by Fidelindo Lim, DNP, CCRN & Vince Tran, BSN, RN
Your “new” room is now ready. Hospital room, that is. The architects are finally catching up with designing and re-designing hospital rooms that could match the suites of the local Marriott, with a built-in perk of making the patient feel better. In August this year, a front-page article in the New York Times (this must be important) extolled the growing trend of curating hospital rooms, this time with the nurses’ input and the patient’s well being in mind. Of course, this is not a revolutionary concept and the author wondered why it has not been the standard all these years.
The Times reported that in the new room, there was a 30 percent reduction in patient’s request for pain medication, patients in the new rooms rated the food and nursing care higher compared with patients in the old rooms, although the meals and care were not different (Kimmelman, 2014). And, oh yes, patient satisfaction scores are improved in the new space that’s lauded as “simple, airy and visually arresting”.
So this nurse walks into a patient’s room…
Imagine this. You walk into a patient’s room that’s larger than an average Manhattan studio apartment. It has floor to ceiling windows with a water view, subdued lighting, artwork, an oversized sofa and a 40-inch flat screen TV (on with no one watching, of course). You scan the room as good nurses do and what “arrested” your field of vision? On the bedside table are empty nebulizer “bullets”, half-empty saline flushes and some unused ones, medication wrappers, empty intravenous medication bags, an insulin syringe cap and a cup with what looks like serousanguinous fluid. You realized the patient is not able to turn her head to see the water view, but smacked in front of her is trash - the detritus of patient care. You sigh. With that, you detected a smell of an unidentified effluvia of bodily discharges you suspected emanated from the miasmatic trash bin. Suddenly you feel tired and it’s only the first hour of your shift.
Nurses often lament the lack of workspace and the outright bad design of some hospital rooms that have outlived customer-service demands. We are now seeing modern patient care spaces that are meant to reinvigorate the patient and staff but the flow of healing energy is blocked or soaked up by clutter and trash – notable for throwing the room’s Feng Shui off balance. Sound design can only go so far in fostering a healing environment around the bedside. People who enter (hospital staff) the room and the clutter they leave behind influence the overall “architecture” and ambience of the space.
Preventable side effects of health care
Bedside clutter is the collateral effect of modern-day patient care. In spite of technological advances in health care (or maybe because of it) the tide of trash-clutter washing ashore at the patient’s bedside shows no signs of retreating. No wonder the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey asks patients to rate how often their room and bathroom were kept clean during their hospital stay (HCAHPS, n. d.). National data suggest that there is plenty of room for improvement. Nationwide, cleanliness ranks an average of only 73% compared with 85% on quality of discharge teaching (HCAHPS, 2014). Could it be that what patient’s consider an unclean room or bathroom simply meant cluttered and disorganized surroundings that may not necessarily be unclean?
We don’t need a randomized control trial study to inform us that clutter around work environments is a threat to patient safety. They can cause accidents, compromise body mechanics or simply make work more inefficient. The effect of clutter at the bedside and the nurse’s role in mitigating it is best illustrated by the observations of Florence Nightingale (1860):
“I once told a ‘very good nurse’ that the way in which her patient’s room was kept was quite enough to account for his sleeplessness; and she answered quite good-humouredly she was not at all surprised at it – as if the state of the room were, like the state of the weather, entirely out of her power. Now in what sense this woman to be called a ‘nurse’?” (p. 45).
A nurse might demure in doing a bit of housekeeping, invoking that it is “not my job.” However, in the greater scheme of culture of safety, keeping the bedside clutter-free is everyone’s concern, including the patient and their visitors.
Perceptual Awareness: Look, listen and de-clutter
Keeping the bedside tidy and uncluttered need not be a Sisyphean ordeal. We can simply tag it along hourly rounding visits to the bedside (hourly rounding is another one of those “new” initiative we should have been doing all along). If the golden rule of patient safety is first “Do no harm”, we propose that the best way to keep the bedside clean is first don’t make a mess. Here are some suggestions, based on the guiding principles of refuse, remove and refresh – the three “Rs”, on how to maintain a healing environment at the bedside and beyond:
Refuse (to clutter)
To keep the bedside and other work areas free from clutter, be aware of the materials required for each task. Nurses often share an affinity to being efficient, highlighted by the common practice of gathering saline flushes, sterile caps for infusion lines, tape, and a plethora of items commonly used in a normal day-to-day shift. While this practice is highly time-saving, being conscientious about the use and disposal of materials will help minimize potential clutter. Whenever choosing a practice that makes caring for patients more convenient to a nurse, refuse to allow such practices from infringing on the patient's often-limited personal space. A nursing mantra could be “I refuse to horde supplies at the bedside.”
And although preventing the accumulation of medical supplies may minimize potential clutter, this suggestion cannot ensure the cleanliness of a patient's room. Due to common interactions between a patient and his or her environment, other personnel including healthcare workers, visitors, and at times the patient, may unintentionally leave clutter at the bedside. This is where hourly rounding is necessary, a time when a nurse can assess a patient's environment and remove impediments of therapy. While hourly rounding is traditionally meant to ensure physiologic needs are met, the extra step of removing clutter in a patient's room can provide wondrous effects on patient outcomes.
After a patient's bedside has been decluttered, a patient may still benefit from refreshing the room. Bear in mind that patient's lengthy stay in a hospital may often be the culprit of a patient's irritability. Simply recall a time when you had felt uncomfortable staying in a hotel or in a friend's guest room for an extended period of time. While the area may be pristine, a hospital room can never emulate the comfort of being in one's own home. A nurse may help refresh a patient's room through using aromatherapy, rearranging some furniture to the patient's preference, or even remaking a patient's bed. While these tasks may seem of little importance, these gestures are often what patients remember, especially for those whose length of stay exceeds a few days.
Keeping a patient's room clean and orderly is one of many ways that nurses exemplify the promise to not only treat diseases, but to also treat patients. There are obvious benefits from keeping a patient's bedside free from tangled IV lines, but let us not forget the psychological benefits of feeling at ease in one's temporary home away from home.
Nightingale reminds us that “the well (hospital staff) have a curious habit of forgetting that what is to them but a trifling inconvenience, to be patiently ‘put up’ with, is to the sick a source of suffering, delaying recovery, if not actually hastening death (Nightingale, 1860, p. 52). Let us keep the bedside clean and clutter free – it does the patient good.
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). (n. d.). HCAHPS Survey. Retrieved from http://www.hcahpsonline.org/files/HCAHPS%20V9.0%20Appendix%20A%20-%20Mail%20Survey%20Materials%20(English)%20March%202014.pdf
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). (2014). Summary of HCAHPS survey results October 2012 to September 2013 Discharges. Retrieved from http://www.hcahpsonline.org/files/Report_July_2014_States.pdf
Kimmelman, M. (2014). In Redesigned Room, Hospital Patients May Feel Better Already. New York Times, August 21, 2014.
Nightingale, F. (1860). Notes on nursing: What it is and what it is not. London: Harrison and Sons.