Improving staff retention and patient experience
Green spaces – or even a view of one from inside a building – can not only boost healing and speed recovery for hospital patients, but also help ease stress in NHS staff and may even improve retention,
WORDS: JO WATERS
We spoke to Beatrice Fraenkel, Design Consultant and Non-Exec Director at Stockport NHS Foundation Trust; Paul Morris, Chief Nurse at James Paget Hospital; Eric Fehily, Associate Director of Estates at Essex Partnership University NHS Foundation Trust; and Magali Thomson, Project Lead for Placemaking at Great Ormond Street Hospital.
We asked them: how can hospitals improve their indoor and outdoor space to boost wellbeing?
Healing hospital design
Hospitals can be stressful places for both staff and patients, yet they also have enormous potential to be healing environments, too. Entering a hospital building for a potentially stressful medical appointment as a patient, or for a hectic working day as a member of staff, can be diffused by light, airy, well-designed spaces that have good flow and easy-to-navigate wayfinding, plus greenery and features such as water fountains and living walls, as well as access to green outdoor spaces for breaks and relaxation. All these features can help soothe the nerves of patients and their families, as well as the staff delivering care.
It’s access to greenery that is part of the zeitgeist in improving health currently, with GPs using social prescribing to recommend walks in green spaces and other nature-based activities to boost their patients’ physical and mental health. The NHS, as one of the largest public landowners in the UK, has also launched initiatives to make more use of its land and estates for staff and patient wellbeing.
The NHS, as one of the largest public landowners in the UK, has also launched initiatives to make more use of its land and estates for staff and patient wellbeing.
Nottinghamshire Healthcare NHS Foundation Trust, for example, has launched its Green Hub, a resource designed to support everyone to spend more time in green space, which includes a ‘Greenspace Social Prescribing Project’, a directory of nature-based activities around Nottingham city.
Up to 89% of NHS staff surveyed in Space to Breathe, a piece of research from the Centre for Sustainable Healthcare based on three hospital sites (Guild Lodge near Preston, Mount Vernon Cancer Centre in north London and Broomfield Hospital in Chelmsford, Essex), said they wanted to spend more time in green spaces. Staff interviewed said green space made them feel “calm, refreshed and energised” and “more effective” when they went back to work.
The report authors called for hospital Trusts to provide green spaces close to where staff work, facilities for rest areas and restaurants outside, privacy for staff to take breaks outside in designated areas, green walking routes and a supportive working culture to encourage staff to get outdoors, as well as organised activities, such as gardening or led walks.
Just over half of the NHS staff surveyed even said the availability of attractive garden access and other green spaces at a hospital was important in considering where to work, suggesting it could also be a factor in improving staff recruitment and retention. This is particularly pertinent when workforce shortages are one of the biggest challenges currently facing the NHS and adult social care in England, with vacancies in the NHS standing at 112,000 full-time equivalents in June 2023.
The 2022 NHS Annual Survey found 44.8% of staff reported feeling unwell as the result of work-related stress (down from 46.9% in 2021). Stress alongside other psychiatric illnesses is consistently the most reported reason for staff sickness absence in the NHS, accounting for 476,000 full-time equivalent days lost.
Green spaces = staff benefits
Beatrice Fraenkel says a healthy hospital environment can measurably reduce stress and anxiety for those who use the hospital as a patient, staff member or visitor. “The first move has to be for the Trust Board, as employers, to understand that a healthy environment matters enough to focus on it. With all the other pressures, it may seem relatively unimportant,” says Beatrice.
“However, there is a bank of evidence that shows our environment impacts directly on our feelings and behaviours. In a hospital setting, which is stressful anyway, reducing stress and anxiety lowers aggressive behaviour, reduces blood pressure and can speed recovery.
“There is a lot that can be done to improve existing areas cost effectively, especially in creating welcoming entrance and waiting areas.”
Beatrice says people are remarkably flexible in putting up with things and don’t necessarily make demands or requests as they are grateful to have the care they need. “Staff will often say ‘It’s okay, we’re used to it’ or ‘There’s no point as no one listens.’
However, getting underneath that can help with staff retention and lead to happier staff, as well as happier patients,” says Beatrice.
“Boards should be aware that there can be financial benefits to the NHS in understanding why good design matters,” she adds.
“Boards should be aware that there can be financial benefits to the NHS in understanding why good design matters”
Eric Fehily agrees. “I think we spend a lot of time designing hospital spaces for patients as we should, but not enough time thinking about the needs of staff, who are there all the time. Our people are our most valuable resource in the NHS, and we must take good care of them. Covid-19 was a horrendous time and staff had no facilities where they could take a break and relax away from the frontline. We must do better now. We spend a long time talking about staff wellbeing and agile work environments, but I’m asking what does that look like in practice?”
Eric is in discussion with his Trust’s health and wellbeing team about providing dedicated relaxation areas for staff to take breaks and plans to consult with staff about what they need.
“We are looking at how we can repurpose some of our older buildings, but we don’t want to just put a coffee table in an empty office, we are talking about access to green surroundings and daylight too.
“We’ve also had some preliminary discussions with Health Spaces about providing some new staff areas – dedicated spaces where staff can go to chill out. Easily accessible, it could be a glass cube in a field, so long as it’s heated and has things like comfortable lounge-style chairs – the sort you would have in your own home.
“If you have a workplace that is happy – and a healthy environment – you are much more likely to retain staff, and this is very important given current staff vacancy and sickness levels nationally.”
Theory in practice
Recognition that access to green spaces and light, airy indoor areas can be therapeutic to hospital patients and staff is central to the design of the new £15 million Concept Ward and Therapy Garden at James Paget University Hospitals NHS Foundation Trust in Great Yarmouth.
The Concept Ward, designed and delivered by Health Spaces, which has 28 beds (20 single side rooms and two four-bed bays) has been built to decant patients from other wards as the RAAC maintenance work is done. The Concept Ward, which has just won a national design award, was a chance to test out new approaches to design ahead of the new hospital that is to be built on the site.
“Our approach is to explore the art of the possible rather than just building a box as a temporary ward for patients while we do the maintenance work,” says Paul Morris. “We’re building on some of the lessons we learnt during Covid-19 and one of those is that staff very much need their own space to relax and take breaks away from the ward and the patients they are looking after. The existing staff spaces had felt quite clinical and there might only have been a door or a thin wall separating them from patients.
“It was also important for staff to have access to private outdoor space where they can eat, drink, relax and connect with nature – feel the sun or the wind on their face. Although the Concept Ward is exceptionally light, traditionally hospitals can be very dark and staff on a 12-hour shift might not even know what the weather is like outside – and it is important you know what is happening in the outside world. Every day is a day in your life, and you will not get it back – and that applies to both staff and patients.”
“It was also important for staff to have access to private outdoor space where they can eat, drink, relax and connect with nature – feel the sun or the wind on their face.”
The Concept Ward has changing rooms for staff at one end of the ward, with showers and comfortable chairs, as well as a staff rest room and training room, which look out onto the garden. Their space is set away from patients so they can switch off and take breaks or eat lunch outside, but still be close by to where they may be needed back at work.
A Therapy Garden for patients is being built adjacent to the new Concept Ward, with flower beds, seating areas, a swing and even piped oxygen for patients who need a constant supply, plus sheltered areas and handrails for those who need support.
“Inside the Concept Ward we’ve built a day room for patients, which leads out onto the garden so they can look out and see nature around them and we can bring the outdoors in, as we know greenery is proven to be beneficial for healing,” says Paul.
The garden has been landscaped and staff are involved in planning the planting to encourage wildlife such as insects and migrating birds. There are also different surfaces to walk on to help patients get used to walking outside again, as well as walking rails and access for wheelchairs.
The garden has been landscaped and staff are involved in planning the planting to encourage wildlife such as insects and migrating birds.
“We’ve created a space that everyone can use, and it’s all been done in consultation with staff and patients using their ideas, so they get a space that works for them both,” concludes Paul.
Healthy Hospital Street
Magali Thomson is part of a team trying to improve the environment surrounding Great Ormond Street Hospital (GOSH) beyond the red line boundary out onto the streets as part of the development of a new children’s cancer centre.
“The street outside the hospital is not a welcoming place for children, their families, staff or the local community,” says Magali. “It is very congested with traffic; air pollution levels are above the WHO standards for air quality every day. There is lots of noise and only one seating bench in the whole street and little green space. My role involves setting a brief and vision for what we are now calling a Healthy Hospital Street.
“The street will become one-way to traffic and the pavements will be widened on the hospital side providing the opportunity for greening, planting more trees and adding seating areas where children can play safely. Not dedicated playing areas but a playful environment – with, for example, low-level walls children may want to walk along. It will provide a safer route to the hospital, improve wayfinding and accessibility. It will hopefully transform the whole area.”
The project is being planned in collaboration with Camden Council, who are responsible for the street and traffic-calming measures. Magali says many of the ideas came from members of the hospital’s Young Persons Forum, who were very concerned about pollution levels caused by cars and wanted to prioritise people over cars. “The young people felt nature and trees were important, so every room in the new cancer centre will also have an outside view and lots of trees will be planted. There is lots of research to show the patients with a view of nature from their bed recover faster.”
Magali attached a camera to her four-year-old son’s head on a walk from the Tube station to get some idea of what small children see at their level on their approach to the hospital. “It can be quite scary for them – all they see down there is car exhausts and litter on pavements,” says Magali. Short-term greening projects outside the hospital have also proved successful, including converting a single parking space to a ‘parklet’ – a bench surrounded by greenery and flowers on the street. “This has proved very popular with staff, patients and their families who just want a short break outside the hospital.
We’ve monitored it and it’s been used 140 times a day,” says Magali. “A lot of staff have been using it too; it’s popular as it’s so close and a lot of them only get a 30-minute break. There are other parks nearby, but they are too far away if you don’t have long or if you are a parent and your child is unwell.”
GOSH also has an annual street party day where the street is closed to traffic and the children can play outside on the pavements and roads. The hospital is keen to improve the street environment, while still recognising that residents need to use their cars and ambulances and lorries still need access to the hospital.
“The concept we are developing is one that could easily be replicated,” says Magali.
“Many Trusts face similar problems with polluted surroundings and traffic congestion. We’re developing a model others could follow where hospital logistics are balanced with the provision of a green and healthy environment.”
Why a healthy hospital environment matters
“A healthy indoor and outdoor hospital environment is crucial for patients and the staff that work in hospitals. It must feel right – people have to feel welcome, safe and comfortable,” says Beatrice. “For huge numbers of Trusts at the moment, the starting point is, understandably, financial, and the hospital environment tends to be pushed very much into the background because of spending pressures.
“Boards may not have thought of design in relation to cost benefit and think it’s unaffordable to improve spaces. Some Trusts have access to charitable funds and have worked with their staff on using them in ways the staff and users feel work best to improve their areas. It could be something as simple as painting the wall in a colour best suited to the needs of their patients, having books in waiting areas, artwork, plants and proper seating. I don’t think Trusts, especially acute Trusts, take enough account of the effects of colour, pattern and shape, sound and smell on the patient who is neurodiverse, has mental health issues, or is partially sighted or has dementia and so on.
“When it comes to the use of art and plants, it depends on what works best for that particular service. It’s great where Trusts have devolved small budgets to teams and let the staff decide what works best for them and their department.”
However, Beatrice is keen to emphasise that stress and anxiety don’t begin in the building, but on the journey to the hospital and the arrival points.
“You must consider the transport infrastructure – whether patients and staff will be arriving by foot, on a bicycle, in cars or buses or trains and then how people will find their way around the site.
“Excellent wayfinding is essential so anyone arriving on site can find their way stress-free to the location they need in a manner that works best for them. That could be visual signage properly designed for anyone to understand, and a choice of using a mobile phone app.”
The shape of the building itself can be important, adds Beatrice, as research shows that a curved entrance is far more welcoming than a building with hard shapes. Clinicians say painting a wall orange can help patients with swallowing difficulties to swallow better – they are small things, but they can make a big difference.
“Staff always have brilliant ideas about what would work best, but too often these things are imposed rather than devolved to the recipients,” Beatrice says. She was involved in the building of five hospitals at Mersey Care NHS Foundation Trust and believes one effective approach to achieving healthy healing hospital environments is having a Design Board to set the design brief in the first place.
“The Design Board is not there to make decisions but recommendations to the Board and provides the design thinking and brief that results in commissioning a cost-effective and beautiful environment. The Board should consist of clinical and non-clinical staff, users, members of the local community and anyone who can contribute to the setting of an excellent brief.
“At Mersey Care, the Design Board became a sounding board for what all these groups wanted and eventually that was embedded in the Trust as the way things are done. It’s a cost-effective model – it includes nature and the external environment, as well as the hospital design, and it stops you making expensive mistakes that must be put right at a later stage.”
Beatrice Fraenkel and Eric Fehily will be joining Health Spaces on 21st February 2024, ‘Designing Better Mental Health Environments: A Deep Dive into Section 136 Suites’. See More From Us on page 65 for information.
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FORTIS magazine is a Health Spaces Limited publication. Opinions expressed in FORTIS magazine are not necessarily those of Health Spaces Limited or Dialogue Content Marketing Ltd. Material contained in this publication may not be reproduced, in whole or in part, without prior permission of the publishers. No responsibility can be taken on behalf of advertisements printed in the magazine.
This article was taken from the January edition of FORTIS magazine.
Want to know more? Read about what improvements are being made for staff welfare spaces in FORTIS magazine.
FORTIS magazine
This article was written for the January 2024 edition of FORTIS magazine; a forum for the NHS to share ideas, innovations and case studies. To read the publication in full and access digital copies, visit FORTIS magazine. FORTIS magazine is free for NHS change-makers and leaders and is available as a print or digital copy.
Please note: Health Spaces is pleased to showcase projects we have worked on and also to be able to share projects and developments which we have not been involved with. The Concept Ward is the only project discussed in this article which is delivered by Health Spaces. To see all of our hospital builds (including modular hospital construction projects) , visit our case studies page.
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