Improving the Environment for Hospice In-Patients

1. Improving the Environment for Hospice In-Patients Janet Rigby Staff Nurse, East Cheshire Hospice, Macclesfield, Cheshire Honorary Research Assistant, Lancaster University CECo Scholarship Holder 2008

2. The Cancer Experiences Collaborative (CECo) and the Compass Collaborative were established in response to the recommendation of the National Cancer Research Institute. Their aim is to strengthen research into supportive and palliative care. CECo is a collaborative between researchers at the Universities of Lancaster, Liverpool, Manchester, Nottingham and Southampton. The Compass Collaborative involves researchers at King’s College, London, and the Universities of Edinburgh and Leeds.

3. East Cheshire Hospice

4. Number of UK adult hospices founded in each 5-year period, 1959-present

5. Many hospice buildings are now 20, 30 or 40 years old, and are in need of updating. What is the best way forward? • Refurbish/extend existing building? (East Cheshire Hospice is currently doing this) • Completely rebuild on the same site? (St Joseph’s Hospice, Hackney, replaced its in-patient unit in 2005) • Rebuild on a new site? (St Richard’s Hospice, Worcester, has recently done this, and St Luke’s, Sheffield, is about to begin)

6. Hospice/palliative care has changed over the last 40 years Around 1960, Dr Cicely Saunders wrote about her plans for St Christopher’s Hospice: ‘The great majority of patients would be suffering from malignant disease’ Hospices are now expanding their services to care for people with a variety of life-limiting illnesses – we need to have appropriate accommodation for them ‘It is often the younger patients who have more pain and mental distress’ We now accept that older patients suffer as much as younger people, and that hospices should be equipped to care for all, regardless of age

7. Treatments available in hospices ‘The nursing staff will not have acute emergencies to cope with, nor complicated treatments or investigations to carry out, but will spent their time making the patients comfortable’ Hospices have increased the range of treatments available to patients – • blood transfusions/IV therapy • drainage of ascites • PEG feeding Appropriate accommodation is needed-washbasins, adequate storage space, treatment rooms, rooms for staff training

8. Single or shared rooms? ‘There is great strength to be found in the community of suffering, and where patients are wisely placed they are often able to help one another’. ‘It is very important that the patients in single rooms should have company as long as they need it, and it must be easy to keep a continual watch on them’ Single rooms with en-suite bathrooms are now found in many health care settings. may help address public concern about • Dignity/privacy • Infection control NB - Ulrich (USA ) argues that patient falls are less common in single rooms than in shared wards.

9. Hospices and Spirituality ‘The Home (St Christopher’s Hospice) would be open to all... although probably the majority of both staff and patients are likely to be Church of England’ ‘Simple family prayers will be conducted in the wards by the staff on duty as part of their daily work for the patients’ Hospices are now multi-ethnic and multi-faith organisations. ‘Chapels’ are now sometimes called ‘faith rooms’ or ‘contemplation rooms’.

10. Hospice Gardens ‘The buildings should be grouped round a courtyard, with one side open to the road. There must be a fountain, some trees if possible, and flowers ad lib.’ ‘..a patient who wants to may spend some time out on the balcony’ Issues that now need to be considered: • Accessibility for those with a disability/confined to bed • Patient safety – level surfaces, safe water features, allergies • Security of the building

11. Office space in hospices The secretary who was employed at the East Cheshire Hospice when it first opened in 1988 recalls her role: ‘There was just me full time in the office, and someone in part time in the mornings. My role then was, I was Matron’s secretary, I was the Chairman’s secretary, I was the Trustee’s secretary, the doctor’s secretary, the social work secretary, you know I worked with every department, and sometimes I’d be an extra pair of hands on the ward if they were really stuck, you know and they wanted someone to sit with someone, you know I’d be there and I’d come down on the ward’

12. Where is the evidence on how hospice buildings should be designed? • There has been some research into building design in hospitals and care homes, particularly in the USA. • Some research is not publicly available due to commercial sensitivity – eg research conducted by architects. • There is a small body of research which specifically relates to hospice buildings.

13. Some Evidence from Research in HospitalsWalch, J, Rabin, B, Day, R, Williams, J, Choi, K and Kang, J (2005) The Effect of Sunlight on Postoperative Analgesic Medication Use: A Prospective Study of Patients Undergoing Spinal Surgery. Psychosomatic Medicine 67: 156-163 (The surgical unit had some rooms which were sunny and some which were shady. Consenting patients were allocated to the first available room).

14. Ulrich, R (1984) View through a Window May Influence Recovery from Surgery. Science, Vol. 224 No 4647: 420-421.(Patients were undergoing cholecystectomy in a U.S hospital, where some bedrooms had a view of a brick wall and some had a view of trees. Patients’ records were examined to find the levels of medication use ).

15. Some evidence from research in hospices and palliative care units: patients’ and families’ views on single and shared rooms. Lucas, C, Townsend, C, and Garland, E (2004) The great debate: single or shared rooms for patients in hospices? Hospice Information Bulletin 03: 5-6 (Questionnaire given to 61 patients and 37 relatives at Princess Alice Hospice in Esher, Surrey (the hospice has single rooms and 5-bedded wards).

16. Kirk, S (2002) Patient preferences for a single or shared room in a hospice. Nursing Times Vol. 98 No 50: 39-41 Structured interviews with 24 patients (12 each from 2 hospices) Patients were also asked what number of beds they would prefer in a shared room – they expressed a preference for 4 bedded rooms.

17. Pease, N, and Finlay, I (2002) Do patients and their relatives prefer single cubicles or shared wards? Palliative Medicine 16: 445-446 (Questionnaire given to 50 patients with advanced disease in a hospital palliative care unit, and 36 next of kin)

18. What about the needs of hospice staff? When the hospice movement first began, there were many young women entering the nursing profession. However, the nursing workforce is now ageing, and in many parts of the country it is difficult to recruit nurses. There are similar problems within other disciplines eg medicine. A survey by PricewaterhouseCoopers in 2004 found that in hospitals, nurse recruitment and retention was influenced by the physical environment of the hospital.

19. Assessing the quality of a health care building A number of assessment tools are available for evaluating the quality of a health care building. Most can be used either pre- or post-occupancy. However, none of these were designed specifically for use in hospices. SCEAM – Sheffield Care Environment Matrix AEDET - Achieving Excellence in Design Evaluation NEAT – NHS Environment Assessment Tool ASPECT – A staff and patient environment calibration tool BREEAM – BRE Environmental Assessment Method PROBE – Post Occupancy Review of Buildings and their Engineering (Torrington, J (2007) Evaluating quality of life in residential care buildings. Building Research and Information 35(5): 514-528)

20. Some possible topics for research: Is there a relationship between physical environment and levels of pain and other symptoms in hospice patients? What type of accommodation do patients and families prefer? Are there any differences between the preferences of patients and families? Are there any variations in preference according to patient gender, age, ethnicity, geographical location, social class, disease, or stage of disease? Does the physical environment have an impact on hospice staff performance/satisfaction? The hospice building is a site of memorialisation for bereaved families – how can we reconcile their needs with those of current patients and families?