Description
Current Care Settings and Their Challenges
The design of healthcare environments is constantly changing in response to developments in medicine, changing social requirements and advances in architecture and building technology. Before we examine the spatial characteristics, functional areas and work processes of standard care wards, as well as the specific building-related hygiene measures available, we should first consider the challenges that the field of nursing has been confronted with over the past decades and the last ten years in particular.
An increase in nosocomial infections and multi-resistant germs
It is expected that the number of seriously ill patients suffering from infectious or nosocomial infectious diseases in hospitals will increase, with intensive care units being particularly vulnerable due to the numerous invasive procedures they involve. Parallel to this, recent years have seen a dramatic increase in MRSA and nosocomial infectious agents that may potentially spread considerably (Kramer et al. 2012). At the same time, the number of antibiotics available to doctors will be significantly limited in the foreseeable future because the number of companies capable of independently developing antibiotics through all clinical phases for active use in medical practice has fallen from 18 in 1990 to just four in 2011 (Fig. 01).
Meanwhile, antibiotics, and reserve antibiotics in particular, are being increasingly prescribed in large quantities, not least because many patients expect their doctors to prescribe antibiotics when they have a fever and other symptoms of infection.
New pathogens
The risk of new pathogens appearing is high. New bacteria, viruses, fungi and parasites are regularly being identifi ed that have the potential to cause infections in humans. The most recent infl uenza epidemics, SARS, Ebola or the outbreak of Covid 19 are examples that are as well-known as they are worrying. The emergence of new pathogens is particularly critical if they are able to spread rapidly. Routine medical care is not prepared for the diagnosis of new pathogens, as most methods are based on the detection of known pathogens. The situation is further aggravated by the fact that general nursing wards and especially intensive care areas have insuffi cient isolation facilities for infected patients.
Demographic change
Since 1972, the death rate in Germany has exceeded the birth rate (Fig. 2), so that the total population has been falling. At the same time, higher life expectancy means that the proportion of older people is rising in relation to the proportion of younger people. Parallel to this, more and more older people up to the age of about 80 have few or no chronic diseases or disabilities. A major challenge regarding this population group is, however, the signifi cantly higher number of immunosuppressed patients with concomitant diseases and their corresponding appropriate accommodation in nursing wards. As the immune system of this group of patients is weakened by an underlying chronic disease or by the administration of certain drugs, they need particular protection against infections in hospitals.
In addition, the nursing sector has faced a series of further shifts within the healthcare sector that have implications for the design of healthcare environments.
A decline in the number of hospitals and an increase in bed occupancy
Increasing competition among German clinics, the Hospital FinancingAct (KHG 1991, 2019) and the German flat-rate billing procedure (DRG for short), introduced in 2004, have led to a continuing reduction in the number of hospitals in Germany as well as in the length of stay for inpatient treatment. At the same time, there has been an increase in the number of inpatients treated per hospital bed (Fig. 3).
An increased need for medical staff
Costs in the German hospital sector have been rising continuously for years by an average of about 3% per year over the past ten years. The overall increase between 2000 and 2008 was 21%. In 2008, the costs amounted to 62 billion euros (Ernst & Young 2010), with personnel costs alone accounting for around 60 % of the overall costs. Changing patient expectations and the services provided to them have led to a sharp increase in medical staff (doctors, nurses and administration combined) in recent decades. The rise in personnel costs, in turn, is primarily due to a significant increase in medical procedures and services, while the cost of nursing care has risen only moderately. Nursing staffing levels have, however, increased steadily, especially in the last ten years (Fig. 4).
On the other hand, there is an acute shortage of skilled staff: there is already a lack of skilled workers in all nursing professions. While official figures on the number of unfilled positions in the nursing professions are not available, an indication of existing bottlenecks can be obtained from the Federal Employment Agency’s analysis of the shortage of skilled personnel. In 2018, there were only 29 unemployed persons for every 100 vacant positions for qualified geriatric nursing staff and specialists (outside temporary employment) and only 48 unemployed persons for every 100 vacant positions for qualified nurses (Fig. 5).
Innovations in medical technology and new forms of treatment
With the development of new diagnostic and therapeutic procedures, examination and treatment facilities were separated from the nursing wards. At the same time, hospitals have become more efficient at treating each individual patient. In recent years, new hybrid forms of treatment have also been established, such as partial inpatient treatment or pre- and post-operative care, which are increasingly replacing the traditional form of nursing care. In addition, there has been a sharp rise in the number of intensive care beds in both university hospitals and general hospitals: between 1991 and today, the number of intensive care beds throughout Germany rose from 20,000 to 27,000 (Wischer, Riethmüller 2007; GBE Bund 2016).
Changing patient demands
In Germany’s modern industrial society, there has been a shift in recent decades from a previously largely universal set of common values to a plurality of quite different values for different subgroups of society. As individualisation, fragmentalisation and diversity increase, the forces of social integration are diminishing. Likewise, as traditional family structures change, the amount of care and support provided within the family is declining, in turn increasing the demand for care services outside the home.
Individualisation has also led to an increase in personal services. In the nursing care sector, care providers are increasingly expanding their service spectrum to include a range of non-medical services for patients. Hospitals have also had to adjust to a growing proportion of foreign patients and staff in recent decades, in particular in urban areas. This places increased demands on communication amongst staff members and between staff and patients and also requires tolerance of different norms and practices.
An increase in patients with dementia
Alongside the steadily increasing number of older patients, the risk of
developing dementia will also increase (Fig. 6). In total, some 1 million
people aged 65 and over are currently affected by dementia in Germany,
which corresponds to about 7 % of this age group. The number
of new cases is increasing by about 300,000 people every year and
is set to reach up to 2.8 million people by 2050 (Deutsche Alzheimer
Gesellschaft 2018). This will lead to a higher level of nursing care and a
greater demand for nursing staff, since the possibilities of automation
in this area are limited.
Prognosis
The developments over the past decades show clearly that the hospital nursing care sector will need to continue to respond to further changes in the future, and in the process will have to consider a multitude of structural, technical, material science and organisational aspects. Research and development into innovative spatial configurations in hygiene-critical areas of nursing wards with a view to preventing infection will be increasingly important.
The number of beds per hospital will continue to decrease in future, as will the average length of stay. The absolute number of inpatients per bed, on the other hand, will increase. As a consequence, we can expect to see a shift towards building structures with uniform and standardised care areas. For non-intensive care and observation phases, more economical care structures will be needed such as admission and observation wards.
Future developments in nursing forms at hospitals will make it necessary to increase intensive care capacities, and even smaller hospitals are now being equipped with these personnel- and technology-intensive care facilities. The costs of investment in medical technology, personnel and equipment are extremely high though the economic returns are also quite attractive.
It is difficult to make precise predictions of the numbers that future nursing care areas will need to accommodate in future. We can expect, on the one hand, to see structural changes such as the increasing splitting off of individual medical fields, new focal areas of patient care and a transition to semi-inpatient or outpatient care. At the same time, it is hard to accurately predict how future financing systems in Germany will affect the size of hospital wards. Every hospital and every area of nursing care will need adapt in response to these developments.
Nursing Wards
Location in the hospital
The location of nursing wards within the structure of a hospital is largely
determined by their optimal relationship to the examination and treatment
areas. Since the 1960s, four typical organisational concepts have emerged in Germany (Fig. 7). The first two are horizontal and vertical building types in which the nursing wards are located on several floors next to or above the examination and treatment areas. Another concept is a single-storey nursing ward arranged either next to or above the examination and treatment areas. A fourth, less common variant is the integration of the nursing ward into the overall hospital structure. Here, the nursing wards are not grouped in a spatially and functionally independent unit but instead adjoin the respective treatment and examination zones of the individual disciplines.
The primary criterion for the location of nursing wards is their optimal connection to other relevant functional areas in the hospital. Travel distances between the nursing wards and the surgical, medical examination and specialist departments should be kept as short as possible. Close proximity to intensive care and IMC (Intermediate Care) is also desirable as many logistical and staffing processes overlap with those of normal care wards. For patients and visitors, proximity to services located at the entrances, access to outdoor areas and to other care facilities is also important.
Spatial-functional layout
The profitability of a nursing ward is based on a nursing organisational standard, which should be in the order of 28–41 beds. Despite the differences between individual medical disciplines with respect to the nursing needs of patients, which are quite different, for example, for trauma surgery than they are for transplant surgery, it is still expedient to have a common denominator for the size of normal care wards for both constructional and organisational reasons (Fig. 8). Nursing groups with different numbers of beds or inconsistent room sizes make it hard to standardise operational processes and result in less efficient staffing organisation. For this reason, a uniform standard for nursing wards in a nursing group should be established.
The spatial-functional arrangement of a nursing ward is divided into core services and nursing areas. The core services of a nursing ward are grouped together spatially and are solely for use by the doctors and nurses. They include preparatory facilities for delivering care services as well as staff and rest areas for internal use and consultation among colleagues. The core services typically comprise a nurses’ station, staff rooms, examination rooms, supplies, storage and disposal rooms. The nursing areas include the ward corridor and patient rooms.
Nurses’ station
The nurses’ station is the central point of every ward and should be easy for patients and visitors to find and reach. It is the contact point for patients and visitors as well as for staff, and the place where all process cycles and information in the ward converge. As a rule, it adjoins the medication store, where further work processes can be carried out.
Staff rooms
This group of rooms includes a common room for the nursing staff, with a kitchenette and workstations for the nursing staff along with sanitary facilities and staff changing rooms.
Doctors’ consultation rooms
Consultation rooms within wards are often only equipped to the extent necessary for ward operations, for example for doctor/patient consultations or for dealing with administrative procedures related to the inpatient stay of patients.
Examination rooms
The examination and treatment of patients does not usually take place in the patient room, especially not in shared rooms. All general care wards have one examination and treatment room for standard examinations, which can be equipped differently depending on the respective ward’s discipline.
Supplies, storage and disposal rooms
The logistics in general care wards can differ with regard to the degree of centralisation of supply and disposal rooms and their relation to the patient rooms. In many cases, the nurses’ station, nursing workroom and unclean storage room are grouped in a connected series of rooms. Unclean storage rooms, which should always be equipped with bedpan washer-disinfectors, are usually set apart from the patient rooms. It makes sense to locate both supplies and disposal rooms close to goods transport lifts.
Ward corridor
The ward corridor is the central axis of the nursing ward and should accordingly be of a sufficient size and clear structure. As a rule, patient rooms are arranged on both sides of the corridor, and it must therefore be wide enough to ensure that two patient beds can be pushed past each other. For patients, staff and visitors, the nursing corridor is both a working and meeting area. Preparatory and follow-up care work for treating patients outside of the examination rooms often takes place in front of the patient’s room. Small niches in the corridors can hold necessary materials, storage space or disposal containers for use by the nursing and medical staff. This arrangement also helps facilitate the care and treatment of patients with different diseases. The ward corridor is also a place of social encounters and exchanges, where patients from often quite different social and cultural backgrounds meet in a variety of ways.
Patient rooms
There are various different solutions for the functional layout and design of patient rooms with respect to their size, arrangement and placement of wet cells and ancillary rooms. A uniform structural wall or column spacing is sensible, both for economic reasons and standardisation as well as to flexibly accommodate future changes of use.
The originally widespread six-bed and four-bed room constellations are increasingly being abandoned in favour of two-bed rooms. In 2012, single-bed rooms accounted for between 5 and 10 % of all beds in Germany, which compared to other European countries lies in the middle range (ECDC 2015). So far, shared rooms are the rule, single rooms the exception.
The higher proportion of two-bed and single-bed rooms requires more space but also makes it possible to use the nursing areas more intensively, as patients can be distributed to smaller room units according to their illness and nursing needs. Single-bed rooms can be designed in such a way that they can also be used as two-bed rooms in the event of peak occupancy (Wischer, Riethmüller 2007).
Special room configurations can apply in particular ward departments such as paediatrics, obstetrics and psychiatry. They may deviate from the pattern of general care wards due to the specific additional functions they need, and their space requirements are generally greater. The patient room is an important cellular unit and base spatial component of a hospital. Its design must be considered in exacting detail as it has significant implications through its replication on the overall structure of the hospital. A patient room includes a sanitary cell, possibly with a separate toilet, the patient bed and wardrobe, a cloakroom for visitors and a seating area (Fig. 9). Architects have continually striven to develop and improve the patient rooms, focusing on and accentuating certain aspects.
Processes
The workflows in normal care wards comprise for the most part standardised processes. Logistical processes, such as the direct supply of laundry, consumables and pharmaceuticals, are designed around modern supply principles. Care and treatment routines undertaken as part of ward operations by medical and nursing staff, including the doctors’ rounds or administering of medication, are carried out either in a circulatory sequence within a ward group or directly for individual patients. These routines are usually preparatory or post-operative measures accompanying medical procedures where specific materials need to be provided or disposed of. Depending on the type of procedure and its hygienic requirements, nursing or medical activities are carried out either at the bedside or in the ward’s examination room. For simple patient examinations, the necessary utensils, for example a syringe or dressing, can be brought from the nurses’ workroom to the patients on a work trolley. After completion of the procedure, this trolley is taken to the unclean disposal room. For more complex or extensive patient procedures, the trolleys in the nurses’ workroom may be equipped with medicines, infusions, instruments, dressing materials, fresh laundry and so on. After completion, the trolley with dirty laundry is stored in the unclean disposal room and replaced once a day.
References
H. Bickel, “Demenzsyndrom und Alzheimer Krankheit. Eine Schätzung des Krankenbestandes und der jährlichen Neuerkrankungen in Deutschland”, Gesundheitswesen, 2000, 62 (4): pp. 211–218
Deutsche Alzheimer Gesellschaft e. V., Informationsblatt 1: “Die Häufigkeit von Demenzerkrankungen”, Berlin, 2018 ECDC (2015) European Center for Disease Prevention and Control (ECDC), Healthcare-associated infections, www.ecdc.europa.eu/en/healthtopics/healthcare-associated_infections/database/pages/hai-pps-database-indicators-maps.aspx. Last accessed 4 February 2020
Ernst & Young (2010), Krankenhauslandschaft im Umbruch,Stuttgart: Ernst & Young, 2010, p. 9
Gesundheitsberichterstattung des Bundes (GBE Bund), Intensivmedizinische Versorgung in Krankenhäusern, Anzahl Betten, http://www.gbebund.de/oowa921. Last accessed 7 April 2016
A. Kramer, O. Assadian and M. Exner, Krankenhaus- und Praxishygiene, 2nd edition, Munich: Urban Fischer Verlag, 2012, pp. 1–7
Gesetz zur wirtschaftlichen Sicherung der Krankenh.user und zur Regelung der Krankenhauspfleges.tze (Krankenhausfinanzierungsgesetz – KHG). Originally issued 1972, reinstated 1991, last revised 2019
Robert Wischer and Hans-Ulrich Riethmüller, Zukunftsoffenes Krankenhaus – Ein Dialog zwischen Medizin und Architektur, Vienna: Springer, 2007
Originally published in: Wolfgang Sunder, Julia Moellmann, Oliver Zeise, Lukas Adrian Jurk, The Patient Room, Birkhäuser, 2020.