wellness & medical
center)
3-story facility
Reception area offers info center
and gift shop; clear orientation
2nd & 3rd floors include inpatient
rooms and services; nurses’
station dispersed-1 nurse can
view 4 patients simultaneously
Private patient rooms; use of
neutral colors, natural light, &
comforting artificial lighting
Restrooms on exterior wall of
inpatient rooms
Courtyard
Private rooms preferred
Woman’s Health Center
in Bellmore, New York
Integrates ideas and images
related to garden, greenhouse,
and lantern
Enhances quality of light by
using skylights
Use of soothing colors, warm
textures, and natural materials
Welcoming design communicate
wellness, good health, and reach out
to the community; Care delivered
with greater efficiency
No mention of preference for single
or multiple room occupancy
Study
Tradewell, G. B.
(1993)
Focus of Article
To describe the design of
patient care units
Type of Healthcare
Facility
All hospitals
Recommendations for
Healthcare Settings
Nightingale ward: open ward
design with a nurse located
among patients; support spaces
are located outside the ward;
visibility of patients the goal;
ward houses 30-32 beds
Continental design: patient
rooms located on one or both
sides of a corridor; use of rooms
with 4-6 beds; central nursing
unit; support space on unit
Racetrack design: patient rooms
are farther apart and support
spaces located between two
corridors; design not favored
because of long travel distances,
only one nursing station for a
large number of beds,
visualization is poor, and only
contains one clean and one
soiled utility room
Cluster design: patient rooms
organized around nursing
substations; one of the stations is
dedicated as central nursing
station
Triangles: reduces travel times
and distances by nurses
Criteria for designs are: patient
rooms, observation, nursing
stations, distribution of support
space, flexibility, and travel
distance
Relationship of findings to room
occupancy
Ward design must take into account
factors such as the patient room, the
nursing station, as well as
observation of patients and travel
distance
Room occupancy varies among the
ward designs and was not
emphasized in the article
Study
Ulrich, R.S. (1997)
Focus of Article
To describe factors of hospital
design that contribute to
positive outcomes for patients
Type of Healthcare
Facility
U.S. Hospitals
Recommendations for
Healthcare Settings
Design takes into account
strategies and environmental
qualities that may positively
affect patient outcomes
Design that fails to support
patients and their attempts to
cope with stress can have
negative effects on health
outcomes
Design should incorporate a
sense of control with respect to
physical surroundings, access to
social support, and access to
positive distractions
Supportive design can reduce
patient stress and anxiety, reduce
pain, improve satisfaction, and
lower costs
Relationship of findings to room
occupancy
Through supportive designs, patients
can experience positive outcomes
No mention made in regards to room
occupancy
Study
Focus of Article
Verderber, S. & Fine,
D. J. (2000)
To describe the design of
patient care units
Type of Healthcare
Facility
Hospitals in the U.S. and
Europe
Recommendations for
Healthcare Settings
Cluster unit design minimized
distances traveled by nurses and
delivered a higher level of care
than traditional linear units
Planetree movement suggested
that hospital care should
maximize the involvement of
patients and family members;
emphasis on improved
education, personalization, and
demystification of illness;
determined that patients were
denied supportive human
relationships, physical comfort,
and independence
Transformational rooms can be
converted and reverted to their
initial stage; functions of these
rooms alterable
Bedside computers enable nurses
to input patient data quickly and
data is made available to the
patients
Private patient rooms are larger
in size to accommodate
equipment as well as family
members
Relationship of findings to room
occupancy
Patient rooms have evolved from
open wards to private rooms that are
large enough to accommodate
equipment and family members
Study
Focus of Article
Type of Healthcare
Facility
Voelker, R. (1994,
December 28)
To describe the use of the
Planetree philosophy in
hospitals
U. S. Hospitals
Watkins-Miller, E.
(1998, February)
To describe the features of the
Marburg Pavilion at John
Hopkins Hospital
Marburg Pavilion at John
Hopkins Hospital,
Baltimore
Recommendations for
Healthcare Settings
Planetree combines soothing,
efficient surroundings and
emotional support with medical
care
Included in the design is soft
lighting, carpets to absorb noise,
and soothing artwork and colors
Patient should have control of
their surroundings such as lights,
temperature, and television
Patients should be able to bring
their favorite possessions
Indoor air quality should be
good
Nursing stations should welcome
communication
Windows help maintain
connection with nature
Cost is $800 a day for a private
room with elegant furnishings
and hotel-like amenities such as
hardwood floors, wooden
cabinets, television, and fax
machine
Warm hues are used to make
setting comfortable
Lighting is warm and
appropriate for each settingbrighter in some areas, and
lower in other areas
Artwork and patterns are used as
wayfinding devices
Relationship of findings to room
occupancy
Patient-centered environments
provide a soothing atmosphere for
healing
No mention was made in regards to
room occupancy though the design
appears to favor private rooms
Private rooms with elegant features
are used to make the stay more
pleasant for the patient
Study
Focus of Article
Type of Healthcare
Facility
Weber, D.O. (1995,
March-April)
To describe features that
promote a therapeutic
environment in hospitals
U. S. Hospitals
Weisman, E. (1994,
November)
To describe the design of
Griffin Hospital
Griffin Hospital, Derby,
Connecticut
Recommendations for
Healthcare Settings
Healthcare architects should
design for the spiritual, mental,
and emotional dimensions of
patients
Planetree incorporates patientcentered values: access to
information, participation,
autonomous decision-making,
involvement of family and
friends, choice, respect for the
individual, & provision of
supportive human and physical
environments
Air should be properly filtered
and ventilated
Natural fragrances have been
used to improve air quality and
promote healing
Excess noise can be reduced
through source attenuation and
source elimination
Use of music and natural sounds
can contribute to wellness
Effective lighting and daylight
should be incorporated into the
design
Design based on Planetree
philosophy
Rooms are semi-private; L-shape
design used; offers patients
sense of own space
Three 23-bed units created with
two swing beds that can be used
by family members
Satellite nursing stations used;
branch off main corridor and are
surrounded by cluster of 3 or 4
rooms
Relationship of findings to room
occupancy
Design should include features that
promote healing
No mention made in regards to room
occupancy
Semi-private rooms in an L-shaped
design are used; offers patients sense
of own space
Study
Withecombe, P.
(1997)
Focus of Article
To describe how the ‘Echelon’
and ‘Focus’ methods of ward
planning are efficient and aid
in patient comfort
Type of Healthcare
Facility
‘Echelon’ ward design:
Mold Community
Hospital, Wales
‘Focus’ ward design:
Princess of Wales DGH
Bridgend
Recommendations for
Healthcare Settings
Echelon Design:
20 bed ward; nurses’ base
located centrally with direct
view into each 8 bed bay
L shape makes length of corridor
appear shorter
Staggered bed head wall
arrangement; each bed in a
corner area within the bay and is
visible from the nurses’ base
Each patient’s bed area has its
own ambience
Focus Design:
2 X 23 bed acute ward template
Incorporates Echelon bays
clustered around a central nurse
base
Short travel distance to utility
rooms
Relationship of findings to room
occupancy
Echelon Design: Enhanced amenity
and privacy for the patient; Ease of
observation for the nursing staff;
cost-efficient; Rooms with multiple
beds are desired
Focus Design: Cost-effective; ward
accommodation approximately 40%
of total footprint area of acute
hospital
Study
Focus of Article
Type of Healthcare
Facility
Williams, M. (2001,
November)
To describe the design of a
critical care unit based on the
premise of offering more
efficient care as well as a
comfortable environment for
patients
Critical Care Units in U.S.
hospitals
Williams, M. A.
(1988)
To review literature linking
physical environment factors
to patient care
Hospitals in the U.S. and
the U.K.
Recommendations for
Healthcare Settings
Layout of central nursing station
should allow for direct and
indirect visualization of each
patient
Separate entrances should exist
for visitors and healthcare
providers as well as for patient
transfer and transport
Patient rooms need an outside
window as well as direct
visualization from the central
nursing station
Patient room divided into patient
area, family area, and caregiver
area
Temperature should be adjusted
for each individual room
Board that displays personal
belongings can help room feel
less technical
Artwork featuring nature scenes
can be comforting
Family waiting area should be
large enough to accommodate
visitors
Design: 2 main aspects related
to effective and efficient nursing
care: short travel distances and
features that maximize contact
between nurses and patients
Spatial Environment:
Relationship between space use
and staff role defined by social
organization
Sound: Infants particularly
vulnerable to adverse effects of
continual loud sound
Physical environment serves
symbolic role and role in
facilitating therapeutic processes
Relationship of findings to room
occupancy
The rooms in the critical care units
should be visible from the nurses’
stations and should be large enough
to accommodate patients and their
family members
Room occupancy was not specified,
though the description implied a
private room design
No mention made in regards to room
occupancy
Empirical Articles Disease Control and Falls Prevention
Study
Focus of Study
Anderson, J. D.,
Bonner, M.,
Scheifele, D. W., &
Schneider, B. C.
(1985)
To compare hospital rooms that
are equipped with negative
pressure ventilation to hospital
rooms without this ventilation
system in terms of prevention of
nosocomial infections
Groves, J. E., Lavori,
P. W., Rosenbaum, J.
F. (1993)
To study the frequency and types
of incident reports filed for
patients by nursing staff
Research Design
Patients with
varicella zoster
were transferred to
the Isolation Unit
They were in single
occupancy rooms
and were nursed
using strict
isolation
techniques
Susceptible
patients were
defined as being on
the ward at the
same time as the
infected patient and
having no previous
history or exposure
to chicken pox
Incident reports
were retrieved
from the files of
the legal
department of the
hospital
The Report of
Incident or
Unusual
Occurrence form
was used to record
incidents; it
includes details
such as the
patients’ names,
unit number,
attending
physician, incident
location and time,
and nature of injury
Sample
Information and
Site
Findings
Relationship of
findings to room
occupancy
Site: Isolation Unit
at British
Columbia’s
Children’s Hospital
Sample: 125
susceptible patients
and 5 index cases
admitted to the
Isolation Unit
Seven out of 41
susceptible patients
acquired chicken pox
from 2 index cases in
the old Isolation Unit in
1979
On the new unit, of the
100 susceptible
patients, none had been
infected
Negative pressure
ventilation appears to
be beneficial in
preventing the spread of
chicken pox on an
isolation unit
Rooms in this study
were private as it was
an Isolation Unit
Site: A 1,082-bed
tertiary-care
hospital
Sample: 806
medical and
surgical patients
Of the subjects
included, 107 patients
experienced 161
incidents
93 incidents were
“hazardous”
(nonmedication), and of
these, 18 were minor
injuries
Hazardous incidents
were more common
among males 20 to 40
years old and medically
ill females over the age
of 60
No mention was made
in regards to room
occupancy
Study
Hendrich, A.,
Nyhuis, A.,
Kippenbrock, T., &
Soja, M. E. (1995,
August)
Focus of Study
To develop a risk model that
could be used to assess and
identify levels of risk of falls in
acute care populations
To identify key areas for nursing
interventions and fall-prevention
programs
Research Design
Retrospective chart
review done using
epidemiological
approach;
Incident reports
were used to assess
falls
Risk factors were
measured using
information found
in the patient
record, especially
nursing
assessments
Sample
Information and
Site
Site: 1,120-bed
Midwest teaching
institution
Sample: 102 fall
charts and 236 nonfall charts
Findings
Most falls occurred in
the patients’ bedrooms
when alone and
unassisted while trying
to get to the bathroom
No significant
differences found
between nursing shifts
Intervention programs
suggested are based on
increased patient
observation, the
environment, bladder
training, assistance with
and promotion of
mobility, and patient
deterioration
Relationship of
findings to room
occupancy
Programs should be
developed that take into
consideration risk
factors of patients in
regards to their falls
No mention was made
in terms of room
occupancy, though the
majority of falls
occurred while the
patient was alone in his
or her room
Study
Jones, W. &
Simpson, J. A.
(1991, Summer)
Focus of Study
To examine the role of patient
age and diagnostic status in
predicting patient falls
Research Design
Incident reports
were collected
from the facilities
Control groups of
non-incident
patients were set up
at both facilities
Data was collected
on patient age and
diagnostic status
Sample
Information and
Site
Site: Large urban
medical center and
small psychiatric
facility in
Memphis,
Tennessee
Sample: 234 fall
patients and 185
control patients at
the medical center;
96 fall patients and
100 control
patients from the
psychiatric facility
Findings
A sharp rise occurs in
falls of patients over the
age of 60 at the medical
center
At the psychiatric
facility, 36% of falls
occurred to patients 19
years of age and under;
30% of falls occurred in
patients over 60 years
of age
At the medical center,
the most likely patients
to fall were those
suffering from
circulatory disorders
At the psychiatric
facility, patients
suffering from affective
disorders were most
likely to fall; those with
substance-dependence
problems also had a
greater likelihood of
falling
Relationship of
findings to room
occupancy
Patient age and
diagnostic status were
significant predictors of
incident status
No mention was made
in regards to room
occupancy
Study
Langner, D. (1996,
September)
Focus of Study
To analyze factors that are
associated with falls on a busy
surgical and urological unit
Research Design
A form was used
which included
data on cot-sides in
situ/refusal, bell at
hand, occupancy
status, and the
number of staff on
duty
Criteria for falls
used in the analysis
included time of
day, age group,
location of
accident, cot-side
influence, patient
activity, and type
of injury
Sample
Information and
Site
Site: The surgical
and urological unit
in a private hospital
in Durban; the unit
consists of 4
general wards, 5
semi-private wards
and 5 private wards
Sample: 22
patients that
suffered falls
during the time
frame of the study
Findings
The majority of
accidents occurred
between 8 and 10 am
Highest accident rate
occurred when patients
were on their way to the
bathroom
At night, most
accidents occurred
between midnight and 4
am
Accidents were most
frequent among patients
between 70 and 80
years of age
Type of ward had little
influence on the
occurrence of an
accident
Of the patients who fell,
45% suffered an injury
Relationship of
findings to room
occupancy
Accidents were most
likely to occur among
the elderly, and those
on their way to the
bathroom
Ward design did not
impact the incidence of
falls
Study
Levene, S. &
Bonfield, G. (1991)
Focus of Study
To investigate accidents
occurring to children on
pediatric units in terms of factors
associated with accidents
To propose measures that may
reduce the frequency and
severity of accidents
Research Design
Questionnaires
were distributed
over a one year
period
Information
collected included
details regarding
the accident; this
consisted of the
injured person and
the injury sustained
and the supervision
of the child
Sample
Information and
Site
Site: Eight
hospitals with
pediatric wards
Sample: Inpatients
outpatients or
visitors age 16 or
under; 781
questionnaires
were collected
Findings
Accidents were more
frequent amongst boys
of all ages and children
under the age of 5
Most common accident
was a fall from a height
followed by being
struck by or coming
into contact with
equipment
Most common result of
an accident was no
injury
Most common injuries
included bruises and
lacerations; most
common injured site
was the head
Relationship of
findings to room
occupancy
Although most
accidents did not result
in injuries, most
accidents could have
been prevented
No mention made in
regards to room
occupancy
Study
Focus of Study
Mulin, B., Rouget,
C., Clement, C.,
Baily, P., Julliot, M.,
Viel, J. F., et al.
(1997)
To assess the rate and routes of
Acinetobacter baumannii
colonization and pneumonia
among patients who were
mechanically ventilated in a
surgical intensive-care unit
Pullen, R., Heikaus,
C., & Fusgen, I.
(1999, December)
To identify risk factors that
contribute to patient falls
Research Design
Specimens were
screened for the
presence of
Acinetobacter
baumanii
Patients were
screened over a six
month period
before and after
modifications took
place to the unit
The unit was
modified from 7
isolation rooms and
2 open rooms with
4 beds each to a
unit with 15
isolation rooms,
each with a handwashing sink
Falls were recorded
prospectively
during a one-year
period
A formal check list
was used to
document the
circumstances of
each fall by the
nurse or therapist
in charge of the
patient’s care
Sample
Information and
Site
Findings
Relationship of
findings to room
occupancy
Site: University
Hospitals of
Besancon, France
Sample: 135
patients prior to the
renovation; 179
patients after the
renovations
29 of 135 patients
before the renovations
had infected
bronchopulmonary
tracts versus 2 of 179
patients admitted after
the renovations
Rate of colonization
was 28.1% prior to the
renovations and 5%
after the renovations
Colonization was
associated with
prolonged stay in
hospital; acquisition of
infection by crosstransmission was the
major route for
colonization
Move from open to
isolation rooms may
help control the
acquisition of A
baumanii in
mechanically ventilated
patients
Site & Sample: All
falls that occurred
at a geriatric
hospital
536 falls occurred at the
5 hospital wards during
the period studied
Only 11 falls were
observed by medical
staff
Most falls occurred
when the patient was
alone or together with
other patients in their
rooms; 444 falls were
recorded in the rooms
74 falls occurred when
the patients were alone
in the bathroom
Improved monitoring is
needed to prevent
patient falls
Most falls occurred in
the patient room; the
majority of the rooms
were multiple
occupancy (two-, three, or 4-bed); only 4
rooms were single
occupancy
Study
Seltzer, E.,
Schulman, A.,
Brennan, P.J., &
Lynn, L. A. (1993,
December)
Focus of Study
To examine patient attitudes in
regards to rooming with patients
with HIV infection and other
medical conditions
Research Design
Surveys were
administered to
patients to examine
their preference for
single or double
occupancy rooms,
to assess their
knowledge of HIV,
and to inquire
about their
attitudes regarding
rooming with a
patient who had
HIV, cancer,
pneumonia,
dementia, or
disfiguring skin
lesions
Surveys were
structured and
intervieweradministrated
Sample
Information and
Site
Site: A University
hospital in an inner
city
Sample: 104
inpatients
Findings
55% of patients said
they would object to
rooming with a person
with HIV; of these
patients, 46% preferred
a private room
A significant number of
objectors felt they had a
right to know why their
roommate was in the
hospital and had poorer
knowledge about the
transmission of HIV
Patients did not know
the hospital policy on
HIV transmission, nor
did they ask
Relationship of
findings to room
occupancy
Lack of knowledge
regarding HIV infection
may be an underlying
cause to people’s fear
of rooming with HIVpositive patients
The majority of patients
preferred a private
room instead of sharing
a room with an HIV –
positive patient
Study
Shirani, K. Z.,
McManus, A. T.,
Vaughan, G. M. et al.
(1986)
Focus of Study
To investigate the effect of using
isolation measures on the
infection and mortality rates of
burn victims
Research Design
The original ward
was open and
consisted of limited
hand washing
facilities; the
renovated unit
consisted mainly of
private rooms, each
with a sink
Paints were
assessed for
infections through
daily through
physical
examinations and
laboratory tests
Observed and
predicted mortality
were compared
Sample
Information and
Site
Site: An open
intensive care ward
and renovated
intensive care ward
Sample: 173
patients on an open
intensive care ward
and 213 patients on
a renovated
intensive care ward
Findings
The observed mortality
was significantly lower
than the predicted
mortality on the
renovated ward for noninfected patients
Infections that were
reduced on the
renovated ward were
bactermia and urinary
tract infection
Relationship of
findings to room
occupancy
The incidences of
nosocomial infections
and mortality were
decreased through
changes in the patient
environment
Having an individual
room with its own hand
washing facility appears
to decrease the risk of
infection for burn
patients
Study
Stelfox, H. T., Bates,
D. W., & Redelmeier,
D. A. (2003, October
8)
Focus of Study
To examine the quality of care
received by patients who are in
isolation due to infection control
Research Design
Consecutive adults
admitted to both
hospitals who were
isolated for at least
two days with
MRSA were
identified
Patients were either
in a general cohort,
which included all
diseases, or a
disease-specific
cohort, which
included patients
with congestive
heart failure
Two matched
controls were
identified for each
isolated patient
Patient charts were
reviewed for
demographic,
hospital, and
clinical data;
process of care
measures included
documentation of
patient vital signs
and clinicians’
narrative notes
Adverse events
were recorded and
patient satisfaction
was measured
Sample
Information and
Site
Site: Sunnybrook
and Women’s
College Health
Sciences Centre in
Toronto, Ontario &
Brigham and
Women’s Hospital
in Boston,
Massachusetts
Sample: 78
isolated patients
and 156 control
patients in the
general cohort &
72 isolated patients
and 144 control
patients in the
congestive heart
failure cohort
Findings
Isolated patients were
more likely to have
their vital signs
incompletely recorded
and to have days where
they were not recorded
at all
Isolated patients were
twice as likely as
control patients to
experience adverse
events
Isolated patients were 8
times more likely to
experience supportive
care failures such as
falls and pressure ulcers
Isolated patients had
longer hospitalizations
and expressed greater
dissatisfaction with
their treatment
Relationship of
findings to room
occupancy
Patients in isolation due
to infection control are
more likely to
experience an adverse
event than patients not
in isolation
Study
Sutton, J. C. (1994,
March/April)
Focus of Study
To report data on three studies
which assess accidents in
hospitals
Research Design
Study 1: Data
were collected over
a 1-year period;
data was collected
from patient
accident reports,
patient interviews,
nurses’
questionnaires, and
medical and
nursing records
Study 2:
Comparative study
of 50 reported
accident and 50
non-accident
patients; data was
same as in 1st study
Study 3: Inpatients
in the first two
studies were asked
whether they
sustained an
accident while in
hospital; records
were checked to
see if an accident
report form was
completed
Sample
Information and
Site
Site: 10 wards in a
large acute care
hospital
Sample: 515
inpatients
Findings
382 patients had one
accident and 133 had
multiple accidents
Most accidents
occurred to patients
over the age of 60
Accident rate was
greater for males
Patients who had
accidents were most
frequently diagnosed
with a neurological
disorder
One-third of patients
were injured as a result
of their accidents
Majority of reported
accidents were falls
83% of the patient
accidents were as
caused by the patients’
condition by staff
Nurses estimated the
visual and hearing
acuity of patients as
being better than what
the patients judged
themselves
Relationship of
findings to room
occupancy
Falls were the most
common type of
accidents, and the
elderly are most prone
to experience an
accident
No mention was made
in regards to room
occupancy
Study
Tutuarima, J. A, van
der Meulen, J. H. P.,
de Haan, R. J., van
Straten, A., &
Limburg, M. (1997)
Focus of Study
To assess the incidence of falls
as well as identify risk factors
for patients hospitalized as a
result of a stroke
Research Design
Trained
nonmedical
research assistants
collected data from
medical and
nursing records
Information
included type of
stroke, stroke
severity, medical
history,
comorbidity,
neurological
deficits,
complications, use
of medications, and
intensity of nursing
care
Information was
collected regarding
the circumstances
of a patient’s fall, if
one occurred
Sample
Information and
Site
Site: 23 hospitals
in the Netherlands
Sample: 720 acute
stroke patients
Findings
104 of the 720 stroke
patients fell at least
once; a total of 173 falls
occurred
Risk factors increasing
the likelihood of a fall
were heart disease,
mental decline,
confusional state, and
urinary incontinence
Risk of falling a second
time increased for
patients who had fallen
once before
Most falls occurred in
the day, in the patients’
room, and during visits
to the bathroom
Approximately 25% of
the falls resulted in
injuries
Relationship of
findings to room
occupancy
Patients who suffered
from a stroke had a
relatively high risk for
falling
Although a large
number of falls
occurred in the patients’
rooms, room occupancy
was not mentioned
Non Empirical Studies
First and Operating Costs of Hospitals
Study
Focus of Article
Type of Healthcare
Facility
Eickhoff (2003,
August)
To discuss recommendations
made in the SHEA Guideline
for preventing nosocomial
transmission of VRE
U. S. Hospitals
Kappstein, I. &
Daschner, F.D.
(1991)
To summarize effective
procedures for preventing
hospital-acquired
staphylococcal infections
Hospitals in general
Recommendations for
Healthcare Settings
VRE recommendations suggest
establishing an institutional
program for active surveillance
Problem with active surveillance
is insensitivity of the
surveillance instrument
60-70% of hospitals do not carry
out active surveillance
Errors could become locked in
policy and damage could be
done to the academic
respectability of hospital
epidemiology
Careful resource management
may make it difficult to establish
active surveillance for VRE
Frequent hand-washing key to
control hospital-acquired
infections
Private rooms only necessary for
patients with staphylococcal
pneumonia or skin lesions that
cannot be covered by a dressing
Architectural design is one of
most costly and least effective
measures in preventing
staphylococcal infections
Isolation of patient with MRSA
is reasonable since it may
become endemic
Relationship of findings to room
occupancy
No mention was made in regards to room
occupancy
Most effective measure for preventing
staphylococcal infections
Isolation is necessary in the case of
patients with MRSA
Study
Muto, C. A.,
Jernigan, J. A.,
Ostrowsky, B. E.,
Richet, H. M., Jarvis,
W. R., Boyce, J. M.,
& Farr, B. M. (2003,
May)
Focus of Article
To present an evidence-based
guideline on preventing the
transmission of nosocomial
infections
Type of Healthcare
Facility
Hospitals in general
Recommendations for
Healthcare Settings
Observation of MRSA has been
controlled with rigorous
infection control practices
designed to prevent
transmission; use of stringent
barrier precautions, cohort
nursing, and isolation of patients
until determined to be free of
MRSA
Infection control practices,
including isolation, influence
VRE transmission rates
Transmission of VRE can occur
via contaminated hands of
healthcare workers or via having
the same healthcare worker as an
infected patient; proximity to an
unisolated patient is a major risk
factor as well
Cleaning and disinfecting
policies should be developed to
control environmental
contamination
Patient outcomes are improved
and health care costs are reduced
through an infection control
program that emphasizes early
identification of infected patients
Relationship of findings to room
occupancy
Infection control programs help to control
the transmission of infection in hospitals
Isolation of the infected patient aids in
reducing the transmission of infections
Study
O’Connell, N. H. &
Humphreys, H.
(2000)
Focus of Article
To describe the design of the
intensive care unit to help
prevent the spread of hospitalacquired infections
Type of Healthcare
Facility
Hospitals in general
Recommendations for
Healthcare Settings
Design should minimize entry
and persistence of microorganisms; thorough cleaning of
surfaces should be facilitated
Transmission of resistant strains
is promoted through poor
compliance with hand-washing
protocols, shortages of nursing
staff, and high density of
crowding of patients
Patients requiring isolation
should be placed in single rooms
Ratio of one cubicle to six bed
spaces is recommended, though
it may be lower in some cases
Enough space should be
provided around the bed to
separate patients
Hand basins should be provided
for every other bed; they should
be equipped with elbow or foot
operated faucets
Air pressure differential should
exists between the patient’s
room relative to the unit
Relationship of findings to room
occupancy
Hand-washing is the most important
infection control measure
Private rooms are needed for patients
requiring isolation
Study
Ognibene, F. P.
(2000)
Focus of Article
To discuss the requirements
that are needed to deal with
the risk of an infection in an
Intensive Care Unit.
Type of Healthcare
Facility
U. S. Hospitals
Recommendations for
Healthcare Settings
In intensive-care units, immunocompromised hosts are more
common & resistant organisms
can be dispersed throughout the
unit; patients can then become
infected by the resistant
organism
Standard source isolation
measures include a singleoccupancy room, aprons or
gowns, gloves, and handwashing
Airborne infected patients
should be in tightly sealed
isolation rooms with separate
areas for handwashing, gowning,
and storage
Protective environment rooms
have positive air pressure
relative to the adjoining space;
purpose is to limit anything from
the outside from entering and
contaminating high-risk patients;
rooms could be risky if a
respiratory pathogen is involved
MRSA can occur in patients
with previous hospitalizations,
intravascular lines, ICU
admission, and recent antibiotics
VRE can be transmitted from
colonized patients or from
inadequate compliance with
handwashing precautions
Relationship of findings to room
occupancy
Larger-sized single rooms are
recommended to accommodate
equipment, sinks in every room, and the
ability to store contaminated products
Large, multi-patient rooms can increase
the spread of infection if patients become
infected
Study
Sehulster, L., &
Chinn, R. Y. W.
(2003, June 6)
Focus of Article
To review previous guidelines
and make recommendations
for preventing environmentassociated infections in
healthcare facilities
Type of Healthcare
Facility
U. S. Hospitals
Recommendations for
Healthcare Settings
Severely immunocompromised
patients should have minimal
exposure to activities that may
cause aerosolization of fungal
spores; time outside of their
rooms should also be minimal
Ventilation specifications and
dust-controlling processes
should be incorporated in the
planning and construction of
protective environments
Rooms of immunocompromised
patients should maintain positive
pressure
Patients diagnosed with or
suspected of having an airborne
infectious disease should be
placed in an isolation room
Standard cleaning and
disinfecting protocols should be
used to control environmental
contamination
Relationship of findings to room
occupancy
Patients with airborne infectious diseases
should be placed in isolation
Empirical Studies
Therapeutic Impacts: Relationship between healing and environment
Study
Focus of Study
Baker, C. F., Garvin,
B. J., Kennedy, C.
W., & Polivka, B. J.
(1993)
To examine the effects of
environmental sounds and
communication on the
cardiovascular responses of
coronary care patients
Research Design
High ambient
stressors were
classified as sounds
inside and outside
the room
Social stressors
included room
conversation and
hall conversation
Low ambient
sounds were
continuous sounds
in the room from
lighting, heating,
and ventilation
Cardiac monitors
were used to obtain
an
electrocardiogram
Blood pressure was
measured every 3
minutes
Trait anxiety was
measured at the
conclusion of data
collection
Data were
collected
continuously for
five 45-min periods
in the morning,
midday, and in the
early evening of
day one and in the
morning and
midday on day two
Sample
Information and
Site
Site: A 29-bed
critical care unit
with private rooms
in a large
Midwestern
teaching hospital
Sample: 20
coronary care
patients
Findings
Room conversation
occurred most
frequently followed by
background sound, hall
conversation, and
environmental sound
Sound levels were
highest during room
conversation and lowest
for background sound
Loudest environmental
sounds came from
furniture moving,
alarms, and toilet
flushing within the
patients’ rooms
Heart rate levels
increased during
conversations
Trait anxiety scores
were not related to
cardiovascular
reactivity
Relationship of
findings to room
occupancy
High sound levels were
related to higher heart
rate levels in certain
instances
No mention was made
in regards to room
occupancy, though it
was mentioned that
sound levels are
probably lower on this
unit with private rooms
than on open intensive
care units
Study
Baldwin, S. (1985,
May)
Focus of Study
To evaluate the impact of
furniture rearrangement on
patients and on the ward
atmosphere
Research Design
Furniture was
rearranged into
group seating
arrangements in the
ward dayrooms on
7 wards; Once a
day at least 2 group
seating
arrangements were
established
The intervention
followed the
sequence of a
baseline,
intervention, a
second baseline,
and a second
intervention; it
lasted 8 weeks
Variables measured
were medication
rates, seclusion
rates, points
earned, perception
of the ward, and
nursing reports
Sample
Information and
Site
Site: 7 male wards
and 3 female wards
in a maximumsecurity hospital in
England
Sample: Residents
on the 10 wards;
each ward has an
average of 20
residents
Findings
Trend exists toward
overall decrease in
seclusion in
intervention wards
A minor trend was
discovered towards
increased involvement
in the ward program in
the intervention wards
Medication rates were
stable across both
wards
The number of casualty
incidents decreased on
the intervention ward
A greater number of
points was earned by
those on the
intervention ward
Relationship of
findings to room
occupancy
Moderate gains in the
social interaction of
patients in a maximumsecurity hospital can be
achieved through shortterm intervention
No mention made in
regards to room
occupancy
Study
Baum, A. & Davis,
G. E. (1980)
Focus of Study
To assess the effects of
architectural intervention on
residential crowding stress and
poststressor effects
Research Design
Survey data was
collected to
measure feelings
regarding
dormitory life and
feelings about the
college
Observational data
was used to
describe the effects
of exposure to
residential
conditions on
behavior in the
dormitory
Laboratory data
was used to assess
the persistence and
generalizability of
the effects of
exposure to
different residential
conditions
Intervention
included adding
more lounge space
and reducing the
number of
residents along the
corridor; floor
housed 2 groups of
20 residents
Sample
Information and
Site
Site: Dormitories
of a small
residential liberal
arts college; 3
dormitories were
used: standard
long corridor, short
corridor, and a long
corridor that has
been manipulated
Sample: 67 female
residents living in
the dormitory
completed
questionnaires; 54
subjects
participated in
laboratory
component
Findings
Residents residing on
the standard long
corridor reported more
crowding and controlrelated problems and
less small group
development
Long corridor residents
reported less perceived
control, increased
difficulty in regulating
social contact,
dormitory life more
hectic and less
controllable, and less
confidence in ability to
control settings
Less social activity
observed on the longcorridor
Residents on the altered
long corridor were
more confident in their
ability to control
events, less withdrawn,
and engaged in more
social interaction
Residents of the short
corridor and altered
corridor experienced
less stress and less
crowding than those on
the long corridor
Relationship of
findings to room
occupancy
Decreased residential
group size on the
altered long corridor
prevented symptoms of
stress, withdrawal, and
helplessness
Findings related to
specific room
occupancy were not
mentioned
Study
Focus of Study
Beauchemin, K. M.
& Hays, P. (1996)
To determine if the recovery of
depressed patients is affected by
their placement in brighter or
darker rooms
Becher, C. (1998,
March 12)
To determine the view patients
had of mixed-sex wards
Research Design
Data was
abstracted from
admission records
over a two-year
period in terms of
the patient’s
diagnosis and
length of stay
Questionnaires
regarding the
patients view on
the mixed-sex
ward, their age,
sex, length of stay,
and specialty were
mailed out after
discharge
Sample
Information and
Site
Findings
Relationship of
findings to room
occupancy
Site: A psychiatric
inpatient unit in
Edmonton, Alberta
Sample: 174
patients that had
been admitted and
discharged
Length of stay was
shorter for patients in
brightly lit rooms; trend
was more marked in
males
No mention made in
regards to room
occupancy
Site: Seven
surgical wards at
Southmead
Hospital, Bristol
Sample: 87
patients (64 on
mixed-sex wards
and 23 on singlesex wards)
The majority of men
did not have a
preference for either
ward
The majority of women
preferred a single-sex
ward
Gynecology patients
were most in favor of a
same-sex ward, though
most other patients
undergoing various
types of surgeries
preferred same-sex
wards too
Patients with previous
experience of mixedsex wards were more
tolerant of them
Single-day cases
preferred same-sex
wards; patients with
longer stays were more
tolerant of mixed-sex
wards
Most patients,
especially women and
those in for 1-day cases
were in favor of singlesex wards
No mention made in
regards to room
occupancy
Study
Brown, C., Arnetz,
B., & Petersson, O.
(2003)
Focus of Study
To investigate the views of staff
members of their work
environment, their health, and
the quality of care they delivered
during a period of downsizing
Research Design
Longitudinal
correlational design
Staff opinions of
the quality of care
delivered and
features of the
work environment
were measured
over a period of
years of hospital
downsizing
Sample
Information and
Site
Site: tertiary care
facility in Sweden
Sample: Doctors
and nurses who
completed the
questionnaires
Findings
Quality of care was
rated similarly prior to
and after the
downsizing occurred
Staff perceptions of
work environment
during the downsizing
was affected; scores
were lower during this
period
Perceptions of
workload increased
after the downsizing
was complete
Relationship of
findings to room
occupancy
No mention was made
in regards to room
occupancy
Study
Burden, B. (1998)
Focus of Study
To observe the strategies women
in a maternity ward use to
preserve their privacy
Research Design
Subject
information was
obtained through
personal records in
regards to type of
delivery, method of
feeding, antenatal
week or postnatal
day, and their
position in the
ward
Discussions were
held with patients
over 12 visits in
regards to their
actions and views
on why they and
other women had
drawn curtains
around their beds
Sample
Information and
Site
Site: A maternity
ward in England
Sample: All
women within the
ward, excluding
those on their first
day following a
Caesarian section
Findings
Three strategies were
discovered in terms of
the position of the
curtains: complete
closure, semi-closure,
and private closure;
complications were a
factor in the amount of
closure used
Complete closure was
used to withdraw or to
change clothes or
sanitary towels
Semi-closure was used
to gain attention of
staff, to get solitude, or
to feed child
Partial closure used
most often throughout
the day to get some rest
or to read
Relationship of
findings to room
occupancy
Women used to curtains
around their beds to
dictate the amount of
privacy they wanted;
Most only partially
closed their curtains,
but others who felt
inadequate around
others tended to use full
closure of their curtains
Study
Cleary, T. A.,
Clamon, C., Price,
M., & Shullaw, G.
(1988)
Focus of Study
To describe the effects of a
reduced stimulation unit on
patient care
Research Design
Pretest-posttest
design used
A reduced
stimulation unit
was created to
reduce the level of
patient stimulation
and minimize their
reliance on
memory
Staff, family
members, and
visitors were
educated in
effective
techniques to use
with patients
Patients were
assessed through
observations and
interviews; family
members filled out
a satisfaction
questionnaire;
nurses were given a
questionnaire
assessing job
satisfaction
Sample
Information and
Site
Site: Oaknoll
Retirement
Residence in Iowa
City, Iowa
Sample: 11 patients
on the new unit
Findings
The majority of patients
who had been losing
weight prior to the
opening of the new unit
had now reversed the
trend
Levels of patient
agitation significantly
decreased
Family members
reported increased
satisfaction; patients
were more calm,
serene, and less agitated
Nurse satisfaction did
not change
Relationship of
findings to room
occupancy
Patients benefited from
the creation a unit with
reduced stimulation
No mention was made
in regards to room
occupancy
Study
Focus of Study
D’Atri, D. A. (1975,
June)
To measure if a correlation
exists between degree of
crowding and blood pressure
levels in an enforced crowded
environment
Research Design
Data was collected
by interviewers
using standardized
questionnaires
Data collected
included
demographic and
subcultural data,
personal
characteristics,
mode of housing,
confinement
history, and blood
pressure
Sample
Information and
Site
Site: 3 correctional
institutes, each
with different
modes of housing
including single
cell, doubleoccupancy cells, or
larger dormitories
Sample: Inmates
in the correctional
facilities
Findings
On average, blood
pressure was higher for
inmates in dormitory
cells
Factors associated with
blood pressure levels
were anxiety which
increased blood
pressure during the first
241 Twtectiona cella6ha first
Relationship of
findings to room
occupancy
Study
Focus of Study
Flaherty, J. H., Tariq,
S., Srinivasan, R.,
Bakshi, S.,
Moinuddin, A., &
Morley, J. E. (2003)
To assess a new model of
treating elderly patients with
delirium
Gotlieb, J. B. (2002)
To discuss the relationship
between patient hospital
satisfaction and their hospital
rooms as well as their evaluation
of nurses and locus of causality
Research Design
Hospital database
reviewed for
patients discharged
from the delirium
room in the acute
care for the elderly
unit (4-bed unit
with constant
monitoring)
Data included
activities of daily
living,
demographic
information, and
the amount of
medication taken
by patients
Questionnaires
were mailed to
patients who had
been discharged
from the hospital
Measures included
patient satisfaction,
patients’ evaluation
of their nurses and
their rooms and
patient perception
of locus of
causality
Sample
Information and
Site
Findings
Relationship of
findings to room
occupancy
Site: Saint Louis
University Hospital
Sample: 69
patients
No physical restraints
were used on patients in
the Delirium Room
Use of medication of
patients similar to or
lower than that found in
previous studies
Use of sedatives was
less than 10%
Mortality was zero
Patients were functional
and achieved early
mobilization
Patients suffering from
delirium appear to
benefit from constant
nursing care in a multibed room
Site: Large
hospital in a major
metropolitan area
Sample: 232
patients discharged
from the hospital
Patients’ evaluation of
their rooms affected
their evaluation of their
nurses and their
hospital satisfaction
Patients’ evaluation of
their nurses affected
their hospital
satisfaction
Patients’ locus of
causality affected their
evaluation of their
nurses
Proper staffing of
skilled nurses and a
positive environment in
patients’ hospital rooms
can increase patient
satisfaction
No mention made in
regards to room
occupancy
Study
Gotlieb, J. B. (2000)
Focus of Study
To investigate whether a
relationship exists between the
patient’s hospital rooms and
their perception of nurses on
their perception of hospital
quality
Research Design
Questionnaires
were sent to
patients
Measures included
patients’
expectations of and
their perceptions of
their rooms and
their nurses, as
well as the amount
of control they felt
they had and
Sample
Information and
Site
Site & Sample:
232 patients who
had received care
in a U. S. Hospital
Findings
Patients’ perception of
their rooms affected
their perception of their
nurses and of overall
hospital quality
Patients’ perception of
control affected their
perception of their
nurses but not the
overall quality of the
hospital
Patients’ perception of
their nurses affected
their overall perception
of the quality of the
hospital
Relationship of
findings to room
occupancy
Patients’ perception of
their rooms impacts
both their perceptions
of the nurses and the
hospital; care should be
taken in designing the
rooms
No mention was made
in regards to room
occupancy
Study
Harris, P. B.,
McBride, G., Ross,
C., & Curtis, L.
(2002, June)
Focus of Study
To investigate the relative
contribution of environmental
satisfaction to overall
satisfaction with the hospital
experience
To determine sources of
environmental satisfaction
within the hospital setting
To examine differences in
satisfaction levels among various
hospital departments
Research Design
Telephone
interviews were
conducted with
patients
Open-ended
questions related to
satisfaction with
the hospital room
and satisfaction
with the
environment
outside the room
The Patient
Perceptions of
Quality InterviewInpatient form was
used to determine
patients’
perceptions of the
overall quality of
care and services
received
Sample
Information and
Site
Site: Six different
hospitals owned by
IHC (2 small, 2
midsize, and 2
large facilities were
used)
Sample: 380
inpatients
Findings
Nursing care was the
strongest predictor of
overall satisfaction
followed by perceived
quality of clinical care,
environmental
satisfaction, and
satisfaction with
admitting procedures
Five major sources of
satisfaction with the
patient room: interior
design features,
architectural features,
social features,
maintenance/
housekeeping, and
ambient environment
Satisfied patients had a
room where the features
were easily accessible,
had a window with a
view, had larger rooms
Patients satisfied with
the social features of
the room had a private
room or had privacy
protected
For the most part,
patients were satisfied
with their rooms
Participants suggested
that hospital design
should include private
rooms that have a
window with a view,
room to accommodate
visitors, and bathrooms
Relationship of
findings to room
occupancy
Patients suggested that
rooms should have
accessible features
Room design should be
private with amenities
such as a bathroom, a
window with a view,
and space to
accommodate visitors
Study
Focus of Study
Research Design
Sample
Information and
Site
Hays, P. &
Beauchemin, K. B.
(1998, October)
To describe the effects of a
sunny room on patients with
myocardial infarction
Natural experiment
Outcomes of
patients treated in
sunny versus dull
rooms were
compared
retrospectively
based on fatal
outcomes and
length of stay over
4 years ending in
March 1996
Site: A cardiac
intensive care unit
in Edmonton,
Canada
Sample: 568
patients admitted
directly to the
cardiac intensive
care unit with a
first attack of
myocardial
infarction
Higgs, P. F.,
MacDonald, L. D., &
Ward, M. C. (1992)
To determine patients’ views in
regards to their stay in long-term
geriatric wards
Patients were
assessed for
performance status
and levels of
confusion
Patients were then
interviewed about
their views of life
in the long-stay
ward
Site: Long-stay
institutions in the
South West
Thames region
Sample: 291 longstay patients in the
South West
Thames region
Findings
The average length of
stay for all patients was
2.46 days
Light does have an
effect on length of stay
Men stayed an average
of 2.3 days in sunny
rooms and an average
of 2.6 days in dark
rooms
Women stayed an
average of 2.3 days in
sunny rooms and 3.3
days in dark rooms
Deaths were more
frequent on the dark
side
The majority of patients
were satisfied with their
relations with the
medical, nursing, and
other staff
Most patients were
satisfied with their
degree of autonomy
Most patients did not
feel lonely
The majority of the
patients found the staff
and care received were
the best thing about the
institution
Relationship of
findings to room
occupancy
The amount of light in a
room does impact a
patient’s stay
No mention made in
regards to room
occupancy
On the whole, patients
were satisfied with the
care received at longterm care facilities
No mention made in
regards to room
occupancy
Study
Hilton, B. A. (1985)
Focus of Study
To determine sources of sound,
levels of sound, patient perceptions
of sound, and which types of sounds
can be modified in acute patient care
areas
Research Design
Exploratory and
descriptive design
Continuous recording
of sound levels made
in proximity of each
patient over a 24hour period
Participants provided
oral answers to a
questionnaire which
asked patients how
noise affected them
and whether or not
they found the noise
levels acceptable
Sample
Information and
Site
Site: Three hospitals
(one large, one small
teaching, and one
small community) in
a large metropolitan
area in Northwest
Canada; four
intensive care units
and two general care
units were used for
this study
Sample: 25 patients;
4 to five patients
from each unit;
convenience sample
used
Findings
The critical and
noncritical areas were
quieter in the two smaller
hospitals
Levels of talking by staff,
patients, and visitors were
louder on all units than
necessary
Sound levels dropped at
night in all units except
the recovery room and
intensive care unit in the
large hospital
Steady sounds included
oxygen, chest-tube
bubbling, and ventilator
functioning
Patients were satisfied
with noise levels in the
pre-and postoperative
ward of the large hospital,
the medical wards and
intensive care units in the
teaching hospital, and the
intensive care unit of the
small community hospital
Sound levels generated
outside of the room were
reduced when the patient’s
door was closed
Differences in noise levels
between the large
hospital’s intensive care
unit and recovery room
and the intensive care
units of the small hospitals
appear related to room
size; the small hospital
consisted of private rooms
while the large hospital
consisted of two rooms
with two to eight patients
per room
Relationship of
findings to room
occupancy
Sound levels appear to be
related to room size in that
they were lower in rooms
with single occupancy
rather than multiple
occupancy rooms
Study
Focus of Study
Holahan, C. J. &
Saegert, S. (1973)
To investigate the relationship
between ward design and patient
behavior on two hospital wards
Ittelson, W. H.,
Proshansky, H. M., &
Rivlin, L. G. (1970,
December)
To determine the impact that
bedroom size has on the
behavior of patients
Research Design
Design was
posttest control
group
Wards were
selected based on
how well matched
they were on
selected criteria
One ward was
remodeled during a
4-week period;
purpose was to
improve ward
atmosphere
Experimental
measures collected
6 moths after
remodeling
occurred during a
5-week period
Patients were
observed and
interviewed
Observations of
patients were made
using a timesample approach
The location,
participants, time,
and nature of
activity on the
ward were
recorded
Bedrooms of
patients were
mainly single- and
double-occupancy;
1 4-bed room was
located on each
ward
Sample
Information and
Site
Findings
Relationship of
findings to room
occupancy
Site: One
remodeled and one
original ward at the
City University of
New York Hospital
Sample: 25
patients on each
ward
Significantly more
socializing and less
passive behavior
occurred on the
remodeled ward
On the remodeled ward,
there was a trend
towards greater
socialization in the
bedrooms than in the
control ward; the
bedrooms were of the
dormitory type but on
the remodeled ward,
partitions were installed
creating a number of 2bed sections
Attitudes were more
positive towards the
physical environment
on the remodeled ward
A well-designed
physical environment
can facilitate recovery
Rooms were shared
occupancy and a trend
towards greater
socialization was
noticed on the
remodeled ward,
though explanations
were not given as to
why this trend may
have occurred
Site: The
psychiatric wards
of three large
metropolitan
hospitals; they are
private, city, or
state hospitals
Sample: Patients
on the wards
Isolated passive
behavior is most
frequent in all
bedrooms
As the number of
patients in the room
increases, isolate
passive behavior
increases
Social behavior
decreases with
increased bedroom size
The smaller rooms,
with less occupants,
provide the patients
with the greatest
freedom of choice for
activities
Study
Focus of Study
Research Design
Sample
Information and
Site
Findings
Relationship of
findings to room
occupancy
Janssen, P. A.,
Harris, S. J.,
Soolsma, J., Klein,
M. C., & Seymour, L.
C. (2001,
September)
To evaluate the responses of
nurses prior to and after working
in a single room maternity ward
in comparison to working in a
traditional maternity ward
Nurses planning to
work on the new
single room ward
completed surveys
6 months prior to
opening the ward
and three months
after the ward
opened
Questions
measured nurses’
perception of the
physical setting,
quality of care,
perceived
competence, and
the nursing practice
environment
Site: BC Women’s
Hospital in
Vancouver, Canada
Sample: 20 single
room maternity
care nurses, 26
delivery suite
nurses, and 26
postpartum nurses
Physical space was
more spacious in the
single rooms and
equipment and supplies
were more easily
accessible than in the
delivery suite; privacy
was also increased and
noise levels decreased
in the single rooms
Nurses were better able
to respond to the
physical, emotional,
and spiritual needs of
the patients in the
single rooms
Nurses felt more
accountable for their
decisions in the single
rooms and they felt
highly competent
Medical staff was less
readily available in the
single room unit
Job satisfaction
increased on the single
room wards
Nurses preferred the
single room maternity
unit
Kulik, Moore, &
Mahler (1993)
To determine effects of roommate
on anxiety levels of patients
To look at interaction patterns of
preoperative patients and their
roommates
Evening prior to
surgery, patients
approached and
asked to complete
questionnaire dealing
with opinions &
experiences as a
surgical patient in a
hospital
Site: San Diego
Veterans
Administration
hospital
Sample: 53 men
undergoing nonemergency surgeries
(hernia, open-heart
(valve),
bladder/prostate)
Anxiety significantly
higher for preoperative
patients assigned to a
preoperative roommate
compared to a
postoperative or nonsurgical roommate
Patients talked
significantly more to
preoperative rather than
postoperative or nonsurgical roommates
Patient’s preoperative
anxiety and affiliation
levels were unrelated
Practical benefit to
assigning preoperative
patients to postoperative
or non-surgical
roommates; semi-private
room beneficial for preoperative patient
Study
Lawson, B. & Phiri,
M. (2000)
Focus of Study
To address patient satisfaction in
relation to their hospital
surroundings
Research Design
Patients were
surveyed over 3
months in regards
to their condition,
treatment, and
health outcomes
Comparisons were
made between
orthopedic patients
treated in a
refurbished ward at
Poole Hospital
versus those treated
in a conventional in
the same hospital
Comparisons were
also made between
psychiatric patients
in a purpose-built
ward at Mill View
hospital with those
on two wards at
Brighton General
Hospital
Patients were also
given a
questionnaire upon
discharge which
dealt with their
hospital stay
Sample
Information and
Site
Site: Poole
Hospital, Mill
View Hospital, &
Brighton General
Hospital in
England
Sample: 237
patients at Poole
Hospital and 151 at
Mill View Hospital
and Brighton
General Hospital
Findings
Patients in the newer
buildings and wards
rated their experience
and treatment higher
than those in the older
wards
Those in the newer
buildings were more
satisfied with the
appearance, layout and
overall design of the
ward
The psychiatric patients
at Mill View were
discharged more
quickly and spent less
time in intensive care
than those in the old
building
Fewer analgesics were
used on orthopedic
patients on the newer
ward
Relationship of
findings to room
occupancy
Hospital design impacts
patient satisfaction in
regards to their
treatment and the
facility
Patients treated in
single rooms were more
satisfied than those
treated in multiple-bed
wards
Study
Leigh, H., Hofer, M.
A., Cooper, J. &
Reiser, M. F. (1972)
Focus of Study
To compare the psychological
states of patients in a Coronary
Care Unit with multiple-room
occupancy versus single-room
occupancy
Research Design
Patients who were
willing were
approached and
were interviewed
and were given
surveys to
complete in regards
to their perceptions
of the Coronary
Care Unit as well
as their degree of
depression,
anxiety, agitation,
and hostility
Patient interactions
were monitored
and their medical
charts were
reviewed to
compare their
medical course
Sample
Information and
Site
Site: Two
Coronary Care
Units in a general
hospital in the
U. S.; one unit
contained multiple
occupancy rooms
(open) while the
other contained
only single
occupancy rooms
(closed)
Sample: 66
patients (33 on
each unit)
Findings
Patient-patient
interaction was higher
in the open ward
Separation anxiety was
higher on the closed
unit and patients felt
more lonely
Patients in the open
ward experienced
higher levels of shame
anxiety
Relationship of
findings to room
occupancy
On the closed unit,
privacy increased but
interaction decreased
and patients felt lonely
Patients on the open
unit had more social
contact with others and
felt they could express
their hostility openly;
lack of privacy led to
higher levels of shame
anxiety
Study
Martin, D. P., Diehr,
P., Conrad, D. A.,
Davis, J. H., Leickly,
R. & Perrin, E. B.
(1998)
Focus of Study
To compare patient outcomes on
the Planetree Model Hospital
Unit with other medical-surgical
units in the hospital regarding
satisfaction, education,
involvement in care, health
behavior and compliance, health
status, and use of services
Research Design
Patients were
interviewed for 20
minutes at
admission; They
were then asked to
fill out
questionnaires 1
week, 3 months,
and 6 months after
discharge
Limitations:
selection bias
between groups;
self reports could
increase chance of
social desirability
in responses; new
scales used which
could have lower
reliability and
validity
Sample
Information and
Site
Site: San
Francisco Hospital
Sample: Patients
18 and older
randomly assigned
to 2 wards
315 were Planetree
patients; 445 were
on other medical
units
Findings
Planetree patients:
significantly more
satisfied with hospital
stay and with unit’s
environment and
architecture; greater
opportunity to see
family and friends and
to interact with other
patients; learned more
about illness and selfcare; satisfied with
education received;
more likely to receive
written information
regarding condition and
treatment
No differences were
found in regards to
physician involvement
or patient control over
coping strategies
Long-term outcome
similar for both sets of
patients
Relationship of
findings to room
occupancy
With the proper
environment and
education, patients’
experience in the
hospital is positive,
regardless of room
occupancy.
Study
Focus of Study
Research Design
Sample
Information and
Site
Matthews, E. A.,
Farrell, G. A., &
Blackmore, A. M.
(1996)
To determine if a client-centered
approach affects agitation levels
and sleep patterns in patients
suffering from dementia
Data was collected
over four phases,
each lasting four
weeks
Levels of patients
sleep and agitation
were measured
prior to and after
the environmental
manipulation of
client-centered care
occurred
Site: 44-bed
dementia ward in a
nursing home in
Perth, Australia
Sample: 33
residents of the
dementia ward
Milne, D. & Day, S.
R. (1986)
To examine factors that impact
the patients’ and nurses’
perspectives of ward atmosphere
Nurses and patients
completed the
Ward Atmosphere
scale at 2 baseline
phases and then
post-intervention
2 versions of the
scale (real and
ideal) were given
to measure patient
and nurse
satisfaction
Staff were trained
on implementing a
revised therapeutic
program to acute
patients; they were
trained in behavior
therapy and anxiety
management
Site: National
Health Service
psychiatric day
hospital
Sample: Staff (6)
and patients (41) of
the day hospital
Findings
11 agitation behaviors
were common to at
least 20% of patients
throughout the study
period
Verbal agitation
significantly decreased
during the day shift
when the intervention
was introduced, but it
increased significantly
during the late shift
Daytime sleep
increased during the
first phase of the
intervention but
returned to preintervention levels by
the end of the study
Nurses’ and patients’
perspectives of the
ward atmosphere
increased after the
intervention was put
into place
The effect was only
noticeable in acute
patients and not chronic
patients, who did not
receive the intervention
Relationship of
findings to room
occupancy
No mention was made
in regards to room
occupancy
Improvements to the
therapeutic program
and to nurse training
can aid in making the
ward atmosphere more
positive
No mention made in
regards to room
occupancy
Study
Morgan, D. &
Stewart, N. (1999,
January)
Focus of Study
To describe the relationship
between environment and
behavior in dementia care
settings
Research Design
Following
completion of a
new building,
patients were
moved from an
existing highdensity Special
Care Unit (SCU) to
new low-density
Special Care Unit
Patients had larger,
private rooms in
new SCU; old SCU
contained smaller,
multiple occupancy
rooms
Interviews of staff
and family
members took
place 3 months
after patients were
moved; questions
were asked
regarding their
impressions of the
new unit
Sample
Information and
Site
Site: 286-bed
long-term care
facility
Sample: 4
registered nurses, 5
resident attendants,
and 9 family
members
Findings
Staff found it more
difficult to supervise
patients because of
corridor design;
resident safety was a
concern
The old SCU was seen
as happier because of
the closer proximity
and busy environment;
felt like a family
New SCU more
institutional because of
lower density and
decrease in activities;
rooms felt more like
home though because
more chance to
personalize them
Significant decrease in
disruptive behavior on
new SCU unit
Private bedrooms
evaluated positively;
more privacy given
Less interaction
occurred on new unit
because of greater
dispersion
Relationship of
findings to room
occupancy
Overall, the new unit
was evaluated
positively
Patients were given
greater privacy and
more space through
their private bedrooms
creating a comfortable,
home-like environment
Study
Nguyen, Briancon,
Empereur, &
Guillemin (2002)
Focus of Study
To identify factors associated
with patient satisfaction
Research Design
Sociodemographic
data and health
status were
collected on first
day of
hospitalization
2 weeks after
discharge, patients
were mailed
questionnaire
measuring patient
satisfaction
Sample
Information and
Site
Site: Nancy
University Hospital
Center, France
Sample: 684
patients with
cardiovascular,
respiratory,
urinary, and
locomotor diseases
Findings
Most patients tended to
rate hospital stay
favorably
Two strongest
predictors of higher
satisfaction were older
age and better selfperceived health status
Patients who stayed in
private patient rooms
were more satisfied
with admissions,
hospital environment
and staff, information,
and overall quality of
care
Patients who did not
choose their hospital
were twice as likely to
complain about their
stay
Relationship of
findings to room
occupancy
Patients in private
rooms were more
satisfied with the
hospital environment as
a whole
Study
Focus of Study
Research Design
Sample
Information and
Site
Pattison & Robertson
(1996)
To examine effect of ward
design on patients’ experience of
hospital and their well-being
To measure patient preference in
hospital design
Administered
detailed
questionnaire to
patients through
individual
interviews on 5th
post-operative day
Site: 2
gynecological
wards in United
Kingdom hospital
Sample: 64 female
patients (32 on
Nightingale ward,
32 on Bay ward)
Peltier, J. W.,
Schibrowsky. J. A.,
& Cochran, C. R.
(2002, Summer)
To determine if the nurse-patient
and physician-patient
interactions impact patient
loyalty and care quality
Questionnaires
were mailed to
patients; items
included nurserelated and
physician-related
questions and
measures of quality
of care and loyalty
Site: Large
metropolitan
hospital
Sample: 193
obstetric patients
from previous 12
months
Findings
Nightingale ward:
better contact with
nurses, higher noise
levels, higher sleep
disturbances, more
privacy
Bay ward: concerned
with lack of contact
with nurses, lack of
auditory privacy,
disturbing noises
75% of patients
preferred bay ward
Quality of care and
loyalty are a function of
wide range of nurse and
physician performance
variables
Quality of care function
of physician-patient
communications, nursepatient
communications, and
physician-patient social
interactions
Loyalty a function of
amount of decisionmaking control allotted
by physicians
Relationship of
findings to room
occupancy
Neither ward
overwhelmingly better
Bay ward preferred, but
could be improved
Patients’ quality of care
and their loyalty toward
the hospital is
dependent upon the
care given to them by
their physicians and
nurses as well as the
amount of control given
to them
No mention made in
regards to room
occupancy
Study
Rogers, S.
(2001/2002, Winter)
Focus of Study
To address the issue of a mixed
gender ward and its impact on
patient transfers, patient
admissions, staff reactions, and
financial costs
Research Design
Patients filled out
surveys in regards
to acceptance of
mixed gender
rooms
Nursing staff filled
out surveys in
regards to beliefs
regarding mixed
gender rooms
Data transfers for
November 2000
were reviewed to
measure costs
incurred with
patient transfers
Sample
Information and
Site
Site: University
Health Network in
Toronto (Toronto
General, Toronto
Western, Princess
Margaret)
Sample: 116
patients from these
3 hospitals were
surveyed; 31 frontline staff responded
to survey as did 27
nurse managers
Findings
If these hospitals
eliminated same gender
wards, they would save
from $58,880 to
$277,200; about 8-10%
of all transfers in these
facilities are due to
gender issues
Savings in transfers
only occur, however, if
patients are not moved
again to same gender
rooms
65% of patients would
accept placement in
mixed gender ward; it
increased to 76% if
placement in mixed
gender ward would
result in faster
admission
81% of nurses and 63%
of nurse managers
thought mixed gender
wards were not a good
idea; 68% of nurses and
67% of nurse managers
thought mixed gender
wards would make
working more difficult
Relationship of
findings to room
occupancy
Patients would
generally accept a
mixed-gender room
arrangement, especially
if it meant faster
admission; nurses did
not approve of mixedgender arrangements
Study
Singer, A. J.,
Sanders, B. T.,
Kowalska, A. Stark,
M. J., Mohammad,
M. & Brogan, G. X.
(2000, January)
Focus of Study
To measure the effect of a
bedside television set on patient
satisfaction
Research Design
A prospective,
randomized,
controlled,
unblended clinical
trial was used
A trained research
assistant recorded
patient information
on a structured
closed-question
data sheet
Patient satisfaction
as well as their
length of stay was
measured through a
100-mm visual
analogue scale and
Likert-type scale
Sample
Information and
Site
Site: The
emergency room of
a suburban tertiary
care center
Sample: 181
patients; 77 were
assigned to a room
with a bedside TV;
104 were assigned
to a room without
bedside TVs
Findings
Patient satisfaction the
same regardless of
whether or not TV was
in room
Patients who stayed
longer than expected
were less satisfied with
hospital than those who
stayed the same or less
than expected
Relationship of
findings to room
occupancy
It appears that bedside
television sets did not
affect patients’ overall
satisfaction levels
No mention made in
regards to room
occupancy
Study
Spaeth, G. L. &
Angell, M. F. (1968)
Focus of Study
To investigate the preference for
multi-bed or private rooms
among ophthalmic patients
Research Design
Patients admitted
or discharged from
the facility between
May 4 and June 2,
1967 were included
Patients were asked
to complete a
questionnaire upon
admission;
information
requested included
age, sex, if the
patient had been
previously
hospitalized, their
opinion of their
visual ability, and
their preference for
room type
Patients discharged
during this time
were also given a
similar form to
complete
Sample
Information and
Site
Site: Wills Eye
Hospital,
Philadelphia
Sample: 254
admission patients
and 376 discharged
patients
Findings
At time of admission,
majority of patients
preferred multi-bed
room
Most important
determinant of room
preference was previous
history of
hospitalization; patients
who had not been
hospitalized previously
preferred single rooms;
multi-bed rooms were
nine times as popular
among patients who
were previously
hospitalized
After their
hospitalization at this
facility, fewer patients
wanted single rooms
and significantly more
patients wanted multibed rooms
Degree of sensory
deprivation did not
influence feeling of
need for assistance by
roommates
Economic factors were
not important in
determining room
preference
Relationship of
findings to room
occupancy
Most ophthalmic
patients preferred multibed rooms to singleoccupancy rooms
Study
Thompson, J. D. &
Goldin, G. (1975)
Focus of Study
To determine what patients
prefer in terms of their hospital
rooms during their hospital stay
Research Design
Patients were
interviewed in
regards to their
hospital rooms;
interviews were
used to evaluate the
patient’s preference
for hospital rooms
Interviews were
completed during
the patient’s
hospital stay
Sample
Information and
Site
Site: Yale-New
Haven Hospital
and Genesee
Hospital in
Rochester, New
York
Sample: 505
patients; patients at
Genesee hospital
were all in singleoccupancy rooms;
patients at YaleNew Haven
hospital were in
single- and
multipleoccupancy rooms
Findings
The majority of patients
at Yale-New Haven
hospital liked the
windows the most in
terms of specific
features of their rooms
Patients at Genesee
Hospital liked seeing
into the corridor (beds
were placed facing the
corridor, not the
window)
Sense of security most
important feature
hospital can offer
Patients in 4-bed rooms
at Yale-New Haven
were bothered by the
other patients and their
visitors
Relationship of
findings to room
occupancy
The patients’ room
occupancy preference
was not studied
directly, but patients in
the 4-bed rooms were
bothered by the other
patients in their rooms
Study
Topf. M. (1985, Fall)
Focus of Study
To examine the impact of noise
on a patient’s health as well
identify the mechanism that
links noise-induced stress with
coping and health
Research Design
Subjects were
randomly assigned
to a group that
received instruction
for control over
hospital noise or to
a control group
Questionnaires
were used to
measure objective
noise, sensitivity of
a person to noise,
the degree of stress
caused by hospital
sounds, social
desirability, and
coping with noise
Seriousness of
illness was
measured by time
spent in surgery
Self-report
measures were
used to determine
health outcomes
Data was collected
over an eightmonth period
Sample
Information and
Site
Site: large
metropolitan
Veterans
Administration
Hospital
Sample: 150 male
surgery patients
Findings
Objective noise, greater
sensitivity of the person
to noise, and greater
noise-induced stress
were related to greater
exercised control over
noise by patients
Those with greater
sensitivity to noise were
more likely to use
coping strategies
regardless of the level
of objective noise
Patients used cognitive
strategies to control
hospital noise
Older patients exercised
less control over
hospital noise
Instruction in control
over noise did not
predict greater coping
strategies
Relationship of
findings to room
occupancy
No mention was made
in regards to room
occupancy
Study
Tyson, G. A.,
Lambert, G., &
Beattie, L. (2002)
Focus of Study
To determine the effect of ward
design on nurses in a psychiatric
ward
Research Design
Observations of
nurses’ behaviors
were made six
months prior and
six month after
moving to a new
ward (acute and
long-stay)
Measures included
interaction with
patients,
interactions with
staff, tasks
completed and
other duties
Questionnaires
were mailed to
nurses measuring
level of burnout
and personal
accomplishment,
emotional
exhaustion, and
depersonalization
towards patients
Staff was
interviewed in
regards to their
views of the new
ward
Sample
Information and
Site
Site: Rural
psychiatric hospital
in Australia
Sample: 40 nurses
from the old ward
and 40 nurses for
the new ward
Findings
Increased burnout
occurred in the new
ward
New ward thought to be
more aesthetic and
pleasing as well as
better for patients
because of increased
privacy (especially on
long-stay ward where
rooms were private)
The new facilities were
thought to be cramped
and nursing offices too
small
The new acute ward
had the most positive
outcomes with
increased staff-patient
interactions in terms of
amount and quality
The increased space
and privacy on the
acute ward made it
more difficult to find
and observe patients;
large space also made
staff feel more isolated
Relationship of
findings to room
occupancy
The evaluations of the
new ward were both
positive and negative
for the nurses; while
patients benefited from
increased space and
privacy, nurses suffered
from increased burnout, especially in the
long-term stay unit
The new long-stay ward
contained all private
rooms which increase
patient privacy; the new
acute ward contained a
mixture of private and
multiple occupancy
rooms-space and
privacy was also
increased for these
patients
Study
Ulrich, R. S. (1984,
April 27)
Focus of Study
To determine whether having a
room with a window view of a
natural setting impacts the
recovery of patients
Research Design
Records were
obtained for
patients who were
assigned to the 2nd
and 3rd floors of a
3-story hospital;
information
included length of
stay, analgesics
taken, minor
complications, and
nurses’ notes
The rooms patients
stayed in either
faced a brown
brick wall or a
small stand of
trees; rooms were
all double
occupancy and
nearly identical in
all features besides
their window view
Sample
Information and
Site
Site: A suburban
Pennsylvania
hospital
Sample: 46
patients who had
undergone
cholecystectomy
between 1972 and
1981
Findings
Patients with the view
of trees had shorter
length of stays
Analgesic doses were
lower between the 2nd
and 5th days of
treatment for those with
the view of trees
Those with the view of
trees received more
positive comments
from nurses
Relationship of
findings to room
occupancy
The nature of the view
patients have from their
windows appears to
have some effects on
their recovery
Rooms in the study
were double occupancy,
but the nature of the
room occupancy was
not discussed in terms
of the findings
Study
Focus of Study
Verderber, S. (1986)
To determine the effect of
windows on patient outcomes
Research Design
Photoquestionnaire
was developed
illustrating
conditions in 11
hospitals that
showed rooms
from entirely
windowless to
having windows
Patients were also
asked to complete
10 written
questions which
were concerned
with patient
preference and
ratings of
satisfaction with
windows in the
patient’s unit
Sample
Information and
Site
Site: Six hospitals
in the physical
medicine and
rehabilitation units
Sample: 125 staff
members and 125
Findings
Relationship of
findings to room
occupancy
Study
Volicer, B. J.,
Isenberg, M. A., &
Burns, M. W. (1977,
June)
Focus of Study
To measure the difference in
scores of psychosocial stress due
to hospitalization between
medical and surgical patients
Research Design
Interviews were
conducted with
medical and
surgical patients
Information
obtained on patient
background and
their physical
status as well as
their scores on the
Hospital Stress
Rating Scale
(HSRS)
Patients contacted
2 weeks after
discharge to report
on physical status
Sample
Information and
Site
Site: Community
Hospital
Sample: 535
medical and
surgical patients
Findings
Age, number of
previous
hospitalizations, and
number of years since
last hospitalization
correlate with stress
scores
Surgical patients
reported higher stress
than medical patients
on factors pertaining to
loss of independence,
threat of severe illness,
and unfamiliarity of
surroundings
Medical patients
reported more stress in
terms of financial
problems and lack of
information
Relationship of
findings to room
occupancy
Surgical patients appear
to report higher
experience of stress in
the hospital though
surgical and medical
patients differ in the
factors they perceive
stressful
No mention made in
regards to room
occupancy
Non-Empirical Articles
Therapeutic impacts: Relationship Between Healing and Environment
Study
Focus of Article
Type of Healthcare
Facility
Anonymous. (2001,
December)
To describe factors that impact
patient satisfaction
U. S. Hospitals
Biley, F. (1993,
October 20)
To demonstrate how patient
environments affect the
patients’ recovery
Hospitals in England
Recommendations for
Healthcare Settings
Nurses with negative attitudes
can impact finances as customer
satisfaction is low
Communication between staff,
patients, and their family
members is important to patient
satisfaction
Employee morale impacts work
Quick responses to patient
complaints are beneficial
Doctors want to feel appreciated
and know that they have a
competent staff
Patient expectations must be
managed
Hospital buildings of the 20th
century were designed with
more money being spent on
technological advances than on
design
In recent years, more attention
paid to aesthetic design of
hospitals
Designs include bright open
spaces, use of natural light, and
art
Illustrations of natural scenes
have positive effects on the
mental and physical state of
patients
Cool colors should be used to
promote relaxation while warm
colors promote activity and
neutral colors minimize attention
Laws passed in North America
stating that hospitals rooms
should have windows or
skylights to avoid delayed
recovery
Relationship of findings to room
occupancy
By improving attitudes among hospital
staff, patient satisfaction with their
experience in the hospital may increase
No mention made in regards to room
occupancy
Colors, art and lighting are important
elements of design that can have positive
effects on the well-being of patients
No mention made in regards to room
occupancy
Study
Focus of Article
Type of Healthcare
Facility
Cabrera, I. N. & Lee,
M. H. M. (2000)
To propose a solution to
reduce stress and anxiety in a
hospital setting through the
use of music therapy
U. S. Hospitals
Davis, B. (2001,
May 28)
To describe the Continuous
Ambient Relaxation
Environment (C.A.R.E)
television channel
U. S. Hospitals
Recommendations for
Healthcare Settings
Use of a Sound Control Center
in hospitals responsible for
reducing extreme noise levels
throughout the hospital and for
providing a center of music
therapy
Music therapy can be used to
help mask procedural sounds as
well as reduce anxiety and
alleviate pain
Television channel is 24-hour
and promotes relaxation and
contributes to therapeutic
environment
Channel appeals to hospital
officials that promote healing
through building design and
environmental cues
Viewers are able to watch nature
scenes accompanied by
soundtrack with woodwinds and
harp
Relationship of findings to room
occupancy
Reduction of noise levels with
appropriate use of music selection can
help improve patients’ health
No mention of preference for single or
multiple room occupancy
C.A.R.E. channel can help patients heal
through its focus on nature and music
No mention made in regards to room
occupancy
Study
Fottler, M. D. (2000,
March/April)
Focus of Article
To examine the importance in
determining patient
satisfaction, promoting patient
healing and well-being, and
improving employee attitudes
Type of Healthcare
Facility
Hospitals in general
Recommendations for
Healthcare Settings
A clean and safe environment
that is easy to use can improve
patients’ satisfaction and the
quality of their experience
It is important for patients and
their family members to feel
their medical, psychological, and
physical needs have been met
Patient-focused design improves
the personalization of service
and provides for maximum
opportunities for family
interaction
A clean, organized, and
comfortable environment is
beneficial to the needs of staff
The patient’s experience can be
enhanced through the use of
natural light, noise control,
appropriate temperature, and
attractive decor
Relationship of findings to room
occupancy
A well-designed setting can have a
positive impact on staff members and can
improve patient satisfaction and clinical
outcome
No mention is made in regards to room
occupancy
Study
Focus of Article
Type of Healthcare
Facility
Hancock, T. (1999)
To examine ways in which
hospitals can promote health
Hospitals in general
Hosking, S. &
Haggard, L. (1999)
To describe aspects of
hospitals that can improve
patient conditions
Hospitals in general
Recommendations for
Healthcare Settings
Healthy hospitals create a
healing environment for patients,
and a healthy workplace for staff
The physical environment
impacts the social and mental
well-being of patients and the
social environment can affect the
physical state of patients
Use of color, texture, and form
and the creation of a homelike
setting are important elements of
design
Role of plants and nature also
important
Patients and their family
members should be active
partners in the process of healing
People who are at ease and
rested in a nurturing
environment will heal more
rapidly
Patients expect the treatment
they receive should be
appropriate for their condition
Noise that a patient cannot
tolerate is a source of stress;
unpleasant sounds can be
excused when deemed necessary
Control of noise should be
important; tolerance of noise is
lower during illness
Positive contribution of sense of
smell is through use of
aromatherapy and scented oils
Efforts are made to preserve the
patient’s dignity; privacy
increased
Petting tame animals can reduce
stress
Relationship of findings to room
occupancy
Healthy environments help put the patient
at ease and facilitate a rapid recovery
No mention is made in regards to room
occupancy
No mention made in regards to room
occupancy
Study
Leith, B. A. (1998,
August)
Focus of Article
To describe the effect that
transfers have on patients
Type of Healthcare
Facility
Hospitals in general
Recommendations for
Healthcare Settings
Separation anxiety can result in
patients about to be transferred;
patients may experience anxiety
because of loss of close
relationship with nurses and
doctors
Patients may also experience
primary transfer anxiety which is
related to the type and timing of
the transfer and the disruption of
interpersonal relationships
Expectant transfer anxiety
occurs when patients are not
fully prepared for their transfer
Patients that are uncertain may
experience stress which can
adversely affect their ability to
cope with their illness;
uncertainty can result due to a
change in environment or
routine
Transfer anxiety is related to
uncertainty caused by being
separated from a familiar
environment and can lead to
stress and inability to cope
Reasons for transfer anxiety
include little or no preparation
for the transfer, reduction in
monitoring, loss of security, and
lack of predictability in the new
environment
Symptoms of transfer anxiety
include insecurity, vigilance, and
withdrawal
When patients were prepared for
the transfer by nurses, they
responded better to the transfer
Relationship of findings to room
occupancy
Transfer anxiety can adversely affect the
coping ability of patients
No mention was made in regards to room
occupancy
Study
Nicholson, L. (1993)
Focus of Article
To describe factors of the
hospital environment that can
aid the healing process
Type of Healthcare
Facility
Hospitals in general
Recommendations for
Healthcare Settings
Emphasis of warm environment
began in 1980’s
Hospital interior environments
must create balance and
harmony
The hospital environment be
humanized and respond to the
physical, mental, emotional, and
spiritual needs of the patients
Patients should be given as much
freedom and independence as
possible
Healing environment enables
patient to have privacy; people
desire flexibility to control their
environment based on their
needs
Healing space should provide
and encourage relaxation;
windows provide access to the
outdoors
Patients should have space for
their personal belongings
Space should be provided for
family members
Pleasant surroundings help
individuals to feel better
Relationship of findings to room
occupancy
No mention was made in regards to room
occupancy
Study
Rich, M. (2002,
November 27)
Focus of Article
To describe how
improvements in design have
therapeutic effects for patients
Type of Healthcare
Facility
Barbara Ann Karmanos
Cancer Institute, Detroit
Methodist Hospital,
Indianapolis
Bronson Methodist
Hospital, Kalamazoo,
Michigan
Swedish Medical Center,
Seattle
Recommendations for
Healthcare Settings
At the Cancer Institute, soft
colors, warmer indirect lighting,
wider hallways and door, and
pullout sofas for visitors were
introduced; on average, patients
gave themselves 45% less selfadministered pain medication
At Methodist Hospital, patient
falls dropped 60% in the cardiac
wing when rooms were
redesigned so the patient did not
have to move from critical-care
units to recovery bays
At Bronson Methodist Hospital,
a new facility was built with
only private rooms; more private
conversations occur with
patients and a sharp reduction
has occurred in hospital-acquired
infections; hospital saving
money because patients are no
longer asking to be transferred to
different rooms
At Swedish Medical Center,
small, still-life paintings were
placed over cubbyholes that
contained oxygen masks, suction
lines, and blood-pressure cuffs;
less intimidating for patients that
do not like hospital equipment
Relationship of findings to room
occupancy
Hospital design can have beneficial
effects for patients
Room occupancy was mentioned only for
Bronson Methodist Hospital, where all
the patient rooms are single-occupancy
Study
Shumaker, S. A. &
Reizensten, J. E.
(1982)
Focus of Article
To describe factors that affect
inpatient stress in acute care
settings
Type of Healthcare
Facility
Hospitals in general
Recommendations for
Healthcare Settings
Factors that affect inpatient
stress are wayfinding, physical
comfort, control over privacy
and personal territory, and the
symbolic meaning of the
environment
Adjusting to the hospital is made
difficult by the vulnerability of
patients
Aspects of environment that can
affect patient comfort are noise,
temperature and humidity,
lighting, body position, and
odors
Patients are highly sensitive to
hospital sounds due to pain,
illness, and because they have no
control over the sounds; soundattenuating surfaces need to be
provided
When temperatures are
incongruent with the needs of
patients, stress may result;
individual temperature controls
should be provided
Poor lighting can cause
discomfort and unpleasant odors
can be disturbing; glare should
be eliminating and appropriate
lighting should be provided for
various tasks; surfaces that do
not retain odors should be
selected
Privacy is needed by patients;
they need an opportunity to rest
and need space to discuss their
needs and feelings with friends
and families
Number of patients in a room
affects privacy as does the
presence of an interior window
to the corridor and the presence
of visual screening devices
Relationship of findings to room
occupancy
An environment that meets the patient
needs and gives them a sense of control
helps reduce stress
No specific mention is made in regards to
room occupancy, though it is noted that
privacy and territoriality are issues in
rooms with multiple occupancy
Solomon, N. (2003)
To discuss a method for
treating elderly patients with
delirium
Saint Louis University
Hospital
Patient control of privacy
should be key to design
Giving patients the ability to
personalize their rooms enables
them to establish their own
territory and increases their
sense of security and selfidentity
Design of patient room can
convey symbolic meaning; in
rooms with more than 1 patient,
layout represents importance of
patient privacy and territoriality
Typically, elderly patients
suffering from delirium are
isolated from others and cared
for in private and semi-private
rooms
At St. Louis University
Hospitals, elderly patients
suffering from delirium are
treated in the Delirium room;
this consists of a four-bed
intensive care unit; no walls are
in the room, so nurses can easily
monitor patients
Because of constant supervision,
the fall rate of patients is near
zero, and none of the patients
died during an 18-month period
of study
Nurses try to reorient the patient
and figure out why the patient is
agitated; physical restraints are
not used and medications are
avoided
A Delirium room with four beds has been
found beneficial for elderly patients who
become delirious
Study
Tate, J. (1980)
Focus of Article
To describe the needs of the
elderly living in institutions
Type of Healthcare
Facility
Institutions for the elderly
Recommendations for
Healthcare Settings
Physical environment important
in institution; factors that need to
be considered are privacy,
personal space and territoriality,
and crowding
Most important qualities of
physical environment are
amount and arrangement of
space
If needs for privacy and
territoriality not met, negative
consequences such as sense of
loss of personal control an
weakened personal identity may
occur
Private rooms should be
provided, or partitions should be
used in double-occupancy rooms
to give person own space
Relationship of findings to room
occupancy
Private rooms, or at least one’s own
personal space, should be provided for the
elderly to prevent negative reactions
Study
Ulrich, R. S. (2003)
Focus of Article
To describe evidence-based
design in regards to
environmental features of
hospitals and how they relate
to patient outcomes
Type of Healthcare
Facility
U. S. Hospitals
Recommendations for
Healthcare Settings
Features of the environment that
affect patient outcomes are
noise, single vs. multiple
occupancy rooms, positive
distractions, quality of patient
window view, and air quality
Design, based on evidence, used
to increase patient safety
Nosocomial infections are lower
in single-occupancy rooms
Excess noise can worsen a
patient’s outcome; single rooms
are quieter than double rooms
Patients can experience stress if
they are not in control with
respect to their surroundings;
privacy can increase a patient’s
sense of control
Social support can help reduce
stress and improve outcomes;
roommates are a source of stress
for patients and can lead to
costly transfers and increased
medication errors
Relationship of findings to room
occupancy
To increase the safety of patients,
hospitals should provide singleoccupancy rooms with good air quality
Study
Focus of Article
Type of Healthcare
Facility
Ulrich, R. S. (1999)
To describe the effects that
gardens have on hospital
patients
U. S. Hospitals
Ulrich, R. (1992,
September/October)
To describe design strategies
that impact the well-being of
patients
U. S. Hospitals
Recommendations for
Healthcare Settings
Poor design is linked to negative
effects such as higher anxiety,
increased pain medication,
elevated blood pressure, and
sleeplessness
Patients feel a sense of loss of
control when they experience a
loss in privacy, lack of
information, inability to adjust
room temperature and lighting,
and way-finding difficulties
Healing gardens promote a sense
of control and privacy, social
support, physical movement and
exercise, and access to nature
Gardens can facilitate social
contact
Patients prefer access to nature
including gardens, sitting areas,
views from their rooms, and
pictures of nature
Visual settings with nature aid in
reducing stress; views of nature
can reduce emotional,
physiological, and behavioral
components of stress
Negative distractions in gardens
include noise and smoking
Good design can reduce stress
and anxiety, lower blood
pressure, improve postoperative
courses, reduce the need for pain
medication, and shorten hospital
stays
Facilities that are noisy, invade
privacy, or interfere with social
support can increase stress of
patients; design should foster
sense of control, access to social
support, and access to positive
distractions
Relationship of findings to room
occupancy
A healthcare setting with a healing garden
can help reduce the amount of stress
experienced by patients
No mention was made in regards to room
occupancy
Well-designed hospital can have positive
effects on patient
No mention made in regards to room
occupancy
Study
Williams, M. A.
(1995)
Focus of Article
To describe how hospital
design can facilitate
therapeutic goals
Type of Healthcare
Facility
Hospitals in general
Recommendations for
Healthcare Settings
Good design should support
activities essential to achieving
desired patient outcomes without
imposing stress on the patient;
serves a symbolic function
Physical design and social
environment are oriented toward
enhancing therapeutic goals
Design supporting therapeutic
goals should be flexible and
must take into account the
functional requisites of patients
Relationship of findings to room
occupancy
No mention made in regards to room
occupancy
1
Empirical Articles: First and Operating Costs of Hospitals
Ashby, J. L Jr. & Lisk, C. K. (1992, Summer). Why do hospital costs continue to increase?
Health Affairs, 11(2), 134-147.
Focus of Study
To determine how three factors, namely general inflation,
medical inflation, and intensity, together determine hospital
cost per case.
Research Design
Data was analyzed using a conceptual model which breaks
down change in hospital operating costs per adjusted
admission into seven components. Total cost per admission
was established as the product of four ratios: services per
admission, full-time-equivalent (FTE) employees per service,
salary cost per FTE employee, and total cost relative to salary
cost. These four ratios were further refined by taking into
consideration employee skill-mix and productivity change,
holding the skill-mix constant. Intensity of services
accounted for the portion required because of increases in the
complexity of patients treated and the portion expanded for
patients who do not have more complex conditions. The final
model is represented as the sum of changes in general
economy input prices, hospital-specific input prices, patient
complexity, intensity of services, employee skill-mix, nonlabor factors, and service-level labor productivity.
Sample Information & Site
Data on FTE employees, admissions (adjusted for outpatient
activity), total charges, and total operating expenses, were
obtained from the AHA annual hospital survey. Prospective
Payment Assessment Commission (ProPAC) methodology
was used to estimate patient complexity change.
Findings
Inflation in the general economy accounts for the largest
single contribution to the increase in hospital operating costs,
which was about 40% of the average total cost increase.
Inflation of prices specific to the hospital industry accounted
for approximately 17% of annual increases in hospital
expenses. Two thirds of this increase arose from rising
wages. Non-labor input prices increased faster than prices in
the general economy, especially in pharmaceuticals and
malpractice insurance premiums. Patient complexity changes
account for 21% of the annual increase in costs per adjusted
admission and the intensity of patient care services accounted
for 20% of the total annual cost increase when case
2
complexity was held constant. Changes in the quality and
quantity of labor and non-labor inputs were related to a 2%
increase in total annual costs.
Although the total increase in costs per adjusted admission
was 8.7% between 1985-1987 and 9.1% between 1987-1989,
the portion of the increase subject to hospital control was
reduced. Expenditures on supply upgrades also decreased
during the period of analysis.
The findings of this study are limited as one cannot fully
account for the effect of quality enhancements on measures of
productivity and intensity of services. The FTE data is
limited in that it does not denote the use of contract labor nor
does it account for the removal of physicians who are no
longer salaried during the period of analysis. A
representation of the labor hours used throughout the year
may not be accurate as only the number of FTE workers
employed on the last day of the year is reported. The
estimates of case complexity are problematic in that medical
records documentation has improved over time in its
comprehensiveness.
Implications of Findings
Containment of costs should focus on controlling increases in
intensity of services as well as implementing lower wage and
salary increases and controlling costs spent on
pharmaceuticals. No mention was made in regards to room
occupancy.
3
Berry, R. E. Jr. (1974, Summer). Cost and efficiency in the production of hospital services.
Milbank Memorial Fund Quarterly - Health & Society,52(3), 291-313.
Focus of Study
To identify and measure the effects of factors that
significantly impact the cost and efficiency of short-term
general hospitals in the U.S.
Research Design
The data was analyzed using a model which measured
hospital cost as a function of the level of output, the quality of
services provided, the scope of services provided, factor
prices, and relative efficiency.
Sample Information & Site
The sample included 6000 short-term general hospitals in the
United States. The data was collected for the years 1965,
1966, and 1967.
Findings
Hospital services are initially produced subject to decreasing
costs and then eventually increasing costs. The average cost
curves of hospital services were shallow “U” shapes.
Empty beds lead to higher average costs for voluntary
hospitals and all hospitals (the majority of the sample
consisted of voluntary hospitals). Empty beds do lead to
lower average costs for proprietary and government hospitals.
Also, higher quality services cost more to produce than lower
quality services. Average costs were found to be higher in
hospitals that involve medical education and more complex
inpatient services and the provision of community medical
services also increase average costs.
Length of stay has an impact on average costs as well, and for
any given type of care, the early days of hospitalization are
generally more expensive.
Wage rate was the most significant variable in explaining
average costs but construction costs were not significant.
It appears that the capacity to provide services explains
hospital costs better than the actual services provided. In
addition, low-cost hospitals were more likely to have
administrators with medical qualifications. Regional
differences also impact average costs; New England and
Pacific states tend to be higher-cost while the southern states
were low-cost. Furthermore, the ratio of personnel expense
to total expense is higher in low-cost hospitals than high-cost
hospitals. Finally, hospitals with relatively high occupancy
rates had lower costs; bed size was not significant.
4
Implications of Findings
Several factors, such as quality of care, length of stay, wage
rates, and regional differences impact the average costs of
hospitals. No mention was made in regards to room
occupancy.
5
Cho, S. H., Ketefian, S., Barkauskas, V. H., & Smith, D. G. (2003, March-April). The effects of
nurse staffing on adverse events, morbidity, mortality, and medical costs. Nursing Research,
52(2), 71-79.
Focus of Study
To examine how nurse staffing affects adverse events,
morbidity, mortality, and medical costs.
Research Design
The data was retrieved from two existing databases: Hospital
Financial Data produced by California’s Office of Statewide
Health Planning and Development (OSHPD), and the State
Inpatient Databases (SID) California-1997 released by the
Agency for Healthcare Research and Quality (AHRQ). To
estimate nursing hours provided and patient days in 1997,
data from three fiscal years was retrieved (1996-1997, 19971998, and 1998-1999). Measures used included hospital
characteristics, nurse staffing, patient characteristics, adverse
events, morbidity and mortality, and costs. Multilevel
analyses were used to examine the data.
Sample Information & Site
The sample included 232 acute care hospitals in California,
excluding government hospitals and long-term care hospitals
as well as non-comparable hospitals. A total of 124,204
patients from twenty surgical diagnosis-related groups were
included.
Findings
On average, nurses spent 8.9 hours per patient day with
patients, and RN nurses provided 6.3 hours of care to patients
per patient day. For the majority of patients (93.2%), no
adverse events occurred during their stay. Of the adverse
events that did occur, pneumonia occurred the most while
falls/injuries occurred the least.
Patient characteristics, such as age, sex, and insurance
provider, were significantly associated with the occurrence of
adverse events. Three types of nosocomial infections
(Urinary tract infection, wound infections, and sepsis)
occurred most frequently in large hospitals.
The length of stay of patients significantly increased with the
occurrence of adverse events. Patient characteristics were
associated with longer lengths of stay whereas hospital
characteristics were not associated. Furthermore, patient
characteristics, except race and sex, were associated with
mortality. The occurrence of adverse events was associated
with higher costs.
Limitations of this study include measurement issues
regarding nurse staffing, a lack of consideration for hospital
6
organizational characteristics, and the use of a non-exhaustive
list of all the possible adverse events that could occur during
a hospital stay.
Implications of Findings
Nurse staffing levels impact the occurrence of adverse events
in hospitals. If the appropriate levels were used, operational
costs could be reduced through the prevention of adverse
events. No mention was made in regards to room occupancy.
7
Delon, G. L. & Smalley, H. E. (1970, April 1). Quantitative methods for evaluating hospital
design. pp. 17-47.
Focus of Study
To develop methodology for evaluating nursing unit design.
Research Design
Qualitative checklists were developed for nursing unit
designs. A model was developed from the checklists and it
was applied to existing nursing units to determine its
usefulness. Both uncontrollable and controllable costs were
considered, including traffic and construction costs.
Sample Information & Site
The sample and site of this study were not specified though
the implication is that the data applies to hospitals in the
United States.
Findings
Seven areas within the nursing unit serve as the basis for the
beginning and end for the majority of trips made by nurses.
These include the nursing station, patient rooms, supply
rooms, the laundry, the kitchen, the bedpan room, and the
elevators. In addition, ten areas comprise of more than eighty
percent of trips originating or destined for the nursing unit.
These consist of the dietary department, the surgical suite, the
central supply room, the radiology department, housekeeping,
the laboratory, the laundry, the pharmacy, the emergency
department, and other nursing units.
The checklists account for the relationship between nursing
traffic and patient self-sufficiency, take into consideration
traffic savings of multiple-occupancy rooms, and they
incorporate the influence that the location of patient rooms
has on traffic patterns.
Arguments have been made suggesting the most efficient unit
size is between 25 and 35 beds. Furthermore, rooms should
not be further than 90 feet from the nursing station.
Advocates of larger units argue that larger units are more
efficient because better staffing patterns are achieved, the
need for tall buildings is eliminated resulting in savings in
elevators and plumbing, for example. Larger units also
require fewer medicine units, linen rooms, and nursing
stations storing materials. Advocates of smaller units argue
that they are better for supervising patients.
Hill-Burton recommends that the average size of singleoccupancy patient rooms is 100 square feet, while the average
size of double-occupancy and 4-bed rooms is 80 square feet.
A trend exists towards the recommendation of singleoccupancy rooms in hospitals. They are advantageous
8
because higher occupancy rates can be achieved, patient care
is improved, the risk of cross-infection is reduced, and greater
flexibility of operation is available.
When designing single-occupancy rooms, they should be
large enough to accommodate two beds. Double-occupancy
rooms should be designed to be easily converted to singleoccupancy rooms. Four-bed rooms should also be easily
converted to two double-occupancy rooms through the
addition of a bathroom.
Nursing stations require space for a head nurse office, a
charting area, a medication unit, and workspace for a ward
clerk.
Implications of Findings
Although arguments are made in favor of both larger and
smaller nursing units as well as single- and multipleoccupancy rooms, neither design is clearly favored.
9
Dexter, F. & Macario, A. (2001). Optimal number of beds and occupancy to minimize
staffing costs in an obstetrical unit? Canadian Journal of Anaesthesia, 48(3), 295-301.
Focus of Study
To describe how analyzing patient arrival and discharge data
from an obstetrical unit can help to determine the optimal
number of staffed beds needed in the unit. This will help
maintain a balance between having as few staffed as possible,
while at the same time, giving the patient the care needed.
Research Design
Data was obtained from patients admitted and discharged
from the obstetrical unit at Stanford University Medical
Center between October 1, 1999 and November 30, 1999.
Two-hour intervals were used in measuring the number of
patients present in the obstetrical unit. The researchers used
the Poisson probabilistic analyses since this type of analysis
takes into consideration the risk that all staff are working and
are not able to take care of any additional patients that may
require care. The level of risk used in this study is five
percent.
Sample Information & Site
The study used data from patients admitted and discharged
from the obstetrical unit at Stanford University Medical
Center. The sample included 777 patients.
Findings
The Poisson distributions fit the data for various times of the
day. In particular, this distribution was applicable for
weekdays and weekends between 6 a.m. and 6 p.m. as well as
between 6 p.m. and 6 a.m. This is based on tests and the
observed versus predicted differences in percentages of
periods with specified numbers of occupied beds. The
number of staffed beds needed on weekdays between 6 a.m.
and 6 p.m. is fifteen. Twelve staffed beds are needed on
weekdays between 6 p.m. and 6 a.m. as well as on weekends
between 6 a.m. and 6 p.m. Only ten staffed beds were needed
on weekends between 6 p.m. and 6 a.m. These numbers
maintain a five percent risk.
This type of analysis would not be useful when patients delay
their admissions. It is also not adequate when gynecology
patients are kept in the obstetrical unit and are then
transferred when an OB patient requires admission. Similarly,
the Poisson distribution assumes that the amount of patients
scheduled is small. If the amount of scheduled admissions is
large, the hospital can develop scheduling rules that can
10
decrease staffing costs. Finally, this type of statistical
analysis is not accurate for hospitals that have fluctuating
average census levels.
Implications of Findings
For the majority of hospitals, the Poisson statistical analyses
can help to determine the optimal amount of staffed beds
need in an obstetrical unit. Using this method can help
hospitals save money by using only the amount of staff
necessary at a given time. No mention was made in regards
to room occupancy in the hospitals.
11
Eastaugh, S. R. (2002, Fall). Hospital nurse productivity. Journal of Health Care
Finance, 29(1), 14-22.
Focus of Study
To determine factors that impact nurse productivity using
production function analyses.
Research Design
Data was collected using Atlas MediQual, the largest
proprietary vendor of nurse workload and nurse scheduling
systems. In this system, nursing output is specified by a
point-scoring system. Production function analyses were
used to determine nurse productivity. Five basic inputs were
studied: nurse extenders (NEs); registered nurses (RNs);
house-staff residents and interns performing some nursing
activities; clerks, licensed practical nurses (LPNs) and nurse
aids; and capital.
Sample Information & Site
The sample included data from 37 hospitals in the United
States during the years 1997-2000. House-staff resident and
intern input was not measured annually. Instead, it was
measured once in 1997.
Findings
The results indicate that as RN labor becomes more costly,
NE labor is used less extensively in place of RNs. This
finding suggests that NEs and RNs may be a complementary
team. As house-staff labor becomes more costly, however,
the labor of NEs is used more extensively. A shortage of
nurses did not decrease nursing productivity. Of the nursing
departments in the study, the average technical efficiency
realized is 81% in the year 2000. Hospitals with the worst
nurse productivity did not employ NE technicians and
operated at 100% RN primary care nursing. Hospitals with
the highest levels of productivity heavily used NEs.
Implications of Findings
Primary care nursing is most productive when a combination
of RNs and NEs is used. NEs tend to increase productivity
and reduce wasted labor. No mention was made in regards to
room occupancy.
12
Garattini, L., Giuliani, G., & Pagano, E. (1999). A model for calculating costs of hospital
wards: An Italian experience. Journal of Management in Medicine, 71-82.
Focus of Study
To present a cost analysis method, which would enable an
understanding of the distribution of resources among
departments.
Research Design
Costs were assessed using a step-down allocation.
Department costs, wards, and costs per stay for each ward
were identified. Direct costs, overhead costs and indirect
costs were identified and allocated.
Sample Information & Site
Data used for this study was based on data recorded in 1996
in terms of days of patient stay on 11 wards in Bolognini
Hospital, Seriate, Italy. A total of 87,476 days of stay were
recorded.
Findings
Thirty cost and revenue centers were identified. Twelve were
indirect departments, twelve were wards, five were overhead
services, and one was for outpatient activity.
The most expensive wards were the Intensive CardioCoronary Unit and ophthalmology. The average bed day
costs is dependent upon the occupancy rate in which the fixed
costs per unit are inversely related to the number of beds
used. Cardiology and pediatrics have the highest variance in
terms of bed day costs.
There are several limitations to this study. For instance, cost
allocations may have been related to the specific diseases.
Also, information was extracted from manual records.
Finally, overhead and indirect costs were not allocated based
on real consumption due to lack of data.
Implications of Findings
No mention was made in regards to room occupancy.
13
Li, T. & Rosenman, R. (2001, June). Cost inefficiency in Washington hospitals: A stochastic
frontier approach using panel data. Health Care Management Science, 4(2),73-81.
Focus of Study
To use the stochastic frontier panel data model to analyze cost
efficiency for hospitals in Washington State. The stochastic
frontier approach uses an error-component model to
encompass the firm-specific inefficiency as well as the
statistical noise, which is inefficiency beyond the control of
the firm.
Research Design
The data were obtained from the year-end report of financial
data and activities of hospitals from the State Department of
Health from 1988-1993. Of 91 eligible hospitals, data was
missing for one hospital. Thus, included in the analysis were
84 not-for-profit hospitals and 6 for-profit hospitals. The data
were analyzed using the stochastic frontier panel data model.
The outputs included were the total number of patient days
and the total number of outpatient visits. The three input
prices used were labor, capital, and an aggregate of other
costs.
Sample Information & Site
The study used data from 84 not-for-profit hospitals and 6
for-profit hospitals in Washington State. Specialty hospitals
were excluded from the analysis.
Findings
Not-for-profit hospitals are larger in terms of outputs and the
number of beds. For-profit hospitals have a greater share of
inpatient business and paid less for most types of labor,
except those used in outpatient services, and psych inpatient
and administration. Capital and other costs were lower for
not-for-profit hospitals. The share of outpatient business
increased for both hospitals, but the increase was greater at
not-for-profit hospitals. Also, costs and labor prices
increased for both hospitals, but the increase was twice as
much for not-for-profit hospitals. Finally, the percent of
outpatient visits made by Medicare patients decreased while
their number of patient days increased.
Hospitals with higher casemix indices or larger numbers of
beds are less efficient. The severity of illness of patients (i.e.
casemix index) is a significant source of inefficiency. Those
with more beds are usually larger hospitals and these have
more capital endowments, making them less efficient.
Hospitals with higher Medicare patient days are more
14
efficient as are for-profit hospitals. The average hospital in
the sample is approximately 67% efficient.
The findings of this study are limited by the scope of the data
set and the dependency of the results on a sensitive functional
form chosen. Also, quality was not controlled for. Finally,
the time period analyzed was one in which change occurred
in the hospital industry and healthcare in general, and thus, it
is difficult to apply the results out-of-sample.
Implications of Findings
Larger hospitals and those with greater casemix indices are
less efficient. Not-for-profit hospitals and those with higher
Medicare patient days are more efficient. No mention was
made in regards to room occupancy.
15
Morey, R. C., Fine, D. J., Loree, S. W., Retzlaff-Roberts, D. L., & Tsubakitani, S. (1992,
August). The trade-off between hospital cost and quality of care. An exploratory empirical
analysis. Medical Care, 30(8), 677-698.
Focus of Study
To estimate the impact on hospital-wide costs if levels of
quality of care are varied.
Research Design
Quality of care was measured as a ratio of actual to riskadjusted predicted inpatient mortalities in the hospital for a
given year. Nine aggregated, hospital-specific measurements
of service output were used, as were nine descriptors of the
hospital environment and resource expenditures.
Hospitals were compared on the bases of size, volume,
complexity of caseload, level of direct medical education
expenditures, and level of quality of care specified. Cost
estimates were based on the costs actually expended by
hospitals. Information, including the number of staffed beds,
outpatient activity, and expenses on medical education,
was extracted from the American Hospital Association
(AHA).
Sample Information & Site
The data was drawn from a 300-hospital data set obtained
from CPHA. It included non-federal, short-term hospitals.
Findings
It was discovered that a hospital’s total cost is highly
correlated with its number of beds and its number of caseseverity-weighted discharges. Non-teaching hospitals were
relatively efficient and generally delivered a lower quality of
care level. Larger hospitals had larger estimated marginal
costs and larger average costs per death deferred. Overall, the
additional, average, efficiently delivered cost for deferring
one death is approximately $29,000.
The results are limited by the measure used for quality of care
and the self-reported data from the AHA. Also, costs after
discharge were not considered.
Implications of Findings
No mention was made in regards to room occupancy.
16
Thompson, J. D. & Goldin, G. (1975). The Yale traffic index. In J. D. Thompson & G. Goldin
(Eds.), The hospital: A social and architectural history (pp. 282-295). London: Yale University
Press.
Focus of Study
To determine the functional efficiency of various nursing unit
designs.
Research Design
The unit of measurement used by this study was the number
of trips taken by nurses. Traffic patterns were measured in
four nursing units, two surgical units, and two medical units,
each with V-shaped corridors. Of these units, one of each
contained thirty beds and the other contained forty-eight beds.
The information was recorded by observers who were
positioned at the nursing stations. The information included
who made the trip, where the person left from and where the
person was going, and when that person went. Data was
collected during 15 shifts over a six-month period.
Sample Information & Site
The study was conducted at Yale-New Haven Hospital. The
sample included nurses in the various units of interest.
Findings
Based on the analyses, it was determined traffic between
patient rooms was affected by the geometry of the V-shaped
corridor. When central facilities such as the nurses’ station
and utility room were located at the apex of the V, patient
rooms were divided into two groups. Nurses had patients
along one wing and rarely had to travel to the other wing.
Researchers formed the Yale Traffic Index based on two
critical variables: the distance between areas and the number
of times this distance is crossed. It was determined that
circulation schemes, such as the double-corridor, circular, and
square plans, are most efficient, especially if the unit
consisted of more than thirty beds.
The design of the unit was found to be the most critical factor
in determining the efficiency of the unit. The size of the unit
and the degree of privacy offered do not influence the
efficiency of the unit.
Implications of Findings
Unit efficiency is determined by the design of the unit. The
size of the unit, including room occupancy, is not related to
the efficiency of the unit.
17
Thompson, J. D. & Goldin, G. (1975). The economics of privacy. In J. D. Thompson & G.
Goldin (Eds.), The hospital: A social and architectural history (pp. 305-310). London: Yale
University Press.
Focus of Study
To determine if occupancy rates are increased with all singleoccupancy rooms as well as to investigate if these increased
occupancy rates offset the increased costs associated with
single-occupancy rooms.
Research Design
Patient rooms were simulated using a computer program.
Groups of patients were generated based on characteristics
such as the sex of the patients, their desire for a particular
type of room, or their need for a single-occupancy room.
Patients were randomly admitted to the hospital, and if
possible, they were admitted into a room. The patients’
length of stay was used to determine occupancy rates.
Patient loads were varied and included 25,869 patients,
29,465 patients, and 33,172 patients. Various configurations
of occupancy rates and room types were used.
Data included the number of patients admitted and the
number of patients who could be given a room, the number of
service failures, the average occupancy rates per year over
five-years, and the number of times patients were moved to
accommodate patients wishing to be admitted.
Sample Information & Site
This study used computer-simulated data.
Findings
Only a minimal difference exists in occupancy rates when
different room configurations are used. For instance, the
difference between occupancy rates is only 0.37-0.39 percent
during a five-year period between hospitals with only 4.6
percent single rooms and those with 100 percent single
rooms. Using the United States Public Health Service
standard, it was determined that only 45 patient days would
be gained by using all single-occupancy rooms in the
hospital.
The ideal occupancy rate was considered to be 80 percent due
to the smaller occurrence of service failures at this occupancy
rate. Most patients requesting admission were also
accommodated when occupancy rates were at this level.
Implications of Findings
The optimal mix of single- and multiple-occupancy rooms
depends on medical, social, and economical factors. It is
18
recommended that hospitals include a minimum of 25 percent
or rooms that are single-occupancy.
19
Thompson, J. D. & Goldin, G. (1975). Maternity: Analysis of a random service. In J. D.
Thompson & G. Goldin (Eds.), The hospital: A social and architectural history (pp. 296-304).
London: Yale University Press.
Focus of Study
To demonstrate that the size of the obstetrical unit affects
average occupancy rates of the unit, as well as to illustrate the
effect that unit size has on the investment and direct
operational costs of the hospital.
Research Design
Data was obtained from 33 Connecticut hospitals in regards
to occupancy rates of the obstetrical units. Unit size was
measured in terms of the number of discharged patients on
the unit. The hospitals were divided into three groups based
on their obstetrical rates: the first group consisted of
hospitals with 2,000 discharges per year, the second group
contained hospitals with 1,000-2,000 discharges per year, and
the third group consisted of hospitals with fewer than 1,000
discharges per year. Analyses were conducted to determine
the impact of unit size on costs.
Sample Information & Site
The study utilized data from the obstetrical units of 33
hospitals in Connecticut.
Findings
Bed investment costs are higher for lower admission rates.
These costs level off at 4,000 admissions per year. Direct
costs per day are higher for obstetrical units servicing a small
population. Hospitals with fewer than 1,000 discharges per
year cost approximately 70% higher per patient day than
hospitals with more than 2,000 discharges per year.
Hospitals whose occupancy rates in the obstetrical units are
low can create “swing” units to help service non-obstetrical
patients. These units would require separate staff members
for the patients and would require a separation of ancillary
areas to help preserve the integrity of the obstetrical unit. The
swing unit can be made larger or smaller based on the
demand for obstetrical beds.
Implications of Findings
Costs are higher for obstetrical units serving a smaller
population. No mention was made in regards to room
occupancy.
20
Yafchak, R. (2000, Fall). A longitudinal study of economies of scale in the hospital industry.
Journal of Health Care Finance, 27(1), 67-89.
Focus of Study
To determine if the long-run average costs per bed are lower
in larger hospitals than in smaller hospitals.
Research Design
Data used in this study was extracted from the Medicare Cost
Report for the years 1989-1997. Cross-sectional regressions
were utilized to determine if the underlying cost structure of
hospitals has changed over time. The unit of interest for the
analyses was the number of operating beds in the hospital. A
Cobb-Douglas production function was modified and used to
incorporate case mix into the analyses.
Sample Information & Site
The sample included both teaching and non-teaching
hospitals as well as for-profit and non-profit hospitals in the
United States. Psychiatric and rehabilitation hospitals were
excluded from the analysis, as were hospitals with fewer than
thirty beds.
Findings
The average size of hospitals is relatively constant over time.
The length of stay, on the other hand, has decreased by 17%
as a shift towards outpatient care is being made. Most of the
inpatient care is more complex as indicated by the case mix
index. Revenue in hospitals is also decreasing as the unit of
service provided by hospitals is declining. High overhead
costs are incurred by hospitals since occupancy levels are
relatively low. Profit margins are increasing, as are revenue
and expenses. The percentage of teaching and for-profit
hospitals has remained steady, but the overall number of
hospitals has declined by 18%. On average, teaching
hospitals are larger and service sicker patients, have higher
revenues and costs, have more inpatient activity, and have
slightly lower return on assets and asset turnover.
Larger hospitals had lower costs per bed in the later years of
the analysis.
Implications of Findings
Hospital revenues are declining as a shift occurs towards
inpatient care. No mention was made in regards to room
occupancy.
21
Zwanziger, J., Anderson, G. M., Haber, S. G., Thorpe, K. E., & Newhouse, J. P. (1993,
Summer). Comparison of hospital costs in California, New York, and Canada. Health Affairs,
12(2), 130-139.
Focus of Study
To compare hospital spending in two U.S. states with
spending in two Canadian provinces to better understand why
differences in spending exist between the two countries.
Reports suggest that hospital costs per person in 1987 were
about one-third higher in the United States than in Canada.
Research Design
The data used was based on admission rates and average
lengths-of-stay from each region. Data was derived from the
British Columbia Ministry of Health for British Columbia,
the Hospital Medical Records Institute (HMRI) for Ontario,
the Statewide Planning and Research Cooperative System
(SPARCS) in New York, and the Office of Statewide Health
Planning and Development (OSHPD) in California. The
years chosen for this study were 1981 and 1985 based on a
variety of reimbursement regimes used these two years.
Sample Information & Site
The study used data from patients admitted and discharged in
hospitals in 1981 and 1985. Hospitals from New York State,
California, British Columbia, and Ontario were used.
Specialty hospitals were excluded from the analysis.
Findings
Hospital costs are lower in Canada than in New York or
California. Canadian hospitals, on average, provide a greater
amount of low-cost sub-acute stays of care whereas hospitals
in the United States provide a far higher proportion of highcost intensive care days. For most inpatient outputs
(discharges, outpatient visits, intensive care days, and acute
care days), costs in California are the highest while the lowest
costs are in Canada. The only exception is subacute days.
Unit costs are lower in Canada due to the production of each
output at a lower cost. The rate of increase in unit costs per
day or per discharge is lower in Canada than in New York or
California. Canadian hospitals also seem to combine lower
treatment intensity with longer inpatient stays. A greater
degree of similarity exists in the outpatient area since the
average incremental costs were, on the whole, identical in
1985.
22
A limitation of this study is that focusing solely on hospital
costs provides a limited analysis. Information on the number
and types of patients can help in interpreting cost differences.
Implications of Findings
Hospital costs appear to be lower in Canada than in the
United States, though clear conclusions cannot be made in
regards to why this discrepancy exists. Possibilities include
the greater costs incurred due to the multiple-payer
environment in the United States as well as differences in
staffing ratios or greater use of capital equipment. Further
analysis need to be conducted to make more significant
conclusions. No mention was made in regards to room
occupancy in the hospitals.
23
Non Empirical Articles: First and Operating Costs of Hospitals
Anonymous. (2003). Top 100 hospitals continue to raise the bar on quality, costs.
Capitation Rates & Data, 8(1), 10-12.
Focus of Article
To describe characteristics of the top 100 hospitals in the
United States. The information is based on the 100 Top
Hospitals: National Benchmarks for Success study conducted
by Solucient.
Type of Healthcare Facility
The information in this article pertains to hospitals in the
United States.
Recommendations for
Healthcare Setting
Implications of Findings
Hospitals in the United States that exhibit excellence in
quality and operational efficiency are also the most profitable.
Metrics are used on a consistent basis in the top hospitals.
Teaching hospitals tend to have the most complex mix of
patients, as they are able to provide innovative treatment,
while small community hospitals, with the absence of tertiary
care facilities, usually have the least complex mix of patients.
The top hospitals had a median total profit margin of 8.81%,
while peer hospitals had a margin of only 3.69%. Between
1996 and 2000, adjusted expenses increased by 4% at the top
hospitals, while at peer hospitals, the increase was 13%. The
admissions per bed were 51.4 in top hospitals and 44.4 for
peer hospitals, due in part to shorter length of stays at the top
hospitals. Salary and benefit packages increased at top
hospitals ($43,614 vs. $41,624 at peer hospitals). Overhead
expenses are also consistently higher at top hospitals. The
Northeast region of the United States is leading in producing
top hospitals.
The top 100 hospitals provide high quality care while
managing to reduce expenses. No mention was made in
relation to room occupancy.
24
Anonymous. (2003, February). Data trends. U.S. hospital operating efficiency may be
improving. Healthcare Financial Management, 57(2),102.
Focus of Article
To describe how hospitals are achieving greater operating
efficiency in the United States.
Type of Healthcare Facility
The article applies to hospitals in the United States.
Recommendations for
Healthcare Setting
Implications of Findings
The challenges faced by hospitals in 2003 are rising costs,
declining payments, and increasing patient volumes,
particular among the aging population. The trend suggested
by recent changes in operating margins suggests that hospitals
are achieving greater efficiency. The highest operating
margins belonged to hospitals with over 300 beds in 1997,
but by the second quarter of 2002, hospitals with 150-299
beds had the highest operating margins. The average daily
census has also increased, as have the costs per adjusted
discharge.
It appears that hospitals in the United States are achieving
greater operating efficiency. No mention was made in
regards to room occupancy.
25
Anonymous. (1981, November-December). Study challenges excess bed theory as big
contributor to cost rise. Review - Federation of American Hospitals, 14(6), 42-43.
Focus of Article
To discuss the results of a study conducted from 1977-1979
by Ernst & Whinney, a public accounting firm. The study
tested the assumption that excess beds are costly to hospitals.
Type of Healthcare Facility
Eight hospitals from the Orange County region in California
that participated in the study.
Recommendations for
Healthcare Setting
Implications of Findings
Excess beds in hospitals are one of the least important factors
contributing to rising healthcare costs as they account for
only two percent of total hospital costs. The total cost per
bed per patient day in Orange County is $8.60. Hospital
utilization is growing and thus, the number of excess beds is
diminishing. Also, it is impossible to have 100% occupancy
in hospitals due to the diversity of patients and their illnesses.
It appears that in Orange County, excess beds are not
contributing a great deal to the rise in costs of healthcare. No
mention was made in relation to room occupancy.
26
Batchelor, G. J., & Esmond, T. H. (Jr.). (1989). Maintaining high quality patient care while
controlling costs. Healthcare Financial Management, 21-30.
Focus of Article
To demonstrate that high quality care costs less than poor
quality care. High quality care includes the elimination of
unnecessary or inappropriate services while providing better
clinical outcomes, fewer avoidable complications, and higher
patient satisfaction. Poor quality care is related to patient
dissatisfaction and negative outcomes.
Type of Healthcare Facility
The article review is intended for all hospitals in the United
States.
Recommendations for
Healthcare Setting
Implications of Findings
The authors suggest that the quality of patient care can be
improved without increasing overall expenditures. Limiting
or eliminating unnecessary or ineffective treatments
associated with poor quality care can reduce hospital costs.
Underutilized facilities should be closed and duplicated
services should be reduced. An over utilization of tests
affects hospital costs as well as quality of treatment.
Customer requirements are set by the patient and are focused
on the interpersonal aspect of care. Patient-centered care
addresses items such as time spent by care workers talking to
the patient, physical attractiveness of hospital rooms,
convenient parking facilities and physical comfort.
If hospitals meet the criteria for patient-related quality care,
they can save money by reducing the number of hours spent
in dealing with patient complaints. This article did not deal
with room density and occupancy rates.
27
Bennett, M. (2002, June). Finances and decision making. Seminars for Nurse Managers, 10(2),
80-82.
Focus of Article
To describe steps healthcare leaders can take in making nonroutine decisions regarding financial impacts to the hospital.
Type of Healthcare Facility
The article applies to hospitals in the United States.
Recommendations for
Healthcare Setting
Implications of Findings
The realized financial impact of non-routine decisions often
varies significantly from the projected impact, and this is
especially true for non-routine decisions. Healthcare leaders
are often asked to make multiple non-routine decisions during
the same time period, and it is difficult to determine the
impact that an individual decision has on financial
performance. In making these non-routine decisions,
hospitals should use cost analysis. This takes into
consideration all the possible alternatives and collecting and
analyzing data for each alternative to determine which is best.
The goal of this process is to demonstrate how financial
results will differ with each alternative enabling the leaders to
choose the most feasible alternative.
Healthcare leaders should use cost analysis when making
non-routine decisions, as these decisions may have large
financial impacts. No mention was made in regards to room
occupancy.
28
Benton, P. (1998, January-February). Learning from others. Three key areas in hospital
financing reporting. Michigan Health & Hospitals, 34(1), 8-10.
Focus of Article
To comment on the data collected on the financial positions
of hospitals in Pennsylvania.
Type of Healthcare Facility
The information in this article pertains to hospitals in
Pennsylvania.
Recommendations for
Healthcare Setting
Implications of Findings
Through the process of collecting and reporting hospital
financial and utilization data for eight years, three key areas
of interest transpired: timeliness, comparability, and
flexibility. Data reported should be the most current available
as this creates an incentive for all hospitals to participate. It
should also enable comparisons between hospitals with the
same core business within the same geographical area.
Finally, flexibility improves cooperation from the facilities
and helps to produce the best report possible.
Financial reports would be improved if the data reported was
current and enabled comparisons between healthcare
providers. No mention was made in relation to room
occupancy.
29
Cleverley, W.O. (2002, July). The hospital cost index: A new way to assess relative costefficiency. Healthcare Financial Management, 56(7), 36-42.
Focus of Article
To describe the Hospital Cost Index (HCI), which is an
effective measure of cost-efficiency.
Type of Healthcare Facility
The article applies to hospitals in the United States.
Recommendations for
Healthcare Setting
Implications of Findings
Measures of cost efficiency are often biased and do not
enable comparisons between hospitals. Some factors that
may affect comparisons are procedure pricing, output
differences, and geographical cost-of-living differences. The
Hospital Cost Index adjusts for case-mix complexity in both
inpatient and outpatient operations. It weighs two measures:
the Medicare cost per discharge (MCPD) adjusted for case
mix and wage index and the Medicare cost per outpatient
claim (MCPC) adjusted for wage index and relative-value
unit. The MCPD is a measure of inpatient costs while the
MCPC measures the costs of outpatient services. Data for
both these measures can be obtained from Medicare cost
reports. A problem with both these measures, however, is
that they may not reflect the costs on non-Medicare patients.
The HCI is a reliable measure of cost-efficiency even though
it assumes that the relative cost efficiency for Medicare
patients will be similar to that of non-Medicare patients. No
mention was made in regards to room occupancy.
30
Gardner, E. (1992, June 22). Eliminating inefficiencies could save hospitals $60 billion—
study. Modern Healthcare, 22(25), 36.
Focus of Article
To suggest that hospitals could save money by eliminating
inefficiencies that prevent employees from doing their job.
Type of Healthcare Facility
The information presented in the article is intended for all
hospitals in the United States. It is based on a study
conducted by E. C. Murphy Ltd., a quality-consulting firm in
Amherst, N. Y., in which 37, 474 employees at 59 hospitals
were asked to analyze their jobs. The study also compared
1,475 hospital workers with 1,144 manufacturing workers.
Recommendations for
Healthcare Setting
Implications of Findings
Information from the study suggests that hospital workers
waste one third of their time overcoming organizational
inefficiencies. By restructuring jobs and improving
communication among departments as well as streamlining
their organizations, hospitals could save as much as $60
billion each year. On average, for every $100 spent on direct
patient care, hospitals spend $53 on clerical and
communication tasks and $25 on administration. Better-run
hospitals only spend $21 to $42 on clerical and
communication costs and $8 to $15 on administrative costs
for every $100 spent on direct patient care. By running
hospitals more efficiently, a minimum 31% decrease in the
total annual labor cost of $210 could be achieved.
Hospital employees suggest that of their wasted time, 60%
came from poor communication among departments and
unnecessary paperwork, 20% came from inefficient methods
of operating, and the remaining was attributed to a variety of
factors such as outdated equipment.
In comparing nurses to manufacturing workers, the study
estimated that the nurse’s job is eight times as complex as
that of a manufacturing line worker. Eliminating clerical
tasks not related to patient care could increase nurse
productivity and efficiency.
By reorganizing and eliminating unnecessary tasks as well as
improving communicating between departments, hospitals
could save a great deal of money. This article did not deal
with room density and occupancy rates.
31
Goe, S. (2002, June). Hospitals need a dual vision to provide effective care for the future.
Managed Healthcare Executive, 12(6), 39-40.
Focus of Article
To discuss Scenario facility planning (SFP), a pre-design
process which looks at thinking about future possibilities in
healthcare to determine hospital needs.
Type of Healthcare Facility
The information presented in the article is intended for all
hospitals in the United States.
Recommendations for
Healthcare Setting
Implications of Findings
Goe suggests that when looking at the past to predict the
future, bed capacity was not managed efficiently. Most
hospitals are designed for inpatient care, but more than 60%
of hospital revenue comes from outpatient care. Scenario
facility planning suggests that hospital administrators and
executives look to possible future trends in healthcare to
predict future needs. One main goal of a managed care
executive is to ensure that hospitals have a sufficient number
of beds to operate effectively. Trends that will emerge in the
future are an aging population, population growth, and
cultural shifts, such as the Internet. Uncertain trends are the
probability of major epidemics and the prospect of
government reimbursement for healthcare.
This article suggests that hospitals should anticipate needs of
the future rather than focus on trends of the past when
managing hospitals. This article did not deal with room
density and occupancy rates.
32
Hoppszallern, S. (2003). Health care benchmarking 2003. Hospitals & Health Networks,
Focus of Article
To describe the financial performance of hospitals.
Type of Healthcare Facility
The article applies to hospitals in the United States.
Recommendations for
Healthcare Setting
Implications of Findings
The department performance of hospitals varies by bed size.
Larger hospitals treat patients with complex illnesses that
require longer stays and greater resource consumption. Total
expenses per discharge are $1187 higher in larger hospitals
than smaller hospitals. Those offering the most complex and
costly services are teaching hospitals and tertiary care
hospitals. Inpatient nursing expenses are increasing as labor
expenses have increased by 6.9% and total expenses have
gone up by 8.5%. In addition, home health service levels
continue to decrease. In 2001, total margins declined for all
hospitals and hospitals in high-managed care markets
outperformed their counterparts in profitability measures. In
terms of medical practices, non-hospital multispecialty
medical practices are growing faster than hospital owned
practices through the addition of more physicians.
Furthermore, HMO enrollment in the United States is at its
lowest in five years. Finally, most opportunities for cutting
costs through a reduction in length of stay have been taken.
Hospitals offering more complex care incur higher total costs.
No mention was made in regards to room occupancy.
33
Kirtane, M. (1999, April). Lessons for physicians. Why are hospitals losing money? Tennessee
Medicine, 92(4), 123-124.
Focus of Article
To discuss the factors that led once financially successful
hospitals to lose money.
Type of Healthcare Facility
The article applies to hospitals in the United States.
Recommendations for
Healthcare Setting
Implications of Findings
Throughout the United States, once financially strong
hospitals are downsizing to reduce expenses. In the early
1990’s, healthcare institutions provided inpatient and
outpatient care. They managed to reduce expenses while
becoming efficient in delivering care. Hospitals and
physicians then tried to neutralize the dominance of the
managed care industry. An integrated delivery system (IDS)
was formed and included hospitals, physicians, HMO’s, home
care services, and assisted living communities. Physician
productivity soon decreased while expenses increased. The
Balanced Budget Act of 1997, which reduced Medicare
reimbursement for hospital and home care services, also
created financial problems for hospitals. The majority of the
hospital sponsored HMO’s were financially disastrous and
were terminated or sold.
Hospitals were unable to run physician practices and became
financially unstable. No mention was made in terms of room
occupancy.
34
Komiske, B. (1995). Innovations of note: Cooperative care-the ultimate in patient-centered care
at a lower cost. Journal of Healthcare Design, 7, 181.
Focus of Article
To describe the features of the Cooperative Care Center in
Providence, Rhode Island.
Type of Healthcare Facility
The material presented in this article pertains to the
Cooperative Care Center in Providence, Rhode Island.
Recommendations for
Healthcare Setting
Implications of Findings
The mission of the Cooperative Care Center is to provide
high-quality care in a hospital where healthcare professionals
join the patient and their healthcare partner to treat the
patient’s illness. An emphasis is placed on educating the
patient on how to treat and manage the illness. While the
facility is a hospital, it does not include a nurse’s station on
the patient floors. Hospital beds are licensed, but they do not
conform to the license or code of the state health department.
High-quality acute care is provided at lower costs in a homelike environment.
In order to receive care, patients must be mobile and they
must have care partners with them. Care partners may leave
throughout the day, but they should be with the patients at
night. There is no charge for the room and board of the care
partner. Privacy is important, and thus, all patient rooms are
private and are locked. Patients are given beepers whey they
are admitted so that they may be tracked.
The facility cost under $128 per square foot to build. The
cost per patient was $420 per evening but has since been
lowered to $380 per evening. The cost at other Rhode Island
hospitals ranges from $440 to $630 per evening for a private
room.
Patients can receive high-quality acute care at lower costs in a
home-like environment, provided they have a care partner to
aid in the treatment of the illness. Rooms in this facility are
private.
35
Moore, J. (1999, December). Shared occupancy. Contemporary Long-Term Care, 22(12), 3536.
Focus of Article
To discuss the advantages of shared occupancy for seniors.
Type of Healthcare Facility
The article applies to assisted living facilities in the United
States.
Recommendations for
Healthcare Setting
Implications of Findings
Assisted living costs seniors approximately $2500 per month,
and only about 25% of seniors can afford this fee. These fees
are based on private occupancy. An alternative for seniors is
shared occupancy, which costs approximately $1650 per
month. The monthly service fee is about 60 to 70 percent of a
private occupancy monthly fee.
There are three unit designs for shared occupancy rooms.
The first is a studio of about 350 square feet. There is also a
modified one-bedroom space of about 400 to 450 square feet.
Each resident has an individual sleeping area and a modest
sitting area. The last alternative is a two-bedroom unit with
equal sleeping areas for the residents and a larger living area;
the unit is about 600 square feet. Compatibility between
residents is key for shared occupancy to work.
Shared occupancy is a feasible alternative for seniors that
cannot afford private occupancy rooms in assisted living
facilities.
36
Morrissey, J. (1994, September 19). Cooperative care acutely less costly. Modern
Healthcare, 181, 32.
Focus of Article
To discuss an innovative method of acute-care at the
Cooperative Care Center in Providence, Rhode Island.
Type of Healthcare Facility
The article describes the Cooperative Care Center, which is a
74-bed facility on the shared site of Rhode Island Hospital
and Women & Infants Hospital.
Recommendations for
Healthcare Setting
Implications of Findings
Acute-care hospitals are being asked to maintain staff levels
under control while providing care to more complex cases
and discharging patients faster. The Cooperative Care Center
has eliminated the traditional hospital structure and provides
acute care at a cost thirty percent lower than traditional acute
care. Family members and friends are used in the routine
care of the patient and are able to take their experience home
with the patient.
Based on results at a similar facility at New York Medical
Center in Manhattan, it is predicted that this type of acute
care will lead to improved patient outcomes resulting in lower
readmission rates as well as shorter lengths of stay, fewer
medication errors, and higher satisfaction scores. Research at
this center demonstrated that medication errors were 79%
below the expected rate and patient falls were 41% below the
expected rate for acute-care settings. This center also
required 43% less personnel and cost 38% less to operate than
a traditional acute-care center.
The Cooperative Care Center was built for $13.3 million,
costing a third less than a comparable traditional acute-care
center. Nursing stations were not required and patient/partner
beepers replaced overhead paging systems. The cost per
square foot was $125 at this center. Rather than using
standard hospital beds, which cost $6000, hotel beds are used
in patient rooms at a cost of $300. Daily costs are at least
$140 less than those at Rhode Island Hospital where
traditional care is provided, as specified on the operating
license provided by the state health department.
Through the use of non-traditional care utilizing family
members and friends, the Cooperative Care Center has saved
money and provided satisfactory care to patients. Patient
37
rooms are described as having beds for both the patient and
care partner, and are thus designed to be private.
38
Priselac, T. (2000, July 17). Do-it-yourself budget relief. Modern Healthcare. 30(29), 26.
Focus of Article
To discuss factors that need to be take into account in funding
healthcare systems. It is based on mitigating losses that are
caused by the Balanced Budget Act of 1997.
Type of Healthcare Facility
The material presented in this article is intended for all
hospitals in the United States.
Recommendations for
Healthcare Setting
Implications of Findings
It is suggested that the foundation for a successful hospital is
built on strategic, financial and operational planning based on
constant observation and ongoing reassessment of internal
and external factors. Several factors are mentioned that are
important. Quality and service improvements are essential in
attracting patients, physicians, and the best employees.
Programs must constantly be developed and reviewed.
Marketing is essential as is managed care, in which
contracting and pricing policies are based on the needs of the
present and the future. Effective management of the treasury
can aid in times of uncertainty due to shifts in public policy.
Fundraising is also an important tool for not-for-profit
hospitals. Since hospitals are labor-intensive, effective
productivity and supply chain management is the number one
operational consideration. Finally, information and Internet
technology help to enhance communication and data
utilization in healthcare systems.
Successful operation of hospitals can occur in spite of
changing governmental policies through constant evaluation
of critical factors that impact hospital productivity and
efficiency. This article did not deal with room density and
occupancy rates.
39
Smet, M. (2002, September). Cost characteristics of hospitals. Social Science & Medicine.
55(6), 895-906.
Focus of Article
To gain insight into the literature pertaining to hospital cost
structures.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
the United States.
Recommendations for
Healthcare Setting
Implications of Findings
It is estimated that third party insurers pay over 85% of all
hospital costs. Their reimbursement policies create costminimizing pressures on hospital management. Hospitals
also do not achieve long-run efficient positions because they
have a tendency to over-invest in capacity and equipment.
Larger, more specialized hospitals may be more cost
effective. Cost savings can be achieved through a decrease in
the average length of stay since day costs account for about
60-70% of a 7-day stay. Having a large portion of the staff
under the age of 45 also increases hospital costs, as young
physicians may use more costly forms of treatment, or they
are less efficient and use more hospital resources.
Overhead costs are driven by volume of patients, capacity in
terms of number of beds available, and complexity of services
offered and the costs of these services. Hospital complexity
increases with the growing number of discharges and the
increase in number of beds.
Overall, hospitals tend to over-invest in capital. No mention
was made in regards to room occupancy.
40
Solucient. (2003). National and local impact of long-term demographic change on inpatient
acute care. http://www.solucient.com/publications/demochange.shtml
Focus of Article
To discuss changing trends in healthcare demographics and
its impact on the healthcare industry.
Type of Healthcare Facility
The article applies to hospitals in the United States.
Recommendations for
Healthcare Setting
Implications of Findings
Over the next twenty-five years, the amount of inpatient
volume in hospitals will dramatically increase. This is due to
an aging baby boom generation, increasing life expectancy,
rising fertility rates, and continued immigration. Of the
services provided, cardiology, pulmonary medicine,
orthopedics, and gastroenterology will experience the greatest
growth. Bed demand will increase gradually over the next
few years, at about one percent per year, but by 2012, bed
demand will increase by approximately two percent annually.
The South and West will experience the greatest increase in
inpatient care due to continued migration. The Midwest and
Northeast regions will experience modest increases in
inpatient care because of the aging population. The growth of
inpatient care will place a financial burden on Medicare.
Due to an aging population and other demographic trends,
inpatient care will increase substantially over the next twentyfive years. No mention made in regards to room occupancy.
41
Terry, K. (2003, January 10). Where has all the money gone? Medical Economics, 80(1), 72-75.
Focus of Article
To shed light on why healthcare costs continue to increase.
Type of Healthcare Facility
The article applies to hospitals in the United States.
Recommendations for
Healthcare Setting
Implications of Findings
In 2001, more than half the total growth in health spending
came from inpatient and outpatient care as hospital outpatient
spending rose 16.3%. Specialists are benefiting from this
rise, while primary care physicians are not. HMO profit
margins have been close to zero for the past few years.
Technology is one reason the cost of care is increasing, as is
the reduced authorization requirements for tests, referrals, and
procedures. Furthermore, the consolidation of hospitals into
bigger systems and the demand for broader networks gave
hospitals more bargaining power in terms of health plans.
Because of these factors, health rates rose and the use of
services increased in hospitals. Insurance premiums are still
on the rise because of accelerated medical-claims expenses
and to make up for past losses.
Hospitals and specialists are benefiting from the increase in
inpatient and outpatient care while primary care physicians
are not seeing any increase in wages. No mention was made
in regards to room occupancy.
42
Thompson, J. D. & Goldin, G. (1975). Progressive patient care writ large. In J. D. Thompson &
G. Goldin (Eds.), The hospital: A social and architectural history (pp. 317-323). London: Yale
University Press.
Focus of Article
To discuss future trends in hospital planning, design,
operation, and management.
Type of Healthcare Facility
The material presented in this article applies to all hospitals.
Recommendations for
Healthcare Setting
Implications of Findings
Hospital care should shift from thinking in terms of a
progressive patient care hospital to developing a progressive
patient-care centered medical system.
Hospitalizations should be used to cure the patient as well as
to educate the patient to prevent relapses from occurring.
Milieu therapy can be used to combine professional support
and support patient interactions. Better outcomes are
achieved with this therapy through patient interactions.
Single-occupancy rooms are not effective in this instance
because patients need to be trained in groups to help one
another and learn from each other.
Two problems facing hospitals are increased costs of new
programs and searching for an institution whose size meets
the needs of its patients and communities. Increased hospital
costs are due in part to new scientific technology. The
machinery used on patients and the nursing skills required are
expensive.
Hospital costs can be decreased by reducing inpatient stays.
This can be achieved through monitoring of the patients by
staff members to determine whether it is necessary to keep
the patient in hospital. Comprehensive care can also be
promoted outside the hospital to reduce the number of
hospital admissions.
The role of the hospital is to meet the needs of the patients
and not the interests of those providing medical care. Room
occupancy was mentioned in terms of training patients, and in
this instance, multiple-occupancy rooms are favored because
they stimulate patient interaction, facilitating the training
process.
43
Empirical Articles: Healthcare Facility Management and Hospital Design
Delon, G. L. & Smalley, H. E. (1970, April 1). Quantitative methods for evaluating hospital
design. pp. 17-47.
Focus of Study
To develop methodology for evaluating nursing unit design.
Research Design
Qualitative checklists were developed for nursing unit
designs. A model was developed from the checklists and it
was applied to existing nursing units to determine its
usefulness. Both uncontrollable and controllable costs were
considered, including traffic and construction costs.
Sample Information & Site
The sample and site of this study were not specified though
the implication is that the data applies to hospitals in the
United States.
Findings
Seven areas within the nursing unit serve as the basis for the
beginning and end for the majority of trips made by nurses.
These include the nursing station, patient rooms, supply
rooms, the laundry, the kitchen, the bedpan room, and the
elevators. In addition, ten areas comprise of more than eighty
percent of trips originating or destined for the nursing unit.
These consist of the dietary department, the surgical suite, the
central supply room, the radiology department, housekeeping,
the laboratory, the laundry, the pharmacy, the emergency
department, and other nursing units.
The checklists account for the relationship between nursing
traffic and patient self-sufficiency, take into consideration
traffic savings of multiple-occupancy rooms, and they
incorporate the influence that the location of patient rooms
has on traffic patterns.
Arguments have been made suggesting the most efficient unit
size is between 25 and 35 beds. Furthermore, rooms should
not be further than 90 feet from the nursing station.
Advocates of larger units argue that larger units are more
efficient because better staffing patterns are achieved, the
need for tall buildings is eliminated resulting in savings in
elevators and plumbing, for example. Larger units also
require fewer medicine units, linen rooms, and nursing
stations storing materials. Advocates of smaller units argue
that they are better for supervising patients.
Hill-Burton recommends that the average size of singleoccupancy patient rooms is 100 square feet, while the average
size of double-occupancy and 4-bed rooms is 80 square feet.
44
A trend exists towards the recommendation of singleoccupancy rooms in hospitals. They are advantageous
because higher occupancy rates can be achieved, patient care
is improved, the risk of cross-infection is reduced, and greater
flexibility of operation is available.
When designing single-occupancy rooms, they should be
large enough to accommodate two beds. Double-occupancy
rooms should be designed to be easily converted to singleoccupancy rooms. Four-bed rooms should also be easily
converted to two double-occupancy rooms through the
addition of a bathroom.
Nursing stations require space for a head nurse office, a
charting area, a medication unit, and workspace for a ward
clerk.
Implications of Findings
Although arguments are made in favor of both larger and
smaller nursing units as well as single- and multipleoccupancy rooms, neither design is clearly favored.
45
Douglas, C., Steele, A., Todd, S., & Douglas, M. (2002, October 17). Primary care trusts. A
room with a view. Source Health Service Journal, 112(5827), 28-29.
Focus of Study
To investigate how hospital design helps patients recover.
Research Design
The study was conducted over a twelve-month period.
Several inpatients were interviewed and questionnaires were
sent to inpatients that had stayed five days or more on
medical, surgical, or maternity wards as well as those that
stayed on wards where care was provided to the elderly
regarding their experiences and satisfaction with their stay.
Community groups were also set up and included people
from the community as well as experts from the Royal
Institute of British Architects and the Royal Institute of
Chartered Surveyors. The focus of these meetings was to
discuss what constituted a patient-friendly environment.
Sample Information & Site
The study was conducted at Salford Royal Hospitals in
England. Fifty inpatients were interviewed and
questionnaires were mailed out to 2,200 people. Of these
questionnaires, 785 were returned.
Findings
Those attending the community group meetings suggested
that hospitals include good signage, good lighting, privacy for
patients, reduced noise levels, temperature controls for
patients, access to nature, safety and security provisions,
accommodations for visitors and good landscaping.
Suggestions were also made for children’s play areas, shops
and personal services, and catering facilities that operated all
day.
Those interviewed wanted a welcoming environment, enough
space to allow for privacy and to accommodate visitors,
views of nature, and a design that would facilitate
communication between staff, patients, and family members.
Those who returned the questionnaires indicated that though
they were generally satisfied with the care they received, they
disliked the lack of privacy they had and the mixed-sex
wards. Those who stayed in single occupancy rooms and in
the small bays clustered around a nursing station were most
satisfied with their stay. Suggestions were made to improve
the atmosphere of the wards to make it more welcoming, to
improve the quality of the curtains, to increase storage space,
to include adjustable lighting and temperature control, to
46
improve the views of the outside, and to increase the amount
of space for visitors.
Implications of Findings
Those that stayed in private rooms and small bay wards
clustered around a central nursing station were most satisfied
with their stay.
47
Gadbois, C., Bourgeois, P., Goeh-Akue-Gad, M. M., Guillaume, J., & Urbain, M. A. (1992).
Hospital design and the temporal and spatial organization of nursing activity. Work &
Stress,6(3), 277-291.
Focus of Study
To analyze the spatial and temporal organization of nurses’
work in medical and surgical units of French hospitals.
Research Design
Nursing activity was observed and recorded on a U-shaped
ward. The observer recorded activity related to the sequence
of areas visited, the tasks executed in these areas, the reasons
for travel between these areas, and the times of entry and exit
in these areas. Data was collected during the day shift over a
six-month period.
Sample Information & Site
The study took place in a medical and surgical ward in a
private hospital in Paris. The sample included nurses
working on this ward.
Findings
It was determined that nursing work is divided into various
acts, which are distributed through time and space. The
majority of the activities performed by nurses lasted less than
two minutes on either unit. An average of 23 activities per
hour were performed in the surgical unit, while an average of
25.3 activities per hour were performed on the medical unit.
The work performed by nurses resided in various sites. On
the surgical unit, nurses performed 3855 trips that lasted
approximately 3 minutes and 25 seconds each. 4521 trips
were performed by nurses on the medical units, each lasting
approximately 3 minutes and 9 seconds. A large number of
activities performed in one area, such as the corridor or
patients’ rooms, were followed by an activity in another
location. The constant movement by nurses varied based on
the spatial organization of the unit as well as the temporal
structure of the tasks.
Nurses’ work areas can be divided into four categories: the
patients’ rooms, the nurses’ area, the corridor, and other
specialized areas such as storage and medical offices.
Nurses generally followed three paths in their trips: different
points of the nurses area, trips between the patients’ rooms
and nurses’ area, and trips between patients’ rooms. Trips
were organized according to spatial and functional logic.
On the surgical unit, nurses were interrupted, on average,
once every 20 minutes, while on the medical unit, nurses
were interrupted an average of once every 12 minutes.
48
Visibility of staff members was difficult due to the U-shaped
design of the ward.
Implications of Findings
The work of nurses is dependent upon the spatial
configuration of the ward as well as the temporal organization
of the work. No mention was made in regards to room
occupancy.
49
Kirk, S. (2002, December 10). Patient preferences for a single or shared room in a hospice.
Nursing Times, 98(50), 39-41.
Focus of Study
To look at the preference of hospice patients for either single
or shared rooms. The study also investigates factors that may
alter a patient’s preference.
Research Design
Researchers conducted structured interviews with twenty-four
patients in two hospices (Twelve patients from each hospice
were interviewed). The interviews looked at the patients’
preferences and experiences in single or shared rooms.
Sample Information & Site
The study was conducted at two hospices in Leeds, England.
Twelve patients in two hospices were interviewed. Six males
and six females from each hospice participated. Three of the
males and three females occupied single rooms, while the
other patients occupied shared rooms. Nineteen of the
patients had previously stayed in a single room and twentythree patients had experience in shared rooms.
Findings
In terms of preferences for single or shared rooms, eighteen
of the patients preferred a single room, five preferred a shared
room, and one did not hold a strong opinion on either room.
Some of the reasons given for preferring a single room are
privacy, quiet, avoiding upsetting other patients, reduced
embarrassment, improved quality of sleep, and having a
family member stay. Reasons given for preferring a shared
room included having company and being able to share one’s
experiences. Eighteen patients stated they would want to
move from a shared room to a single room if they had
diarrhea or vomiting. Only twelve patients said they would
want to move if another patient was dying. A limitation of
this study is its small sample size.
Implications of Findings
The majority of patients preferred single rooms to shared
rooms, especially if they were suffering from distressing
symptoms. Patients with previous experiences in single
rooms were more likely to prefer a single room.
50
Pease, N. J. F. & Finlay, I. G. (2002). Do patients and their relatives prefer single cubicles or
shared wards? Palliative Medicine,16(5), 445-446.
Focus of Study
To determine the preferences of patients and family members
in regards to single and multiple occupancy rooms on an
oncology ward.
Research Design
Questionnaires were given to fifty patients who were
admitted consecutively on an oncology ward. Questionnaires
were also given to family members of these patients in
regards to their preference for single or multiple occupancy
rooms.
Sample Information & Site
The sample included fifty patients on an oncology ward.
Twenty-one males and twenty-nine females agreed to
participate, but seventeen patients died during admission.
Thirty-six family members of the patients were surveyed as
well.
The study took place on a 17-bed oncology ward in England
that provides both oncology and palliative care for the
severely ill patients in the cancer center. There are three
single occupancy rooms on this ward, while the remaining
area is open, with partitions between three four-bed areas and
one two-bed area.
Findings
Of the patients surveyed, only twenty percent of them
preferred single occupancy rooms. Thirty-four percent
preferred to be in an open area while twelve percent of
patients did not have a preference. Of the relatives surveyed,
twenty-eight percent preferred for their family member to be
treated in a single occupancy room. The wishes of the family
members and the patients agreed in only fifty percent of the
cases surveyed. The main reason that patients preferred a
four-bed bay was to avoid isolation. The majority of patients
and all relatives stated that they would use a day room if one
were available.
Implications of Findings
Ward design on an oncology ward should include some single
cubicles as well as open areas, as the majority of patients
prefer to stay in multiple occupancy rooms.
51
Reid, E. A. & Feeley, E. M. (1973, January). Roommates. American Journal of Nursing, 73(1),
104-107.
Focus of Study
To determine the perceptions of patients in relation to factors
involved in sharing a double-occupancy room.
Research Design
Questionnaires were mailed out to patients who had stayed in
a double-occupancy room in a large community hospital three
days after they had been discharged. The respondents were
asked about their background, their hospital stay, and their
experiences with their roommates.
Sample Information & Site
The sample included 100 patients who had stayed in a
double-occupancy room in a large community hospital in the
United States. Of the 100 questionnaires mailed out, fiftyfour were returned and fifty-one were useable.
Findings
Fewer than half the respondents would prefer to stay in a
private room if given a choice. Some patients would have,
however, preferred a different roommate. Patients enjoyed
double-occupancy rooms because they felt they had someone
to talk to and they could help each other out. Privacy was an
issue for some in these rooms. Double-occupancy rooms
were also problematic when noise levels were high and when
one patient had too many visitors. Roommates that were very
ill or that had a large age difference between them were
undesirable.
Implications of Findings
Overall, patients preferred double-occupancy rooms to
private rooms.
52
Shepley, M. M. (2002). Predesign and postoccupancy analysis of staff behavior in a neonatal
intensive care unit. Children’s Health Care, 31(3), 237-253.
Focus of Study
To provide data on the behavioral issues associated with the
design of a neonatal intensive care unit.
Research Design
This study used a multimethod approach, which included
behavioral mapping, interviews, questionnaires, and
calibrated measures of walking, noise, and temperature.
Observations were made of staff members over a 3-hour
period and information was recorded in terms of patient
census, staff designation, activity location, and time data.
The interviews and questionnaires focused on the efficiency
of the floor plan, the impact of natural light, and perceptions
of space allocation.
Sample Information & Site
The sample included nursing staff that worked on the
predesign and postoccupancy units. Twenty-one staff
members were observed, ten staff members filled out
questionnaires, and eight staff members were interviewed.
The study was conducted prior to and after renovations were
made to a neonatal intensive care unit. The original unit
consisted of six small rooms that accommodated one to five
babies in each room. The new unit was open and divided into
bays of six baby stations each.
Findings
The new design focused on the development of a more
efficient floor plan, the provision of space for supportive
family-centered care, and the use of natural light. On the new
unit, nurses were found to spend most of their time in active
baby care followed by walking, conversations, passive baby
care, and charting. More time was spent taking care of the
babies on the new unit than on the old unit.
Those responding to the questionnaires perceived the new
unit as comforting and clean but less secure than the old unit.
Family-centered care was perceived as supportive of babies
and their families, though its ratings were lower for the
supportiveness of nurses and physicians. The unit was rated
as generally being efficient and the new lighting was thought
to have a positive impact on the patients.
Those who were interviewed felt that families were utilizing
the majority of space designated to them. They felt the
design was efficient, lighting was improved, and noise levels
were lower.
53
Implications of Findings
For the most part, the new unit was rated positively. Nurses
were able to move at a greater velocity in the new unit as well
as spend more time with the infants.
54
Trites, D. K., Galbraith, F. D. Jr., Sturdavant, M., & Leckwart, J. F. (1970, December).
Influence of nursing-unit design on the activities and subjective feelings of nursing personnel.
Environment and Behavior, 303-334.
Focus of Study
To investigate the impact of radial, single-corridor, and
double-corridor nursing unit designs on the activities and
subjective feelings of nurses working on these units.
Research Design
Twelve observers collected work sampling data over a period
of eighty-two days. Nurses were also asked to complete
questionnaires pre-shift and post-shift, which examined
patient care and the subjective feelings of staff members. The
units examined were four units of each design type. These
designs included radial, single-corridor, and double-corridor.
Sample Information & Site
The study took place at Rochester Methodist Hospital. The
sample included 590 staff members who worked on the units.
Findings
In terms of nursing activities and their locations, radial design
was found to be the best design, while single-corridor design
was the worst of the three designs. Nurses had the most
accidents on the single-corridor design and the lowest
absenteeism on the radial design. The majority of nurses
stated that they would prefer to work on the radial design unit
and the radial design had the most positive effect on the
subjective feelings of the nurses studied. Time spent
traveling by nurses was lowest on the radial design unit.
Implications of Findings
The radial design was preferred as nurses spent less time in
travel than those on the other units and, as a result, they were
able to spend more time with patients.
55
Trites, D. K., Galbraith, F. D. Jr., Leckwart, J. F., & Sturdavant, M. Radial nursing units prove
best in controlled study. Modern Hospital, 112(4), 94-99.
Focus of Study
To investigate the impact of radial, single-corridor, and
double-corridor nursing unit designs on the activities and
subjective feelings of nurses working on these units.
Research Design
Nursing students collected work-sampling data between June
and September of 1967. Nurses were also asked to complete
questionnaires pre-shift and post-shift, which examined
patient care and the subjective feelings of staff members. The
units examined were four units of each design type. These
designs included radial, single-corridor, and double-corridor.
The radial units contained one private room, while the linear
designs had four to ten private rooms.
Sample Information & Site
The study took place at Rochester Methodist Hospital. The
sample included 590 staff members who worked on the units.
Findings
The radial design was superior to the other designs on all
three shifts. Nurses spent significantly less time traveling on
this ward, and in turn, they were able to spend more time with
patients. The average distance from the center of the radial
nursing unit to the patient’s bedside is 34 feet; in the doublecorridor design the distance is 48 feet; on the single-corridor
design the distance is 71 feet. Nurses preferred working on
the radial unit and fewer staff absences and fewer accidents
occurred on the radial unit. A fewer amount of complaints
were received on the radial unit by patients, relatives, and
physicians.
Implications of Findings
The radial design was preferred as nurses spent less time in
travel than those on the other units and, as a result, they were
able to spend more time with patients. No reference was
made in terms of the impact room occupancy had on nursing
efficiency.
56
Veatch, R. M. & Veatch, L. L. (1994, Winter). Hospital roommates: An interview with a
terminally ill patient. Cambridge Quarterly of Healthcare Ethics, 71-80.
Focus of Study
To present information regarding the impact that roommates
have on one another in the hospital environment.
Research Design
This study followed the experiences of one man in regards to
his hospitalizations and his experiences with roommates. He
was interviewed in his home.
Sample Information & Site
The case study was of a 72-year old man with metastasized
cancer, a herniated diaphragm, trigeminal neuralgia, a
partially paralyzed leg, and diverticulitis.
Findings
The quality of patient care is affected by the patient’s
interaction with roommates. One’s roommate can create
anxiety and confusion regarding the responsibility one has
toward the roommate. Roommates can also create anxiety in
a patient in terms of the experience of pain and medication.
Nurses should be made responsible for assessing the impact
that roommates have on each other. They should have
conversations with patients and their family members in
regards to any concerns they may have with roommate
assignment. Care should be taken in placing patients with
roommates, and sensitivity should be used with assigning
roommates with the same diagnoses, especially if they are at
different stages of the disease.
Implications of Findings
If patients are in multiple-occupancy rooms, care should be
taken in assigning them a roommate.
57
Whitehead, C., Polsky, R. , Crookshank, C. & Fik, E. (1984). Objective and subjective
evaluation of psychiatric ward redesign. American Journal of Psychiatry, 141(5), 639-644.
Focus of Study
To describe and evaluate the redesign of a psychiatric unit,
which used a psychoenvironmental model.
Research Design
Various patients were observed prior to and eight weeks after
moving to a redesigned ward. The original ward was in the
shape of a cross and included large open dormitories at the
top and on one arm of the cross. The day room was located
along the other arm. The redesign housed the same number
of patients, but the long corridor is broken up and flexibility
was increased to the day and group room areas. To measure
their behaviors, the Behavioral Environment Assessment
Technique was used, as was the Sepuvelda
Psychoenvironmental Assessment Record.
Sample Information & Site
The study was conducted in a 30-bed psychiatric facility.
Subjects included male and female veterans whose ages
ranged from early twenties through the sixties.
Findings
Prior to the redesign, socially related behaviors occurred
more often in the hallways and hall intersection. After the
redesign, socially related behaviors were more common in the
visiting room, cafeteria, and day room. Staff were also seen
more frequently in the day room after the redesign, as
opposed to the nursing station prior to the changes. Staff and
patients both responded positively to the changes, but patients
were more affected by the change than the staff, as exhibited
by their strong positive reactions to some of the changes.
Implications of Findings
The subjective experience of patients was improved as was
staff behavior after the ward was redesigned. Although an
emphasis was not placed on room design, it was mentioned
that patients were in dormitories.
58
Non Empirical Articles: Healthcare Facility Management and Hospital Design
Aldridge, E., Smith, L. D., & Sperling, L. (1991). VIP suites: A new trend, Journal of
Healthcare Interior Design, 3, 85-95.
Focus of Article
To describe the design of VIP suites in hospitals.
Type of Healthcare Facility
The facility described in this article is the Camellia Pavilion
at the University of Alabama Hospital.
Recommendations for
Healthcare Setting
The unit consists of twenty beds, all of which are private.
The rooms are a minimum of 390 to 400 square feet, and the
rooms are double in size when they consist of a sitting room
as well. Armoires conceal televisions and VCRs, and patients
have the ability to use computers if they desire to. Bathrooms
consist of a tub and shower as well as soaps, towels,
refrigerators, and terry cloth robes. The décor of the unit is
based on a Georgian style. The facility also includes
specialty areas such as a gourmet kitchen, a fitness center,
and family rooms.
The facility is designed for non-acute patients only. The ratio
of nurses to patients is one to four.
The cost of staying in theses suites is slightly greater than
staying in a regular semiprivate room.
Implications of Findings
The rooms in this facility are private, and the majority of
them also consist of a sitting room.
59
Anonymous. (2001, March). ‘Speedy’ patient rooms to debut at Cheyenne’s United Medical
Center. Facilities Design & Management, 20(3), 10.
Focus of Article
To describe the features of a new six-story tower at United
Medical Center in Cheyenne, Wyoming.
Type of Healthcare Facility
This article features the United Medical Center in Cheyenne,
Wyoming. The non-profit hospital is in the midst of a twoyear $25 million construction project. A new six-story tower
will include 195 beds. Private patient rooms are being
constructed in addition to 115 medical/surgical rooms and
five isolation rooms.
Recommendations for
Healthcare Setting
Implications of Findings
The new patient rooms are comfortable and have a clean,
modern look. Patients are able to control the lights and blinds
from the beds. A sleeper sofa is available for family
members who stay overnight. In-room nurses’ stations are
included in the design. These areas give the nurses and
clinical staff a separate area to work so they don’t have to use
the patient’s private bathroom.
While the use of private patient rooms is suggested, it is
unclear if all the patient rooms are private. No empirical
evidence is given to support the use of private rooms.
60
Anonymous. (2000, March). Designing a streamlined recovery. Facilities Design &
Management, 19(3), 12.
Focus of Article
To discuss how the patient rooms of the future will be
designed. The information is based on the opinion of H. Bart
Franey, the CEO of Wellness, LLC in Nashville, a company
that designs and installs modular hospital patient rooms.
Type of Healthcare Facility
This article pertains to the TriStar Health System’s
Centennial Medical Center in Nashville.
Recommendations for
Healthcare Setting
Implications of Findings
Franey suggests that the patient room of the future will be
larger. The larger room will help to actively promote healing
and staff efficiency. It will also increase flexibility to allow
healthcare professions to adapt to technological advances.
The rooms should be holistic in nature and use flowing,
curved surfaces, soothing colors, in-room nursing stations and
easy to clean floor and wall coverings.
Larger rooms will be beneficial to both staff and patients. No
mention was made in regards to a preference for single or
multiple room occupancy.
61
Anonymous. (2000, January). Hospitals discover cost efficiency of private rooms. Executive
Solutions for Healthcare Management, 3(1), 7-8.
Focus of Article
To describe the reasons why two healthcare facilities have
chosen to change their semi-private rooms into private
rooms.
Type of Healthcare Facility
The information in the article applies to two facilities.
These are Northwestern Memorial Hospital in Chicago and
William Beaumont Hospital in Royal Oak, Michigan.
Recommendations for
Healthcare Setting
Implications of Findings
Northwestern Memorial Hospital has converted all its
semi-private rooms into private rooms. This is due to the
belief that privacy is a critical factor for a patient’s
comfort. Because they believe that families are important
in the care process, each room has a window seat with a
pullout bed to accommodate visitors. William Beaumont
Hospital is in the process of converting 70% to 80% of its
beds into private rooms. Currently, 85% of Beaumont’s
beds are semi-private. Ninety percent of patients at
Beaumont hospital request private rooms, but the hospital
usually does not have any to offer. The semi-private
rooms typically have a 10% lower occupancy rate than the
private rooms, and combined with transfer costs, private
rooms are a better alternative.
Some of the benefits of private rooms include shortening
one’s length of stay and cutting costs. Private rooms also
help reduce the risk of acquiring a hospital born infection
as well as reduce the risk of medication errors. This
information is based on a cost-benefit analysis conducted
by Watkins, Hamilton, Ross Architects on the William
Beaumont Hospital.
Both Northwestern Memorial Hospital and William
Beaumont Hospital are in favor of private rooms.
62
Anonymous (1998, October). Critical care update. Facilities Design and Management, 17(10),
48-49.
Focus of Article
To describe the remodeling of the telemetry and intensive
care units at Methodist Hospital.
Type of Healthcare Facility
The information presented in this article pertains to Methodist
Hospital in St. Louis Park, Minnesota.
Recommendations for
Healthcare Setting
Implications of Findings
This facility was remodeled with a focus on improving
working conditions on a telemetry unit. Care was
decentralized and the number of private rooms was increased
from twelve to sixteen. If the demand for beds exceeds the
supply of beds, patients are placed in an eight-bed swing area.
The central nursing station was eliminated and bathrooms
were repositioned to enable the placement of charting
alcoves. These alcoves are located along the corridors and
are dispersed among the patient rooms. They are furnished
with seating, storage, lighting, and a work surface along with
a telephone and a computer. Infrared technology is used to
track staff members down when they are needed.
In this facility, the number of private patient rooms were
increased, and if more beds are needed, patients are placed in
a multi-bed swing area.
63
Anonymous. (1991a). The design of buildings. Health Services Management, 87(1), 3-4.
Focus of Article
To discuss how hospitals should be designed in the future.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
England.
Recommendations for
Healthcare Setting
Implications of Findings
Hospital design should enable the departments and staff to
run efficiently and should meet the needs of staff as well as
be pleasant for patients. The norm for independent hospitals
and for private wings in the NHS is single rooms. The case
against single rooms is their cost in terms of building and
staff. Supervision of patients is also more difficult with
single rooms. An argument is made towards open wards as
supervision is best on these wards and patients are given more
privacy than in the four or six bed wards.
While there is an increasing trend towards single rooms, due
to their cost and the difficulty of supervising patients, open
wards may be better. Supervision is increased on these wards
and patients are given more privacy than in the bay wards.
64
Anonymous. (1991b). Patient-focused hospital. Health Services Management, 87(1), 4
Focus of Article
To describe aspects of a patient-centered hospital.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
England.
Recommendations for
Healthcare Setting
Implications of Findings
The goal of the patient-centered hospital is to decentralize so
that services are brought nearer to the patient.
Decentralization requires the appropriate equipment,
appropriate staffing, and an appropriate size unit. It is
suggested that then optimal number of beds in a ward should
be about 130.
Patient-focused hospitals are lest costly to build than
traditional hospitals and the main costs are running costs, in
particular, staffing.
Patient-focused hospitals are a viable alternative to traditional
hospitals. No mention was made in regards to room
occupancy.
65
Anonymous. (1971, October). New hospital will offer private accommodations in a semiprivate room. Modern Hospital, 117, 84-85.
Focus of Article
To describe a newly devised semi-private room that offers
private space to both of the occupants.
Type of Healthcare Facility
The information in this article applies to Carlisle Hospital,
PA.
Recommendations for
Healthcare Setting
Implications of Findings
The author suggests that the design makes it possible for one
patient to converse with visitors without inconveniencing or
disturbing the other patient. It is also possible for staff
members to provide treatment and services to one patient
without disturbing the other patient. Both patients have equal
access to the toilet and wardrobe facilities and both have
equal access to the outside through two windows in each
room. Pillow speakers allow each patient to listen to or watch
radio or television programs without creating distractions or
discomfort for the other patient. A standard fabric curtain set
in a recessed ceiling track is used to separate the patient areas.
Windows are indented six feet from the building façade,
creating an overhang that provides sun and weather
protection.
Each patient room occupies an area of 351 square feet.
Normal rooms are approximately 300 square feet. The extra
fifty feet adds approximately $2000 to the cost of each room.
Bright colors are used throughout the nursing units, which are
designed with a conventional structural system. This
eliminates costly framing. The nurses’ stations are centrally
located and are not more than ninety feet away from any
patient room.
The color schemes are different for each patient room on the
same corridor. Rooms with the same basic color are as
distant from one another as possible. All the rooms are
carpeted. A day room, located adjacent to the nursing unit
and elevators, offers an exterior view.
Through this design, patients are able to experience the
privacy of a single room in a semi-private room.
66
Bacon, A. S. (1920). Efficient hospitals. Journal of American Medical Association, 24(2), 123126.
Focus of Article
To describe the ward design of an efficient hospital.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
the United States.
Recommendations for
Healthcare Setting
Implications of Findings
The ideal efficient hospital should serve people in moderate
circumstances and should provide them with all the
conveniences of the most exclusive institutions.
Hospitals are not achieving maximum bed capacity because
of diseases that become epidemics and because of differences
in preferences between males and females. Private rooms
increase flexibility and help hospitals achieve maximum bed
capacity. Also, patients are provided with more comfort,
better examinations can take place in these rooms,
temperatures can be controlled based on the needs of the
patients, and visiting schedules can be adjusted based on the
patient. A centralized control system is needed to prevent
poor judgment by nurses as well as to provide a means of
checking up more systematically.
Private rooms are desired to maximize bed occupancy and to
provide patients with a more comfortable environment.
67
Baker, J. & Lamb, C. W. Jr. (1992). Physical environment as a hospital marketing tool. Journal
of Hospital Marketing, 6(2), 25-35.
Focus of Article
To illustrate the importance of managing the physical
environment in hospitals as well as to explore the role of the
physical environment in hospital marketing.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
the United States.
Recommendations for
Healthcare Setting
Implications of Findings
The physical environment of the hospital plays four important
roles in the marketing of health care services. These include:
communication, contributions to the psychological welfare of
patients, contributions to the perceptions of service quality,
and market targeting and positioning.
In terms of communication, the appearance of a patient’s
room conveys the attitude of hospital management towards
the needs of the patients. Patients’ attitudes are also affected
by the design of the building, signage, lighting, and reception
areas. Staff members are also affected by building design,
and attention to their needs can improve morale and service to
patients.
Good building design helps to minimize patient stress and
permits feelings of competence and control.
Environments that are pleasant, comfortable, and relaxing
contribute to patient satisfaction.
Patients are increasingly given more control in choosing the
healthcare facility they want to be treated in, and thus,
appearance is critical in attracting patients.
Patients and staff are affected by the hospital environment,
and a positive environment can boost staff morale and
productivity and can make the stay more pleasant for the
patient. No mention was made in regards to room occupancy.
68
Barista, D. (2000, November). Health care embraces hospitality. Building Design and
Construction, 41(11), 36-40.
Focus of Article
To describe changes made to Baptist Memorial Hospital to
make the environment more pleasant for patients.
Type of Healthcare Facility
The design described in this article applies to Baptist
Memorial Hospital in Collierville, Tennessee.
Recommendations for
Healthcare Setting
Implications of Findings
The hospital design incorporates more private rooms that are
large enough to accommodate family members and integrate
hospital equipment. Most rooms are divided into two
sections: a patient area and a family area. The design is
fueled by changes in healthcare delivery as well as increased
competition between facilities. The design is based on the
“medical mall” concept, which integrates healthcare
departments into the layout of a retail mall. It consists of a
main lobby and long corridors that lead to each department
and allows for smooth outpatient-traffic flow. This design
also facilitates future expansion.
The design incorporates more private rooms that are large
enough to accommodate family members as well as integrate
necessary equipment.
69
Bilchik, G. S. (2002, July-August). A better place to heal. Health Forum Journal, 45(4), 10-15.
Focus of Article
To describe various facilities incorporating the pebble project,
which uses empirical evidence to evaluate impacts of
healthcare design.
Type of Healthcare Facility
The facilities featured in this article are Children’s Hospital in
San Diego, Methodist Hospital/Clarian Health Partners in
Indianapolis, Bronson Methodist Hospital in Michigan, and
the Barbara Ann Karmanos Cancer Institute in Michigan.
Recommendations for
Healthcare Setting
Children’s Hospital in San Diego is opening a convalescent
care hospital, which is designed to promote long-term care for
permanently disabled children. The design includes
wheelchair storage in patients’ rooms that is out-of-sight, as
well as private spaces outside the patient rooms for parents to
hold their children. The air ventilation system will be
improved and it is expected that fewer respiratory infections
will occur.
The Methodist Hospital in Indianapolis opened a 56-bed
cardiovascular critical care unit. Patients are admitted
directly to their rooms from the emergency room, admitting,
physicians’ offices or the Lifeline helicopter. Patient rooms
are private and patients are in control of the temperature and
light. Each room also has an interior window that can
become opaque to increase privacy. Nurses can observe
patients better and the number of falls has decreased by half
and transfers have decreased substantially from 200 per
month to an average of 20 per month.
Bronson Methodist Hospital in Michigan opened a new
facility with private patient rooms. Patients have access to
nature through indoor gardens, natural light, and landscape
views. Stress is reduced through the use of positive
distractions such as music, water sounds, artwork, and
daylight.
The Barbara Ann Karmanos Cancer Institute renovated
several hospital areas to be patient-centered and to provide a
more pleasant environment. Medical rooms were made larger
and an emphasis was placed on lighting and acoustics. A
decrease has occurred in the use of pain medication on these
units as well as a decrease in medication errors.
70
Implications of Findings
The majority of these facilities incorporated private rooms
into their designs and patients have had successful outcomes
in these new and renovated facilities.
71
Bobrow, M. & Thomas, J. (2000). Inpatient care facilities. In Kobus, R. et al., Building type
basics for healthcare facilities (pp. 131-192). New York: John Wiley & Sons.
Focus of Article
To describe efficient designs of patient rooms and nursing
units.
Type of Healthcare Facility
The material presented in this chapter applies to all hospitals.
Recommendations for
Healthcare Setting
The patient rooms is seen as a place where the patient and
family members can have control of their lives and their
environment. It is also looked upon as a place of privacy,
safety, and sanctuary. The nursing unit is an extension of this
environment, and provides a family support system. The
primary goal of nursing design is to minimize the distance
traveled by nurses as well as the range of distance between
patient rooms and the nurse work core.
Efficient nursing plans include groupings of concentric pods
and the use of bedside computers. Examples of previously
used nursing unit designs include the double corridor plan,
the compact rectangular plan, and the compact circular plan.
Patient rooms have evolved from open wards to single- and
double-occupancy rooms. Single-occupancy rooms are
favored because patients are given privacy in these rooms and
these rooms can be used for isolation purposes. Medication
errors are also reduced with a reduction in patient transfers.
This also reduces hospital costs, as transfers in multipleoccupancy rooms can average from six to nine per day.
Occupancy rates also increase with single-occupancy rooms.
In multiple-occupancy rooms, occupancy reaches an average
of 80 to 85 percent, whereas in single-occupancy rooms,
occupancy can reach 100 percent. Single-occupancy rooms
should be flexible to accommodate patients requiring general
acute care as well as those requiring isolation. Patients prefer
single-occupancy rooms because they are given greater
privacy, space is provided for family members, and patients
are able to control their environment, such as lighting and
temperature. Universal rooms are large enough to
accommodate various bedside treatments and are situated to
allow for maximum patient visibility by nurses.
The San Bernardino County Arrowhead Regional Medical
Center in California was designed to include a cluster of units
connected by beds on the perimeter. Three 24-bed nursing
units are located on one floor and each nursing unit has three
72
substations, each assigned to eight beds. Single-occupancy
rooms are used in this design.
The environment provided should be sensitive to the needs of
patients including comfort and control. Natural light should
be incorporated whenever possible.
Maximum flexibility and use of patient beds can be achieved
by creating generic patient units, providing patient beds that
can be used for a variety of acuity levels, and providing a
sufficient number of single and isolation patient beds to
accommodate increasing patient acuity.
Patient care units should be decentralized into smaller clusters
that contain decentralized nursing substations, provide
increased visibility of patient beds and reduced congestion.
Nurse servers should be located adjacent to patient rooms to
provide immediate access to supplies. Traffic on the unit
should be reduced through the use of supply holding areas
and through the use of large patient rooms that can
accommodate family members. Space should also be
provided for ancillary and support services.
Each patient care floor should consist of two to three patient
units. Support shared by all units on the floor should be
included.
Implications of Findings
Efficient hospital design includes clusters of singleoccupancy patient rooms and nursing substations to serve
these clusters.
73
Bobrow, M. & Thomas, J. (1994, November 21). Hospitals’ prosperity should be by design.
Modern Healthcare, 24(47), 54.
Focus of Article
To describe trends in designing hospitals.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
the United States.
Recommendations for
Healthcare Setting
Implications of Findings
Many hospitals need to redesign their facilities to reflect the
requirements of a changing market. The hospital
environment needs to be less institutional and more consumer
friendly. Hospital wings should be redesigned to include
more ambulatory care facilities and less inpatient services.
Multibed units will be replaced by larger single patient rooms
with the capabilities for bedside care as well as space to
house family members. Clusters of small nursing stations
will be responsible for pods of four to eight beds. Tracking
records and computerized patient records will help increase
nursing efficiency in single rooms.
The flexibility of private rooms outweighs the costs, as fewer
beds are need in hospitals. Single occupancy rooms also
increase patient comfort and privacy and enable family
members to partake in the care of patients.
The key to future designs is flexibility. Rooms of the future
should be larger and should be single occupancy to increase
patient comfort as well as increase privacy and accommodate
family members.
74
Brown, P. & Taquino, L. (2001). Designing and delivering neonatal care in single rooms.
Journal of Perinatal Neonatal Nursing, 15(1), 68-83.
Focus of Article
To outline the design and outcomes of a neonatal intensive
care design project.
Type of Healthcare Facility
The material presented in this article applies to the neonatal
intensive care unit at Children’s Hospital and Regional
Medical Center in Seattle, Washington.
Recommendations for
Healthcare Setting
Implications of Findings
Clusters of single occupancy rooms around a central nursing
station was the design chosen for this unit. This design
improved the ability to control each individual infant’s
environment. Variable lighting, decreased noise, and the
individualization of patient spaces were easier to achieve.
Carpeted finishes, sound-absorbent ceiling tiles, and the
placement of larger staff work areas outside patient rooms
contributed to decreased noise levels. The flexibility to
provide care to patients in the various developmental stages is
increased in single rooms, as is the ability to perform critical
procedures without impacting other patients. Familycentered care is also enhanced as room is provided for family
members to partake in the patient’s care. Privacy is also
increased and conferences can occur between physicians and
family members at the patient’s bedside.
This design also benefits staff members as visibility is
increased through low desks, counters, and walls. Sliding
doors between patient rooms enable the nurses to view
neighboring patients. Staff members wear locator badges to
facilitate communication between them.
Rooms on the neonatal intensive care unit are single
occupancy and this design has benefits for patients, staff
members, and family members.
75
Brown, W. J. (1994). Big design changes on small budgets. Nursing Homes, 43(7), 37.
Focus of Article
To describe how a patient’s room should be personalized
within a health-care facility.
Type of Healthcare Facility
The suggestions within the article apply to Extended care
facilities in the United States.
Recommendations for
Healthcare Setting
Implications of Findings
Brown suggests that a problem with semi-private rooms is
that both beds are placed against the same wall with only one
resident able to be placed next to the window. A solution to
this problem is to place both beds on opposite walls or direct
both beds toward the window. If room permits, a table and
chair can be placed by the window to provide residents with
an exterior view. The room should include tack boards to
enable the resident to personalize the space with photographs
or mementos. When painting, a variety of colors and textures
that are compatible should be used, with light colors against
dark colors being more visible. An emphasis wall can be
included to add color and visual interest and should be
directly visible to both patients. Blinds and curtains on
windows provide privacy. When doors are painted, the color
should be compatible with, but contrasting from, the
surrounding wall color. Within the facility itself, corridors
should each have their own unique character and should
include single-color carpeting, the nursing station should
invite interaction between staff and residents, and the sitting
rooms should be designed like family living rooms with small
groupings of sofas and chairs to encourage interaction.
Artwork, plants, and appropriate lighting should also be used.
Semi-private rooms can be designed to promote a home-like
environment. Patient interaction is encouraged while still
enabling residents to have their own unique space. A
comparison with single-occupancy rooms was not provided.
76
Burmahl, B. (2000, February). Facilities of the future: New designs put patients first. Health
Facilities Management, 13(2), 30-34.
Focus of Article
To describe trends in healthcare design.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
the United States.
Recommendations for
Healthcare Setting
Implications of Findings
The trend in healthcare is towards an increase in outpatient
services. The number of short-stay hospitals is also
increasing, as they offer more services than outpatient
services. Patients may stay for several hours of observation
to 72-hour stays.
Most inpatients are seriously ill, and thus, hospitals are more
likely to build critical care beds than intermediate care beds.
To make nursing more efficient, nurse stations are being
decentralized in that charting stations are located at the
patient’s bedside. Patient rooms are also being built larger to
accommodate family members.
The trend in hospitals is to build larger private rooms to
accommodate the changing needs of patients.
77
Carpman, J. (1992). Design research: Emerging trends. Journal of Healthcare Design, 5, 97111.
Focus of Article
To describe how research can aid in the process of designing
hospitals.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
the United States.
Recommendations for
Healthcare Setting
Implications of Findings
Design is viewed as a marketing tool, as it can attract or repel
patients from a particular facility. Design can also affect the
well being of patients and visitors and it can help prevent
illness and injury. Since family care is important to the
patient’s treatment, space should be allotted to the needs of
visitors to ensure they have some privacy and escape. Family
members’ cognitive and emotional needs should be met.
Hospital design should also incorporate the Americans with
Disabilities Act (ADA), which requires hospitals to remove
barriers that prevent physically handicapped people to have
equal access to the facility. A universal design emphasizes
independence and safety as well as adaptability over time.
Warm and cool colors can be used in the healthcare setting if
used knowledgeably. A person’s cognitive abilities should be
considered in the design so that it does not become to
complex to navigate or find one’s way. The use of windows
is also important to create a positive environment.
Hospital design should be pragmatic, it should be based on
the needs of the users, it should be reviewed periodically, and
it should undergo a systematic postoccupancy evaluation. A
participatory design process should also be included.
Hospital design is critical to patient satisfaction. No mention
was made in regards to room occupancy.
78
Cawood, C. (1993). Nursing units and common staffing problems. In D. K. Hamilton (Ed.)
Unit 2000: Patient beds for the future. A nursing unit design symposium (pp. 103-109).
Houston: Watkins Carter Hamilton Architects, Inc.
Focus of Article
To discuss the designs of nursing units.
Type of Healthcare Facility
The designs identified in this component of the symposium
apply to Rochester Methodist Hospital in Rochester, MN,
Scott and White Hospital in Temple, Texas, and the Kaiser
Foundation hospital in Panorama City, California.
Recommendations for
Healthcare Setting
Implications of Findings
Smaller patient units are more costly per patient per day, as a
higher mix of registered nurses is used and patients with
higher than average acuity are being treated.
One possible unit design is radial. This design reduces travel
distances and times in comparison to single- and doublecorridor units. The majority of nurses, if given the choice,
would prefer to work on radial units. Radial units, however,
cannot accommodate a sufficient number of private rooms
without wasting a large amount of central core space. Lateral
expansion of these units is also difficult.
The triangular shape decreases travel distances while
enabling a capacity of 30 to 36 beds. This helps to reduce
staffing problems. The utilization of two nursing stations
helps to increase visibility into more patient rooms.
Flexibility in functionality of patient rooms and nursing units
is critical to design.
With the increase in demand of private rooms, radial units are
no longer an effective design, as this design cannot
accommodate a large number of private rooms.
79
Che, P. (2002). Solucient report forecasts 46% jump in demand for hospital beds in U.S. AHA
News, 38(44), 6.
Focus of Article
To present the results of a study conducted by Solucient on
hospital needs in the United States in relation to the demand
for beds and the impact of demographic changes on acute
care.
Type of Healthcare Facility
The findings pertain to all hospitals in the United States
Recommendations for
Healthcare Facility
Implications of Findings
The demand for beds in the United States is expected to
increase by as much as 46% over the next 25 years. Factors
contributing to this increase are the age of the baby boom
generation, increased life expectancy, rising fertility rates,
and continued immigration. Inpatient demand is expected to
grow fastest in the Western and Southern states. The demand
is expected to grow more slowly in the Midwestern and
Northeastern regions.
The inpatient demand is going to increase in upcoming years.
There was no mention made in this article, however, in
reference to single or multiple room occupancy
80
Coile, R. Jr. (1997). Competing by design: What you need to know about tomorrow’s business
in healthcare. Journal of Healthcare Design, 9, 25-26.
Focus of Article
To describe changes that are occurring to the healthcare
system based on a shift in capital expenditures and
investments.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
the United States.
Recommendations for
Healthcare Setting
Implications of Findings
The healthcare industry is experiencing a shift of capital
investments from inpatient care to ambulatory care and nonacute facilities as well as other continuum-of-care facilities.
A priority is being placed on creating cost and clinical
efficiency to create a sustainable healthcare system.
Community health information networks will also be
universal.
The healthcare industry is shifting from inpatients services to
continuum-of-care services. No mention was made in regards
to room occupancy.
81
Contemporary Longterm Care (1997, August). A room of one’s own. Contemporary Longterm
Care, 20(8), 14.
Focus of Article
To present the results of a survey conducted by the American
Association of Retired Persons in regards to private and
shared occupancy rooms.
Type of Healthcare Facility
The material presented in this article applies to assisted living
facilities in the United States.
Recommendations for
Healthcare Setting
Implications of Findings
Of those surveyed, 82% of people would prefer a private
room, 4% would prefer a shared occupancy room and 14%
either did not know or did not care. Women and people from
the western United States were the most likely to prefer a
private room. Those of low and high incomes had the same
preference for private rooms.
Most people surveyed would prefer to stay in a private room
in an assisted living facility.
82
Cys, J. (1999, March). Want healthy patients? Ambience may be the answer. AHA News, 35(12),
9.
Focus of Article
To review design factors that can impact the outcome of
patients.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
the United States.
Recommendations for
Healthcare Setting
Implications of Findings
When the environmental design of hospitals is good, patient
outcomes can improve. Excess noise, for instance, can
elevate the patients’ blood pressure and heart rate and can
result in sleep loss. To reduce noise, ceiling heights and
types can be varied. The use of carpeting also helps lower
noise levels. Air quality can also be affected if vents are
placed improperly. Sunlight exposure has a positive impact
on patients and can help reduce depression. Positive
distractions are offered by nature scenes, outside spaces,
plants, indoor atriums and windows. In private rooms, beds
should be placed on an angle so that patients can focus on the
view outside rather than the corridor. Finally, seniors tend to
walk faster and better on carpeted floors.
Environmental factors can impact the outcome of patients. In
private rooms, the placement of the bed to face the outside
rather than the corridor can be a positive element of design.
83
Downing, K. (2002). Patients’ perspective central in drawing Planetree model. Modern
Physician, 6(4), 19.
Focus of Article
To provide background information on the Planetree model of
healthcare.
Type of Healthcare Facility
This article pertains to Planetree based hospitals in the United
States.
Recommendations for
Healthcare Facility
Implications of Findings
Planetree hospitals have been on the rise since 1998, when
the organization had only 15 affiliates. The number of
affiliates has now increased to 55. Their model includes the
architecture and design of the rooms based on the patients’
perspective. Double rooms are used and are set up so that
both patients have a window view. Soothing artwork hangs
on the walls and shelves are available to hold photographs
and other personal belongings. Room controls are installed
by the bed. Planetree has tried to make the affiliation costneutral. The model relies on a large number of volunteers.
While the article mentions the use of double-occupancy
rooms, no reason is given and empirical evidence for their use
is not provided.
84
Duffin, C. (2002, May 29). Private rooms in hospital 'would hasten recovery'. Nursing
Standard, 16(37), 8.
Focus of Article
To discuss the preference of architects for single occupancy
rooms.
Type of Healthcare Facility
The information presented in this hospital is pertinent to
hospitals in England.
Recommendations for
Healthcare Setting
Implications of Findings
The architects commissioned by ministers suggest that all
patients should have single occupancy rooms monitored by
nursing sub-stations. Recovery of patients would be quicker
due to less exposure to noise, better sleep, and greater
privacy. The logistical problems of fitting patients together
are not an issue with single occupancy rooms. Patients would
also receive most treatments in their rooms, and thus, space
surrounding the bed should be large enough to accommodate
necessary equipment. Monitoring of patients is not difficult if
the rooms are placed in clusters with glass fronts. Infection
control is greater with private rooms.
Recommendations are made for private rooms due to their
benefits to patients.
85
Edgman-Levitan, S. (1997). Through the patient’s eyes. The Journal of Healthcare Design, 9,
27-30.
Focus of Article
To describe elements of hospital design that the Picker
Institute found critical to patient satisfaction.
Type of Healthcare Facility
The material presented in this article applies to the Picker
Institute in Boston.
Recommendations for
Healthcare Setting
Implications of Findings
The mission of the Picker Institute is to promote quality
assessment and improvement strategies that address the needs
of the patients and their family members. Patients want to be
involved in the decision-making process, and they want their
cultural values and religious beliefs respected. Patient
satisfaction with care is determined by their physical comfort,
information and education, and respect for their preferences.
Hospital design should include wayfinding and signs,
emotional support (ex. artwork, windows, & noise control),
gardens and plans, meditation space, private areas, music,
comfortable beds and chairs, bedside tables, and places for
alternative tables, among other features. Patients can receive
information and become educated on their illnesses through
bedside computers, patient learning centers, tape recorders,
family members, and patient lounges.
Patients’ satisfaction is dependent upon their level of physical
comfort, the information and education received, and respect
for the patients’ preferences. No mention was made in
regards to room occupancy.
86
Fishback, B. W. & Krewson, C. (1981). Design team simplifies interiors to aid patient
recuperation. Hospitals, 55(4), 151-156.
Focus of Article
To describe the ward design of Vanderbilt University Medical
Center.
Type of Healthcare Facility
The information presented in this article applies to Vanderbilt
University Medical Center in Nashville, Texas.
Recommendations for
Healthcare Setting
Implications of Findings
The design principles for this project sough to combine
sophisticated design with the needs of the patients. One goal
was to simplify elements that are chaotic and disorienting.
Patient rooms were painted off-white, floors were carpeted
and wardrobes were built into the walls. The layout is
modified octagonal and patient rooms are located along the
periphery. Nurses’ stations, as well as other support spaces,
were contained within the service core.
No mention was made in regards to room occupancy.
87
Fisher, S. (1982). Design reduces nurses’ walking, encourages patients to visit with each other.
American Health Care Association Journal, 8(2), 40-43.
Focus of Article
To discuss the design of a nursing home.
Type of Healthcare Facility
The information presented in this article applies to the
Christian City Convalescent Center, near Union City,
Georgia. It is a 200-bed nursing home.
Recommendations for
Healthcare Setting
Implications of Findings
Two frequent complaints made by nurses in nursing homes
are that they have tired feet and that patients have a tendency
to gather around their workstations.
The design of this facility incorporates a square structure.
Rooms are located around the perimeter, and patient rooms
are located within 45 feet of the nurses’ station. Patient
bathrooms are located on the exterior walls, and this feature
enables nurses to observe patients without entering the patient
room.
This design maximizes the use of space, increases the
intensity of patient care, and makes the facility feel less
institutional. Less walking is required to get anywhere within
the facility. Nurses have to walk less and visitors have an
easier time locating the patients. Morale is high and turnover
is low among registered nurses, partly because of the reduced
amount of walking that is required.
Lounges are designed to be conducive to socializing, as an
open space is located at each corner of the square.
The compact design of this facility reduces the amount of
traveling done by nurses. No mention was made in regards to
room occupancy.
88
Forman, A. D., Stoller, J. K., & Horsburgh, C. R. Jr. (1996, February 1). Healing by design.
The New England Journal of Medicine,334(5), 334-336.
Focus of Article
To offer commentary on the article written by C.R.
Horsburgh Jr. (1995).
Type of Healthcare Facility
The material presented in this article applies to hospitals in
the United States.
Recommendations for
Healthcare Setting
Implications of Findings
A. D. Forman suggests that medical economic pressures are
influencing hospital design. Money is being spent on
elaborate designs while staff are being cut to improve bottom
lines. The key to managing medical problems, he suggests,
is through skilled and labor-intensive care.
J. K. Stoller suggests that hospital design should optimize
coordination among health care staff. Face-to-face
interaction should be encouraged and alcoves in hallways can
facilitate the occurrence of private conversations.
C. R. Horsburgh Jr. replies that health care providers should
be included in health care design to prevent unnecessary
expenditures.
No mention was made in regards to optimal room occupancy.
89
Francis, S. (2002). The architecture of health buildings: Providing care - Can architects
help? British Journal of General Practice, 52(476), 254-255.
Focus of Article
To describe future trends in designing hospitals.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
England.
Recommendations for
Healthcare Setting
Implications of Findings
Hospital design has addressed the functional needs of a
clinical environment, but has not been comforting or inspiring
for patients. A shift has been recently occurring towards a
patient-centered design. Hospital designs should be
functional, durable and robust, and therapeutic. New
buildings will accommodate multidisciplinary teams and
include healthy living centers, information kiosks, and social
and advice centers. Distinctive characteristics will be created
for public, social, and private spaces. A good design should
relieve stress for staff members and reduce anxiety for
patients.
Designs should benefit patients and staff members. No
mention was made in regards to room occupancy, though it
was mentioned that private spaces are needed for treatments
and consultations to offer the patients privacy and maintain
their dignity.
90
Fromhart, S. G. (1995). Will shared rooms in LTC facilities become a thing of the past?
Contemporary Longterm Care, 18(6), 26.
Focus of Article
To address the issue of private versus shared rooms in longterm care facilities. Long-term care administrators give their
opinions.
Type of Healthcare Facility
Administrators from three long-term care facilities in the
United States give their opinions. These facilities are the
Schoellkopf Health Center in Niagara Falls, New York, the
Beth Sholom Home of Eastern Virginia in Virginia Beach,
Virginia, and Capital Senior Living in Dallas, Texas.
Recommendations for
Healthcare Setting
Implications of Findings
In New York, Patricia W. O’Connor suggests that private
rooms are best because there are no “roommate” problems
and families can freely visit and decorate their loved one’s
room. The increased costs are justified by the improved
quality of life.
In Virginia, Charles Weiden suggests that single rooms are
for private paying residents. Until government funding
improves, semi-private rooms are the “cost-effective”
standard. Most people in nursing facilities, however, would
prefer a private room if given the choice.
In Texas, Fred Tanner suggests that shared living
arrangements are cost-effective. He does suggest that an
alternative to a single apartment is a low-cost two-bedroom
apartment-type situation in which two people share a
common room and have separate, walled bedrooms. Smaller
facilities might benefit from having fewer units in order to
control costs.
Privacy is an important issue for long-term care patients.
While most prefer a single-occupancy room, it is costeffective to have shared rooms. No empirical evidence was
provided to support these recommendations.
91
Gallant, D., & Lanning, K. (2001, November). Streamlining patient care processes through
flexible room and equipment design. Critical Care Nursing Quarterly. 24(3), 59-76.
Focus of Article
To describe the design of acuity-adaptable rooms in hospitals.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
the United States.
Recommendations for
Healthcare Setting
Implications of Findings
The room is designed to support the complete range of care
needed for the population it is intended to serve. This type of
room must be able to serve both critical care patients as well
as recovering patients and their family members. The rooms
are private and are large enough to accommodate critical care
equipment, staff, procedures, and family members. The
organization of space is critical, and to increase hallway wall
space in rooms, the bathroom should be located on the
exterior room wall. Clinical activities occur on the hallway
side of the room.
Acuity-adaptable rooms are large and private and are able to
serve the needs of the patients as well as their family
members.
92
Garber, K. (1999, February). Doctored design. Hospitals and Health Networks, 73(2), 26.
Focus of Article
To describe revisions made by the Joint Commission on
Accreditation of Healthcare Organizations to their manual.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
the United States.
Recommendations for
Healthcare Setting
Implications of Findings
It is suggested that hospitals be designed to create warm
environments that support patient dignity as well as create
awareness among staff. Elements of nature should be used in
hospitals to help brighten rooms and make people feel better.
Wayfinding, including signs and visual clues, should also be
used to help people get around. This can help reduce the
anxiety of patients, which in turn, improves their attention
span and treatment compliance.
Hospitals should include wayfinding and elements of nature
to help patients feel better and increase their compliance to
treatments. No mention was made in regards to room
occupancy.
93
Gilpin, L. (1996). Acute Care Design: A workshop on patient-centered environments. Journal of
Healthcare Design, 8, 41-46.
Focus of Article
To describe how healthcare is moving from the Industrial
Age to the Information Age.
Type of Healthcare Facility
The information in this article applies to hospitals in the
United States.
Recommendations for
Healthcare Setting
Implications of Findings
This article summarizes what was discussed at a workshop on
patient-centered environments. It was suggested that the goal
of the Information Age is not information, but knowledge.
Information is integrated to create health. Patients are
becoming partners and are taking personal responsibility for
their health. They are making decisions about treatment
options that technology offers. People (patients, families, and
staff) will always be more important than information. The
Planetree organization has developed a variety of techniques
that encourage the facilitation of change among healthcare
providers and design professionals.
Social support needs to be encouraged in care and people
must make the best use of treatments and preventative care
that requires less technology and expense. Opportunities also
need to be created for learning. Finally, every person should
feel valued and nurtured despite cultural and ethnic
differences.
Patients are taking more control in their healthcare. No
mention was made in regards to a preference for private or
shared inpatient rooms.
94
Glanville, R. (1996, November). Northern exposure. Hospital Development, 27(10), 17-19.
Focus of Article
To describe the design of a Swedish hospital ward.
Type of Healthcare Facility
The information presented in this article applies to Norrtalje
Sjukhus, a hospital in Sweden.
Recommendations for
Healthcare Setting
Implications of Findings
The patients’ experience in this hospital is meant to be
comfortable and home-like. Patients are encouraged to
progress from their private bed space through a variety of
areas with opportunities for social activity. The inpatient area
is divided into twenty-four bed groups, and these are arranged
in three subgroups of eight, each with its own nursing team.
Each subgroup consists of a three-bed room, a two-bed room,
and three single bedrooms, each with its own en suite
bathroom. Folding screens are provided for individual bed
privacy and each patient has a view from his or her bed.
Staff facilities are provided for the nurses and staff members
are expected to take relaxation breaks while on the ward.
Though a variety of occupancy rooms are used, patients are
given their own space to ensure they have the privacy they
need.
95
Graven, S. N. (1997). Clinical research data illuminating the relationship between the physical
environment and patient medical outcomes. Journal of Healthcare Design, 9, 15-20.
Focus of Article
To describe how the environment in the neonatal intensive
care unit can be modified to better suit the needs of infants.
Type of Healthcare Facility
The material presented in this article applies to neonatal
intensive care units.
Recommendations for
Healthcare Setting
Implications of Findings
It is suggested that the elements in the neonatal intensive care
units can affect infant development. Infants have limited
defense from bright light, and thus the use of focused lighting
and dimmer controls can aid in individualizing light levels for
infants based on their needs. Infants exposed to high levels of
background noise may suffer from an interference with the
development of frequency discrimination as well as sound
pattern recognition. Noise levels can be reduced by adding
sound-absorbing surfaces, incorporating silent alarms with
blinking lights, and using paging systems with vibrators.
Environmental factors within neonatal intensive care units
can affect the development of infants and thus, care should be
taken in designing the environment to suit the infants’ needs.
No mention was made in regards to room occupancy.
96
Hahn, J. E., Jones, M. R., & Waszkiewicz, M. (March, 1995). Renovation of a semiprivate
patient room. Bowman Center Geriatric Rehabilitation Unit. Nursing Clinics of North America,
30(1), 97-115.
Focus of Article
To discuss the renovations made to two semiprivate rooms in
a geriatric unit.
Type of Healthcare Facility
The facility described in this hospital is the Geriatric
Rehabilitation Unit in the Johnston R. Bowman Health Center
for the Elderly at Rush-Presbyterian-St. Luke’s Medical
Center.
Recommendations for
Healthcare Setting
Implications of Findings
Total quality management strategies, which include statistical
techniques, brainstorming, indicator development,
monitoring, and evaluation, were used to aid the renovation
process. It was determined that the primary functions of
patient rooms are: patient care, nursing care, medical
treatment and therapy; activities of daily living; examinations
and evaluations; socializing; sleeping; and cleaning and
repair. Problems identified with the rooms were inadequate
storage, as well as sensory-related issues. Rooms were
modified to increase storage, to maximize the diminishing
visual abilities of the elderly (through window sheers,
nonglare light-colored flooring, and floor molding), and to
provide a warm, homelike appearance (through a custom
wardrobe, vinyl flooring that looked like hardwood flooring,
privacy curtains, and window treatments).
To evaluate the designs, surveys were collected from patients
over a period of three months. Based on the responses,
customer satisfaction rose significantly.
Semiprivate patient rooms were successfully modified to
create a more aesthetically pleasing environment for patients.
97
Hendrich, A., Fay, J., & Sorrells, A. (2002, September). Courage to heal: Acuity-adaptable
patient rooms and decentralized nursing stations-A winning combination. Healthcare Design,
11-13.
Focus of Article
To describe the design of the Critical Care Unit at Methodist
Hospital
Type of Healthcare Facility
The material presented applies to the Comprehensive Cardiac
Critical Care Unit in Methodist Hospital of Clarian Health
Partners in Indianapolis.
Recommendations for
Healthcare Setting
Based on data from a time-and-motion study on a
nursing unit, it was discovered that patients in the
hospital were moved between three and six times due to
changes in their acuity levels. Multiple caregivers were
used for one patient and, as a result, tasks were
duplicated and error rates increased. Nurses were also
traveling long distances each shift to find supplies.
A highly flexible environment was created with private rooms
that supported the changing levels of acuity in patients.
Rooms are 400 square feet and are divided into three areas: a
family zone, a patient zone, and a caregiver zone. Equipment
and supplies are easily accessible for staff members and
patients can control lighting, temperature, and privacy as their
condition improves.
Initial baseline data indicates that unit-to-unit transfers have
decreased by 90 percent. Overall patient days per bed have
increased since the patient is not required to move. Patient
falls and medication errors have also decreased and patient
safety has improved with the decentralized nursing stations.
Implications of Findings
The acuity adaptable rooms have helped improve clinical
outcomes, cost and operational efficiency, and staff and
patient satisfaction.
98
Hewitt, T. & McFarlane, J. (1997, August). The wards. Hospital Development, 28(7), 24.
Focus of Article
To describe the wards of Leeds General Infirmary (Phase
One) in terms of the location and size of the wards as well as
the environment provided for the patients.
Type of Healthcare Facility
The facility described in the article is Leeds General
Infirmary in England.
Recommendations for
Healthcare Setting
Implications of Findings
The maximum capacity of the wards described is twentyeight beds, with four-bedded bays being the maximum
allowed in the bed areas. Each bed bay has exclusive use of a
shower and toilet, and thus, each ward can accommodate both
sexes. On most wards there are four single rooms, and some
of these rooms contain ensuite facilities. Large windows are
used at low levels, enabling patients to see the outside from
their beds. Each floor also has a clean and dirty hold area to
help minimize congestion on corridors. Day spaces are
distributed around the ward and are small and friendly.
The design incorporates the use of both single and multiple
bedrooms and a preference for either type of room is not
mentioned.
99
Hill-Rom (2002). The patient room of the future. IN: Hill-Rom Publications.
Focus of Article
To describe the benefits of the acuity adaptable room.
Type of Healthcare Facility
The material presented in this article applies to U.S. hospitals.
Recommendations for
Healthcare Setting
Implications of Findings
Changing trends in healthcare include an aging population,
and thus, treating patients requiring higher acuity care. In
regular hospitals, patients requiring high acuity care are
generally admitted through the emergency department, then
transferred to the critical care unit, and then transferred again
to the medical-surgical ward. The use of the acuity adaptable
room reduces the need for transferring patients, since patients
can receive all the required care in one room regardless of
their acuity level.
The acuity adaptable room is larger in size than a regular
hospital room. Patient visibility from the corridor is possible,
and space is provided for visitors. In facilities that are using
this type of room, medication errors, patient falls, phlebitis,
and procedural and lab errors have all decreased. The
average length of stay for the patient has also been shorter
when staying in the acuity adaptable room.
The acuity adaptable room is single-occupancy and reduces
the need for patient transfers, since the patient receives all the
necessary treatments in one room.
100
Hohenstein, J. (2001, December). Facility profile. Health Facilities Management, 14(12), 12-13.
Focus of Article
To describe the newly constructed Children’s Hospital in
Omaha, Nebraska.
Type of Healthcare Facility
The healthcare facility featured in this article is Children’s
Hospital in Omaha, Nebraska.
Recommendations for
Healthcare Setting
Implications of Findings
The exterior of Children’s Hospital is inviting and uplifting
with the use of bright colors such as peach, beige, and gray
brick. On the interior of the hospital, themes are drawn from
the environment of Nebraska. Within the 130-bed facility,
diversion and entertainment play an important role. Game
rooms are located on every floor and art created by the
children hangs on the walls. The patient floors are curved,
dividing the nursing duties into six-room pods. The
equipment is centralized in the inner nursing area of the pod,
and the curved layout is less cluttered and quieter than the
long, straight-hall design, according to the nursing director.
All the patient rooms on the medical and surgical floors are
single occupancy, ensuring privacy and reducing the risk of
spreading contagious illnesses. Rooms are designed to look
like a child’s bedroom at home and include a parent bed, a
refrigerator, a wardrobe, a satellite television with a VCR and
a data port allowing parent to access the Internet. For parents
of long-term patients, separate sleeping rooms are available.
Natural light is used extensively throughout the hospital, but
when it is impossible, indirect light is used to create a less
harsh environment.
The article suggests a preference for single occupancy rooms
to give the family privacy and to help reduce the spread of
infectious illnesses.
101
Horsburgh, C. R. Jr. (1995). Healing by design. The New England Journal of Medicine,
333(11), 735-740.
Focus of Article
To describe current trends in hospital design that focus on
patients and their families.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
the United States.
Recommendations for
Healthcare Setting
Implications of Findings
Hospital design has recently begun to focus on patients and
their families. There is increasing competitiveness in the
health care industry, and pleasant facilities can help attract
patients. Four qualities of space characterize good
architecture: orientation, connection, scale, and symbolic
meaning.
Orientation refers to the patient’s ability to find and gain
entrance into the building as well as to locate one’s
destination within the building. Entrances should be clearly
identifiable, and signs, visual cues, and landmarks can help a
person orient oneself.
Connection describes the quality of interaction between
people and their environment. Lobbies should be open and
inviting and alcoves in lobbies enable private conversations to
occur. Windows with views of nature have positive
influences such as reduced stress in employees. Social spaces
are also included in designs.
Scale encompasses the relationship between the size of the
architectural forms and the patient. Scales should be
modified to provide variety, to accent changes in ambience,
and to define the progression from public spaces to private
spaces.
Hospitals should also be designed to convey the symbolic
meaning of security, cleanliness, and physical comfort.
Hospital design should include a balance between function
and good architecture. No mention was made in regards to
room occupancy.
102
Hosking, S. & Haggard, L. (1999). Patient wards. In S. Hosking and L. Haggard, Healing the
hospital environment: Design, management and maintenance of healthcare premises (pp.70-73).
London: Routledge.
Focus of Article
To describe the advantages and disadvantages of the
Nightingale and Bay wards.
Type of Healthcare Facility
The material presented in this chapter applies to all hospitals.
Recommendations for
Healthcare Setting
Implications of Findings
In the Nightingale ward, beds are arranged down each side of
a long, narrow ward. The nursing station is located on one
end of the ward, while the convalescent bay is located at the
other end. Nurses are able to monitor patients with relative
ease. This ward became unpopular, however, because the
patients’ need for privacy was not met.
Newer designs include bay wards, which subdivide wards
into four-, six-, or eight-bed bays. This type of design offers
patients more privacy and intimacy, and it is more flexible.
Patients can be clustered according to sex or illness. This
ward also has some disadvantages. The patients’ view of the
nurses is limited, and thus, the patient is unaware of what the
nurse is doing. This can increase the patients’ anxiety if they
are trying to call the nurse and the nurse does not respond
quickly. Patients also feel confined to their bay and are
hesitant to approach other patients not on their bay. New
sources of noise appear on this ward through the use of more
equipment and open and longer visiting hours. Nurses also
find it harder to be more vigilant about the noise.
The Nightingale wards and bay wards have advantages and
disadvantages. Rooms on these wards are multipleoccupancy.
103
Jones, W. (1995). Acute care design: emerging trends. In S. O. Marberry (Ed.), Innovations in
healthcare design: Selected presentations from the first five symposia on healthcare design
(pp.12-20). New York: John Wiley & Sons, Inc.
Focus of Article
To discuss emerging trends in healthcare facility design.
Type of Healthcare Facility
The material presented in this chapter applies to all hospitals.
Recommendations for
Healthcare Setting
Implications of Findings
Old hospital forms offered basics such as food and shelter,
and perhaps some cleanliness. Florence Nightingale inspired
the design of wards; she suggested that wards should be long,
low pavilions connected by corridors. Windows were located
on both sides of the corridor. Modern hospitals were
influenced by the invention of the elevator, which allowed the
stacking of the Nightingale wards. The central elevator also
determined the size of the nursing units and influenced the
distance traveled by nurses.
Newer, future-oriented designs, incorporate bed clusters to
reduce patient travel as well as the number of people
associated with patient care. Critical to future designs are
adaptability and flexibility. Patient rooms need to be larger,
and separable, in order to accommodate patient care.
Larger, separable patient rooms that provide both flexibility
and adaptability are important for future designs.
104
Kaldenberg, D. O. (1999). The influence of having a roommate on patient satisfaction. The
Satisfaction Monitor, (January/February).
Focus of Article
To discuss the impact that having a roommate has on patient
satisfaction.
Type of Healthcare Facility
The material presented applies to hospitals in the United
States.
Recommendations for
Healthcare Setting
Hospitals with more private rooms tend to have higher
patient satisfaction. Patients without roommates
reported higher levels of satisfaction than those with
roommates. In terms of gender, female patients with
roommates were less satisfied than males, while female
patients without roommates reported higher levels of
satisfaction than males. In terms of the environment,
patients with roommates were less satisfied with the
noise, pleasantness, cleanliness, and temperature of the
room.
Implications of Findings
Patient satisfaction is greater for those who do not have a
roommate.
105
Kennedy, S. (1994, March 21). As care delivery evolves, facility design must change. Modern
Healthcare, 24(12), 38.
Focus of Article
To describe how building design should be flexible to
accommodate changes in the long term.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
the United States.
Recommendations for
Healthcare Setting
Implications of Findings
Due to the shift in outpatient services, inpatient facilities are
struggling to survive. Some facilities are incorporating
complementary medicine, which attempts to assist the healing
process through the patients’ mind-body connection.
Facilities should be flexible to accommodate both short-term
purpose as well as changes that may occur in the long-term
with minimum inconvenience and cost.
Hospital design needs to be flexible to accommodate changes
in the healthcare industry. No mention was made in regards
to room occupancy.
106
Larson, L. (2003, February). Putting safety in the blueprint. Patient safety is the guiding force
for a new hospital. Trustee, 56(2), 8-13.
Focus of Article
To describe the design of a new hospital whose emphasis is
on patient safety.
Type of Healthcare Facility
The information presented in this article applies to St.
Joseph’s Community Hospital, West Bend, Wisconsin.
Recommendations for
Healthcare Setting
Implications of Findings
All rooms in this facility are private, and all are designed
identically. Rooms feature cameras to be used when
necessary, with the patient’s permission. Nurses will be able
to monitor patients from their workstations in an attempt to
prevent patient falls. A small alcove adjacent to the patients’
rooms will enable nurses to view the patients through a
window while simultaneously protecting the patients’
privacy. Rooms will also contain a cabinet, which contains
the patients’ medications, locked in boxes, as well as other
supplies necessary to care for the patient. Bedside computers
will be used to double-check patient treatment and to enable
patients to view their records. Shorter hallways between
patient rooms and the nurses’ stations will help to minimize
employee fatigue.
Private rooms are used in this new facility, though specific
reasons as to why this is the case area not given.
107
Leccese, M. (1992). Nature meets Nurture. Landscape Architecture, 85(1), 68.
Focus of Article
To describe the design, and in particular, the landscaping of
St. Michael’s Hospital.
Type of Healthcare Facility
The material presented in this article applies to St. Michael’s
Hospital in Texas.
Recommendations for
Healthcare Setting
Implications of Findings
The goal for this facility was to create a compassionate
setting for healing. The landscape is considered part of the
healing process, and thus, the design incorporated jogging
paths, fountains, lakes, and trees. Patient rooms consist of
floor-to-ceiling bay windows, giving patients views of forests
or seasonal plants and flowers. Two courtyards have also
been included in the design.
This design incorporates the landscape, as it is thought to
influence the healing process. No mention was made in
regards to room occupancy.
108
Leibrock, C. A. (2000). Inpatient hospitals: General hospitals. In C. Leibrock, Design details
for health: Making the most of interior design’s healing potential (pp.231-256). New York: John
Wiley & Sons, Inc.
Focus of Article
To describe details of design in hospitals.
Type of Healthcare Facility
The material presented in this chapter applies to hospitals in
the United States.
Recommendations for
Healthcare Setting
Implications of Findings
Ambulatory care facilities are beginning to replace general
hospital delivery systems. Tertiary care hospitals encourage
the participation of the patient and family members in the
decision-making process.
The Planetree model empowers patients with research.
Patients are given access to libraries and research articles to
learn more about their condition. Rooms in these facilities
are private, and they are large enough to accommodate the
patient as well as the patient’s caregiver. The nursing station
is decentralized into a series of pods, each of which serves
three to four patients.
Various features of design have a positive impact on patients.
A well-maintained garden, for instance, provides sensory
stimulation. Art can help a person develop a heightened
sense of self and can free the imagination. Stress can be
reduced through the use of wayfinding and scenes of nature,
while sound can be a positive distraction. Patients should
also have a sense of control over their personal space.
Hospitals must comply with ADA requirements.
Patient-centered care gives the patients a sense of control, as
they are active participants in their care. Room occupancy is
mentioned in regards to the Planetree model, where patient
rooms are private.
109
Lippman, H. (1991, July). Is this the ideal hospital? Registered Nursing (RN), 46-47.
Focus of Article
To describe the design of Irvine Medical Center.
Type of Healthcare Facility
The information presented in this article applies to Irvine
Medical Center in California.
Recommendations for
Healthcare Setting
Implications of Findings
The philosophy of this facility is patient-centered with a
business orientation. All the inpatient rooms are private and
are divided into pods of four rooms. A nursing alcove exists
for every two pods. This alcove serves as a mini-nursing
station where staff members can discuss patients, print
records, replenish supplies, and reach patients quickly.
The inpatient rooms in this facility are private, but reasons are
not given as to why this form of occupancy was chosen.
110
Lowers, J. (1999, August). Improving quality through the built environment. Quality Letter for
Healthcare Leaders, 11, 2-9.
Focus of Article
To describe the design of patient-centered hospitals.
Type of Healthcare Facility
The material presented in this article pertains to hospitals that
incorporate the patient-centered approach.
Recommendations for
Healthcare Setting
Implications of Findings
Based on focus groups conducted by The Picker Institute, it
has been suggested that important factors for patients in terms
of a hospital stay are a sense of control, safety, and
confidentiality. The built environment should enable patients
to connect with staff members, be conducive to the patients’
sense of well-being, be convenient and accessible, include
private rooms which give the patient privacy and space for
family members, be safe and secure, and should foster
connections to the outside world.
Indirect lighting diffuses light and creates a more natural
effect. Carpeted hallways help keep noise to a minimum.
Through temperature controls, patients are able to adjust the
temperature as needed. Music should be available for
patients to help reduce stress. The design should engage the
patients’ senses. This can be accomplished through the use of
plants and outdoor gardens, as well as atrium lobbies and
artwork. Nursing stations should be accessible to patients,
and thus, should have low counters and no glass. Mininursing stations can eliminate the central gathering point.
Staff should also be provided with lounges to relax and
recover from stressful work.
In this design, single-occupancy rooms are preferred as they
increase the patients’ privacy and confidentiality. Family
members also have space to take part in the patients’ care.
111
Lumsdon, K. (1996, November). Bricks, mortar and a whole lot more. Hospitals and Health
Networks, 70(21), 55.
Focus of Article
To discuss changes made to West Allis Memorial Hospital
based on patient satisfaction surveys.
Type of Healthcare Facility
The material presented in this article applies to West Allis
Memorial Hospital in Wisconsin.
Recommendations for
Healthcare Setting
Implications of Findings
Patient surveys suggested that patients were unhappy with
semiprivate rooms. Complaints were made in regards to
noisy visitors, bothersome roommates, and a large amount of
traffic both in and out of rooms. This problem will be
rectified with the creation of private rooms.
Centralized nursing stations will be removed and replaced
with smaller satellite pods, which will serve seven to nine
patients. Cabinets in alcoves outside patient rooms will store
small amounts of drugs and supplies needed for each patient.
Patient care associates, a new staff category, will handle
support tasks formerly done by nurses.
This facility will create private patient rooms to improve
patient care.
112
Lumsdon, K. (1993, February 5). Form follows function: Patient-centered care needs strong
facilities planning. Hospitals, 67(3), 22-24&26.
Focus of Article
To describe the design of patient-centered Mercy Hospital
and Medical Center.
Type of Healthcare Facility
The material presented in this article applies to Mercy
Hospital and Medical Center in San Diego, California.
Recommendations for
Healthcare Setting
Implications of Findings
In facilities using the patient-centered care model, inpatient
rooms are transformed to reduce the stress of patients as well
as give them a sense of control over their surroundings.
Rooms at Mercy Hospital and Medical Center are larger to
accommodate family members and friends involved in the
patients’ care. Artwork, paint, and wall coverings are all
carefully chosen to be sensitive to the needs of the patients.
Rooms also include a patient server, which is a cabinet of
drawers and shelves that holds all the supplies a patient may
need.
The nursing station is decentralized and located at smaller
pods throughout the patient unit. Patients are linked to
caregiver teams via pagers and one nurse is stationed at a
central telephone area to help prevent communication snags
between nurses.
The facility also includes activity rooms, dining areas, and
reference libraries on patient units.
Rooms in this facility are large and accommodate family
members, though it is not specified if the rooms are private.
113
McMorrow, E. (2001, March). Have a pebble project? Facilities Design & Management, 20(3),
7.
Focus of Article
To describe The Center for Health Design Pebble Project.
The purpose of this projects is to provide researched and
documented examples of projects that have created lifeenhancing environments for patients, families, and staff.
Type of Healthcare Facility
The information presented in this article pertains to the San
Diego Children’s Hospital and Health Center.
Recommendations for
Healthcare Setting
Implications of Findings
The Center for Health Design (CHD) concentrates on five
core areas: environmental standards, education/information,
technical assistance, research, and partnerships with selected
healthcare organizations. There are two components to the
Pebble project. The first is an emphasis on understanding
how organizational behavior changes as a result of the
planning and design process. The second component is the
development of a standardized evaluation methodology,
which will enable a comparison of outcomes, the
identification of the best practices and continuous
improvements in healthcare design.
The pebble project is trying to provide the healthcare
community with researched and documented examples of
projects that have been positive for staff, patients, and their
families. No mention was made in regards to a preference for
single or multiple room occupancy.
114
McTaggart, R. (1996, June). Base lines. Hospital Development, 27(6), 13.
Focus of Article
To discuss issues relevant to designing hospital wards. The
discussion was centered upon the design of a staff base.
Type of Healthcare Facility
The facilities included hospital wards with private rooms in
the United Kingdom.
Recommendations for
Healthcare Settings
Implications of Findings
McTaggart found that the main problems with private rooms
were that doors did not have observation windows and
distracting light was being reflected from the windows. She
also felt that the staff base (nurse’s station) was the central
control point for ward management. Architects suggested
that unit size should be increased for cost-reduction to occur.
Also, 30-50 % of the rooms should be single rooms.
Visibility of the beds from the staff bases should be improved
and core ward support services should be moved closer to all
beds. The design includes a 34-bed ward with patients being
in groups of 12. Rooms are designed to be single or 4-bed. 2
more beds can be accommodated if the stems at the point of
the triangle design are filled. Nursing teams have their own
staff base and each patient group has their own nursing team.
Wards should be designed to include a majority of single-bed
rooms with the remaining rooms being 4-bed. This ward
design is suggested to reduce time spent by nurses traveling
between patient rooms and various supply points. These
suggestions are proposed without any mention of empirical or
financial evidence to support them.
115
McTaggart, R. (1996, May). Whose space is it anyway? HD: Hospital Development, 27(5), 1113.
Focus of Article
To discuss ward design in England.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
England.
Recommendations for
Healthcare Setting
Implications of Findings
Hospital design should incorporate patient-focused care. The
use of the Planetree model, which stresses the importance of
the physical environment, is suggested. Ward design should
include non-clinical spaces such as quiet lounges and rooms
for counseling relatives. Patients should be given the option
to move from unwelcome neighbors, their own personal
space, and a room to escape for privacy.
Two-bed rooms can be designed in an “L”-shape with an en
suite toilet. This design can be economical and patients are
given their own sense of space. Rooms should have enough
bed space allocated to enable bedside procedures to take
place.
An increased provision of single rooms also exists as a
marketing asset and for infection control.
Wards should separate the sexes into their own bed bays or
rooms and common service areas should not be shared.
Two-bed rooms designed in an “L”-shape can be economical
and both patients have their own sense of space. The number
of single rooms is increasing, though, for infection control as
well as to market the hospital.
116
Mader, B. (November 11, 2002). Private hospital rooms the new norm. The Business Journal
of Milwaukee. http://milwaukee.bizjournals.com/milwaukee/stories/2002/11/11focus2.html.
Focus of Article
To discuss the trend of private rooms in Milwaukee hospitals
and the costs and benefits of private rooms versus semiprivate rooms.
Type of Healthcare Facility
This article pertains to hospitals in Milwaukee.
Recommendations for
Healthcare Settings
Implications of Findings
Consumers are becoming more vocal and are demanding
private rooms in hospitals. Health Management
Organizations believe that health care costs are increasing
because of these individual expectations. Hospital
administrators argue that private rooms are cost-effective in
the long run. Patients are sicker now than they were 15 or 20
years ago and they require more intensive care type services.
This requires more privacy. Private rooms help to control the
spread of infectious diseases and provide a more efficient
layout and a safer environment to conduct business. Room
usage can increase by as much as 15 percent with private
rooms while not sacrificing patient revenue. Private rooms,
however, are hard to justify when the patient volume is high.
Semi-private rooms have the advantage of using less square
footage per patient. The disadvantage of semi-private rooms
is that gender and infectious disease issues limit which
patients can be placed together in one room.
Both patients and hospital administrators prefer the use of
private rooms to semi-private rooms. Hospital Management
Organizations, however, feel that semi-private rooms are
more cost-effective. Empirical evidence was not provided for
either argument.
117
Martin, C. (2000, August 5). Putting patients first: Integrating hospital design and care. Lancet,
356(9228), 518.
Focus of Article
To evaluate the 2nd International Conference on Health and
Design that was held in Stockholm, Sweden in June 2000.
The premise of the conference was that the physical
environment affects well-being.
Type of Healthcare Facility
The article applies to all hospitals.
Recommendations for
Healthcare Setting
Implications of Findings
Roger Ulrich, the chairman of the conference, suggests that
stress is the scientific starting point for understanding how
design affects medical outcomes. There is international
acceptance that the design of healthcare facilities should be
human centered, functionally efficient, and should benefit
patients, families, and staff members. Architects value a
homelike environment in their designs and are critical of
healthcare facility design, in particular with difficulties
experienced in way-finding in hospitals and poorly designed
inpatient rooms.
In Trondheim, Norway, for instance, the patient perspective
was taken into account and the new regional hospital will
have seven clinical centers, each with its own building. This
is advantageous because patients will be able to go directly to
the building they require and will need to relate with fewer
health professionals.
The conference emphasized that the patient perspective
should be taken into account when designing a hospital. No
mention was made, however, in regards to a preference for
private or shared inpatient rooms.
118
Miller, R. L. & Swensson, E. S. (1995). The patient care unit (Chapter 9) New directions in
hospital and healthcare facility design (pp.177-208). New York: McGraw-Hill, Inc.
Focus of Article
To describe trends in the design of hospitals.
Type of Healthcare Facility
The material presented in this chapter applies to hospitals in
the United States.
Recommendations for
Healthcare Setting
Implications of Findings
Patient-focused care was given momentum from the
development of the Planetree model in 1978, which sought to
improve the human quality of patient care. The open ward is
essentially obsolete due to a team approach to care as well as
technological developments.
The patient room should be a humane environment, which
provides the patient with privacy, dignity, cleanliness, and
security, among other factors. The needs of the nurses, at
times, conflicts with the needs of patients. Their need to have
easy access to patients and the ability to see patients, for
instance, may impact a patient’s privacy.
In patient-centered care facilities, rooms are larger and of
single-occupancy. The large space allows for the
performance of procedures in the rooms and it reduces the
necessity of transporting the patient to various specialists. A
larger room is also feasible economically, for in the long run,
the rooms can be used for rehabilitation and elderly housing
or for other programs. Flexibility is also increased through
the use of disabled-access bathrooms. This enables all
patients to use the rooms at all times. Room space is
increased if the bathrooms are located on the outside wall.
A design incorporating a cluster of beds, which can readily be
supervised by a nursing team, is recommended. It is also
easily managed to accommodate fluctuating patient
populations.
Bedside computers enable more detailed and frequent
updating of patient charts to occur.
Patient-focused care incorporates single-occupancy rooms
which provide for increased flexibility and adaptability to
care for an array of patients.
119
Moore, J. P. (1974). Renovation and expansion of health facilities: Cost primarily determines
feasibility. Hospitals, 48(3), 111-114.
Focus of Article
To discuss the renovations and expansions that occurred at
Methodist Hospital.
Type of Healthcare Facility
The material presented in this article applies to Methodist
Hospital, Lubbock, Texas.
Recommendations for
Healthcare Setting
Implications of Findings
Methodist hospital underwent expansion and renovations to
solve some of its functional deficiencies, which included a
need for single-care bedrooms. Renovations and expansions
were chosen over building a new site due to the large costs of
creating a new building. A new tower was built and included
five floors of patient rooms. Each floor consisted of 38 beds,
all in single-care rooms.
The new facility includes a large number of single-care
rooms, though specific reasons were not given as to why
these rooms are preferred.
120
Morrissey, J. (1998). Planetree model gets new caretaker. Modern Healthcare, 28(16), 45.
Focus of Article
To discuss the acquisition of the Planetree organization by
Griffin Health Services Corporation.
Type of Healthcare Facility
This article pertains to Planetree based hospitals in the United
States.
Recommendations for
Healthcare Setting
Implications of Findings
The Planetree organization was acquired by Griffin Health
Services Corporation. Since 1986, only 15 facilities have
been converted to the Planetree program. The organization
had trouble following up on facilities that showed interest and
demonstrating the ongoing benefit of paying an annual
$15,000 licensing fee. The Planetree organization could not
guarantee a reduction in costs and greater operating
efficiency.
The Planetree organization has not performed to its
expectations and is now under new management. No mention
was made in regards to a preference towards single or
multiple room occupancy.
121
Murphy, E. (2000, March). The patient room of the future. Nursing Management, 31(3), 38-39.
Focus of Article
To describe patient rooms of the future, which are designed to
promote healing.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
the United States.
Recommendations for
Healthcare Setting
Implications of Findings
The healing process is affected by light, color, nature, and the
ability to control one’s environment. Patient rooms of the
future will be larger to enhance patient comfort and
emphasize patient-centered care. Rooms will include
comfortable seating, guest sleeping, and storage to help ease
family members. Artwork on walls features nature scenes,
and rooms will have controls for lighting, television, and
window shades by the bedside. Space around the bed will
increase to allow bedside procedures to take place.
Rooms of the future are designed to accommodate patients
and family members. No mention is made in regards to room
occupancy, though the implication is that these rooms are
single occupancy to include family members in the treatment
of patients.
122
Napthine, R. (1997-1998, December-January). Should hospital architects test drive wards?
Australian Nursing Journal, 5(6), 30-32.
Focus of Article
To describe inefficiencies with the layout of the patient’s
room.
Type of Healthcare Facility
The material presented in this article applies to all hospitals.
Recommendations for
Healthcare Setting
Implications of Findings
While hospitals offer enough space for the patients’ safety
and comfort, nurses are not given enough space to work
effectively. The layout of the patient room, in particular,
hinders the ability of nurses to complete their tasks. For
instance, the service outlets behind the patients’ bed-head are
often inaccessible. This problem can be rectified by
increasing the number of wall-mounted service outlets to
make them more accessible. Another problem is with the
towel rails located behind the patient’s bed or beside their
bedside locker. The towels are often out of reach and nurses
are not able to hang a used towel back onto the rail.
Other inefficiencies include shallow wardrobes, narrow
shelves and doorways, and shallow hand basins. These
inefficiencies impact nurses as they may take longer to
complete their tasks, or they may injure themselves in the
process of performing a task.
Efficient layout of the patients’ rooms will help nurses
perform their tasks more efficiently. No mention was made
in regards to room occupancy.
123
Neumann, T. & Ruga, W. (1995, April). How to improve your unit's environment. American
Journal of Nursing, 95(4), 63-65.
Focus of Article
To offer some suggestions, based on experience, on how to
improve the nursing unit’s environment in a hospital.
Type of Healthcare Facility
The information provided in this article applies to St. Luke’s
Episcopal Hospital in Houston, Texas.
Recommendations for
Healthcare Setting
Implications of Findings
Based on the successful renovations of St. Luke’s Episcopal
Hospital, the authors have suggested some changes that have
improved the quality of healthcare at this facility. Neumann
and Ruga suggest that viewing nature scenes can shift a
patient’s feelings into a more positive state. Their activity
levels increase, anxiety is decreased, blood pressure and
muscle tension are reduced, and the length of stay is
minimized. Natural images, which the patient can see or
choose, are best. Plants are popular among staff, patients, and
families. Aquariums have also been shown to decrease
anxiety and discomfort, while increasing patient compliance.
Any unnecessary noise, such as overhead paging (except in
emergencies), should be eliminated. Carpeting should be
installed to decrease noise and sound-deadening covers
should be used for noisy devices. Patients should be
encouraged to listen to music and when possible, live music
should be brought in to patient units and waiting areas. Soft
blankets help to provide a goodnight’s sleep. Comfortable
seating should be provided for family members and visitors.
Ambient temperature should be assessed and negative odors
should be eliminated.
The authors suggest that a positive environment can have a
great impact on the patients. No mention was made in
regards to a preference for private or shared inpatient rooms.
124
Noakes, T, Glynis, M. (1998, October). King’s cross stations. Hospital Development,
29(9), 24-26.
Focus of Article
To describe the proposed ward design for the Millennium
Hospital in New South Wales.
Type of Healthcare Facility
The material presented in this article applies to Millennium
Hospital in King’s Cross, New South Wales.
Recommendations for
Healthcare Setting
Implications of Findings
The ward design in this facility includes continuous bands of
at least 200 beds on each floor. Wards are divided into
clusters of eight beds, including one four-bed room and four
single bed rooms. Each cluster also has its own nursing
station and supply trolley, reducing the amount of time
traveled by a nurse. Rooms contain drug cupboards with the
prescriptions needed by each patient. Beds are spaced wider
apart to facilitate bedside treatment and to help reduce the
risk of infection. An increase in the number of single rooms
is also suggested to help control the risk of acquiring an
infection.
The ward design in this facility will include a combination of
single and multiple occupancy rooms. A larger number of
single occupancy rooms is needed to help reduce the risk of
acquiring an infection.
125
Orr, S., Farrell, J., & Portman, F. (2002, August). Room to improve? Nursing Standard, 16(47),
20-21.
Focus of Article
To describe viability of single occupancy rooms based on the
perspective of nurses.
Type of Healthcare Facility
The information presented in this article applies to hospitals
in England.
Recommendations for
Healthcare Setting
Implications of Findings
Orr suggests that single rooms are not viable for all patients.
Acutely ill patients need constant monitoring, and if staffing
is not increased, mortality rates may increase, as patients may
not be able to attract attention when help is needed in single
rooms.
Farrell believes that the security and safety of patients is an
issue in single rooms as they are harder to monitor. Bed
capacity would also be reduced with single rooms. Overall,
single rooms are not practical for hospitals.
Portman feels that patients in single rooms may become
‘invisible’ since monitoring them is more difficult. Costs
would also increase as wards would have to be redesigned
and staff would have to increase. She states that patients,
when asked, prefer to stay on ward where their psycho-social
needs are being met through contact with other patients.
From the perspective of nurses, single occupancy rooms are
not practical, as the safety and security of patients is placed in
jeopardy.
126
Patterson, M. (1999, July). Smooth healing. Buildings, 3(3), 16-17.
Focus of Article
To describe the features of the Cardiac Comprehensive Care
Unit at Methodist Hospital in Indianapolis.
Type of Healthcare Facility
The material described in this article applies to the Cardiac
Comprehensive Care Unit at Methodist Hospital in
Indianapolis.
Recommendations for
Healthcare Setting
Implications of Findings
The rooms were designed with the staff, patient, and the
patient’s family members in mind. Computers are located
outside each patient room, enabling the nurses to easily input
patient information. The windows of the patient rooms are
angled, giving the nurses the ability to view into three patient
rooms simultaneously. Patient rooms are private, and patients
have shelving in the rooms to keep personal material. Within
these rooms, family members have their own space equipped
with a sleeper sofa, a dresser, a desk, a refrigerator, a
telephone, and a computer. There are also spaces outside the
patient rooms where family members can be alone. Interior
gardens are included in the design.
Patient rooms are private and large enough to accommodate
family members who are willing to participate in the patient’s
care.
127
Rainey, J.B. (1990, May 19). Requiem for a ward. BMJ: British Medical Journal, 300(6735),
1347.
Focus of Article
To describe the effects of moving from an open ward to a bay
ward.
Type of Healthcare Facility
The material presented in this article applies to a hospital in
Scotland.
Recommendations for
Healthcare Setting
Implications of Findings
A move was made from a facility that included open wards to
a facility that included six-bed bays as well as single
occupancy rooms. This transition was a difficult one as
patients had to be moved around on the bay wards and a great
deal of time is spent tracking down patients. Privacy is also
an issue in the bay wards and counseling cannot occur in the
patient rooms, as conversations are audible to others. The
opposite was true on the open wards. The patients in the
single rooms can feel lonely and isolated. The open ward, on
the other hand, offered patients a chance to interact with one
another.
A preference is suggested towards open wards as privacy is
increased and patients have the opportunity to interact with
one another.
128
Shumaker, S.A. & Pequegnat, W. (1989). Hospital design, health providers, and the delivery of
effective health care. In E. H. Zube & G. T. Moore (eds.), Advances in environment, behavior
and design (Volume 2) (pp.161-202). New York: Plenum Press.
Focus of Article
To discuss elements of design that can influence patient
stress.
Type of Healthcare Facility
The material presented in this chapter applies to all hospitals.
Recommendations for
Healthcare Setting
Implications of Findings
Poor design and organization have both direct and indirect
implications on health. The effective and timely delivery and
receipt of care may be directly impacted, while stress may be
indirectly affected by the environment. Sources of stress
include factors of the environment that contribute to
perceived lack of control (ex. light and temperature), lack of
privacy, competing role demands, multiple and competing
stimuli, noise, and crowding.
Hospital design and patient care are influenced by changes in
technology associated with diagnosis and treatment.
Equipment is expensive and requires larger spaces. Hospital
design is also influenced by medical regulations and
construction and design codes.
The use of light, materials, and color to liven up the patient
environment is a recent trend.
The pattern of design of the nursing unit may influence the
nurses’ satisfaction and delivery of healthcare.
Hospital design should attempt to minimize stressors that can
influence patient care. No mention was made in regards to
room occupancy.
129
Solovy, A. (2002, December). “Home” Improvement. H&HN: Hospitals and Health Networks,
76(12), 28.
Focus of Article
To describe the change in design of hospital rooms.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
the United States.
Recommendations for
Healthcare Setting
Implications of Findings
Driven by consumerism and increased involvement of family
members in the treatment of patients, larger private rooms
with greater space for family members have been designed.
Rooms now include foldout beds, desks, Internet access, and
greater control of lighting. Privacy is also increased and
patients can confer with their doctors and family members.
A trend towards large private rooms exists to accommodate
family members and to increase privacy.
130
Spear, M. (1997). Current issues: Designing the universal patient care room. Journal of
Healthcare Design, 9, 81-83.
Focus of Article
To describe how the universal patient care room should be
designed.
Type of Healthcare Facility
The recommendations suggested have been applied to
Massachusetts General Hospital in Boston.
Recommendations for
Healthcare Setting
Implications of Findings
Spear suggests that the problem with current patient rooms is
that they have not been designed for any active functioning.
Most patient rooms do not acknowledge family participation.
There are also too many double occupancy rooms which
often do not comply with ADA standards. Beds cannot be
moved out of the room, medical equipment does not fit in the
rooms, and patients fall because the room is cluttered.
The universal patient room is designed for single occupancy.
The goal of this room is to support the clinical functions of a
patient and the hospital should have the ability to place any
patient in any room. Family, friends, and others are included
in the care of the patient. The universal design anticipates
changes in practice patterns, enables more bedside care, and
includes smarter building infrastructure.
There are four functional processes that go into the patient’s
room: activities of daily living, communication among staff,
visitors, families, patients and students, interactions with the
environment, and therapies and diagnostic services.
To ensure optimal patient care, patient rooms should be single
occupancy.
131
Stichler, J. F. (2001). Creating healing environments in critical care units. Critical Care Nursing
Quarterly, 24(3), 1-20.
Focus of Article
To describe how the critical care unit can be designed to
enhance the healing process of patients.
Type of Healthcare Facility
The material presented in this article applies to the Critical
Care Units of hospitals in the United States.
Recommendations for
Healthcare Setting
Patients experience a positive outcome in environment that
incorporates natural light, elements of nature, soothing colors
and pleasant sounds. Healing environments improve one’s
connection with nature, culture, and people, and promote a
positive awareness of one’s self.
A trend exists toward the use of universal rooms. These
rooms are larger and can accommodate patients and family
members as well as provide increased storage for equipment.
Bathrooms should be placed in each patient room or between
every two patient rooms to increase flexibility and
adaptability of the unit. Visibility into and out of the patient
room is also critical and patients should have a view from an
outside window. A balance must be achieved between the
need for staff to view patients and respect for the patients’
privacy.
Natural light should be included in the rooms, and patients
and their visitors should control the intensity of lighting.
Colors should be soothing, and artwork should focus on
nature scenes that are serene. Furnishings used in the rooms
and on the ward should be comfortable and durable. Noise
reduction strategies should be in place and patients should
have their need for privacy respected.
In terms of nursing units, the optimal design would include a
mini-station between every two patient rooms, which includes
computers, telephones, and visibility into the patients’ rooms.
A central nursing unit should be placed within the unit to
maximize visibility into all the patient rooms.
The family room should be located adjacent to the critical
care unit and should be large enough to accommodate family
members. Staff lounges should be comfortable and should be
located nearby so that staff can return to the unit quickly
should an emergency arise.
132
The optimal design of the patient unit is in multiples of four
beds to provide easy access to the patients and to promote
visualization of patients.
The circular design of a unit allows for the centralization of
care functions and provides immediate access to the patient.
Disadvantages of this unit are that it is noisy, storage space is
small, and it appears cluttered.
The triangular design reduces travel distance from the nursing
station to the patients’ rooms, it provides for a maximum
number of rooms to be located on one floor, it allows for the
design of multiple nursing stations, and centralizes space for
supplies and equipment. Disadvantages of this design are that
visibility of patients in remote corners is minimized and
expansion of this unit is difficult.
Clustered designs facilitate the visualization of nurses of their
patients, enable more patient rooms to be located on the
peripheries of the building, and allow for the design of mininursing stations. The disadvantages of this design are the
decentralization of care and the social needs of nurses not
being met.
The rectilinear design is less costly to build, contains a
centralized location for supplies and equipment, and improves
way-finding for visitors. The disadvantages of this design are
increased distance traveled by nurses, diminished
visualization of patients in remote rooms, and increased space
required for patient rooms.
Implications of Findings
Patient rooms incorporate the universal design, which
facilitates patient comfort. The environment should be
designed to promote healing. Various ward designs can be
used, and each has its own advantages and disadvantages.
133
Thompson, J. D. & Goldin, G. (1975). Supervision/observability: A review of contemporary
British literature on privacy versus supervision. In J. D. Thompson & G. Goldin (Eds.), The
hospital: A social and architectural history (pp. 231-250). London: Yale University Press.
Focus of Article
To discuss the design of wards in British hospitals.
Type of Healthcare Facility
The material presented in this chapter applies to hospitals in
Britain.
Recommendations for
Healthcare Setting
Implications of Findings
Hospitals in Britain place an emphasis on supervision and
economy rather than privacy of patients The Nightingale
ward design was prominent in hospitals from 1861 to the
beginning of World War II. This design included two rows of
beds in an open ward design. Two bathrooms were available
for every 25-30 beds. Private rooms were not highly
regarded by Florence Nightingale as she felt they interfered
with a nurse’s ability to supervise patients.
Important for nurses was their ability to supervise patients, to
respond to them quickly in the event of an emergency, and to
reach a patient in the shortest amount of time possible.
Private rooms, which became more evident after the war,
were used mainly for extremely ill or dying patients and for
those who had infectious diseases.
Nuffield studies determined that a trained nurse could handle
approximately 8 patients during peak hours and about twice
the amount during non-peak hours. Wards were configured
in multiples of 8, with an average number of beds being 32.
Various ward designs were used such as the racetrack design
and the single-corridor design. Multiple-occupancy rooms
formed the majority of the rooms, though single-occupancy
rooms were available for the infectious patients. Lighting and
artificial ventilation affected how hospitals were designed.
Rooms with six beds often did not have the proper lighting
for doctors to examine patients, and wards required the use of
artificial ventilation to reduce the risk of spreading infections.
Privacy is an issue, and there are some supporters of the
single-occupancy rooms since they offer patients the greatest
amount of privacy.
Hospitals in Britain tend to favor the use of multipleoccupancy rooms to facilitate supervision of patients, though
there are some proponents of single-occupancy rooms.
134
Thompson, J. D. & Goldin, G. (1975). A loud, loud noise about privacy: A review of
contemporary American literature on the hospital room. In J. D. Thompson & G. Goldin (Eds.),
The hospital: A social and architectural history (pp. 207-225). London: Yale University Press.
Focus of Article
To discuss the issue of privacy in hospitals in relation to room
occupancy.
Type of Healthcare Facility
This chapter applies to all hospitals, though an emphasis is
placed on hospitals in the United States.
Recommendations for
Healthcare Setting
One’s preference for single occupancy rooms is affected by
one’s social class. Specifically, those of lower classes prefer
shared-occupancy rooms.
In terms of design, the Victorian hospitals were influenced by
Florence Nightingale, whose preference was towards open
wards that facilitated the supervision of patients by their
nurses. Hospitals adapted the Nightingale wards and
provided for a small number of private rooms for patients
requiring isolation. Private rooms were also provided to
patients who desired them for social reasons and were willing
to pay a fee for the rooms.
Asa S. Bacon encouraged the use of private rooms. He felt
that the hospital was more efficient if it consisted of private
rooms since these rooms offered more flexibility. Bed
occupancy would no longer be an issue as patients could be
placed in any of the rooms and the rate of infection could be
reduced. Better examinations of patients could be conducted
as well, visiting rules could be less stringent, and room
temperatures could be adjusted to suit the individual patient’s
needs.
L. J. Frank also supported the use of private rooms as he felt
the patient could relax and would not be disturbed to the same
extent as in a shared occupancy room. He felt the issue of the
amount of traveling by nurses could be reduced through the
inclusion of a utility room between every two rooms.
World War II helped support the provision for private rooms
as it was discovered that patients recovered faster when they
had their own private toilet.
From an economical point of view, multiple-occupancy
rooms are more efficient as more patients can be placed along
one corridor. This also facilitates the nurses’ supervision of
their patients as their traveling time is decreased. The most
135
economical configuration is a six-bed room with three beds
on each side of the room.
The double-corridor design reduces the amount of walking
the nurse will incur. This design became popular with the
advent of air conditioning.
In designing the patient room, planners take into account
various factors. These include reducing the amount of travel
done by nurses through the inclusion of necessary utilities in
the room, subdividing multiple-occupancy rooms into
cubicles, changing the placement of the bed to reduce the
width of the room, and designing a smaller room altogether.
Patient room design includes circular, square, and hexagonal
shapes.
Implications of Findings
Private rooms are preferred by those of upper social classes,
whereas those of lower social classes prefer multipleoccupancy rooms.
136
Tidwell, C., & Sowman, J. (2002). The healing space. Managed Healthcare Executive 12(5),
35-36
Focus of Article
To demonstrate how effective healing environments produce
quantifiable effects on the patient’s experience. This
includes, but is not limited to, a reduction in pain
medications, enhanced patient satisfaction, shortened lengths
of stay, and decreased operational expenses
Type of Healthcare Facility
The facilities described in the article are the Florida Hospital
Heartland Medical Center and the Woman’s Health Center in
Bellmore, New York.
Recommendations for
Healthcare Setting
Implications of Findings
The Florida Hospital Heartland Medical Center is a threestory facility. It features a reception rotunda, which includes
an information center as well as a gift shop. Elevator access
as well as central stairs are located within a central corridor
and are clearly visible. The second and third floors include
the inpatient rooms and services. The nurses’ stations are
dispersed so that one nurse can simultaneously view four
patients. The patient rooms are private and are painted in
neutral colors. Lighting is both natural and artificial.
Restrooms are located on an exterior wall of the inpatient
rooms, enabling the staff to view and respond to the patient if
necessary. Other wings include a health club, physician’s
lounge, emergency entrance, clinical pharmacy and labs, as
well as physicians’ offices. A courtyard with a reflecting
pool is also visible.
The Woman’s Health Center integrates ideas and images
related to garden, greenhouse, and lantern. It includes a
medical suite, an imaging suite, and a healthy living suite.
Soothing colors, warm textures and natural materials are used
throughout the building. The quality of light is enhanced
through the use of skylights.
Private rooms are preferred in the design of the Florida
Hospital Heartland Medical Center, although reasons were
not provided for this preference. Care is delivered with
greater efficiency and wellness and good health are promoted
in the Woman’s Health Center. No mention is made in terms
of preference for single or multiple room occupancy at the
Woman’s Health Center.
137
Tradewell, G. B. (1993). Contemporary nursing unit configuration. In D. K. Hamilton (Ed.)
Unit 2000: Patient beds for the future. A nursing unit design symposium (pp. 191-215).
Houston: Watkins Carter Hamilton Architects, Inc.
Focus of Article
To describe the design of patient care units.
Type of Healthcare Facility
The material presented in this chapter applies to all hospitals.
Recommendations for
Healthcare Setting
Implications of Findings
The Nightingale ward is a basic open ward design. Nurses
are located among patients and the support stations are
located outside the ward. This type of ward contains
approximately 30 to 32 beds and visibility of all patients was
the goal of this design.
The Continental, or single- and double-corridor design
contains patient rooms along one or both sides of the corridor.
Instead of an open ward, rooms contain 4 to 6 beds. The unit
also contains a central nursing station and support space
supplies the unit.
In the Racetrack design, patient rooms are located further
apart and support spaces are located between two corridors.
Nurses do not favor this design because travel distances are
high, visualization of the corridors is poor, one nursing
station supports a large number of patients, and only one
clean and one soiled utility room is provided.
The cluster design encompasses patient rooms around nursing
substations. One nursing station is dedicated as the central
nursing station.
Travel distances are fairly short in the triangular design.
The criteria that must be met to create a good design include
the organization of patient rooms, observation of patients,
number of nursing stations needed, distribution of support
space, flexibility, and travel distances.
Ward design must encompass factors such as the organization
of patient rooms and the number of nursing stations needed.
Room occupancy varies among the designs, and preferences
were not specified.
138
Ulrich, R. S. (1997). Pre-Symposium Workshop: A theory of supportive design for healthcare
facilities. Journal of Healthcare Design, 9, 3-7.
Focus of Article
To describe factors of hospital design that contribute to
positive outcomes for patients.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
the United States.
Recommendations for
Healthcare Setting
Implications of Findings
Hospital design is increasingly taking into account the
environmental qualities and strategies that can have a positive
effect on patient outcomes. Design that does not enable
patients to cope with stress can have a negative effect on their
health outcomes. Stress can manifest itself in problems with
sleeping, outbursts of anger, and noncompliance with
medication. Noisy and visually unstimulating environments
undermine a patient’s sense of control and autonomy.
Design that helps patients cope with stress includes a sense of
control with respect to physical surroundings, access to social
support, and access to positive distractions.
Approaches for increasing the patient’s sense of control
include bedside dimmers, headphones to listen to music, and
attractive grounds.
Social support can be fostered through the inclusion of a
sleeper sofa in patient rooms, comfortable waiting areas, and
sitting areas.
Positive distractions include nature (gardens, trees, water,
plants…), music, television, aquariums, and window views.
Positive outcomes that a patient can achieve through
supportive design are reduced stress and anxiety, reduced
pain, improved satisfaction, and improved alertness.
Hospitals can also experience lower costs as length of patient
stay may be reduced.
Patients can experience positive health outcomes through
supportive designs. No mention was made in regards to room
occupancy.
139
Verderber, S. & Fine, D. J. (2000). Reinventing the patient room. In S. Verderber & D. Fine,
Healthcare architecture in an era of radical transformation (pp. 195-222). New Haven, CT:
Yale University Press.
Focus of Article
To describe the design of patient care units.
Type of Healthcare Facility
The material presented in this chapter applies to hospitals in
the United States and Europe.
Recommendations for
Healthcare Setting
Implications of Findings
Hospital design has shifted from traditional open wards to the
use of private rooms. Single-occupancy rooms were deemed
by the U.S. General Accounting office to be the most costefficient in terms of day-to-day operations and initial
construction costs. Nightingale hospitals were deemed
inefficient due to the excess vertical movement between
floors, the difficulty of expansion, and the basic changes in
overall service mix of hospitals.
The cluster unit minimized the distances traveled by nurses
and enabled nurses to deliver a higher-level of care than the
traditional linear unit.
The use of high-tech equipment and furnishings affected
room design in terms of bed positioning, ceiling height,
closets, overall size of the rooms, and window positioning.
The Planetree movement incorporated the participation of the
patients and their family members. An emphasis was placed
on education, personalization, and the demystification of the
illness. Planetree determined that patients were denied
supportive human relationships, physical comfort, and
independence in the hospital environment.
Transformational rooms can be converted and reverted to
their initial stage. These rooms can be altered to possess
various functions. Bedside computers enable nurses to input
patient data immediately and give patients access to their
medical information. Private patient rooms are made larger
to accommodate equipment, such as the bedside computers,
as well as family members.
Patient rooms have evolved from open wards to private
rooms that are large enough to accommodate equipment and
family members.
140
Voelker, R. (1994). New trends aimed at healing by design. Journal of the American Medical
Association, 272(24), 1885-1886.
Focus of Article
To describe the use of the Planetree philosophy in hospitals.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
the United States.
Recommendations for
Healthcare Setting
Implications of Findings
The Planetree philosophy blends efficient surroundings and
emotional support with medical care. In terms of design, soft
lighting is used as well as carpeting to absorb noise. Soothing
colors and artwork help to make the environment more like
home. Patients are also given control of their surroundings.
This includes lighting, temperature, and the television.
Patients should be allowed to bring personal possessions to
the hospital. Air quality should also be good. Nurses’
stations are designed to encourage communication.
Incorporated in the design are windows that give the patients
an external view.
The Planetree philosophy focuses on patient-centered care.
No mention is made in regards to room occupancy, though it
appears that this philosophy is geared towards a private room
which incorporates space for caregivers.
141
Watkins-Miller, E. (1998, February). Design cures. Buildings (Supplement – Building
Interiors),10-14.
Focus of Article
To describe the features of the Marburg Pavilion at John
Hopkins Hospital in Baltimore.
Type of Healthcare Facility
The material described in this article applies to the Marburg
Pavilion at John Hopkins Hospital in Baltimore.
Recommendations for
Healthcare Setting
Implications of Findings
The facility incorporates elegant furnishings and hotel-like
amenities. The cost for a private patient room is $800 per day
and the rooms include, for instance, hardwood floors, and a
cherry wood cabinet that holds a television, fax machine, a
safe, and the patient’s clothing. Warm colors and lighting
were used to make the setting comfortable for the patient.
Lighting is brighter in certain areas and dimmer in other
areas. Artwork and patterns are used and can serve as
wayfinding devices.
Private rooms with elegant features are used to make the stay
more pleasant for the patient
142
Weber, D. O. (1995, March-April). Environments that heal. The Healthcare Forum Journal,
38(2), 42.
Focus of Article
The focus of this article is to describe features of hospitals
that promote a therapeutic environment.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
the United States.
Recommendations for
Healthcare Setting
Implications of Findings
Hospitals should be designed to encompass the spiritual,
mental, and emotional dimensions of patients. The Planetree
philosophy integrates seven patient-centered values into
healing: patient participation, autonomous decision-making,
choice, involvement of family and friends, access to
information, respect for the individual, and the provision of
supportive human and physical environments. Emphasis is
placed on factors such as a good medical reference library,
eliminating barriers between caregivers and patients, and
urging patients to read and annotate their own medical charts.
Air quality should be good and hospitals have been
experimenting with natural fragrances to improve the quality
and to promote healing.
Excess noise should be eliminated. This can be accomplished
through source attenuation and source elimination. Natural
sound and music can be used to contribute to a positive
environment for the patient.
Lighting should be effective and patients should have
windows to view daylight.
Hospitals should be designed to promote a therapeutic
environment. No mention was made in regards to room
occupancy.
143
Weisman, E. (1994, November 25). Built-in care. Health Facilities Management,24-33.
Focus of Article
To describe the design of Griffin Hospital.
Type of Healthcare Facility
The information presented in this article applies to Griffin
Hospital in Derby, Connecticut.
Recommendations for
Healthcare Setting
Implications of Findings
The design of this hospital is based on the Planetree
philosophy, which is based on patient-centered care. Rooms
in this facility are semi-private and are designed in an Lshape to give the patients a degree of separation from each
other as well as a sense of their own space. The bathroom is
located in the center of the room. There are three 23-bed
units, and each includes two swing beds available to family
members. Each unit also consists of several satellite nursing
stations located in corridors that branch off the main corridor.
These stations are surrounded by a cluster of three to four
patient rooms and shield patients from those walking down
the main corridor.
This facility consists of semi-private rooms designed in an Lshape. This design helps to give patients a sense of control
while simultaneously offering a degree of separation between
patients.
144
Withecombe, P. (1997). Focusing on innovation. Hospital Development, 28(3), 18-19.
Focus of Article
To describe how the Echelon and Focus methods of ward
planning promote efficiency and patient comfort. The
Echelon ward design incorporates the Nightingale multi-bed
dormitory design and enhances amenity and privacy for the
patients combined with the ability of the nursing staff to
easily observe patients. It is a cost-efficient design. The
Focus design incorporates and expands the Echelon design.
Type of Healthcare Facility
The Echelon design was developed by Estatecare for
community hospitals in Wales. Mold Community Hospital is
the focus of the article. The Focus design was used in the
Princess of Wales DGH Bridgend hospital.
Recommendations for
Healthcare Setting
Implications of Findings
The Echelon design suggests the use of a 20-bed ward. The
nurse’s base should be located centrally with a direct view
into each 8-bed bay. An “L” shaped corridor is used to give
the perception of a shorter corridor. The bed heads should be
staggered with each bed located in a corner area within the
bay. Each bed head is visible from the nurse’s base and each
patient can see the nurse’s base as well. The bed area should
have its own ambience with interior finishes and light
fixtures, which illuminate each bed area. Storage provisions,
including a bedside locker and storage alcove on a sidewall
are planned as well as a pin-board behind the alcove.
The Focus design includes a two 23-bed acute ward template.
It incorporates the Echelon bays, which are clustered around a
central nurse base. Patient rooms are only a short distance
away, facilitating observation. The focus design is
compatible with a Nucleus hospital design and is costefficient.
While both designs incorporate multiple beds in the rooms,
each design offers increased privacy for the patient while
promoting cost-efficiency.
145
Williams, M. (2001, November). Critical care unit design: A nursing perspective. Critical
Care Nursing Quarterly, 24(3), 35-42.
Focus of Article
To describe the design of a critical care unit based on the
premise of offering more efficient care as well as a
comfortable environment for patients.
Type of Healthcare Facility
The material presented in this article applies to the Critical
Care Units of hospitals in the United States.
Recommendations for
Healthcare Setting
Implications of Findings
The goals of the critical care unit should be to provide
efficient care for patients and to promote a healing
environment for both patients and their family members.
From the nursing stations, nurses should have both direct and
indirect visualizations of patients. Supply areas should be
accessible from patient areas to make efficient use of the
nurses’ time. There should also be multiple entrances to the
critical care area: one for visitors and health care providers
and one for patient transport and transfer.
Patient rooms need outside windows and direct visualization
from the nurses’ station. Patient rooms may be divided into
three areas: a patient area, a family area, and a caregiver area.
The patient area consists of a bed, bedside table, and a
bedside chair. The family area should include storage space
as well as somewhere to sleep. The caregiver area includes
supplies and equipment.
Temperature controls should be in all rooms and adjusted for
the patients’ needs. A board can also be in the room and used
by the patient to display personal belongings. Artwork,
including nature scenes, are comforting for patients and their
families. The family waiting area needs to be large enough to
accommodate visitors.
The rooms in the critical care units should be visible from the
nurses’ stations and should be large enough to accommodate
patients and their family members. Room occupancy was not
mentioned, though the implication was that rooms were
single-occupancy.
146
Williams, M.A. (1988). The physical environment and patient care. Annual Review of Nursing
Research, 6, 61-84.
Focus of Article
To review literature linking physical environment factors to
patient care.
Type of Healthcare Facility
The material presented in this article pertains to studies
conducted in the United States and the United Kingdom.
Recommendations for
Healthcare Setting
Implications of Findings
Nursing behaviors that are affected by unit design are ease
and frequency of interaction with patients and families, travel
time, staffing requirements, infection control, satisfaction,
surveillance, and communication. Effective and efficient
nursing care was related to short travel distances traveled by
nurses and features that maximize communication between
nurses and patients. The social organization of the hospital
was discovered to define the relationship between space use
and staff roles. Infants were found to be particularly
vulnerable to continual loud noises. Average levels of sound
in patient rooms were found to exceed recommended levels
on a surgical nursing unit. Color is thought to elicit certain
psychophysiologic reactions in humans.
Two main functions of the physical environment are a
symbolic role and the facilitation of the therapeutic process.
The physical environment can impact patients in a variety of
ways. No mention was made in regards to room occupancy.
147
Empirical Articles: Disease Control and Falls Prevention
Anderson, J. D., Bonner, M., Scheifele, D. W., & Schneider, B. C. (1985). Lack of nosocomial
spread of varicella in a pediatric hospital with negative pressure ventilated patient rooms.
Hospital Infection, 6(3), 120-121.
Focus of Study
To compare hospital rooms in a new hospital that are
equipped with negative pressure ventilation to rooms in an
old hospital without this ventilation system in terms of
prevention of nosocomial infections.
Research Design
Patients with Varicella zoster were transferred from other
wards to the Isolation Unit. They were admitted to a room
with single occupancy and nurses used strict isolation
techniques.
Index cases were considered infectious from one day before
the appearance of the rash until scabbing was complete.
Susceptible persons were identified as patients who were on
the ward at the same time as the infectious patient and who
had not been previously exposed to chickenpox during the
previous 21 days. They also had no previous history of
chickenpox.
Sample Information & Site
The study was conducted on the Isolation Unit of British
Columbia’s Children’s Hospital. The sample included 5
index cases and 125 susceptible cases.
Findings
No secondary spread of the infection was found in the
susceptible patients in the new hospital with negative pressure
ventilation. In 1979, in the Isolation Unit of the old hospital,
7 chickenpox infections were detected among 41 susceptible
patients from 2 index cases.
Implications of Findings
Negative pressure ventilation appears to be beneficial in
preventing the spread of chicken pox on an isolation unit.
Rooms in this study were single occupancy as it was an
Isolation Unit and patients were susceptible to acquiring
infections from other patients.
148
Groves, J. E., Lavori, P. W., & Rosenbaum, J. F. (1993, Winter). Accidental injuries of
hospitalized patients. A prospective cohort study. International Journal of Technology
Assessment in Health Care, 9(1), 139-144.
Focus of Study
To study the frequency and types of incident reports filed for
patients by nursing staff.
Research Design
Incident reports were retrieved for patients from the files of
the legal department in the hospital. To record the incidents,
the ‘Report of Incident or Unusual Occurrence” form was
used. Details on this form include items such as the patients’
names, the incident location and time, the person who
discovered the incident, condition at discovery, and nature of
injury.
Sample Information & Site
The study was conducted over a three-month period at a
1,082-bed tertiary-care hospital. The sample included 806
patients who were admitted through the emergency ward.
Findings
Of the subjects included in the study, 107 patients
experienced a total of 161 incidents. Of these, 93 incidents
were considered hazardous, or nonmedication errors. 18
patients suffered minor injuries. Hazardous incidents were
more common among males between the ages of 20 and 40
and medically ill females over the age of 60.
Limitations of this study include a sample drawn from
admissions from the emergency ward. The sample may have
been skewed toward the more seriously ill patients. Another
limitation is the assumption of the hospital as a single
environment. Different wards may have different risks of
accidents as the nature and severity of illnesses varies among
the wards.
Implications of Findings
The majority of incidents that occurred were not due to
medication errors. Rather, they were due to falls and other
incidents. No mention was made in regards to room
occupancy.
149
Hendrich, A., Nyhuis, A., Kippenbrock, T., & Soja, M. E. (1995, August). Hospital falls:
Development of a predictive model for clinical practice. Applied Nursing Research, 8(3), 129139.
Focus of Study
To develop a risk model that may be used to assess and
identify different levels of risk of falls in acute care
populations. This study also attempts to identify key areas
for nursing interventions and fall-prevention programs.
Research Design
A retrospective chart review was completed using an
epidemiological approach. Falls were assessed using incident
reports from the hospital during a one-month period. Risk
factors were measured based on the information in the
patient’s record, in particular, the nursing assessments.
Patients’ charts were reviewed for risk factors present at
admission and within 24 hours preceding the fall.
Sample Information & Site
The study took place at a 1,120 Midwest teaching institution.
The sample included 102 fall charts and 236 non-fall charts,
as the researchers wanted a ratio of approximately two nonfall subjects for each fall subject. The subjects were
randomly selected.
Findings
Most falls occurred in the patients’ rooms while they were
alone and attempting to get to the bathroom. No significant
differences were found between the nursing shifts, and
physician activity orders were not always reflective of the
patients’ risk levels.
Nursing interventions are based on increased patient
observation, the environment, assistance with and promotion
of mobility, patient reorientation, and bladder training.
Patients are classified on their degree of risk during a nursing
shift.
Implications of Findings
Programs should be developed that take into consideration
risk factors of patients in regards to their falls. No mention
was made in terms of room occupancy, though the majority
of falls occurred while the patient was alone in his or her
room.
150
Jones, W. J., Simpson, J. A., & Pieroni, R. E. (1991, Summer). Preventing falls in hospitals.
Hospital Topics, 69(3), 30-33.
Focus of Study
To examine the role of patient age and diagnostic status in
predicting patient falls.
Research Design
Incident reports were collected from the facilities, as was
information pertaining to the patients’ age and diagnostic
status. Control groups consisting of non-incident patients
were set up at both facilities.
Sample Information & Site
The study took place at a large urban medical center and a
small psychiatric facility in Memphis, Tennessee. Subjects
included 234 patients who reported incidents and 185 control
patients at the large urban medical center. 96 patients who
reported incidents and 100 control patients were used from
the psychiatric facility.
Findings
At the medical center, a sharp rise in falls was noted for
patients over the age of sixty. Patients at this facility
diagnosed with circulatory system problems were more likely
to fall.
At the psychiatric facility, 36% of falls occurred in patients
19 years of age and younger, and 30% of falls occurred to
patients over the age of sixty. This may be due to the fact that
most adolescents in the facility were being treated for
substance dependence problems. This problem was second
only to affective disorders in predicting patient falls.
Implications of Findings
Age and diagnostic status were significant predictors of
incident status. No mention was made in regards to room
occupancy.
151
Langner, D. (1996, September). Accident analysis in a busy surgical ward. Curationis, 19(3),
52-53.
Focus of Study
To analyze factors that are associated with falls on a busy
surgical and urological unit.
Research Design
Forms were filled out which included information on cotsides in situ/refusal, occupancy status, number of staff on
duty, and whether a bell was at hand. The analysis of the
falls comprised of time of day, age group, location of
accident, cot-side influence, patient activity, and type of
injuries.
Sample Information & Site
The study took place on a busy surgical and urological unit in
a private hospital in Durban. This hospital consists of 4
general wards, 5 semi-private wards and 5 private wards. The
sample included 22 patients who experienced falls during the
time of this study.
Findings
The majority of accidents occurred during the morning,
between 8 and 10 am. During the night, most accidents
occurred between midnight and 4 am, when staff coverage is
low. Most accidents took place while the patient was on his
or her way to the bathroom. Accidents were most frequent
among patients between 70 and 80 years of age. The type of
ward did not influence the occurrence of an accident. Those
without cot-sides were more likely to experience a fall. Of
the patients who fell, 45% suffered an injury.
Implications of Findings
Accidents were most likely to occur in the morning, among
the elderly, and those on their way to the bathroom. Ward
design did not impact the incidence of falls.
152
Levene, S., & Bonfield G. (1991, September). Accidents on hospital wards. Archives of
Disease in Childhood, 66(9),1047-1049.
Focus of Study
To investigate accidents occurring to children on pediatric
units. Information was gathered in regards to factors
associated with accidents and measures were proposed to
reduce the frequency and severity of accidents.
Research Design
Questionnaires were distributed over an initial pilot period
lasting three months and then over the course of one year.
Information collected consisted of details regarding the
accident including the injured person and the injury sustained
and the supervision of the child.
Sample Information & Site
The convenience sample included eight hospitals with
pediatric wards. These hospitals varied from specialized
pediatric hospitals to district hospitals. Subjects included
inpatients, outpatients, or visitors to these hospitals sixteen
years of age or younger. A total of 781 questionnaires were
collected and analyzed.
Findings
Accidents were most frequent amongst boys of all ages and
children under the age of five. Of the accidents that occurred,
falls from a height were the most common followed by being
struck by or coming into contact with equipment, and being
scalded by a hot drink. One child was trapped between the
cot bars and the mattress.
The most common result of an accident is no injury. Of
injuries that did occur, bruises and lacerations were most
frequent. The head was the site most injured.
Of the 732 accidents that occurred, forty-one percent
occurred while the child was in the presence of his or her
parents, and twenty-seven percent of accidents involved beds
and cots.
Several of these injuries could have been prevented with
educating parents as to how the cot sides should be used. The
hospital should also take into account the height of the bed as
it is probably higher than the beds children have at home.
Implications of Findings
Although the majority of accidents did not result in an injury,
several of these accidents could have been prevented with the
proper use of equipment. No mention was made in regards to
room occupancy.
153
Mulin, B., Rouget, C., Clement, C., Bailly, P., Julliot, M., Viel, J. F. et al. (1997). Association of
private isolation rooms with ventilator-associated Acinetobater baumanii pneumonia in a surgical
intensive-care unit. Infection Control and Hospital Epidemiology, 18(7), 499-503.
Focus of Study
To assess the rate and routes of Acinetobacter baumannii
colonization and pneumonia among patients who were
mechanically ventilated in a surgical intensive-care unit.
Research Design
Specimens from patients were screened for the presence of
Acinetobater baumanii over a six-month period prior to and
after renovations were completed on the unit. The old unit
included seven isolation rooms and two open rooms with four
beds each. The new unit included fifteen isolation rooms and
each room had a hand-washing sink.
Sample Information & Site
The study took place on the surgical intensive-care unit at
University Hospital of Besancon, France. The subjects
included 135 patients prior to the renovations and 179
patients after the renovations were complete.
Findings
Of the patients who had infected bronchopulmonary tracts,
twenty-nine of the patients were infected prior to the
renovations, while only two were infected after the
renovations. Colonization rates were greater prior to the
renovations (28.1% prior to the renovations versus 5% after
the renovations), and were associated with prolonged stay in
hospital. Cross-transmission was the major route of
colonization.
Implications of Findings
The move from open to isolation rooms may help control the
bronchopulmonary tract acquisition of Acinetobacter
baumanii in mechanically ventilated patients.
154
Pullen, R., Heikaus, C., & Fusgen, I. (1999, December). Falls of geriatric patients at the
hospital. Journal of the American Geriatrics Society, 47(12),1481.
Focus of Study
To identify risk factors that contribute to patient falls in a
geriatric facility.
Research Design
Falls were recorded prospectively during a one-year period.
Formal check lists were used by the nurse or therapist
assigned to the patient to document the circumstances
regarding the fall.
Sample Information & Site
The study included all patients at a geriatric hospital during a
one-year period (January 1, 1997-December 31, 1997). The
majority of the rooms in this facility consist of two, three, or
four beds. Only four rooms are single occupancy.
Findings
During the time frame of this study, 536 falls occurred on the
five hospital wards. Most falls (444) occurred in the patients’
hospital rooms when they were alone or with other patients.
Seventy-four falls occurred when the patients were alone in
the bathroom.
Implications of Findings
Improved monitoring is needed to prevent patient falls. Most
falls occurred in the patients’ rooms, though it was not
specified if there was a relationship in regards to the falls that
occurred and how many people were in the room.
155
Seltzer, E., Schulman, K. A., Brennan, P. J., & Lynn, L. A. (1993, December). Patient attitudes
toward rooming with persons with HIV infection. Journal of Family Practice, 37(6), 564568.
Focus of Study
To examine patient attitudes in regards to rooming with
patients with HIV infection and other medical conditions.
Research Design
Surveys were administered to patients to examine their
preference for single or double occupancy rooms, to assess
their knowledge of HIV, and to inquire about their attitudes
regarding rooming with a patient who had HIV, cancer,
pneumonia, dementia, or disfiguring skin lesions. Surveys
followed the structured-interviewer format.
Sample Information & Site
The study took place at a University hospital in an inner city.
The sample included 104 inpatients.
Findings
Of the patients surveyed, 55% stated that they would not
room with an HIV-positive patient. Of these patients, 46%
preferred a private room while in the hospital, whereas 24%
of those who did not object preferred a private room. Those
that objected tended to have a roommate with other medical
disorders.
A significant number of those that objected to rooming with a
person with HIV felt they had the right to know the reason
why their roommate was hospitalized. These patients also
had a poorer knowledge in regards to the transmission of
HIV. There were no differences between those that did and
did not object to rooming with an HIV-positive patient in
regards to their perceptions of their knowledge of HIV. None
of the patients knew the hospital’s policy in isolating HIVpositive patients, and none requested this information.
Implications of Findings
Lack of knowledge regarding HIV infection may be an
underlying cause to people’s fear of rooming with HIVpositive patients. The majority of patients preferred a private
room instead of sharing a room with an HIV-positive patient.
156
Shirani, K.Z., McManus, A.T., Vaughn, G.M., McManus, W. F., Pruitt, B. A. Jr. & Mason, A. D.
(1986). Effects of environment on infection in burn patients. Archives of Surgery, 121, 31-36.
Focus of Study
To investigate the effect of using isolation measures on the
infection and mortality rates of burn victims.
Research Design
Two wards were used for this study. The first ward was open
in design and facilities for hand washing were limited. The
second ward was renovated to include individual rooms, most
of which were single-occupancy. Each room contained a
sink. Patients on each ward were observed for a year, and
each patient was assessed daily through physical
examinations and laboratory tests, when needed. Observed
and predicted mortality were determined.
Sample Information & Site
The study took place on two wards, one of which was open,
and the other which contained individual wards. 173 patients
were observed on the open ward, while 213 patients were
observed on the renovated ward.
Findings
On the renovated ward, the observed mortality was
significantly lower than the predicted mortality for patients
who did not acquire an infection. Infections that were
reduced on the renovated ward were bactermia and urinary
tract infections. The prevention of infection was the primary
reason that survival rates increased on the renovated ward.
Implications of Findings
The incidences of nosocomial infections and mortality were
decreased through changes in the patient environment.
Having an individual room with its own hand washing facility
appears to decrease the risk of infection for burn patients.
157
Stelfox, H. T., Bates, D. W., & Redelmeier, D. A. (2003, October 8). Safety of patients isolated
for infection control. Journal of the American Medical Association, 290(14), 1899-1905.
Focus of Study
To examine the quality of care received by patients who are
in isolation due to infection control.
Research Design
Consecutive adults admitted to both hospitals who were
isolated for at least two days were identified as subjects. For
each isolated patient, two matched controls were identified.
Patient charts were reviewed for hospital, demographic, and
clinical data. Process of care measures included
documentation of patient vital signs and clinicians’ narrative
notes. Injuries caused by medical management were used to
define the occurrence of an adverse event. These included
injuries that prolonged the patients’ stay or produced
disability and injuries that resulted in transient disability or
abnormal laboratory value measurements. Patient satisfaction
was also measured through reviews of medical records and
unsolicited complaints.
Sample Information & Site
The study took place at 2 North American hospitals. The first
was Sunnybrook and Women’s College Health Sciences
Centre in Toronto, Ontario, and the second location was
Brigham and Women’s Hospital in Boston, Massachusetts.
Patients from Sunnybrook comprised of a general cohort of
patients who had various diagnoses. Patients from Brigham
comprised of a disease-specific cohort; these patients were
admitted with a diagnosis of congestive heart failure. The
general cohort consisted of 78 isolated patients and 156
control patients while the disease specific cohort included 72
isolated patients and 144 control patients.
Findings
Isolated patients were more likely to have incomplete
recordings of their vital signs and to have days where their
vital signs were not recorded at all. Patients with congestive
heart failure were less likely to have a stress test or
angiogram once they were admitted to the ward from the
emergency department.
Isolated patients were twice as likely as control patients to
experience an adverse event during their hospital stay. In
particular, isolated patients were eight times more likely to
experience supportive care failures such as falls and pressure
ulcers. No differences were noted in diagnostic, operative, or
158
medical procedures, and no adverse drug events were
discovered.
Isolated patients expressed greater dissatisfaction with their
treatment and had longer hospital stays than control patients.
Implications of Findings
Patients in isolation due to infection control are more likely to
experience an adverse event during their hospital stay than
patients not in isolation.
159
Sutton, J. C., Standen, P. J., & Wallace, W. A. (1994, March-April). Patient accidents in
hospital: Incidence, documentation and significance. British Journal of Clinical Practice, 48(2),
63-66.
Focus of Study
To report data on three studies which assess accidents in
hospitals.
Research Design
The data reported in this article stems from three interrelated
studies. The first, and largest, study was conducted over a
one-year period and included all reported patient accidents on
ten hospital wards. Data were collected from patient accident
reports, patient interviews, nurses’ questionnaires, and
medical and nursing records.
The second study was a comparative study of fifty reported
accidents and 50 non-accident patients. The first study was
the source of data for this study.
The third study used anecdotal evidence from the first two
studies. Patients were surveyed on three separate occasions
as to whether or not they experienced an accident during their
hospital stay. Records were checked to see if an accident
report form had been completed.
Sample Information & Site
The study took place on ten wards of a large acute care
hospital. The subjects included 515 inpatients on these wards
who reported an accident.
Findings
It was discovered that of the inpatients who reported
accidents, 382 patients had one accident and 133 had multiple
accidents. Patients aged 60 years or older had the most
accidents, and the accident rate was greater for males. Those
who had an accident were most frequently diagnosed with a
neurological disorder. Of those that had an accident, falls
were most frequently reported, and one-third of patients were
injured as a result of the accident. The majority of accidents
were reported by staff to be caused by patient conditions.
Nurses also tended to estimate the visual and hearing acuity
of patients as higher than the patient thought they were.
Implications of Findings
Falls were the most common type of accidents, and the
elderly are most prone to experience an accident. No mention
was made in regards to room occupancy.
160
Tutuarima, J. A., van der Meulen, J. H., de Haan R.J., van Straten, A., & Limburg, M. (1997,
February). Risk factors for falls of hospitalized stroke patients. Stroke, 28(2), 297-301.
Focus of Study
To assess the incidence of falls as well as identify risk factors
for patients hospitalized as a result of a stroke.
Research Design
Trained nonmedical research assistants collected data from
the medical and nursing records of patients shortly after they
were discharged. The information collected included the type
of stroke suffered, stroke severity, medical history,
comorbidity, neurological deficits, complications, use of
medications, and the intensity of nursing care. When falls
occurred, circumstances regarding the fall, such as time of
day, place, the patient’s activity before the fall and the
consequences of the fall, were recorded.
Sample Information & Site
The study was conducted using data from the neurological
departments of twenty-three hospitals in the Netherlands.
The sample included 720 patients who had suffered from an
acute stroke.
Findings
104 of the 720 stroke patients fell at least once. 69 of the
patients fell only once, 19 fell twice, and 16 fell three or more
times, with a total of 173 falls occurring. Risk factors that
increased the likelihood of a fall were heart disease, mental
decline, confusional state, and urinary incontinence. Those
using major psychotropic drugs were less likely to fall. If
patients fell once, their risk of falling a second time was
increased.
The majority of the falls occurred during the day, in the
patients’ rooms, and during visits to the bathroom.
Approximately 23% of the falls occurred while the patient
was in bed or sitting on a chair and approximately 25% of the
falls caused injuries, the most serious of which were hip
fractures.
The number of patients per nurse was unrelated to the number
of falls that occurred.
Limitations of this study include the use of formal incident
reports in hospitals, which may have resulted in
underreported incidences of falls. Also, with the use of a
large number of hospitals, the quality of data varies because
of the different staff and neurologists registering the data.
161
Implications of Findings
Patients who suffered from a stroke had a relatively high risk
for falling. Although a large number of falls occurred in the
patients’ rooms, room occupancy was not mentioned.
162
Non Empirical Articles: Disease Control and Falls Prevention
Eickhoff. (2003, August). Active surveillance for the control of VRE: Science or bandwagon?
Infectious Disease News.
Focus of Article
To discuss recommendations made in the SHEA Guideline
for preventing nosocomial transmission of VRE.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
the United States.
Recommendations for
Healthcare Setting
Implications of Findings
Dr. Eickhoff comments on the “SHEA guideline for
Preventing Nosocomial Transmission of Multidrug-Resistant
Strains of Staphylococcus aureus and Enterococcus.” In
particular, he focuses on the recommendations for VRE,
which focus on the development of an institutional program
for active surveillance of VRE. Problems with the
development of such a program include the sensitivity of the
surveillance instrument, which is at approximately 60%. The
proportion of hospitals that do not carry out active
surveillance for VRE ranges from 60%-70%.
Errors in measurement can become ingrained in policy and
can damage the academic respectability of hospital
epidemiology. Also, due to careful resource management in
hospitals, it may not be cost-effective to justify the expenses
incurred by active surveillance of VRE.
No mention was made in regards to room occupancy.
163
Kappstein, I. & Daschner F. D. (1991, September). Potential inroads to reducing hospitalacquired staphylococcal infection and its cost. Journal of Hospital Infection, 19(Suppl B), 31-34.
Focus of Article
To summarize effective procedures for preventing hospitalacquired staphylococcal infections.
Type of Healthcare Facility
The article review is intended for all hospitals.
Recommendations for
Healthcare Setting
Implications of Findings
Frequent hand-washing is critical in preventing hospitalacquired infections from occurring. Private rooms are only
required for patients suffering from staphylococcal
pneumonia or skin lesions that cannot be covered by a
dressing, as these patients shed a great deal of organisms that
can lead to environmental contamination. Those caring for
these patients should also wear a mask, and may need
impermeable plastic aprons rather than cotton gowns.
The design of a hospital is costly and one of the least
effective measures in controlling the number of hospitalacquired staphylococcal infections.
Patients should have a private room if they suffer from
MRSA (methicillin-resistant S. aureus), as MRSA has the
potential to be endemic.
The most effective measure for preventing staphylococcal
infections is frequent hand-washing. Private rooms are
necessary in the case of patients suffering from MRSA.
164
Muto, C. A., Jernigan, J. A., Ostorowsky, B. E., Richet, H. M., Jarvis, W. R., Boyce, J. M., &
Farr, B. M. (May, 2003). SHEA guideline for preventing nosocomial transmission of multidrugresistant strains of Staphylococcus aureus and Enterococcus.. Infection Control and
Epidemiology, 362-386.
Focus of Article
Type of Healthcare Facility
Recommendations for
Healthcare Setting
Implications of Findings
To present an evidence-based guideline on preventing the
transmission of nosocomial infections, in particular MRSA and
VRE.
The article review is intended for all hospitals.
Most patients acquire MRSA through external sources, and
efforts must be made to control the transmission of this
infection. Rigorous infection control practices have been
successful in controlling the transmission of MRSA. Some of
these practices include stringent barrier precautions, cohort
nursing, and isolation of patients.
The transmission of VRE can occur via the contaminated
hands of healthcare workers or by having the same healthcare
worker as an infected patient. Proximity to an unisolated
patient is a major risk factor as well. Infection control
practices, including isolation, help to reduce the transmission
of VRE.
Cleaning and disinfecting policies should be developed to
control environmental contamination. The pathogens can
persist on environmental surfaces for days to months.
Infection control programs that emphasize early detection of
infected patients help to reduce costs and improve patient
outcomes.
Infection control programs help to control the transmission of
infection in hospitals. Isolation of patients, hand washing,
and disinfecting surfaces can help reduce the transmission of
infections.
165
O'Connell, N. H., & Humphreys, H. (2000). Intensive care unit design and environmental
factors in the acquisition of infection. Journal of Hospital Infection, 45(4), 255-262.
Focus of Article
To describe a design of the intensive care unit to help prevent
the spread of hospital-acquired infections.
Type of Healthcare Facility
The article review is intended for all hospitals.
Recommendations for
Healthcare Setting
Implications of Findings
The design of the ICU should minimize the entry and
persistence of microorganisms. Cleaning of surfaces,
especially those that may have been contaminated, should
also be enabled.
Pathogens such as Pseudomonas aeruginosa and
staphylococcus aureus, as well as infections such as
ventilator-associated pneumonia, and wound infections are
common in the ICU. The transmission of these and other
strains is promoted by poor compliance with hand-washing
protocols, shortages of nursing staff, and high density
crowding of patients.
Single rooms are recommended for patients requiring
isolation. A minimum ratio of one cubicle to six bed spaces
is recommended, though it may be lower in some cases. The
amount of room around the bed should be adequate to
separate patients and accommodate equipment. Hand basins
should be available for every other bed and they should be
equipped with elbow or foot operated faucets. Ventilation is
also important, and an air-pressure differential should exit
between the patient’s room relative to the unit, the filtration
of air, and the airflow.
Floors should be slip-resistant and easy to clean. Walls
should be washable and resistant to the impact of equipment.
Countertops should be made of a nonporous sold material and
ceiling tiles need to be appropriate for the necessary
locations.
Handwashing is the most important measure for preventing
and controlling the spread of hospital-acquired infections.
Private rooms are needed for patients requiring isolation.
166
Ognibene, F. (2000). Resistant strains, isolation, and infection control. In K. Hamilton (Ed.),
ICU 2010: ICU design for the future. Houston: Center for Innovation in Health Facilities, 103111.
Focus of Article
To discuss the requirements that are needed to deal with the
risk of an infection in an Intensive Care Unit.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
the United States.
Recommendations for
Healthcare Setting
In intensive-care units, immuno-compromised hosts are
becoming more common, and as a result, resistant
organisms can be dispersed throughout the unit. Patients
can then become infected by the resistant organism.
Standard source isolation procedures include placing the
patient in a single-occupancy room. Aprons or gowns and
gloves are used for direct patient contact, and handwashing
with an antiseptic detergent is needed.
For airborne infections, patients should be placed in a tightly
sealed isolation room with separate areas for handwashing,
gowning, and storage. Protective environment rooms, which
have positive air pressure, can also be used. The positive air
pressure is used to limit anything from the outside
environment from entering and contaminating high-risk
patients. These rooms are risky with if a respiratory pathogen
is involved.
MRSA (Methicillin-Resistant Staphylococcus aureus) can
occur in patients with previous hospitalizations, intravascular
lines, and those that have been admitted to the Intensive Care
Unit. VRE (Vancomycin-Resistant Enterococci) can be
transmitted by colonized patients or through incomplete
compliance with handwashing and barrier precautions.
Implications of Findings
Larger-sized single rooms are recommended to accommodate
equipment, sinks in every room, and the ability to store
contaminated products. Large, multi-patient rooms are not
recommended, as they can increase the spread of infection if
patients become infected.
167
Sehulster, L. & Chinn, R. Y. W. (2003, June 6). Guidelines for environmental infection control
in health-care facilities. Recommendations of CDC and the healthcare infection control
practices advisory committee (HICPAC), 52(RR-10), 1-44.
Focus of Article
To review previous guidelines and make recommendations
for preventing environment-associated infections in
healthcare facilities.
Type of Healthcare Facility
The material presented applies to hospitals in the United
States.
Recommendations for
Healthcare Setting
Implications of Findings
Immunocompromised patients require rooms where positive
pressure is maintained. Their time spent outside their rooms
should be minimized and they should have minimal exposure
to activities that may cause “aerolsolization of fungal spores”
(p. 10). Respiratory protection should be provided for these
patients and ventilation specifications and dust-controlling
processes should be used in the protective environment units
(units with a positive air flow in relation to the corridor).
Patients diagnosed with or suspected of having an airborne
infectious disease should be placed in isolation rooms that
receive numerous air changes per hour and are under negative
pressure. Patients with smallpox should also be placed in a
negative pressure room, preferably one that includes an
anteroom.
Standard cleaning and disinfecting procedures should be used
to control environmental contamination with antibioticresistant strains of bacterial culture.
Patients with airborne infectious diseases should be placed in
isolation.
168
Empirical Articles: Therapeutic Impacts: Relationship between Healing and
Environment
Baker, C.F., Garvin, B.J., Kennedy, C.W. & Polivka, B.J. (1993). The effect of environmental
sound and communication on CCU patients’ heart rate and blood pressure. Research in Nursing
& Health, 26, 415-421.
Focus of Study
To examine the effects of environmental sounds and
communication on the cardiovascular responses of coronary
care patients.
Research Design
The study measured high ambient stressors, social stressors,
and low ambient sounds. High ambient stressors included
sounds inside and outside of the rooms such sounds of
equipment and environmental sounds (telephones, toilets,
carts, and vacuum cleaners). Social stressors included room
conversation and hall conversation. Low ambient sounds
were continuous sounds in the room from lighting, heating,
and ventilation.
Cardiac monitors were used to obtain an electrocardiogram
and blood pressure was also measured every three minutes.
Trait anxiety was measured at the end of data collection.
Data were collected over five 45-minute periods in the early
morning, midday, and in the early evening during the first
day. On the second day, data were collected during early
morning and midday.
Sample Information & Site
The study was conducted on a 29-bed critical care unit, with
private rooms, in a large Midwestern teaching hospital. The
sample included 20 coronary care patients.
Findings
Room conversation occurred most frequently followed by
background sound, hall conversation, and environmental
sound. Sound levels were highest during room conversation
and were lowest for background sound. Environmental sound
and hall conversation were in between the other sound levels.
The loudest environmental sounds were from furniture
moving, alarms, and toilet flushing in the patients’ rooms.
Heart levels increased during conversations. Cardiovascular
reactivity was not related to trait anxiety scores.
Implications of Findings
High sound levels were related to higher heart rate levels in
certain instances. No mention was made in regards to room
occupancy, though it was mentioned that sound levels are
169
probably lower on this unit with private rooms than on open
intensive care units.
170
Baldwin, S. (1985, May). Effects of furniture rearrangement on the atmosphere of wards in a
maximum-security hospital. Hospital and Community Psychiatry, 36(5), 525-528.
Focus of Study
To evaluate the impact that the rearrangement of furniture has
on patients and on ward atmosphere.
Research Design
Furniture on seven out of ten wards was rearranged in the
ward dayrooms to promote group seating. Three of the ten
wards remained control wards and did not undergo any
changes. Once a day, at least two group seating arrangements
were established. The intervention followed a sequential
format. The first phase was baseline. This was followed by
the intervention and then a return to baseline. The final phase
was a second intervention. The four phases lasted a total of
eight weeks, with the intervals lasting a total of fourteen days.
The variables measured throughout the intervention were
medication rates, seclusion rates, casualty incidents,
perception of the ward, and nursing reports. The investigator
made observations three times a week.
Sample Information & Site
The study took place on seven male and three female wards
of a maximum-security hospital in England. This hospital
serves mentally disordered patients that require treatment
under special security due to their tendency for violent or
dangerous acts. The sample included the residents of these
ten wards, with the average number of patients on the wards
being twenty.
Findings
A trend exists towards an overall decrease in seclusion on the
intervention wards and improved social interaction.
Increased involvement in ward activities was discovered in
the intervention wards, although the change was minor. The
number of casualty incidents decreased on the intervention
wards while the number of points earned for improved
behavior and quality of work increased. Medication rates
remained stable across the control and intervention wards.
Implications of Findings
A minor short-term change such as furniture rearrangement
can have a moderate on the social interaction of patients in a
maximum-security hospital. No mention was made in
regards to room occupancy.
171
Baum, A., & Davis, G. (1980). Reducing the stress of high-density living: An architectural
intervention. Journal of Personality and Social Psychology, 38, 471-481.
Focus of Study
To assess the effects of architectural intervention on
residential crowding stress and poststressor effects.
Research Design
The study consisted of questionnaires, observational data, and
a laboratory component. The survey was used to assess the
perceptions of residents of dormitory life, including how
crowded, hectic, and predictable they found life to be on their
floor as well as perceptions regarding maintaining control and
social experience. Observations were used to describe how
the various residential conditions affected the behavior of
residents. Laboratory data were used to assess the persistence
and generalizability of the effects of their experiences on the
dormitory.
Sample Information & Site
The study was conducted on the dormitories of a small
residential liberal arts college. Three settings were used: a
standard long corridor, a short corridor, and a long corridor
altered by architectural intervention. This intervention
included bisecting the corridor to form two groups of twenty
residents. Bedrooms were also converted to lounge space.
The sample included sixty-seven females who participated in
the questionnaire component of the study. Fifty-four subjects
were randomly selected to participate in the laboratory phase
of the study.
Findings
Those on the standard long corridor reported more crowding
and control-related problems and less small group
development than those on the other two corridors.
Specifically, those on the long corridor reported less
perceived control, increased difficulties in regulating social
contact, perceived dormitory life to be more hectic and less
controllable, and expressed less confidence in their ability to
control their experiences. Those on the standard long
corridor were observed to engage in less social activity than
the other settings.
Those on the altered long corridor experienced more positive
interaction, more local group development, greater
confidence in their ability to control events in the dormitory,
and less withdrawal. Those on the both the altered corridor
and the short corridor used shared spaces for social purposes,
172
regulated social contact more effectively, and experience less
crowding and less stress than those on the long corridor.
In the laboratory, residents of the long corridor assumed more
withdrawal positions and felt more uncomfortable than the
other residents.
Implications of Findings
Architectural intervention reducing group size in residential
settings can prevent stress experienced due to crowding.
Specific room occupancy was not dealt with.
173
Beauchemin, K. M., & Hays, P. (1996, September 9). Sunny hospital rooms expedite recovery
from severe and refractory depressions. Journal of Affective Disorders, 40(1-2). 49-51.
Focus of Study
To determine if the recovery of depressed patients is affected
by their placement in brighter or darker rooms.
Research Design
Data was abstracted from admission records obtained over a
two-year period (October 1993 to September 1995) in regards
to the patients’ diagnoses and length of stay.
Sample Information & Site
The study was conducted at a psychiatric inpatient unit in
Edmonton, Alberta. The sample included 174 patients that
had been admitted and discharged over the course of the
study.
Findings
The average length of stay of patients was shorter in the
brighter rooms than the darker rooms (16.9 days versus 19.5
days). This effect was more prominent in males as their
average length of stay was 15.3 days in brighter rooms and
22.1 days in darker rooms. Females stayed an average of
17.9 days in brighter rooms and 18.6 days in darker rooms.
Implications of Findings
It appears that staying in a brighter room expedites a patient’s
stay, especially for males. No mention was made in regards
to room occupancy.
174
Becher, C. (1998, March, 12). Caring about sharing. Health Service Journal, 30-31.
Focus of Study
To determine the view patients have of mixed-sex wards.
Research Design
Questionnaires regarding the patients view on mixed-sex
wards, their age, sex, length of stay, and type of surgery
undergone were mailed out to 140 patients after they were
discharged.
Sample Information & Site
The study was conducted on seven surgical wards at
Southmead Hospital in Bristol. The sample included eightyseven patients who responded to the questionnaire. Sixtyfour of these patients had stayed on a mixed-sex ward while
twenty-three stayed on as single-sex ward.
Findings
The majority of men did not have a preference for either type
of ward, while the majority of women preferred a single-sex
ward. Of the types of surgeries experienced, gynecology
patients were in favor of same-sex wards to the greatest
extent. All other surgeries demonstrated a marginal
preference towards same-sex wards. Patients who had
previously stayed on a mixed-sex ward were more tolerant of
them. Length of stay also impacted patients’ preferences:
longer lengths of stay were associated with greater tolerance
of mixed-sex wards while shorter lengths of stay were
associated with greater preference towards same-sex wards.
Older patients seemed to be in favor of same-sex wards as
well.
Implications of Findings
Most patients, especially women and those with short lengths
of stay, were in favor of same-sex wards. No mention was
made in regards to room occupancy.
175
Brown, C., Arnetz, B., & Petersson, O. (2003). Downsizing within a hospital: Cutting care or
just costs? Social Science & Medicine, 1-8.
Focus of Study
To investigate the views of staff members in terms of their
work environment, their health, and the quality of care they
delivered during a period of downsizing.
Research Design
The design was longitudinal and correlational in nature. Over
a period of hospital downsizing (1994-1999), staff opinions
of the quality of care they delivered, their individual health,
as well as features of the work environment were measured.
Sample Information & Site
The study included doctors and nurses who chose to
participate. It was conducted in a tertiary care facility in
Sweden.
Findings
It was discovered that quality of care delivered was the same
prior to and after the downsizing occurred. Perceptions of the
work environment did change, however, in that during the
downsizing, their scores declined. Scores also declined for
their perceptions of organizational efficiency. Perceptions of
workload increased after the downsizing, and this can, in turn,
affect their mental energy and the way they provide care.
Implications of Findings
Hospital downsizing did not appear to affect the quality of
care provided by doctors and nurses, but it did affect staff
views of their workload and mental energy, which can affect
the quality of care delivered. No mention was made in
regards to room occupancy.
176
Burden, B. (1998, January). Privacy or help? The use of curtain positioning strategies within the
maternity ward environment as a means of achieving and maintaining privacy, or as a form of
signalling to peers and professionals in an attempt to seek information or support. Journal of
Advanced Nursing, 27(1),15-23.
Focus of Study
To observe the strategies women in a maternity ward use to
preserve their privacy.
Research Design
Subject information was obtained through personal records in
regards to the type of delivery of their child, the method of
feeding they used, their position on the ward, and whether
they were antenatal or postnatal. During twelve visits to the
hospital, discussions were held with patients in regards to
their views and strategies used in drawing the curtains around
their beds.
Sample Information & Site
This study took place in a maternity ward in England. The
sample included all women on the wards except those on their
first day following a Caesarian section.
Findings
Women used three strategies in drawing the curtains around
their beds. The first is complete closure of the curtains to
withdraw from the other women for long periods of time or to
change clothing or sanitary towels for a short period of time.
If patients suffered from complications, which then created
anxiety, they were more likely to close their curtains
completely. Semi-closure of the curtains was used by
postnatal women to gain solitude or by antenatal women to
attract staff and gather information from them and other
women. Women also used this type of closure if mixed
feeding took place in the room. Partial closure was used most
often by the women throughout they day. Women used this
strategy to rest or to read.
Implications of Findings
Privacy was a key factor in women closing the curtains
around their beds to a greater or a lesser extent. Women who
felt inadequate around others or anxious due to complications
were more likely to completely isolate themselves.
177
Cleary, T., Clamon, C., Price, M. & Shullaw, G. (1988). A reduced stimulation unit: Effects on
patients with Alzheimer’s disease and related disorders. Gerontologist, 28, 511-514.
Focus of Study
To describe the effects of a reduced stimulation unit on
patient care. Patients suffered from Alzheimer’s disease and
related disorders
Research Design
A pretest-posttest design was used. A reduced stimulation
was created to reduce the level of stimulation among patients
as well as decrease their dependency on their memory. Staff,
family members, and visitors were trained to use techniques
effective in dealing with patients. Patients were assessed
through observations and interviews. Both family members
and staff filled out questionnaires regarding their satisfaction
with the new unit.
Sample Information & Site
This study was conducted in Oaknoll Retirement Residence
in Iowa City, Iowa. The sample included the eleven patients
on the new unit.
Findings
The majority of patients improved on the new unit. All
patients had been losing weight prior to their move into the
new unit, and once on the new unit, eight of the eleven
patients reversed the trend and had gained weight. Patient
agitation levels also decreased. Family members were highly
satisfied with the new ward and reported more calmness,
serenity and less agitation in the patients. The satisfaction
levels of nurses did not change significantly.
Implications of Findings
It appears that the patients benefited from their move to a
reduced stimulation unit. No mention was made in regards to
room occupancy.
178
D’Atri, D. A. (1975). Psychophysiological responses to crowding. Environment and Behavior,
7(2), 237-252.
Focus of Study
To measure if a correlation exists between degree of
crowding and blood pressure levels in an enforced crowded
environment.
Research Design
Interviewers collected data using standardized questionnaires.
Information collected included demographic and subcultural
data, personal characteristics, confinement history, mode of
housing, and blood pressure.
Sample Information & Site
The study was conducted with inmates in three correctional
institutions. The first institution had three modes of housing:
single cell, double-occupancy cell, and a larger cell that
housed three or more inmates. The second and third
institutions had two modes of housing: single cell or large
dormitories.
Findings
On average, blood pressure was higher for inmates staying in
the dormitory cells in all three institutions. Duration of
confinement was found to be associated with blood pressure
levels. Elevated blood pressure during the first two weeks of
confinement was attributed to anxiety. Crowding affected
blood pressure levels after being confined for a month and
progressed thereafter.
This study is limited by its cross-sectional nature. Also,
inmates were not completely randomly assigned.
Implications of Findings
Inmates staying in dormitory cells were more likely to have
higher blood pressure levels than those staying in single- or
double-occupancy cells.
179
Dolce, J. J., Doleys, D. M., Raczynski, J. M. & Crocker, M. F. (1985). Narcotic utilization for
back pain patients housed in private and semi-private rooms, Addictive Behavior, 10, 91-95.
Focus of Study
To investigate if private rooms have an effect on the use of
narcotic analgesics in pain patients.
Research Design
Patient records were reviewed for the patients’ first five days
of hospitalization. The type and amount of narcotic analgesic
used were determined. Room type (semiprivate or private)
was also used as a factor.
Sample Information & Site
The study was conducted in private and semi-private rooms
for patients with pain-related back disorders. Forty patients in
each type of room were studied.
Findings
No significant differences were discovered in observed
narcotic use between room types for time-contingent
medication. Those in private rooms were twice as likely to
receive injectable request-contingent medication, as
intramuscular request-contingent medication use was
significantly higher in private rooms.
Implications of Findings
Patients in private rooms were more likely to request
injectable pain medication.
180
Flaherty, J. H., Tariq, S. H., Srinivasan, R., Bakshi, S., Moinuddin, A., & Morley, J. E. (2003).
A model for managing delirious older patients. Journal of the American Geriatrics Society, 51,
1031-1035.
Focus of Study
To assess a new model of treating elderly patients with
delirium.
Research Design
Data was reviewed for patients seventy years of age or older
discharged from the acute care for the elderly unit from July
1997 through June 1998. Patients suffering from delirium
were placed in the Delirium Room, which is a 4-bed unit with
constant monitoring by a nurse. Physical restraints were not
used on patients, and medication was only prescribed as a last
resort.
Data reviewed included activities of daily living,
demographic information, and medications taken by patients.
Sample Information & Site
The study included 69 patients discharged from the acute care
for the elderly unit at Saint Louis University Hospital.
Findings
Physical restraints were not used on patients. Also, during
the time period of the study, the mortality rate was zero.
Patients used similar or lower amounts of medication than
that found in previous sedatives. Only ten percent of patients
needed sedatives. These patients did preserve function and
achieved early mobilization, possibly due to the constant
monitoring by nurses.
This study has various limitations. For instance, the effect
that certified nursing assistants had, the accuracy of the
evaluations of the patients by the physicians, and the type of
nonpharmacological approach that was most effective were
not measured. A report of the overall prevalence of older
patients on the unit was not possible. Finally, input from
geriatricians may have impacted patients.
Implications of Findings
Patients suffering from delirium appear to benefit from
constant nursing care in a multi-bed room.
181
Gotlieb, J. (2002). Understanding the effects of nurses on the process by which patients develop
hospital satisfaction. Holistic Nursing Practice, 17(1), 49-60.
Focus of Study
To discuss how patients’ evaluations of their hospital rooms
and their nurses as well as locus of causality impact their
hospital satisfaction.
Research Design
Questionnaires were mailed out to patients that had been
discharged from the hospital. The questionnaire addressed
patient satisfaction, patients’ evaluation of their nurses and
their hospital rooms, and their perception of locus of
causality.
Sample Information & Site
The study took place at a large hospital in a major
metropolitan area. The questionnaires were mailed to 849
patients who had been discharged and 232 patients
responded.
Findings
Patients’ evaluations of their hospital rooms affected both
their evaluations of their nurses and their overall hospital
satisfaction. Positive evaluations of their nurses and their
rooms resulted in a positive evaluation of the hospital. Also,
when patients were made to feel that they had some control
over their care, they evaluated their nurses positively.
Implications of Findings
Proper staffing of skilled nurses and a positive environment
in patients’ hospital rooms can increase patient satisfaction as
well as reduce hospital costs through a reduction in the length
of stay of patients. No mention made in regards to room
occupancy.
182
Gotlieb, J. (2000). Understanding effects of nurses, patients’ hospital rooms, and patients’
perception of control in the perceived quality of a hospital. Health Marketing Quarterly, 18(1/2),
1-14.
Focus of Study
To investigate the relationship between patients’ perceptions
of their hospital rooms and their nurses as well as their
perception of control on their perception of hospital quality.
Research Design
Questionnaires were sent to patients after they were
discharged from the hospital. The measures included
pertained to the patients’ perceptions and expectations of their
hospital room, their nurses, and the amount of control given
to them as well as the quality of the hospital.
Sample Information & Site
Questionnaires were mailed to 849 patients and responses
were received from 232 patients. The subjects were all
patients in a hospital in the United States.
Findings
Patients’ perceptions of their rooms affected their perception
of their nurses as well as the overall quality of the hospital.
In addition, their perception of control affected their
perception of nurses but not the quality of the hospital.
Finally, patients’ perception of their nurses affected their
perception of the quality of the hospital.
Implications of Findings
Patients’ perceptions of their rooms impacts their perceptions
of the nurses and the quality of the hospital and thus, care
should be taken in designing the room. No mention was
made in regards to room occupancy.
183
Harris, P.B., McBride, G., Ross, C. & Curtis, L. (June, 2002). A place to heal: Environmental
sources of satisfaction among hospital patients. Journal of Applied Social Psychology, 32(6),
1276-1299.
Focus of Study
To investigate sources of environmental satisfaction within
the hospital setting as well as the relative contribution of
environmental satisfaction to the overall hospital experience.
Differences in satisfaction levels among various departments
were also explored.
Research Design
Patients were interviewed during the winter of 1997-1998.
The Patient Perceptions of Quality Interview-Inpatient form,
as well as questions of interest, were used. Patients received
one of two versions of open-ended questions. One set related
to satisfaction with the hospital room, while the other set
related to satisfaction with the hospital environment outside
the room. Closed-ended questions were identical for all
patients and referred to environmental satisfaction as well as
the overall quality of care and services received.
Sample Information & Site
The study was conducted at six different hospitals owned by
the IHC. Two hospitals were large in size, two were midsize,
and two were small. 380 inpatients were interviewed.
Findings
Differences in levels of satisfaction among the various
departments were not found. The strongest predictor of
overall satisfaction was nursing care. This was followed by
perceived quality of clinical care, environmental satisfaction,
and satisfaction with admitting procedures. Participant
satisfaction with the environment also was a strong predictor
of overall satisfaction.
Sources of satisfaction with the hospital room include interior
design features, social features, maintenance/housekeeping,
architectural features, and the ambient environment. Satisfied
patients liked the color of the walls, the artwork, had a
comfortable bed, had a television and telephone that were
functional, and had a room where features were easily
accessible. Satisfied patients also had larger rooms, had a
window with a nice view, and had an accessible bathroom.
Those satisfied with the social features had a private room or
had their privacy protected, and they appreciated space to
accommodate family members. Overall, patients were
satisfied with their rooms.
Satisfaction with the environment outside the patient room
was associated with maintenance/housekeeping, interior
184
design features, architectural features, ambient environment,
remodeling/construction, and parking.
Patients felt that architects should provide private rooms that
have windows with views, space to accommodate visitors,
and a bathroom in each room. The furnishings should be
comfortable, and the décor should be aesthetically pleasing.
Implications of Findings
Patients prefer larger, private rooms that are aesthetically
appealing and that have enough space to accommodate
visitors.
185
Hays, P. & Beauchemin, K. B. (1998, October). Seeing ward design in a new light. Hospital
Development, 29(9), 15-17.
Focus of Study
To describe the effects of a sunny room on patients suffering
from a myocardial infarction.
Research Design
This study utilized a natural experiment. The outcomes of
patients with a myocardial infarction were compared based on
their stay in a sunny room or a dark room. Measures included
length of stay and fatal outcomes. The study was conducted
over a four-year period ending in March 1996.
Sample Information & Site
This study took place in a cardiac intensive care unit in
Edmonton, Canada. The sample included 568 patients who
were directly admitted to a cardiac intensive care unit with a
first attack of myocardial infarction. 272 patients stayed in
bright rooms and 296 patients stayed in dark rooms.
Findings
The average length of stay for all patients was 2.46 days.
Men in the sunny wards stayed an average of 2.3 days while
those on the dark wards stayed a mean of 2.6 days. The
effect was more prominent for women. Those on the sunny
wards stayed an average of 2.3 days, while those in the dark
rooms stayed an average of 3.3 days. Deaths were also more
frequent in the dark rooms over the four years of the study.
Implications of Findings
It appears that brighter rooms do impact the length of stay of
patients as well as their outcomes. No mention was made in
regards to room occupancy.
186
Higgs, P. F., Macdonald, L. D., & Ward, M. C. (1992, August). Responses to the institution
among elderly patients in hospital long-stay care. Social Science & Medicine, 35(3), 287-293.
Focus of Study
To determine patients’ views in regards to their stay in longterm geriatric wards.
Research Design
Patients were assessed in terms of their performance status,
and levels of confusion. If their mental scores were less than
four out of ten, they were excluded from the rest of the study.
Those meeting the criteria were interviewed about their views
of living on a long-stay ward.
Sample Information & Site
The study was conducted in long-stay wards in the South
West Thames region. The sample included 291 patients
staying in these facilities.
Findings
The majority of patients were satisfied with their relationships
with medical and nursing staff as well as other staff members.
In addition, most patients were satisfied with their degree of
autonomy and most did not feel lonely. Patients thought the
best things in the facilities were the staff and the care
provided by the staff as well. Loss of physical independence
was seen as the worst thing.
The study is limited by its selective sample in which patients
with low mental scores and those that produced unintelligible
responses were excluded from the sample.
Implications of Findings
Overall, patients were satisfied with the care they received in
these long-term facilities. No mention was made in regards
to room occupancy.
187
Hilton, B. A. (1985). Noise in acute patient care areas. Research in Nursing and Health, 8, 283291.
Focus of Study
To determine sources of sound, levels of sound, patient
perceptions of sound, and which types of sounds can be
modified in acute patient care areas.
Research Design
This study used an exploratory and descriptive design. Sound
levels measured in the proximity of each patient over a 24hour period. An observer sat near the patient for two 3-hour
observation periods during each 24-hour period to determine
the sources of sound. For each patient, an observer sat near
the patient for two 3-hour observation periods, during the 24hour interval, to determine the sources of sound. The sounds
were then categorized according to source, number of
occurrences, duration, and loudness. Participants were also
asked to complete a short questionnaire through interviews.
Questions asked pertained to how the noise affected patients,
whether they thought the noise levels were acceptable, and
whether the noise levels were bothersome and affected the
patients’ sleep.
Sample Information & Site
The study was conducted at three hospitals in a large
metropolitan area in Northwest Canada. Of these three
hospitals, one was a large hospital, one was a small teaching
hospital, and one was a small community hospital. Intensive
care units were studied at each hospital. In addition, pre- and
postoperative wards for open-heart surgery were studied at
the large hospital, and two medical wards were studied at the
small teaching hospital. A convenience sample of 25 subjects
was used and consisted of four to five subjects from each of
the units.
Findings
The critical and noncritical areas in the small hospitals were
quieter than those at the large hospital. Sound levels dropped
at night on all units except the recovery room and intensive
care unit of the large hospital. Staff, patients, and visitors
created levels of talking that were higher than necessary.
Equipment noises that were steady were those created by
oxygen, chest-tube bubbling, and ventilator functioning.
Patients were satisfied with sound levels at the large
hospital’s pre- and postoperative ward, the medical wards and
intensive care units at the small teaching hospital, and the
intensive care unit at the small community hospital. Patients
were dissatisfied with the sound levels of the recovery room
188
at the large hospital. Noise levels that were generated outside
the room were reduced when the door to the patient’s room
was closed.
A factor that was related to higher noise levels in the
intensive care unit and recovery room of the large hospital
was room occupancy. On the intensive care units of the small
hospital, rooms were single occupancy, and noise levels were
lower. In the large hospital, patient rooms consisted of two to
eight patients and this produced unacceptable sound levels.
Limitations to this study include difficulty in identifying and
recording the duration of all events because some occurred
simultaneously. It was also difficult, in some instances, to
identify the sources of noise and some data were lost due to
equipment failure.
Implications of Findings
Sound levels appear to be related to room size, in that they
were lower in rooms with single occupancy rather than
multiple occupancy rooms.
189
Holahan, C. & Seagert, S. (1973). Behavioral and attitudinal effects of large-scale variations in
the physical environment of psychiatric wards. Journal of Abnormal Psychology, 82, 454-462.
Focus of Study
To investigate the relationship between ward design and
patient behavior on two hospital wards.
Research Design
The study was a posttest control group design. Prior to
conducting the study, two wards were selected based on being
similar on a variety of specific criteria such as architectural
structure and furnishings. Once the wards were selected, one
became the control ward and remained the same while the
other ward was remodeled to improve ward atmosphere
through the addition of furniture and bedspreads as well as
repainting. Areas were also created to facilitate social
interaction. In the bedrooms, which were designed as
dormitories, two-bed sections were created through the
installation of partitions on the remodeled ward.
Six months after the ward was remodeled, researchers
observed the behavior of the patients and conducted
interviews with them. The observations and interviews took
place over a five-week period.
Sample Information & Site
The study took place on two wards at the City University of
New York hospital. Twenty-five patients on each ward took
part in the study.
Findings
Significantly more socializing and less passive behavior took
place on the remodeled ward. Patients also had more positive
attitudes towards the physical environment on the remodeled
ward. They found it more stimulating and attractive and thus,
they felt more positive towards it. A greater trend towards
socialization occurred in the bedrooms on the remodeled
ward.
Implications of Findings
A well-designed ward can contribute to patients feeling
positive towards the ward. This, in turn, can aid in their
recovery. Rooms in this design were designed as dormitories,
and a trend towards more socializing occurred on the
remodeled ward, though reasons why this may have occurred
were not addressed.
190
Ittelson, W. H., Proshansky, H. M., & Rivlin, L. G. (1970, December). Bedroom size and social
interaction of the psychiatric ward. Environment and Behavior, 2, 255-270.
Focus of Study
To determine the impact that bedroom size has on the
behavior of patients. The behavior observed was grouped
into three categories: isolated passive, isolated active, and
social.
Research Design
Observations of patients were made using a time-sample
approach. The nature of the activity on the ward, the
location, and the participants were recorded. Observations
were made every fifteen minutes during active periods of the
day. The wards observed differed in their size and case-mix.
The rooms on the wards include mainly single- and doubleoccupancy rooms. Each ward also contained one four-bed
room.
Sample Information & Site
The site was conducted on four psychiatric wards of three
large metropolitan hospitals. One ward in a city hospital, one
ward in a private hospital, and two wards in a state institution
were included. The sample included all patients on the
wards.
Findings
Isolated passive behavior was the most frequent behavior
observed in all the bedrooms. This behavior increased and
social interaction decreased when the number of patients
increased. Smaller rooms provide patients with greater
choice in regards to activities the patients choose to undertake
in their rooms.
Implications of Findings
Smaller, private rooms appear to give patients the most
freedom in regards to their behavioral choices.
191
Janssen, P. A., Harris, S. J., Soolsma, J., Klein, M. C.. & Seymour, L. C. (2001, September).
Single room maternity care: The nursing response. Birth, 28(3), 173-179.
Focus of Study
To evaluate the responses of nurses in regards to working on
a single-room maternity unit after having worked in
traditional delivery suites.
Research Design
Nurses scheduled to work on a new single room maternity
ward as part of a pilot project were asked to complete surveys
six months prior to the new ward opening and three months
after the new ward opened. Surveys were also distributed to
nurses working in the traditional delivery suites as well as the
postpartum ward. Questions addressed the nurses’ perception
of the physical setting, the quality of care given to patients,
their perceived competence, and their practicing environment.
Sample Information & Site
The study was conducted at BC Women’s Hospital in
Vancouver, Canada. The sample included twenty nurses who
worked both on the new and traditional wards, 26 delivery
suite nurses, and 26 postpartum nurses.
Findings
The physical space of the single rooms was greater and
enabled easier accessibility of equipment and supplies.
Privacy was also greater in this environment and noise levels
were reduced. Quality of care was perceived as greater in the
single room unit as nurses were better able to respond to the
physical, emotional, and spiritual needs of the patients.
Nurses also felt greater accountability for their decisions in
the single rooms and felt highly competent in all aspects of
their work. Job satisfaction increased for nurses once they
moved to the single room unit.
The one disadvantage of the new unit was that the medical
staff was less readily available.
The study is limited by its small sample size. In addition,
previous experience, or education, or other factors could have
differentiated nurses who moved to the new ward from those
that stayed on the traditional ward, and thus their perceptions
of their experiences may differ. Also, selection was not
random and nurses could have conferred with each other
during their shifts in regards to their responses.
192
Implications of Findings
Nurses appeared to prefer working on the single room wards
as they felt the quality of care was greater, the rooms offered
more privacy, and they were better able to respond to the
needs of the patients.
193
Kulik, J. A., Moore, P. J., & Mahler, H. I. M. (1993). Stress and affiliation: Hospital roommate
effects on preoperative anxiety and social interaction. Health Psychology, 12, 118-124.
Focus of Study
To determine the relative effect on patients’ preoperative
anxiety levels in regards to the type of roommate assigned to
them: preoperative, postoperative, and non-surgical. This
study is also interested in looking at the interaction patterns of
preoperative patients and their roommates.
Research Design
Patients were approached on the evening prior to their
surgery and were asked to complete a questionnaire dealing
with their opinions and experiences as surgical patients in the
hospital. The questionnaire specifically measured
preoperative anxiety (10 item subscale from Spielberger
State-Trait Anxiety Inventory) and patient interactions (time
spent with roommate).
Sample Information & Site
The study was conducted at the San Diego Veterans
Administration Hospital. The sample included 53 men
undergoing non-emergency surgeries (28 hernia patients, 9
open-heart (valve) patients, and 16 bladder/prostate patients).
Patients ranged between 33 and 88 years of age with the
mean age being 60 (SD = 11.19). 94% of the sample was
Caucasian, 4% Hispanic, and 2% African American.
Findings
Anxiety levels were significantly higher for preoperative
patients assigned to a preoperative roommate compared to a
postoperative or non-surgical roommate. Patients also spent
significantly more time interacting with roommates that were
preoperative rather than those that were postoperative.
Affiliation was greatest with other preoperative patients,
intermediate with non-surgical patients, and least with
postoperative patients. Discussions including both medical
and nonmedical topics occurred most frequently with
preoperative patients and least frequently with postoperative
patients. The more similar the health problems were between
roommates, the greater the proportion of the conversation was
focused on medical topics.
194
Implications of Findings
Preoperative patients may benefit if they are assigned
roommates who are postoperative or non-surgical rather than
other preoperative patients. Patient distress may be reduced,
as well as the amount of staff time allocated to an anxious
patient. Semi-private rooms, therefore, are beneficial for a
preoperative patient if the roommate is postoperative.
195
Lawson, B. & Phiri, M. (2000, January 20). Hospital design. Room for improvement. Health
Service Journal, 110(5688), 24-26.
Focus of Study
To address patient satisfaction in regards to their hospital
surroundings.
Research Design
During their hospital stay, patients were surveyed in regards
to their condition, treatment, and outcomes. Upon discharge,
patients were given questionnaires to complete that dealt with
their hospital stay. Comparisons were made between
orthopedic patients on a refurbished ward versus those on an
older, more conventional ward. Comparisons were also made
between psychiatric patients on a newer ward versus those on
an older ward.
Sample Information & Site
The study took place at three hospitals in England.
Orthopedic patients were treated at Poole Hospital.
Psychiatric patients were treated at Mill View Hospital in a
purpose-built unit and at two wards in the Freshfield Mental
Health Unit in Brighton General Hospital.
The sample included 237 patients treated at Poole Hospital
and 151 patients treated at Mill View Hospital and Brighton
General Hospital.
Findings
Overall, patients staying in the newer or refurbished units
rated their experience and treatment higher than those in the
older units. Those in the newer buildings were more satisfied
with the appearance, layout and overall design of the unit.
Caregivers, such as nurses and doctors, were given higher
scores in the new buildings. The psychiatric patients on the
newer units had shorter lengths of stay than those in the older
units. The orthopedic patients on the newer wards required
lower levels of analgesia than those on the older wards.
Implications of Findings
Hospital design impacts patient satisfaction in regards to the
design itself and the treatment received. Patients treated in
single rooms were more satisfied with their treatment than
those on multiple-bed wards.
196
Leigh, H., Hofer, M. A, Cooper, J., & Reiser, M. F. (1972). A psychological comparison of
patients in “open” and “closed” coronary care units. Journal of Psychosomatic Research, 16,
449-457.
Focus of Study
To compare the psychological states of patients on a
Coronary Care Unit. Patients were either in an open,
multiple-room occupancy unit or a closed, single-room
occupancy unit.
Research Design
Patients willing to participate in the study were approached
and interviewed. They were asked to complete
questionnaires regarding their levels of anxiety, depression,
agitation, and hostility as well as their perceptions of the
Coronary Care Unit. Medical charts were obtained to
compare the medical course of the patients on both units and
patient interactions were monitored.
Sample Information & Site
The study was conducted on two Coronary Care Units in a
general hospital in the United States. The two units differed
in the amount of space and privacy allotted to patients in that
one ward was open and busy and the other ward was closed
and private. The sample included thirty-three patients on
each unit.
Findings
Interaction among patients was greater on the open ward.
Separation anxiety was higher on the closed ward and
patients felt lonelier. Shame anxiety was higher on the open
ward but patients felt they were able to express their hostility
to a greater extent.
Implications of Findings
While the closed, single-occupancy rooms offered the
patients more privacy, separation anxiety was higher as was
the amount of loneliness experienced by these patients. The
open, multiple-occupancy enabled patients to interact more,
but these patients exhibited higher levels of shame anxiety.
197
Martin, D. P., Diehr, P., Conrad, D. A., Davis, J. H., Leickly, R., & Perrin, E. B. (1998).
Randomized trial of a patient-centered hospital unit. Patient Education and Counseling, 34, 125133.
Focus of Study
To compare patient outcomes on the Planetree Model
Hospital Unit with other medical-surgical units in the
hospitals. Factors studied were patient satisfaction,
education, involvement in health care, health behavior and
compliance, health status, and use of services.
Research Design
The design included several phases. Patients were first
interviewed for 20 minutes upon admission. Patients were
also asked to fill out questionnaires 1 week, 3 months, and 6
months after being discharged. The interview was used to get
baseline information from the patients, while the
questionnaires were used to assess both short-term effects of
the hospitalization as well as long-term effects on outcomes.
Sample Information & Site
The study took place in a San Francisco Hospital. Patients 18
years of age or older were able to participate and were
randomly assigned to a Planetree ward or a medical unit. 315
patients were on the Planetree ward while 445 were on the
other wards.
The Planetree Model is patient-oriented. The environment is
home-like and soothing. Primary nurses are trained to
provide personal care, to educate patients, and to promote
patient involvement. Patients are trained to be partners in
learning about their condition and are taught skills regarding
self-care, nutrition, and healthy behaviors. Family and
friends are encouraged to be involved in the care process. Art
and entertainment are included in the healing process.
Findings
Planetree patients were significantly more satisfied with their
hospital stay as well as with the unit’s environment,
architecture, and the technical aspects of care. They had
greater opportunity to interact with other patients as well as
see family and friends. They were more satisfied with the
involvement of nurses and were satisfied with the education
they received. Planetree patients were more likely to receive
written information regarding prescription medications,
special diets, and how to reduce stress.
No differences existed for both groups in terms of physician
involvement as well as long-term effects on their outcomes.
198
In the short-term, Planetree patients reported slightly better
mental health status and role functioning.
Implications of Findings
When patients are given the proper environment and
education, their experience in the hospital is positive,
regardless of room occupancy. No mention was made in
regards to room density.
199
Matthews, E., Farrell, G., & Blackmore, A. (1996, September). Effects of environmental
manipulation emphasizing client-centered care on agitation and sleep in dementia sufferers
in a nursing home. Journal of Advanced Nursing, 24(3), 439 –447.
Focus of Study
To determine if a change from a task-oriented care approach
to a client-centered approach affects agitation levels and sleep
patterns in patients suffering from dementia.
Research Design
A longitudinal design was used and consisted of four phases
which each covered a four-week period. Data was collected
at the end of each phase. Baseline levels of the patients’
sleep and agitation were collected after phases one and two.
Client-centered care was introduced after phase two, and
levels of agitation and sleep were collected again after phases
three and four. Task-oriented care involves mandatory
institutional routines, while client-centered care involves
freedom of choice for the patients.
Sample Information & Site
The study took place in a 44-bed dementia ward in a
metropolitan nursing home in Perth, Australia. Participants
included thirty-three patients suffering from dementia who
resided on the ward.
Findings
In terms of agitation, eleven agitated behaviors were
displayed by at least twenty percent of the patients throughout
the study. Verbal agitation significantly decreased during the
day, but increased significantly during the night. Staff
working the day shift were observed to be more flexible than
staff working the night shift and this may have contributed to
the discrepancy in the results.
Residents were also found to have increased their daytime
sleep during the first few weeks following the intervention.
The time spent sleeping did return to pre-intervention levels,
however, by the end of the intervention.
Limitations of this study include the limited sample size and
lack of control group. Also, the intervention on the night
shift was incomplete due to inadequate staffing. Finally, the
environment in which the intervention was introduced may
have outweighed its therapeutic effects.
Implications of Findings
The client-centered intervention did improve levels of patient
agitation throughout the day, but due to its limitations, other
improvements were not discovered. There was no mention of
room occupancy.
200
Milne, D. & Day, S. R. (1986). Planning and evaluating innovations in nursing practice by
measuring the ward atmosphere. Journal of Advanced Nursing, 11, 203-210.
Focus of Study
To examine factors that impact the patients’ and nurses’
perspectives of the ward atmosphere in a psychiatric day
hospital.
Research Design
Patients and nurses completed the two versions of the Ward
Atmosphere Scale (ideal and real) at two baseline phases and
then after an intervention was implemented. The intervention
included training staff on implementing and revising the
therapeutic program. They were trained in behavioral therapy
and anxiety management. The intervention was introduced to
increase levels of support, and to increase involvement,
spontaneity, and program clarity.
Sample Information & Site
This study took place in the National Health Service (NHS)
psychiatric day hospital, which is located in a large traditional
psychiatric hospital. The sample included staff (6) and
patients (41) of the day hospital.
Findings
The perspectives of ward atmosphere increased for both
nurses and patients after the intervention was put into place.
This effect was only noticeable in acute care patients though,
and not in chronic care patients, as they did not receive the
therapeutic intervention.
Implications of Findings
Ward atmosphere can be improved in the psychiatric day
ward if the therapeutic program is improved to take into
consideration the needs of staff and patients. No mention was
made in regards to room occupancy.
201
Morgan, D. & Stewart, N. (1999, January). The physical environment of special care units:
Needs of residents with dementia from the perspective of staff and family caregivers. Qualitative
Health Research, 9(1), 105-119.
Focus of Study
To describe the relationship between environment and
behavior in a dementia care setting.
Research Design
Residents of a high-density special care unit (SCU) were
moved to a low-density special care unit upon completion of
the new building. Patient size on the new unit decreased from
sixty-nine on the old unit to twenty. Patients were also giving
larger rooms that were private, compared to the multiple
occupancy rooms on the old unit. Staff and family members
were interviewed three months after the patients had moved
in regards to their perceptions of the new unit.
Sample Information & Site
This study took place at a 286-bed long-term facility that
provided care to patients suffering from dementia. Staff and
family members of the patients took place in the study. The
sample included four registered nurses, five resident
attendants, and nine family members. The researchers based
their sample size on theoretical saturation.
Findings
Resident safety on the new ward was in question based on the
corridor design. Staff members felt that it was more difficult
than in the previous ward to monitor the patients. Critical to
the participants was an environment that was similar to that
which the patients experienced prior to entering the facility.
The old unit was seen as a happy family because of the close
proximity between patients and staff as well as the busy
atmosphere. The new unit was seen as more institutional
because of the lower density and decrease in activities. The
private rooms were favorable because family members were
able to personalize the rooms to a greater extent and patients
had greater privacy.
There was a significant decrease in disruptive behavior on the
new units due to less stimulation. Some participants,
however, found that there was too little stimulation. Social
interaction was encouraged in the rest areas along the
corridors, which also enabled the patients to rest. Social
interaction did decrease on the new units, though, due to
greater dispersion between staff and residents.
202
Implications of Findings
Overall, the participants of the study were satisfied with the
new unit. The private room gave the resident more privacy
and helped create a more home-like environment.
203
Nguyen, P. L. N., Briancon, S., Empereur, F., & Guillemin, F. (2002). Factors determining
inpatient satisfaction with care. Social Science & Medicine, 54, 493-504.
Focus of Study
To identify factors associated with patient satisfaction in
medical and surgical care.
Research Design
Patients were contacted on the first day of hospitalization and
were asked to participate in the study. If they consented,
research assistants collected sociodemographic data as well as
information on their health status. Two weeks after being
discharged, patients were mailed questionnaires regarding
their hospital experiences and their satisfaction with their
hospital stay.
Sample Information & Site
The study was conducted at Nancy University Hospital in
France. Subjects included patients with cardiovascular,
respiratory, urinary, and locomotor system diseases. 684
patients participated.
Findings
Overall, most patients were satisfied with their stay. The two
strongest predictors of higher satisfaction were older age and
better self-perceived health status when admitted. Those that
stayed in private rooms were more satisfied with admissions,
the hospital environment and staff, information, overall
quality of care, and recommendations/intentions. Those who
did not choose the hospital they stayed in were twice as likely
to complain about their hospital stay.
The results of this study are limited by its sampling bias, in
that some patients were excluded from the study. The
response rate was good, at 78%, but it may have been better if
the questionnaires were shorter in length.
Implications of Findings
Patients in private rooms appeared to more satisfied than
those in multiple occupancy rooms on a variety of factors
such as the overall hospital environment and the quality of
care they received.
204
Pattison, H. M. & Robertson, C. E. (1996). The effect of ward design of the well-being of postoperative patients. Journal of Advanced Nursing, 23, 820-826.
Focus of Study
To examine the effect of ward design on the patients’
experience of being in the hospital and on their well-being as
well as to determine their preferences in ward design.
Research Design
Questionnaires were administered to patients spending more
than 5 days in either the Nightingale ward or the Bay ward of
the hospital. Questionnaires included 63 questions pertaining
to sleep, friendships, privacy, and isolation. The scales used
were the Disturbance Due to Hospital Noise Questionnaire
(Topf,1985) and the Hospital Anxiety and Depression (HAD)
scale (Zigmond & Snaith, 1983). The patients were
individually interviewed between 18:00 and 22:00 on the fifth
postoperative day over a six week period.
Sample Information & Site
The study took place on two gynecological wards of a
hospital in the United Kingdom. 64 female patients
participated, 32 on the Nightingale ward and 32 on the Bay
ward. The average patient age was 43.6 (SD = 14.4) on the
Bay ward and 47.1 (SD = 13.7) on the Nightingale ward. The
design of the Nightingale ward includes a long open corridor
which enables nurses to clearly view all their patients at one
time. The Bay ward design incorporates bays of four or more
beds parallel with the corridor and the external wall.
Findings
This article compares the layout of multiple occupancy rooms
on different wards. On the Nightingale ward, patients felt
contact with nurses was better, noise levels were higher,
privacy was greater, and sleep disturbances were greater
(although this result is not significant). On the Bay ward,
patients were concerned with the lack of information
regarding the whereabouts of the nurses and the activity of
the rest of the ward. These patients also felt a lack of auditory
privacy on the bay ward due to disturbing noises (ex. talking
in the hallway, intercoms, call buttons, and radios and
televisions). Patients on both wards felt they were part of
friendly groups and anxiety and depression were not related
to the ward design. 75% of patients surveyed preferred the
Bay ward.
205
Implications of Findings
Neither ward was overwhelmingly better. Patients preferred
the Bay ward, which suggests that this design should be
continued. Changes could be made, however, to improve the
patients’ well being (ex. noise levels). No mention of a
comparison with single occupancy rooms was made.
206
Peltier, J. W., Schibrowsky, J. A., Cochran, C. R. (2002, Summer). Patient loyalty that lasts a
lifetime. Marketing Health Services, 22(2), 29-33.
Focus of Study
To determine if the nurse-patient and physician-patient
interactions impact the quality of care received by obstetrics
patients as well as their loyalty toward the hospital.
Research Design
Questionnaires were mailed to obstetrics patients from the
previous twelve months. Measures on the questionnaire
included those pertaining to care given by nurses and
physicians as well as those pertaining to patient loyalty
towards the hospital.
Sample Information & Site
The study took place at a large metropolitan hospital.
Questionnaires were mailed to 505 obstetrics patients, and
responses were received from 193 patients.
Findings
The patients’ perceived quality of care as well as their loyalty
toward the hospital is a function of a wide range of nurse and
physician performance variables. Prior to delivery,
physician-patient communication, as well as control given by
nurses, were most critical to quality of care received. During
delivery, communication with nurses and interactions with
physicians were most important in determining quality of
care. After delivery, communication with physicians and
nurses as well as communication between nurses and other
caregivers was most important. Loyalty is a function of the
amount of decision-making control given to patients by
physicians.
Implications of Findings
Patients’ quality of care and their loyalty toward the hospital
is dependent upon the care given to them by their physicians
and nurses as well as the amount of control given to them.
No mention was made in regards to room occupancy.
207
Rogers S. (2001-2002, Winter). Mixed gender wards: What does the evidence indicate?
Hospital Quarterly, 5(2), 77-84.
Focus of Study
To address the issue of a mixed gender ward and its impact
on patient transfers, patient admissions, staff reactions, and
financial costs.
Research Design
Surveys were given to patients, front-line nurses, and nurse
managers to complete. These surveys addressed patient
acceptance of mixed-gender rooms and the beliefs of nurses
regarding these rooms. Data transfers for November 2000
were reviewed to measure costs incurred with patient
transfers.
Sample Information & Site
The study took place at the University Health Network in
Toronto. This includes three hospitals: Toronto General,
Toronto Western, and Princess Margaret.
The sample includes 116 patients; 38 were from Princess
Margaret Hospital, 31 were from Toronto General, and 47
were from Toronto Western.
Findings
In terms of costs, hospitals could save money if patients were
not transferred to accommodate gender issues. These
transfers accounted for 8-10% of all patient transfers;
hospitals could save from $58,800 to $277,200 by not
performing these types of transfers. These savings are only
incurred, however, if these patients are not moved to same
gender wards after being allocated to mixed gender wards.
Of the patients surveyed, 65% of patients stated that they
would accept placement in a mixed gender ward. The
number increased to 76% if placement in a mixed gender
wards meant faster admission.
The majority of nurses (81%) and nurse managers (63%) felt
that mixed gender wards were not a good idea. Furthermore,
68% of nurses and 67% of nurse managers thought mixed
gender wards would make the work of nurses more difficult.
Nurses felt that mixed gender wards would be difficult to
accept by alert and oriented patients, elderly of confused
patients, young patients, old patients, female patients, and
religious patients, to name a few.
208
Implications of Findings
Patients appear to accept mixed-gender room placement,
especially if it is related to faster admission for the patient.
Nurses, on the other hand, are not in favor of mixed gender
room placement.
209
Singer, A. J., Sanders, B. T., Kowalska, A., Stark, M. J., Mohammad, M., & Brogan, G. X.
(2000, January). The effect of introducing bedside TV sets on patient satisfaction in the ED.
American Journal of Emergency Medicine. 18(1), 119-120.
Focus of Study
To measure the effect of a bedside television set on patient
satisfaction
Research Design
A prospective, randomized, controlled, unblended clinical
trial was used. A trained research assistant recorded
information pertaining to the patient such as demographic
information and room assignment. Patients’ satisfaction and
length of stay was evaluated using a 100-mm visual analogue
scale and a reversed 7-point Likert-type scale.
Sample Information & Site
The study took place in the emergency room of a suburban
tertiary care center. The sample included 181 patient, of
which 77 were assigned to a room with a bedside television
set and 104 were assigned to a room without a bedside
television set.
Findings
Patient satisfaction was determined to be the same regardless
of whether or not there was a bedside television set in the
room. Length of stay did impact patient satisfaction, as those
who were required to stay longer than their expected length of
stay were less satisfied than those who stayed the same or less
than expected.
Results may have been different if the televisions offered
more variety in channel selection (only 11 channels were
available). Also the presence of a television set may have had
more impact on patient satisfaction in lower acuity areas of
the hospital.
Implications of Findings
Bedside television sets do not impact patient satisfaction. No
mention was made in regards to room occupancy.
210
Spaeth, G. L., & Angell, M. F. (1968). Preference of ophthalmic patients for multi-bedded
hospital rooms. Archives of Opthalmology, 79, 362-365.
Focus of Study
To investigate the preference for multi-bed or private rooms
among ophthalmic patients.
Research Design
Patients admitted or discharged from this facility were
included in the study. Upon admission, patients were asked
to complete a questionnaire that requested information
including age, sex, previous hospitalizations, the patients’
opinion of their visual ability, and their preference for room
type. Patients discharged during this time were also asked to
complete a similar questionnaire.
Sample Information & Site
The study was conducted at Wills Eye Hospital in
Philadelphia. The sample included 254 patients completing
questionnaires upon admission and 376 patients that
completed questionnaires when discharged.
Findings
Those completing the questionnaires upon admission
preferred a multi-bed room. The most important factor
influencing room preference was previous hospitalization.
Those who did not have any prior experience as a hospital
patient preferred the single-occupancy room by a small
margin. Those who had previous experience as a hospital
patient were approximately nine times more likely to prefer a
multi-bed room.
Of patients that completed the form both upon admission and
discharge, significantly fewer patients wanted private rooms
after their stay while significantly more patients wanted
rooms with more than four beds.
Sensory deprivation of these patients did not influence their
need for assistance by roommates. Also, economic factors
did not impact the patients’ room preference. Only nine
percent of patients, after discharge, preferred a private room
if cost was no object.
Implications of Findings
The majority of ophthalmic patients preferred multi-bed
rooms to single-occupancy rooms.
211
Thompson, J. D. & Goldin, G. (1975). A patient interview study: What do patients like? In J.
D. Thompson & G. Goldin (Eds.), The hospital: A social and architectural history (pp. 270275). London: Yale University Press.
Focus of Study
To determine what patients prefer in terms of their hospital
rooms during their hospital stay.
Research Design
Patients were interviewed during their hospital stay.
Questions were asked to determine the specific preferences of
patients in regards to the features of their hospital room.
Sample Information & Site
The study took place at Yale-New Haven Hospital and
Genesee Hospital in Rochester, New York. A total of 505
patients were interviewed. Patients at Genesee Hospital were
in single-occupancy rooms, while those at Yale-New Haven
Hospital were in single- and multiple-occupancy rooms.
Findings
The majority of patients at Yale-New Haven Hospital felt the
windows were the most positive feature of the rooms. Those
at Genesee Hospital, whose beds faced the corridor and not
the window, enjoyed the opportunity to view what was
occurring in the corridor.
Patients felt that a sense of security was the most important
feature a hospital could offer. Hospital noise did not bother
the majority of patients in either hospital. Those in four-bed
rooms were bothered, however, by the other patients in their
rooms as well as their visitors.
Implications of Findings
Although the patients’ preference for room occupancy was
not studied directly, patients at Yale-New Haven hospital in
rooms containing four patients were bothered by the other
patients in the room.
212
Topf, M. (1985). Noise-induced stress in hospital patients: Coping and nonauditory health
outcomes. Journal of Human Stress, Fall, 125-134.
Focus of Study
To examine the impact of noise on a patient’s health as well
identify the mechanism that links noise-induced stress with
coping and health.
Research Design
Data was collected over an eight-month period. Patients were
randomly assigned to a control group or to a group that
received instruction for control over hospital noise.
Questionnaires were used to measure objective noise,
sensitivity to noise, the degree of stress caused by noise,
coping strategies for controlling noise, and social desirability.
The seriousness of the patients’ illness was measured by the
amount of time spent in surgery. Self-report measures were
used to assess post-operative surgery.
Sample Information & Site
The study included 150 male surgery patients at a large
metropolitan Veterans Administration Hospital.
Findings
It was discovered that objective noise, greater noise-induced
stress, and greater sensitivity of the person to noise were
positively related to greater exercised control over noise.
Greater control over noise was exercised by patients who had
a greater sensitivity to the noise, regardless of the level of
objective noise. Patients were more likely to use cognitive
strategies to control noise. Older patients were less likely to
exert control over noise. Instruction for control over noise
did not predict the use of greater coping strategies.
Limitations of this study include the use of self-report data,
correlational data, and an exclusive group of male subjects in
a military hospital.
Implications of Findings
Sensitivity to noise is a large predictor of the use of coping
strategies over hospital noise. No mention was made in
regards to room occupancy.
213
Tyson, G. A., Lambert, G., & Beattie, L. (2002, June). The impact of ward design on the
behaviour, occupational satisfaction and well-being of psychiatric nurses. International Journal
of Mental Health Nursing, 11(2), 94-102.
Focus of Study
To determine the effect that ward design has on nurses in a
psychiatric ward.
Research Design
Nurses were observed six months priors and six months after
their relocation to a new psychiatric ward, which included
both long-stay and acute care units. Observations included
measures pertaining to the interaction of nurses with patients
and staff, as well as their tasks and other duties completed.
Questionnaires were also mailed to nurses that measured their
levels of burnout and personal accomplishment, their
emotional exhaustion, and their depersonalization towards
patients.
The long-stay unit was designed to have private bedrooms.
The acute care unit included single occupancy rooms, double
occupancy rooms, and four-bed occupancy rooms.
Sample Information & Site
The study took place in a psychiatric hospital in Australia.
The sample included forty nurses from the new ward and
forty nurses from the old ward. The composition of nurses
was virtually the same for both wards in regards to their
gender and rank.
Findings
It was discovered that nurses on the new ward suffered from
greater burnout. Nurses working on the new long-stay unit
also had higher depersonalization scores. Advantages of the
new ward included more aesthetic and pleasing environments,
increased privacy and personal space for patients, and the
atmosphere increased morale and provided a better
therapeutic environment. Disadvantages of the new ward
were cramped facilities and inappropriate client mix in the
long-stay ward, and small offices and understaffing in the
acute care ward. Nurses on the acute care ward also found it
difficult to observe patients due to the increased space and
privacy and staff were now more isolated. These nurses
found their jobs to be more stressful on the new ward. The
majority of the nurses did rate the new wards as better for the
patients.
214
Implications of Findings
While the nurses felt that the new wards were better for
patients, they also noted that the design made their jobs more
stressful and increased their levels of burnout. The new
rooms, including all private rooms for patients on the longstay ward and a few private rooms for patients on the acute
care ward, enabled patients to have greater privacy and more
space.
215
Ulrich, R. (1984, April). View through a window may influence recovery from surgery. Science,
224(4647), 420-421.
Focus of Study
To investigate whether having a room with a window view of
a natural setting impacts the recovery of patients.
Research Design
Records were obtained for patients assigned to the second and
third floors of a three-story hospital. The data included the
length of stay of patients, the complications suffered, the
amount of analgesics and tranquilizers, barbiturates, and antianxiety drugs taken as well as the notes made by nurses. The
rooms patients stayed in either had a view of a brown brick
wall or a small stand of trees. Rooms were all double
occupancy and were nearly identical in all facets besides their
view.
Sample Information & Site
Records for patients staying in a suburban Pennsylvania
hospital during 1972 and 1981 were obtained. The sample
included forty-six patients who had undergone
cholecystectomy.
Findings
Patients with a view of trees had a shorter length of stay in
the hospital and took a smaller amount of analgesics between
their second and fifth days of treatment. Those with a view
of trees also received more positive comments from the
nurses.
The study is limited by the “built” view provided to patients.
Results may be different if patients had different views such
as a busy city street.
Implications of Findings
The nature of the view patients have from their windows
appears to have some effects on their recovery. While the
rooms in the study were double-occupancy, no mention was
made in regards to the effect room occupancy had on the
patients’ outcomes.
216
Verderber. S. (July, 1986). Dimensions of person-window transaction in the hospital
environment. Environment and Behavior, 18(4), 450-466.
Focus of Study
To determine the effect of windows on patient outcomes.
Research Design
A photoquestionnaire was used and illustrated a range of
rooms from being windowless to having windows. Pictures
were rated on a five-point scale. Patients were also asked to
complete ten written questions which addressed the
preference of patients, their satisfaction levels with windows
on their unit, and the extent to which patient and staff
members engaged in behavior associated with having
windows in one’s room. Questions were also included
regarding the ideal windows and views from these windows.
Sample Information & Site
The study was conducted on the physical medicine and
rehabilitation units of six hospitals. Subjects included 125
staff members and 125 inpatients.
Findings
In terms of the photos, most subjects preferred views from the
therapy room that included trees and lawns, the surrounding
neighborhood, people outside, and near and distant vistas.
The depiction of nature appears to help in satisfying one’s
informational needs. Artificial views were less preferred than
real views. Rooms with small and poorly positioned
windows were the least preferred. Those in hospitals with
poor views or no windows at all were unsatisfied.
Staff and patients responded positively to potted plants in
rooms.
Implications of Findings
Patients prefer rooms with windows that have pleasant views.
No mention was made in regards to room occupancy.
217
Volicer, B. J., Isenberg, M. J., & Burns, M. W. (1977). Medical-surgical differences in hospital
Stress. Human Stress, 3, 3.
Focus of Study
To measure the difference in scores of psychosocial stress
due to hospitalization between medical and surgical patients.
Research Design
Interviews were conducted with both medical and surgical
patients. Information was obtained on patient characteristics
such as age and number of previous hospitalizations as well
as their scores on the Hospital Stress Rating Scale (HSRS).
Patient charts were used to obtain information pertaining to
the patients’ diagnoses. Two weeks after they had been
discharged, the patients were interviewed again to report on
their physical status.
Sample Information & Site
The study was conducted at a community hospital in the
United States. Interviews were conducted with 880 medical
and surgical patients, and complete data was obtained for 535
of these patients.
Findings
Scores on the stress scale were correlated with the patient’s
age, number of previous hospitalizations, number of years
since last hospitalization, and seriousness of illness. Surgical
patients reported higher stress scores than medical patients.
This occurred particularly for factors representing
unfamiliarity of surroundings, loss of independence, and
threat of illness. Medical patients experienced more stress in
terms of financial problems and lack of information. No
differences were observed in terms stress associated with
problems with medications and factors related to separation
from others.
Implications of Findings
Surgical patients appear to suffer from greater stress than
medical patients, although the factors that are related to
increased stress vary for both types of patients. No mention
was made in regards to room occupancy.
218
Non Empirical Articles: Therapeutic Relationship between Healing and
Environment
Anonymous. (2001, December). Poor customer service has significant impact on bottom-line
results. Hospital Peer Review, 26(12), 167-168.
Focus of Article
To describe factors that have an impact on patient
satisfaction.
Type of Healthcare Facility
The information in this article pertains to hospitals in the
United States.
Recommendations for
Healthcare Setting
Implications of Findings
When the satisfaction of patients in regards to their hospital
stay is low, the hospital may suffer financial implications.
Nurses with negative attitudes can have long-term negative
consequences for hospitals as patients are not satisfied with
the care they received. Employee morale needs to be high to
prevent job turnover and staff shortages. Communication
between staff and family members and patients is important
and patients’ expectations must be managed. Responses to
complaints should be quick to prevent further complaints.
Finally, doctors want to feel appreciated and they are happiest
when a competent staff is working for them.
Patient satisfaction can improve if the hospital staff is
positive and patients are dealt with in a timely manner. This,
in turn, may impact hospital finances. No mention was made
in regards to room occupancy.
219
Biley, F. (1993). Ward design: Creating a healing patient environment. Nursing Standard, 8(5),
31-35.
Focus of Article
To demonstrate how patient environments affect the patients’
recovery.
Type of Healthcare Facility
The material presented in this article pertains, for the most
part, to hospitals in England.
Recommendations for
Healthcare Setting
Implications of Findings
Hospital design, in the early days, paid attention to aesthetic
and functional features of the environment. In the twentieth
century, with the advancement of technology, hospitals spent
more money on technology rather than on the design of the
hospital. In recent years, the focus has once again shifted to
the aesthetic features of the environment. Hospitals are
incorporating bright, open spaces, natural light, artwork, and
color co-ordination. Illustrations featuring natural scenes
have a positive effect on the physical and mental states of
patients. Cool colors, such as blue and green, help to promote
relaxation. Warm colors, including red, orange, and yellow,
promote activity, while neutral colors minimize attention.
The control of undue noise can also help in the reduction of
patient stress.
Innovations in design, such as attention to color, use of
natural light, and incorporation of artwork, can help reduce
the stress of patients and increase the speed of recovery from
an illness. No mention was made in regards to room
occupancy.
220
Cabrera, I. N., & Lee, M. H. M. (2000). Reducing noise pollution in the hospital setting by
establishing a department of sound: A survey of recent research on the effects of noise and
music in health care. Preventive Medicine, 30, 339-345.
Focus of Article
To propose a solution to reduce patients’ stress and anxiety in
a hospital setting by using music therapy.
Type of Healthcare Facility
The suggestions in the article apply to hospitals in the United
States.
Recommendations for
Healthcare Setting
Implications of Findings
The authors note that noise pollution causes increased
amounts of anxiety, pain perception, loss of sleep, and
prolonged convalescence in the population. They further
suggest that a problem in hospitals is that the noise levels are
significantly higher than the recommended levels, and this
has been correlated with increased length of stay for patients
as well as burnout symptoms among critical care nurses.
They recommend that excess noise be replaced with carefully
monitored music. A “Sound Control Center” should be
established throughout the hospital. It would be responsible
for reducing noise levels as well as providing a center for
music therapy. Music has been proven to successfully reduce
anxiety prior to and during surgery and is a practical source
for alleviating pain.
With the installation of a “Sound Control Center,” excess
noises in a hospital can be reduced. With the induction of
music therapy, patients may experience reduced anxiety and
improvement in their health. No mention was made in regards
to room density.
221
Davis J.B. (2001, May 28). Channeling calm. Hospitals turn to innovative TV to promote healing
in their patients. Modern Healthcare. 31(22), 26.
Focus of Article
To describe the Continuous Ambient Relaxation Environment
(C.A.R.E.) television channel available in hospitals.
Type of Healthcare Facility
The information in this article pertains to hospitals in the
United States.
Recommendations for
Healthcare Setting
Implications of Findings
The C.A.R.E. television channel is a 24-hour channel that
enables viewers to watch programming that revolves around
nature scenes accompanied by music. It is believed that this
channel can help to relax patients and promote a therapeutic
environment. It appeals to hospital officials who promote
healing through environmental cues and building design.
The cost of initial set-up is $8000 per hospital and a monthly
subscription fee of $200.
The C.A.R.E. channel can help patients heal through its focus
on nature and music. No mention was made in regards to
room occupancy.
222
Fottler, M. D., Ford, R. C., Roberts, V., Ford, E., & Spears, J. (2000, March/April). Creating a
healing environment: The importance of the service setting in the new consumer-oriented
healthcare system. Journal of Healthcare Management, 45(2), 91-107.
Focus of Article
To examine the importance in determining patient satisfaction,
promoting patient healing and well-being, and improving
employee attitudes.
Type of Healthcare Facility
Recommendations for
Healthcare Setting
Implications of Findings
The material presented in this article applies to hospitals in
general.
A clean, safe hospital environment that is easy to use can
improve patients’ satisfaction and the quality of their
experience. It is important for patients and their family
members to feel that their medical, psychological, and social
needs have been met. A patient-focused design increases a
sense of personalization and allows for maximum
opportunities for interaction between patients and their family
members. The patients’ experience can be enhanced through
the use of natural light, noise control, appropriate
temperature, and attractive décor. The spatial layout of the
design should enable patients to have a sense of orientation
throughout the facility.
Staff members want to work in an environment that is clean,
organized, and comfortable.
A well-designed setting can have a positive impact on staff
members and can improve patient satisfaction and clinical
outcome. No mention was made in regards to room
occupancy.
223
Hancock, T. (1999). Creating health and health promoting hospitals: A worthy challenge for the
twenty-first century. Leadership in Health Services, 12(2), viii.
Focus of Article
To examine ways in which hospitals can promote health.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
general.
Recommendations for
Healthcare Setting
Implications of Findings
Healthy hospitals create a healing environment for patients
and a healthy workplace for staff. The physical environment
of the hospital has a significant impact on the social and
mental well-being of patients, and thus, the physical
environment should not be damaging to the health of patients.
The social environment can also affect the physical state of
patients. Pleasing environments can be created through the
use of color, texture, form, plants, and elements of nature.
The creation of a home-like setting is also satisfying for
patients.
In a healthy hospital, patients and their family members are
viewed as active participants in healthcare. Patients and their
family members should be fully informed, have access to
information, and be involved in the decision-making process.
Staff members need to respect the needs of patients. When
patients are at ease and in a nurturing environment, they will
heal more rapidly.
Communication among staff members should be facilitated
and the environment should be composed and uncluttered to
facilitate a positive working environment for staff members.
Healthy environments help put the patient at ease and
facilitate a rapid recovery. No mention is made in regards to
room occupancy.
224
Hosking, S. & Haggard, L. (1999). The human factor. In S. Hosking and L. Haggard, Healing
the hospital environment: Design, management and maintenance of healthcare premises
(pp.159-171). London: Routledge.
Focus of Article
To describe aspects of hospitals that can improve patient
conditions.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
general.
Recommendations for
Healthcare Setting
Implications of Findings
Patients expect that the treatment they receive should be
appropriate for their conditions. Noise in the environment
can increase patient stress. Unpleasant noise, however, is
tolerated when the noise is identified and deemed necessary.
Control of noise is important for the recovery of patients, as
tolerance of noise is lower during illness. Pleasant smells can
contribute positively to the recovery of patients. This can be
achieved through the use of aromatherapy and scented oils,
among other items. Efforts are made to preserve the patients’
dignity. This can be achieved through increased privacy,
especially when the patient is in the bathroom, undressing, or
in a great deal of pain. The sense of touch can also facilitate
recovery. Patients have experienced lower stress levels when
petting tame animals.
Factors such as a reduction in noise, increased privacy, and
pleasant smells can contribute to a positive healing
environment. No mention was made in regards to room
occupancy.
225
Leith, B. A. (1998, August). Transfer anxiety in critical care patients and their family members.
Critical Care Nurse, 18(4), 24-32.
Focus of Article
To describe the impact that transfer anxiety has on
hospitalized patients.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
general.
Recommendations for
Healthcare Setting
Separation anxiety can result in patients who are about to be
transferred. They experience anxiety because they feel they
are losing a close relationship with their doctors and nurses.
Patients can also experience primary transfer anxiety, which
is related to the timing and type of transfer and to the
disruption of interpersonal relationships. Expectant transfer
anxiety can also occur if patients are not fully prepared for
their transfer. Uncertainty due to a change in environment,
change in routine, or lack of monitoring devices can result in
patient stress.
The experience of transfer anxiety is related to the
uncertainty, which is caused by being separated from a
familiar environment and personnel. It can result in stress
and a decreased ability to cope with one’s illness.
Attributes of transfer anxiety include a negative perception of
the transfer, psychological of physiological symptoms of
anxiety, and the occurrence of these symptoms within the
time frame of the transfer. Reasons for transfer anxiety
include a lack of preparation for the transfer, a sudden
reduction in patient monitoring, a lack of predictability of the
new environment, and a decrease in the patient’s control of
individual care. Symptoms of transfer anxiety include
insecurity, need for excessive reassurance, vigilance, and
withdrawal.
Transfer anxiety can be detected through the use of a few
instruments. These include the Myocardial Infarct Stress
Transfer Inventory and the Perception of Transfer as a
Stressor questionnaire.
When patients are prepared for the transfer by their nurses,
the respond better to the transfer. Transfer anxiety can be
reduced through structured discharge planning and through
the involvement of relatives in the transfer.
226
Implications of Findings
Transfer anxiety can adversely affect the coping ability of
patients and can lead to increased stress in patients. No
mention was made in regards to room occupancy.
227
Nicholson, L. (1993). Humanizing the patient environment. In D. K. Hamilton (Ed.) Unit
2000: Patient beds for the future. A nursing unit design symposium (pp. 251-253). Houston:
Watkins Carter Hamilton Architects, Inc.
Focus of Article
To describe factors of the hospital environment can aid the
healing process.
Type of Healthcare Facility
The material presented in this component of the symposium
pertains to all hospitals.
Recommendations for
Healthcare Setting
Implications of Findings
In the 1980’s, an emphasis was placed on making the hospital
environment more warm and home-like. The hospital interior
environment should create balance and harmony. In doing
this, the environment must be humanized and respond to the
emotional, spiritual, physical, and mental needs of the
patients. Patients should also be given as much freedom and
independence as possible.
A healing environment is one which gives the patient privacy
and personal space, as patients desire the flexibility to control
their environment. It should also provide and encourage
relaxation. Windows connect the patient to the outdoors.
Space for personal belongings, as well as family members, is
also necessary. Finally, pleasant surroundings help patients
to heal.
A positive healing environment may be beneficial for
patients. No mention was made in regards to room
occupancy.
228
Rich, M. (2002, November 27). Healthy hospital designs: Improving décor can have impact on
care; Fewer fractures and infections. The Wall Street Journal, B1.
Focus of Article
To describe how improvements in design have therapeutic
effects for patients.
Type of Healthcare Facility
The facilities mentioned in this article are the Barbara Ann
Karmanos Cancer Institute in Detroit, Methodist Hospital in
Indianapolis, Bronson Methodist Hospital in Kalamazoo,
Michigan, and the Swedish Medical Center in Seattle.
Recommendations for
Healthcare Setting
Implications of Findings
The redesign at the Barbara Ann Karmanos Cancer Institute
included the use of softer colors, warmer, indirect lighting,
wider hallways and doors, and pullout sofas for visitors.
After the renovations, sickle-cell anemia patients, on average,
gave themselves 45% less self-administered pain medication.
Those admitted with prostate cancer cost the hospital an
average of 23.5% less than patients admitted prior to the
redesign. This is mainly due to a reduction in pain
medication.
At Methodist Hospital, patient falls were reduced by 60% in
the cardiac wing. This is due to redesigned rooms, which
have eliminated the need for patients to be transferred from
critical-care units to recovery bays.
At Bronson Methodist Hospital, a new facility was built with
only single-occupancy rooms. Doctors are now able to have
more private conversations with their patients. A sharp
reduction has also occurred in the number of hospitalacquired infections. The hospital has saved money because
patients are no longer asking to be transferred from their
rooms.
At Swedish Medical Center, small still-life paintings were
placed over cubbyholes containing equipment such as oxygen
masks, suction lines, and blood-pressure cuffs in the surgical
recovery room. These paintings were inserted to reduce the
feeling of intimidation among patients who do not like
hospital equipment.
Effective hospital design can have therapeutic effects on
patients and can help the hospital save money. Room
occupancy was only mentioned for Bronson Methodist
Hospital. The rooms in this facility are private, and the
229
hospital has noticed a reduction in costs and hospital-acquired
infections.
230
Shumaker, S. A. & Reizemstein, J. E. (1982). Environmental factors affecting inpatient stress in
acute care hospitals. In G. Evans (ed.), Environmental stress (pp.179-223). Cambridge, London:
Cambridge University Press.
Focus of Article
To describe factors that affect inpatient stress in acute care
settings.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
general.
Recommendations for
Healthcare Setting
A major function of hospitals is to provide services to patients
with different needs. The adjustment to a hospital setting is
made difficult by the vulnerability of patients. Factors of
hospitals that affect a patient’s level of stress are wayfinding,
physical comfort, control over privacy and personal territory,
and the symbolic meaning of the hospital environment.
Aspects of the environment that can influence patient comfort
are noise, temperature and humidity, lighting, body
positioning, odors, and manipulation of switches. Patients are
highly sensitive to hospital sounds due to pain, the nature of
their illness, or their lack of control over the sounds. Soundattenuating surfaces need to be used to reduce the amount of
noise produced. When temperatures are incongruent with the
needs of the patients, stress may result. Patients should be
provided with individual controls in their rooms. Poor
lighting can cause discomfort and unpleasant odors can be
disturbing. Surfaces that reduce glare should be used and
appropriate lighting should be used for various tasks. To curb
odors, surfaces that do not retain odors should be used.
Privacy serves many functions for patients, including control
over personal information, an opportunity for resting, and an
opportunity to discuss feelings and needs with family and
friends. The nature of a patient’s illness and the patient’s
response to the illness can impact the stress experienced in
regards to privacy. The number of patients in a room as well
as the presence of an interior window to the corridor, the
relation of the head of the bed to the doorway, the presence of
visual screening devices, and the location of the bathroom in
relation the hallway all impact the privacy of patients. Using
curtains around the beds, as well as lowering voices when
discussing the patients’ illnesses, can meet the needs of
patients. A patient’s control of privacy is key to design.
231
Giving patients the ability to personalize their rooms enables
them to establish their own territory and increases their sense
of security and self-identity.
The design of the patient rooms can convey symbolic
meaning to patients. The layout and visual and acoustical
screening represent the hospital’s view of importance of a
patient’s privacy and territoriality. The patient’s territory in a
multiple occupancy room is also symbolic in terms of the
patient’s proximity to the bathroom, the door, or closet,
especially if distances are uneven among patients.
Implications of Findings
An environment that meets the patient needs and gives them a
sense of control helps reduce patient stress. No specific
mention is made in regards to room occupancy, though it is
noted that privacy and territoriality are issues in rooms with
multiple occupancy.
232
Solomon, N. (2003, July 15). New way of treating elderly patients with delirium defies
conventional medical wisdom. Retrieved on July 16, 2003, from
http://www.eurekalert.org/pub_releases/2003-07/slu-nwo071503.php
Focus of Article
To discuss a method for treating elderly patients who are
delirious.
Type of Healthcare Facility
The material presented in this article applies to Acute Care
for the Elderly Unit at Saint Louis University Hospital.
Recommendations for
Healthcare Setting
Implications of Findings
Elderly patients who are delirious and agitated are typically
treated in isolation in private or semi-private rooms. At Saint
Louis University Hospital, a Delirium room, which is a fourbed intensive care unit, was created. There are no walls in the
room enabling constant monitoring of the patients by nurses.
Physical restraints are not used and medications are avoided,
and are the last choice of treatment. Instead, nurses try to
figure out why the patient is agitated. Over an 18-month
study period after the unit opened, the fall rate was near zero
and the mortality rate was zero.
A Delirium room with four beds has been found beneficial for
elderly patients who become delirious.
233
Tate, J. (1980). The need for personal space in institutions for the elderly. Journal of
Gerontological Nursing, 6(8), 439-449.
Focus of Article
To describe the needs of the elderly living in institutions.
Type of Healthcare Facility
The material presented in this article applies to institutions for
the elderly.
Recommendations for
Healthcare Setting
Implications of Findings
The physical environment provided to residents is critical to
the functioning of residents. Factors that need to be
considered in the design are privacy, personal space and
territoriality, and crowding. The most important qualities of
the physical environment for the elderly are the amount and
the arrangement of space. If their needs for privacy and
territoriality are not met, negative effects, such as a sense of
loss of personal control and a weakened personal identity,
may occur.
Aspects of design that promote social interactions, permit
privacy, and minimize feelings of crowding are, for instance,
providing private rooms, limiting the number of residents,
and providing small dining areas and social lounges.
The needs of privacy and territoriality of the elderly may be
facilitated through the use of private rooms.
234
Ulrich, R. S. (2003). Creating a healing environment with evidence-based design. Paper
presented at the American Institute of Architects Academy of Architecture for Health
Virtual seminar- Healing Environments. October 10.
Focus of Article
To describe how evidence based design in regards to
environmental features of hospitals can be used to improve
patient outcomes.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
the United States.
Recommendations for
Healthcare Setting
Implications of Findings
Evidence-based design is used to create healthcare
environments that help facilitate patient outcomes, including
increasing the safety of patients. Architectural features that
affect patient outcomes are noise, single versus multiple
occupancy rooms, positive distractions, the presence of
windows and the views provided by windows, air quality,
furniture arrangements, and carpeting.
Nosocomial infections, for instance, are affected by air
quality and single versus multiple occupancy rooms. In
particular, infection rates are lower in single-occupancy
rooms than in open wards or double-occupancy rooms.
Excess noise can increase the amount of stress experienced
by patients. Single-occupancy rooms appear to be quieter
than double-occupancy rooms.
One’s sense of control in regards to their environment can
affect a patient’s stress levels. Privacy can aid in increasing
control and decreasing stress levels.
Social support can also help reduce stress and improve patient
outcomes. Roommates are a source of stress for patients and
incompatible roommates can lead to costly transfers and
higher medication errors as a result of the transfers. When
family members are able to stay with the patient, falls can be
reduced, as patients are less likely to get up out of bed
without assistance.
To increase patient safety and improve patient outcomes,
single-occupancy rooms with good air quality should be used.
Single-occupancy rooms reduce the likelihood of the
occurrence of nosocomial infections, patient falls, and patient
transfers, and they can result in lower noise levels.
235
Ulrich, R. S. (1999). Effects of gardens on health outcomes: Theory and research. In C. C.
Marcus & M. Barnes (Eds.) Healing gardens: Therapeutic benefits and design
recommendations (pp. 27-86). New York: John Wiley & Sons, Inc.
Focus of Article
To describe the effects that healing gardens have on hospital
patients.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
the United States.
Recommendations for
Healthcare Setting
Implications of Findings
Poor environmental design is associated with negative effects
such as higher anxiety, increased need for pain medication,
sleeplessness, and higher blood pressure. Healing gardens aid
in reducing patient stress and include elements of nature such
as green vegetation, flowers, and water. They help reduce
stress by promoting a sense of control and access to privacy,
social support, access to nature, and physical movement.
Patients feel a sense of loss of control when they experience a
loss in privacy, when they are not given information, when
they are unable to adjust room and temperature and lighting,
and when they have way-finding difficulties.
Healing gardens can also facilitate social contact, which has
been demonstrated to have a positive effect on the health
status of patients.
In terms of design, patients prefer access to nature including
gardens, sitting areas, views from their rooms, and pictures of
nature. Nature scenes have a positive impact on emotional,
physiological, and behavioral aspects of stress experienced by
patients.
Some advantages of including healing gardens in hospital
design are a reduction in stress by patients, staff, and visitors,
a reduction in depression, a higher quality of life for chronic
patients, reduced pain, improved way-finding, and higher
patient and job satisfaction. Patients may also experience
greater independence and a shorter length of stay.
Negative aspects of healing gardens include noise and
smoking, and in certain instances, sunlight.
A healing garden in a healthcare setting can have many
positive impacts on patients, including a reduction in the
stress they experience. No mention was made in regards to
room occupancy.
236
Ulrich, R, (1992, September-October). How design impacts wellness. Healthcare Forum
Journal, 20-25.
Focus of Article
To describe design strategies that impact the well-being of
patients.
Type of Healthcare Facility
The material presented in this article applies to hospitals in
the United States.
Recommendations for
Healthcare Setting
Implications of Findings
A well-designed hospital can have positive effects on the
patients. These include reduced stress and anxiety, lower
blood pressure, improved postoperative progress, reduced
need for pain medication, and shortened length of stays.
Hospitals that are poorly designed, such as those that are
noisy, invade one’s privacy, and interfere with social support,
can increase patient stress. Facility design should foster a
sense of control, access to social support, and access to
positive distractions. Facilities should include gardens
accessible to patients, convenient and comfortable
accommodations for visitors, and elements of nature such as
trees, plants, and water. Artwork can also have positive
influences on patients.
A well-designed hospital can have positive effects on
patients. No mention was made in regards to room
occupancy.
237
Williams, M. A. (1995). Design for Therapeutic outcomes. In S. O. Marberry (Ed.), Innovations
in healthcare design: Selected presentations from the first five symposia on healthcare design
(pp.105-114). New York: John Wiley & Sons, Inc.
Focus of Article
To describe how hospital design can facilitate therapeutic
goals.
Type of Healthcare Facility
The material presented in this article applies to all hospitals.
Recommendations for
Healthcare Setting
Implications of Findings
Good hospital design should support activities that are
essential to achieving desired patient outcomes. This should
be achieved without adding any stress to the patients besides
that which they incur due to their illness and treatment. The
therapeutic environment includes the physical design and
social environment that enhance therapeutic goals and
activities. To achieve therapeutic goals, the design must take
into account the functional requirements of patients.
Hospital design is critical to achieving therapeutic goals. No
mention was made in regards to room occupancy.
1
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DISEASE CONTROL AND FALLS PREVENTION
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Nursing unit floor plans utilized in overview analysis by Davis Langdon Adamson:
•
•
Swedish Medical Center – First Hill, Seattle, Washington (This floor plan has been utilized in the cost model done by BTY Group,
Appendix F)
Evergreen Medical Center – Old Patient Tower, Kirkland, Washington
Evergreen Medical Center – New Patient Tower, Kirkland, Washington
University of Washington Medical Center, Seattle, Washington
Providence Newberg Medical Center, Newberg, Oregon.
St Luke’s Medical Center, in Milwaukee, Wisconsin
Valley Presbyterian, in Van Nuys, California
Permission to share the floor plans of the following hospitals pending:
San Joaqin General Hospital, Med/Surg.
VA Menlo Park, Psychogeraitric floor
University of California at Davis Medicval Center, Davis Tower, 14th floor.
Swedish Medical Center - First Hill
Seattle, Washington
Evergreen Medical Center– Old Patient Tower
Kirkland, Washington
Evergreen Medical Center – New Patient Tower
Kirkland, Washington
University of Washington Medical Center
Seattle, Washington
Providence Newberg New Medical Center
Newberg, Oregon
Valley Presbyterian
Van Nuys, California
St Luke’s Medical Center,
Milwaukee, Wisconsin
Preliminary
Comparative Cost Study
One-Bed Room vs. Two-Bed Room
Cost Comparison
July 29, 2003
TABLE OF CONTENTS
Item
Page No.
1.0
INTRODUCTION
1
2.0
EXECUTIVE SUMMARY
1
3.0
AREAS
2
4.0
SCOPE
2
5.0
METHODOLOGY
3
6.0
PRICING AND ESCALATION
4
7.0
DOCUMENTATION
4
8.0
ELEMENTAL ANALYSES
8–9
Preliminary Comparative Cost Study
One-Bed versus 2-Bed Cost Comparison
Page No. 1
July 29, 2003
1.0
INTRODUCTION
BTY Group (BTY) has been appointed by Dr. Habib Chaudhury of the Gerontology
Program at Simon Fraser University, British Columbia (B.C.), to conduct a preliminary
comparative study of construction costs of one-patient-bed room versus two-patientbed room design for hospitals in the United States.
Based on a reference floor plan of a sample hospital provided by Dr. Chaudhury and
unit-rate cost data obtained from our cost records of similar projects, BTY has
developed a representative cost model for the above comparison.
2.0
EXECUTIVE SUMMARY
The following comparative construction costs have been derived using a sample hospital
floor plan as a guide and cost data available from similar hospital projects. Both figures
shown are based on one floor of the sample hospital with 28 beds.
Description
GFA (per floor) Cost per floor
$ per sf
$ per Bed
One-Bed Option
20,600 sf
$4,285,000
$208
$153,000
Two-Bed Option
18,800 sf
$3,752,000
$200
$134,000
As this is a preliminary analysis based on broad, parametric data, these figures are more
useful as a comparison between options than an absolute indication of construction
cost.
Preliminary Comparative Cost Study
One-Bed versus 2-Bed Cost Comparison
Page No. 2
July 29, 2003
3.0
AREAS
Our cost study has been based on the following Gross Floor Areas (GFA) measured in
accordance with the Guidelines Established by the Canadian Institute of Quantity Surveyors:
Description
GFA (per floor)
One-Bed Option
20,600 sf
Two-Bed Option
18,800 sf
The reference floor plan for one level of the sample hospital provided to BTY appears
to be an extension to an existing building(s) and is designed to serve twenty-eight (28)
patient beds, each of which is contained in an individual room (one-bed room design).
In assessing the floor area required for a two-bed room design, BTY has assumed that
the total patient room areas and half of corridor areas immediately adjacent to these
patient rooms would be reduced by 20% while the core area would remain the same as
that required for the one-bed option.
4.0
SCOPE
The cost model includes all direct and indirect building construction costs normally
identified by design documents. It specifically excludes the following:
•
•
•
•
•
•
•
•
•
•
•
•
•
Professional fees and disbursement
Planning and administrative costs
Legal fees and expenses
Financing fees
Permits
Development cost charges
Loose furnishings and equipment
Removal of hazardous materials
Temporary facilities
Site work
Demolition and alterations
Design allowance (e.g. contingencies to offset design changes during design phase)
Construction allowance (e.g. contingencies to offset changes during construction)
Preliminary Comparative Cost Study
One-Bed versus 2-Bed Cost Comparison
Page No. 3
July 29, 2003
5.0
METHODOLOGY
The comparative cost model has been prepared using historical $ per Gross Floor Area
cost data available from our projects. The Gross Floor Area (per floor) of the one-bed
room option was measured directly from the reduced scale drawing provided by the
client and that of the two-bed option was calculated in the manner described in Section
3.0 above.
The construction costs of the two options have been developed by applying $ per gross
floor area unit rates to their respective floor areas on an elemental basis. The elemental
cost summaries of the two options can be found in Section 8 of this report. Further
adjustments have been made to the elemental unit rates on several building elements for
the two-bed option to take into consideration the reduced scope of work for the
following items:
•
•
•
•
•
•
Partitions
Interior doors
Wall finishes
Washroom accessories
Plumbing fixtures
Washroom exhaust
The floor plan of the sample hospital project provided to us appears to be an extension
to an existing building(s) and has likely attracted increased requirements for elevator
capacity (i.e. 11 elevators) in order to serve the balance of the entire campus. For the
purpose of this costing exercise, we have discounted this inflated capacity.
Please also note that costs of elevators for both options are the same as each requires a
system to handle the identical capacity.
Preliminary Comparative Cost Study
One-Bed versus 2-Bed Cost Comparison
Page No. 4
July 29, 2003
6.0
PRICING AND ESCALATION
The cost plan reflects current rates taking into account the size and nature of the
project. The unit rates utilized are considered competitive for a project of this type, bid
under a stipulated lump sum form of tender in an open market, with a minimum of five
bids, supported by the requisite number of sub-contractors.
The cost model developed is applicable to high-rise, acute-care hospitals in the Pacific
Northwest region of the U.S. and British Columbia. A location factor may be required
to adjust for differences in labour and material prices for projects outside these regions.
No allowance has been made to cover costs for escalation beyond today’s date. An
allowance equivalent to 3% per annum should be included for further application of the
derived data.
7.0
DOCUMENTATION
The estimated cost is based on the following reference drawing received:
Dwg #
Description
Architectural
A2.10
Floor Plan - Level 10 SE (reduced scale)
Date
March 15, 2001
This floor plan represents a “triangular” configuration for a typical medical-surgical unit.
8.0 Elemental Analyses
BTY GROUP
PROJECT: Preliminary Comparative Cost Study
One-Bed Option
Element
A1 SUBSTRUCTURE
A11.1 Standard Foundations
A11.2 Special Foundations
A12
Basement Excavation
A2 STRUCTURE
A21
Lowest Floor Construction
A22.1 Upper Floor Construction
A22.2 Stair Construction
A23
Roof Construction
A3 EXTERIOR ENCLOSURE
A31
Structural Walls Below Grade
A32.1 Walls Above Grade
A32.2 Structural Walls Above Grade
A32.3 Curtain Walls
A33.1 Windows & Louvres
A33.2 Glazed Screens
A33.3 Doors
A34.1 Roof Covering
A34.2 Skylights
A35
Projections
B1 PARTITIONS & DOORS
B11.1 Fixed Partitions
B11.2 Moveable Partitions
B11.3 Structural Partitions
B12
Doors
B2 FINISHES
B21
Floor Finishes
B22
Ceiling Finishes
B23
Wall Finishes
B3 FITTINGS & EQUIPMENT
B31.1 Metals
B31.2 Millwork
B31.3 Specialties
B32
Equipment
B33.1 Elevators
B33.2 Escalators & Moving Walkways
B33.3 Material Handling Systems
C1 MECHANICAL
C11
Plumbing and Drainage
C12
Fire Protection
C13
HVAC
C14
Controls
C2 ELECTRICAL
C21
Service & Distribution
C22
Lighting, Devices & Heating
C23
Systems & Ancillaries
Z1 GENERAL REQUIREMENTS & FEES
Z11
General Requirements
Z12
Fee
NET BUILDING COST
$/ BED
QUANTITY SURVEYORS
DATE:
GROSS FLOOR AREA:
NUMBER OF BEDS
Gross Floor Area Unit
Unit
Rate
Amount
$
Total Cost
$
Cost/Floor Area
$/ sf
192,000
20,600
20,600
20,600
sf
sf
sf
5.62
2.98
0.75
116,000
61,000
15,000
20,600
20,600
20,600
20,600
sf
sf
sf
sf
1.09
17.38
1.27
6.51
22,000
358,000
26,000
134,000
20,600
20,600
20,600
20,600
20,600
20,600
20,600
20,600
20,600
20,600
sf
sf
sf
sf
sf
sf
sf
sf
sf
sf
2.21
9.13
6.52
0.72
2.89
0.43
0.96
3.75
0.42
1.39
46,000
188,000
134,000
15,000
60,000
9,000
20,000
77,000
9,000
29,000
20,600
20,600
included
20,600
sf
sf
sf
sf
7.07
0.10
0.00
4.05
146,000
2,000
0
83,000
20,600
20,600
20,600
sf
sf
sf
3.91
2.95
1.60
81,000
61,000
33,000
20,600
20,600
20,600
20,600
20,600
20,600
20,600
sf
sf
sf
sf
sf
sf
sf
0.65
6.87
3.25
1.84
8.21
0.00
2.51
13,000
142,000
67,000
38,000
169,000
0
52,000
20,600
20,600
20,600
20,600
sf
sf
sf
sf
12.24
2.93
32.09
8.97
252,000
60,000
661,000
185,000
20,600
20,600
20,600
sf
sf
sf
12.68
3.92
9.19
261,000
81,000
189,000
%
9.32
4.5%
26.21
12.6%
28.50
13.7%
11.21
5.4%
8.50
4.1%
23.35
11.2%
56.21
27.0%
25.78
12.4%
18.93
9.1%
208.01
100.0%
5.63
2.96
0.73
540,000
1.07
17.38
1.26
6.50
587,000
2.23
9.13
6.50
0.73
2.91
0.44
0.97
3.74
0.44
1.41
231,000
7.09
0.10
0.00
4.03
175,000
3.93
2.96
1.60
481,000
0.63
6.89
3.25
1.84
8.20
0.00
2.52
1,158,000
12.23
2.91
32.09
8.98
531,000
12.67
3.93
9.17
390,000
7.00%
3.00%
July 29, 2003
20,600
sf
28
no.
273,000
117,000
13.25
5.68
$4,285,000
$153,000
Page No. 5
BTY GROUP
PROJECT: Preliminary Comparative Cost Study
Two-Bed Option
Element
A1 SUBSTRUCTURE
A11.1 Standard Foundations
A11.2 Special Foundations
A12
Basement Excavation
A2 STRUCTURE
A21
Lowest Floor Construction
A22.1 Upper Floor Construction
A22.2 Stair Construction
A23
Roof Construction
A3 EXTERIOR ENCLOSURE
A31
Structural Walls Below Grade
A32.1 Walls Above Grade
A32.2 Structural Walls Above Grade
A32.3 Curtain Walls
A33.1 Windows & Louvres
A33.2 Glazed Screens
A33.3 Doors
A34.1 Roof Covering
A34.2 Skylights
A35
Projections
B1 PARTITIONS & DOORS
B11.1 Fixed Partitions
B11.2 Moveable Partitions
B11.3 Structural Partitions
B12
Doors
B2 FINISHES
B21
Floor Finishes
B22
Ceiling Finishes
B23
Wall Finishes
B3 FITTINGS & EQUIPMENT
B31.1 Metals
B31.2 Millwork
B31.3 Specialties
B32
Equipment
B33.1 Elevators
B33.2 Escalators & Moving Walkways
B33.3 Material Handling Systems
C1 MECHANICAL
C11
Plumbing and Drainage
C12
Fire Protection
C13
HVAC
C14
Controls
C2 ELECTRICAL
C21
Service & Distribution
C22
Lighting, Devices & Heating
C23
Systems & Ancillaries
Z1 GENERAL REQUIREMENTS & FEES
Z11
General Requirements
Z12
Fee
NET BUILDING COST
$/ BED
QUANTITY SURVEYORS
DATE:
GROSS FLOOR AREA:
NUMBER OF BEDS
Gross Floor Area Unit
Unit
Rate
Amount
$
Total Cost
$
Cost/Floor Area
$/ sf
176,000
18,800
18,800
18,800
sf
sf
sf
5.62
2.98
0.75
106,000
56,000
14,000
18,800
18,800
18,800
18,800
sf
sf
sf
sf
1.09
17.38
1.27
6.51
20,000
327,000
24,000
122,000
18,800
18,800
18,800
18,800
18,800
18,800
18,800
18,800
18,800
18,800
sf
sf
sf
sf
sf
sf
sf
sf
sf
sf
2.21
9.13
6.52
0.72
2.89
0.43
0.96
3.75
0.42
1.39
42,000
172,000
123,000
14,000
54,000
8,000
18,000
71,000
8,000
26,000
18,800
18,800
included
18,800
sf
sf
sf
sf
5.59
0.10
0.00
2.82
105,000
2,000
0
53,000
18,800
18,800
18,800
sf
sf
sf
3.91
2.95
1.22
74,000
55,000
23,000
18,800
18,800
18,800
18,800
18,800
18,800
18,800
sf
sf
sf
sf
sf
sf
sf
0.65
6.87
2.66
1.84
8.99
0.00
2.51
12,000
129,000
50,000
35,000
169,000
0
47,000
18,800
18,800
18,800
18,800
sf
sf
sf
sf
7.77
2.93
31.76
8.97
146,000
55,000
597,000
169,000
18,800
18,800
18,800
sf
sf
sf
12.68
3.92
9.19
238,000
74,000
173,000
%
9.36
4.1%
26.22
11.5%
28.51
12.5%
8.51
3.7%
8.09
3.5%
23.51
10.3%
51.44
22.6%
25.80
11.3%
18.14
8.0%
199.57
87.6%
5.64
2.98
0.74
493,000
1.06
17.39
1.28
6.49
536,000
2.23
9.15
6.54
0.74
2.87
0.43
0.96
3.78
0.43
1.38
160,000
5.59
0.11
0.00
2.82
152,000
3.94
2.93
1.22
442,000
0.64
6.86
2.66
1.86
8.99
0.00
2.50
967,000
7.77
2.93
31.76
8.99
485,000
12.66
3.94
9.20
341,000
7.00%
3.00%
July 29, 2003
18,800
sf
28
no.
239,000
102,000
12.71
5.43
$3,752,000
$134,000
Page No. 6
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