How staying in a single room affects the experiences of haematology inpatients in an Australian cancer hospital

Hospital design has long been considered a factor that can influence patient health outcomes. In the late 1850s, Florence Nightingale proposed a ward design that would promote ventilation, and included sanitation, clean water and food. This would later be developed into a 32-bed, open-plan ward with a central corridor that was considered efficient for nursing and the observation of patients (Nightingale, 2013). In the 19th century, hospital design continued to evolve in response to knowledge about diseases, such as the tuberculosis sanatoriums that enabled access to outdoor air and sunshine as a curative measure. Today, hospital design is regarded in response to patients' mental as well as physical wellbeing. The physical outcomes of patients are said to be congruent to mental health, which can be directly affected by the hospital environment (Dowdeswell et al, 2004; Ulrich et al, 2008), and as such hospital design configurations have evolved to include single-room design.

Single rooms have been a preference for many patients due to perceived privacy and prevention of the spread of infection (Persson et al, 2015; Bloomer et al, 2016; Maben et al, 2016), despite the known psychological isolation that can result (Pennington and Isles, 2013; Persson et al, 2015). For haematology patients who require involved, intense treatment in a long-stay facility, there is limited research regarding the impact of staying in a single room, especially in relation to a patient's psychosocial wellbeing. In particular, the opportunities for peer support from fellow patients could be compromised by the single room, further affecting the wellbeing of the patient.

Haematology patients can experience long periods of time as an inpatient while having treatment and recovering from the associated side effects (Nirenberg et al, 2006; Duffy, 2009; Albrecht and Rosenzweig, 2012). One study (Wittmann et al, 2006) among haematology patients found that long inpatient stays can be detrimental to their psychological wellbeing. More broadly, a systematic review (Babalola et al, 2014) did not find that length of stay influenced outcomes such as death and readmission rates among patients with severe mental illness, a patient cohort that also characteristically has long acute stays, although the authors did note that the evidence base was limited: the studies were more than 30 years old and many were of low quality.

There is a deficit of research studies on the experience of long-stay haematology patients who are accommodated in single rooms in hospitals. This study investigated the experience of haematology patients in single rooms and, in doing so, adds to the growing body of research concerning hospital design and patient welfare.

Method

Design

A phenomenological approach was used to understand the meaning of being a long-term haematology patient in a single room from the unique viewpoint of the patient. Semi-structured interviews were used to collect the data and analysis was conducted using Colaizzi's (1978) seven-step analysis.

Ethical approval

Ethical approval for the study was received from the Peter MacCallum Cancer Centre Human Research Ethics Committee (HREC) [LNR/17/PMCC/282] and the La Trobe University Ethical Committee [based on external approval LNR/17/PMCC/282].

Sample

Participants were identified from the 100% single-room haematology ward of a large metropolitan cancer hospital. The ward comprised 32 single rooms that had their own toilet and shower. The rooms were of varying sizes, ranging from 35 m² to 48 m².

Patients were eligible for inclusion in the study if they met the following criteria:

• They had a formal diagnosis of a haematological malignancy
• They had experience staying in a single room while they were a long-term (≥7 days) inpatient for treatment of their haematological malignancy
• They were aged 25 years or older (younger patients are treated in a children's hospital).

Potential participants in the haematology ward who met the eligibility criteria were sent an information sheet regarding the study. Forty-two patients were screened and then approached by the student investigator to take part in the study, with 10 eligible patients agreeing to take part. Patients who expressed an interest were given an option of a face-to-face or telephone interview. All potential participants agreed to having the interview in their hospital room. After leaving the information sheet with them to read and understand, they were approached the following day (about 24 hours later) to ascertain their interest in participating, before written informed consent was obtained.

Data collection

All interviews were conducted in patients' hospital rooms. Recruitment and data collection were attended by the same interviewer (EB) between March 2018 and August 2018 by conducting semi-structured interviews. The interviewer did not know the participants, nor was the interviewer involved in their care. An interview guide was developed to expand on the themes emerging from the literature and was refined by members of the research team to reflect their expertise with this patient cohort and in conducting qualitative research. The interview guide was used to assist interviews, with prompts to further investigate answers.

At commencement of the interview, participants filled out a demographic information sheet. They were instructed that the interview could be stopped at any time if they became upset or tired. Interview recordings were transcribed verbatim by one author (EB), with the initial transcripts reviewed by two co-investigators (CM and SM). During the interview process and data analysis, bracketing—acknowledging through documentation one's own experiences and beliefs—was used by the student investigator as a way of strengthening the research by keeping a diary to minimise the risk of imposing their own values or knowledge on that of a participant.

Data analysis

Transcripts were re-read several times to gather the fundamental meaning of the interviews, following Colaizzi's (1978) seven-step analysis as follows:

• Each transcription was read and re-read to determine the general meaning of the content
• The transcript was searched for statements associated with the phenomenon, and these were recorded
• Meanings were formulated from the statements
• Meanings were organised into categories, clusters of themes and themes
• The findings were integrated into a description of the phenomenon
• The findings were refined into a final structure of the phenomenon
• Validation of the study was sought from all participants.

Transcripts were sent to participants via email and mail, as per preference. No feedback or further comments was received from participants. Coding of transcripts was performed in NVivo software. The investigators determined data saturation when new or original codes ceased to be generated from the data.

Findings

Ten participants were recruited and consented to participate. They had a range of haematological diagnoses, including multiple myeloma (n=4), diffuse large B cell lymphoma (n=3), Hodgkin lymphoma (n=2), and chronic lymphocytic leukaemia (n=1) (Table 1). Time as a cancer patient since diagnosis ranged from 3 months to 11 years. Because of the differing diagnoses and length of time as a patient, there were individual variations in participants' treatment regimens and patients were at different points in their cancer journeys. At the time of the interviews one patient was being discharged following a stem-cell transplant, another was being discharged after chemotherapy, three patients were actively having a stem-cell transplant, another three were actively having chemotherapy treatment, one had colitis as a result of previous chemotherapy, and one was persistently febrile and not having therapy. Time spent in hospital ranged from 7 to 21 days at the time of the interview. Six participants were male and four were female. Their ages ranged from 31 to 69 years, with an average age of 56.

Four major themes emerged from the participant data to explain the impact that the single room has on a haematology patient (Table 2).

A theme of ‘privacy’ was derived from the data and revealed three subcategories of ‘access to own toilet’, ‘infection control’ and ‘silence’. Another theme was ‘isolation’, which included subcategories ‘expectation of loneliness’, ‘isolation for self-preservation’, ‘questionable reciprocity of social contact’ and ‘reliance on the healthcare team for social contact’. A further theme of ‘independence’ produced the subcategories ‘control of environment’ and ‘creating a environment for healing’. Finally, the theme of ‘enabling sleep and relaxation’ emerged within the data collected. Each theme with subcategories is represented by quotes from participant interviews.

Theme 1:

Privacy

Within the context of the single room, privacy was described by many of the participants to be one of the main benefits. Patients considered that privacy was a right that having a single room could guarantee. At times the term ‘single room’ and ‘private room’ were used interchangeably.

‘A single, private room for me. Not just for me, but for every patient because I believe that, even though we're coming into hospital, we still need that privacy.’

Participant 8

Elaborating on the theme of privacy, participants described this as not being disturbed by others, as well as not being privy to the sensitive details of those with whom they might share a room.

‘His whole family would come in and there'd be about 14 of them, jammed around his bed … They'd be talking and chatting and carrying on … you have no privacy.’

Participant 2

More particularly the subcategories of ‘access to one's own toilet’, ‘infection control’ and ‘silence’ were derived from within this data.

Silence

Highlighted within the context of privacy, single rooms provided silence. Although the concept of silence crosses other themes, such as ‘independence’ and ‘enabling sleep and relaxation’ within the data, silence is articulated as being integral to privacy. Patients described it as a preference that comes with having privacy.

‘If you are sick, sometimes, you don't want to hear nobody and that's the beauty of a single room.’

Participant 3

Infection control

The necessity of maintaining an environment that prevented the spread of infection that could be detrimental to the health and treatment of patients was identified. Patients discussed having privacy as related to reduced stress associated with worrying about getting an infection from other patients or their families.

‘It reduces a lot of stress. I think if I wasn't here [in a single room], I would be in a lot of stress if I was surrounded with other people. Especially knowing your immune system is down, and you can get sick really easily … you've got this extra thing you have to think about. And that's the last thing you want when you're surrounded by other people who could possibly pass on other stuff.’

Participant 8

Patients also discussed the privacy of a single room as being a deterrent to passing on an infection to others. They used the privacy of a single room to manage their own family or friends who may have colds.

‘I even have to limit the number of them [my relatives] who come and visit because they've got colds. I've got grandchildren who go to crèche.’

Participant 4

Access to own toilet

For many, the benefit of having a single room was having an en suite toilet and bathroom. Participants expressed an appreciation of having their own private toilet, as the treatment they received often led to an urgent need to use it.

‘I had to get up every 15 minutes for the toilet. I just had to get up and go. Because I've been so sick, I haven't had to worry about anything else … I can just get up naked or just pee in a bottle when I have to.’

Participant 9

Not having to be mindful of disturbing others with an untimely need for the toilet was mentioned, as well as the issue of embarrassing sounds and smells. A private toilet also meant that cleanliness was not an issue.

‘I've got my own bathroom and I don't … I think all the hygiene kind of stuff—you don't have to worry about.’

Participant 8 Theme 2:

Isolation

As well as the benefits of being in a single room, the interactions with other patients on the ward, or lack of, were discussed. There was a general consensus that the price of privacy was loneliness and, although participants were oriented to communal places on the ward, there was some reluctance to using these spaces to mix with their peers. Subcategories identified within the concept of isolation were ‘expectation of loneliness’, ‘isolation for self-preservation’, ‘questionable reciprocity of social contact’ and ‘reliance on the healthcare team for social contact’.

Expectation of loneliness

Depending on participants' prior experience in hospitals and the presence of social networks, loneliness was an expected consequence of having a private room. Patients reflected on feeling less lonely in previous experiences when they had shared rooms. Some reported that they had few social networks near them and had to deal with feelings of isolation, whereas others who had frequent visitors did not feel the need to extend themselves to interacting with other patients.

‘[In a shared room] You can just contact the person through the curtain, and you don't feel so lonely. But, in a single room, you feel like you're the only sick person in the world. When you're there [in a shared room] you realise you're not the only sick person. You appreciate what you have when you see sicker people.’

Participant 9

Isolation for self-preservation

There was a tendency for participants to want to isolate themselves in order to concentrate on themselves rather than seek out social connections with others.

‘It's a very vulnerable time. It's a disease that makes you shut down your social feelers. All your energy is going to looking after yourself, so that going out there and connecting with other people isn't there, other than with your family, friends and staff.’

Participant 10

Although patients did engage with other patients on the ward, it tended to be quite casually when passing in the corridor, rather than sitting down and sharing information or experiences, to allow energy to be reserved for self-healing.

‘But you can't get too close to some of these guys because you got to deal with your own box and dice.’

Participant 4

‘It's just “G'day”. “Oh, g'day” … yeah, they don't want to get personal. They'd rather this horrible thing went away, and they could just forget about it. That's the way I see it anyway. There might be people out there making great mates, but I haven't seen it.’

Participant 7

Although, at times, there was a willingness to want to impart knowledge and to support other patients, patients often felt unable to do so due to distress associated with their own disease or treatment. Patients also expressed a willingness to be a resource for others when they felt better or were healed.

‘I'm happy to be involved and share what I've seen, and I've experienced, but I feel at this stage I'm ready to not do that … I'm ready to be on my own and be peaceful and calm.’

Participant 2

Questionable reciprocity of social contact

There was reluctance of patients to approach other patients in the ward, lending itself to isolation. The willingness to want to engage with others was, at times, overridden by feelings of possible rejection or perceived unwillingness on the part of the other patient.

‘Maybe some of them, they don't like it [the contact], that's what I'm scared of, you know?

Participant 1

‘People don't seem keen to engage in conversation. I've gone down to the common room and sat there and people pretty much keep to themselves. Maybe the sort of illness is a bit embarrassing for people, you know, cancer's the horrible one: “the big C”.’

Participant 7

There was also the assumption that other patients on the ward were feeling as vulnerable as the participant, and it would not be helpful to engage with them.

‘The peer support isn't here. It isn't, in here. The peer support, in my point of view, isn't from people who are in the same sort of stage as you are … they are weak and vulnerable, and they are unsure what is going to happen. The peer support has come from other people that I've found out have had cancer before, and have gone through the radiotherapy, have gone through the chemotherapy. That's where the peer support comes from, OK?’

Participant 10

Reliance on the healthcare team for social contact

Although not wanting to bother other patients on the ward, patients relied on members of the healthcare team to fill the void of isolation, with a general understanding that, although not always available right at the time, ward staff such as nurses and sometimes doctors would be present if called upon.

‘When I've needed company or support, it's been there at the click of a finger … I get a response, I get support.’

Participant 9

‘I just ring the bell to the nurse [sic]. Sometimes they don't come straight away, but I believe they are busy.’

Participant 1 Theme 3:

Independence

The importance of a single room contributed to feelings of independence within the hospital environment. Independence was related to the subcategories of being able to take ‘control of the environment’ and ’creating a space for healing’.

Control of the environment

To be able to control one's environment meant that patients felt free to come and go as they pleased. Not having to negotiate other patients meant they could focus on recovery and healing independently.

‘I think for getting better, a solitary room is much better because you can just focus on, ok, I don't have to listen to anyone, I don't have to put up with other people, people's smells and noises. I can just lie here and go: “OK, I can focus on getting better”.’

Participant 7

One participant likened having a space that you can control as a ‘home away from home’. Furthermore, patients felt that they did not have to ask permission or seek the approval of roommates to be able to do what they wanted.

‘If I want to go outside, if I've got the strength to be social, I can. But if I don't—it's brilliant. I come back here, I can do what I want. I can go to sleep.’

Participant 4

Creating an environment for healing

An environment that participants felt promoted healing was central to being in a single room. Noise levels, smells and other people's personal tics could be avoided to create an environment where the patient could focus on getting better. Patients who had been in shared rooms reflected on past experiences in establishing ideas.

‘There might have been occasions when I was in a shared space and I wasn't so happy with who I was put next to, whether it was a big snorer or someone who smoked. That's a problem for me, because the smell from two rooms away is too much for me … but those were transient.’

Participant 2

‘It was so interesting, but annoying [laughs]. They had this same habit where at 2 o'clock or 1 o'clock at night they had to wake up and start doing—cleaning their drawers and their cupboards and all that, and open all the curtains and the blinds. And, of course, I did get a bit crabby one night and I went out and said to the nurses: “Listen, I'm here to recover, I'm not here to listen to someone do their washing or clean their drawers”.’

Participant 9

To create a space for healing, patients seemed aware that having their needs met might encroach on the space of another if they were in a shared space.

‘I listened to music. I had my little computer there with speakers, which I think I played day and night. I'm sort of beyond the reach of it now, but for years I've done that, and it's been really nice to be able to do that in hospital if I need to, just have it playing very quietly through the night. I've used that a lot and I really appreciate having my own space to do that.’

Participant 2

This culminated in the patient being able to have their own space, so social connections, within the patient's existing networks, could be maintained.

‘It's easier for people to stay. You can have many people in the same room, even if it's just blokes in the same room, and it's very hard for family who want to stay.’

Participant 4

‘You talk on the phone with your relatives at any time. It's much better, you don't interrupt no one [sic].’

Participant 1 Theme 4:

Sleep and relaxation

It was identified that ‘enabling sleep and relaxation’ was integral to patients being able to both recover from treatment and as a means to cope with treatment. A single room facilitated opportunities for sleep and relaxation at any time of day or night, so that, rather than it being solely an issue of privacy, it meant that patients were able to defy the natural rhythms of the hospital environment, which can be very busy during the day, and to catch up on sleep, if needed.

‘To sleep, it helps me a lot because time goes very quickly.’

Participant 1

‘Because it's quite intense and you need a lot of time to relax and recover—it's not like any other type of medicine.’

Participant 4

Discussion

The current study has highlighted the value in examining the experiences of haematology patients experiencing a long stay in a single room in an acute facility. The study has shown that patients' experiences of having the use of a single room facilitate privacy, provides them with autonomous space to recover, and enables them to maintain connections with existing social circles as well as with staff. The study also reveals the desire for a self-controlled environment that restricts spontaneous social connections.

A qualitative design that was informed by phenomenological tenets was adopted from which rich data were harnessed from haematology patients regarding their experience of staying in a single room. These results add to previous findings on the experiences of staying in a single room undertaken with other patient populations, which explored how a private room affected privacy, dignity and infection control measures (Chaudhury et al, 2005; Persson et al, 2015; Bloomer et al, 2016; Maben et al, 2016).

The results of the present study have indicated that, as long-term patients, the haematology population feels vulnerable when undergoing intensive treatment regimens. This, in turn, has led to the perception among patients that a single room is a means of maintaining privacy and autonomy—concepts that were perceived to be a patient's right. Although previous studies in a range of different settings have similarly indicated that patients prefer single rooms (Taylor et al, 2018), the preferences of long-term haematology patients have not been explored, with the exception of those in protective isolation (Annibali et al, 2016; Biagoli et al, 2016).

The interview data elicited in the present study shows that all participants preferred staying in a single room while having treatment as an inpatient, despite describing the shortcomings of the space, citing issues such as isolation and loneliness.

Privacy was a central theme that emerged from the data. Patient statements showed that they considered privacy to include a space that provided silence and that was free from possible contaminants, such as waterborne and airborne pathogens and fungi, brought in by other people. The private toilet space that came with the single room was appreciated for the dignity it provided during moments of sudden onset of vomiting or diarrhoea.

Isolation sometimes occurred as a result of such privacy and this was also a key finding. Analysis of the data collected from participants showed that they had expected to experience loneliness while in hospital, as they considered that self-preservation was a necessity during periods of sickness. Isolation led to patients becoming worried about approaching others on the ward and, instead, they relied on staff for social contact.

Another key finding was that of independence. Patients found that staying in a single room meant they did not have to negotiate other people or their families, which made them feel more independent to come and go, to create a space for healing and to have control of their environment.

Finally, a single room offered opportunities for sleep and relaxation, particularly for patients who needed to sleep during daylight hours.

The current study has identified that patients accepted the isolation they may experience as a reasonable trade-off for a certain level of loneliness. Further, because patients had a range of diagnoses and were undergoing different treatments at different times, they reported a reluctance to approach other patients or to engage in meaningful information sharing with other patients. Although there is evidence that patients benefit from talking with other patients who have been through or are going through similar treatments (Dennis, 2003), further investigation is required to substantiate any negative psychological impacts from the isolation and the loneliness experienced by this cohort of patients. Should it be demonstrated that patients' mental health and wellbeing is negatively impacted, a range of strategies could be pursued to alleviate this, including group drop-in sessions, a shared communal space on the ward or triggers that invite interactions (ie putting a sign on their door if they wanted other patients to visit).

This study has further identified implications for the healthcare workforce, and especially nurses, caring for haematology patients. Study participants staying in a single room experienced loneliness, and frequently relied on nursing staff to address their social deficit—a strategy that can place both time and professional pressures on nurses. Neutropenic patients experiencing extreme fatigue and illness require more psychological support during treatment, as noted in previous studies (Beattie et al, 2013; Swash et al, 2014), and this can place greater demands on healthcare staff. The results of this study prompt further consideration of the impact of single-room design on patients and staff, which could, for example, examine whether nurse-to-patient ratios for haematology patients are adequate and whether the training and support needs of this workforce are being met.

The findings of the present study have uncovered potential areas of interest that could be explored in subsequent research. Due to the deficit of robust research on the psychological needs of haematology patients in general (Swash et al, 2014), further investigation could be undertaken to determine when psychological support is most needed by haematology inpatients staying in single-room wards. Quantitative measures could add strength to support the research. Investigation of the nurse perspective of supporting haematology patients while they are being treated in single-room wards would produce a greater understanding of the workload involved in planning and assisting this patient cohort. Research investigating the experiences of haematology patients from different age groups would produce greater insight into the difference and similarities between child, adolescent and adult populations and their needs while staying in a single room. Finally, evidence as to whether single rooms help to reduce hospital infection rates would continue to illuminate whether this perceived healthcare benefit of single-room design is substantiated.

There are several limitations to this study, which could be addressed by further research. Although it was perceived that data saturation had been reached and no new themes were emerging after 10 interviews, the sample size of the current study was small, and the participants came from just one metropolitan Australian hospital. The design of the hospital where the study was conducted may be different to that of other cancer hospitals in the country or internationally and, therefore, the results are not directly transferable to a broader haematology population. Although participants reported their experiences at different stages in their treatment, the study design did not account for changes in perceptions over time. Patients who were interviewed 5 days into their hospital stay may not have been able to articulate their entire experience, which might have happened had they been interviewed at the end of their stay.

Conclusion

This study showed that haematology patients perceived that staying in a single room as an inpatient was beneficial, creating an environment that enabled them to maintain privacy. Establishing privacy provided patients with a space to rest and heal, to sleep and to be with family, and a space that they could control and where they had autonomy. However, these benefits come with the risk of experiencing isolation and loneliness. Future work examining the impact of isolation and loneliness on patient wellbeing is encouraged and, if substantiated, could prompt the development of novel approaches to reduce patient isolation and create opportunities for social contact during their inpatient stay.

KEY POINTS

• There is a trend towards single-room designs in acute care settings
• There is a lack of extensive research on the impact of single-room design for patients, especially for those who are there for long stays
• Long-stay haematology patients expressed a preference for single rooms for a variety of reasons, including privacy and independence
• Isolation and loneliness was an accepted consequence of staying in a single room

CPD reflective questions

• Consider the needs of long-stay patients. How can privacy and control over their space be enhanced when patients need to share a room?
• Think about which systems, process and supports could be implemented to reduce the isolation of patients staying in single rooms
• Consider how a single-room design impacts on the workflow of interdisciplinary teams. What are the implications of single rooms for the way that interdisciplinary teams co-ordinate care?