Final report: Fit for purpose? OrganisationaL prOdUctivity and woRkforce wellbeIng in workSpaces in Hospital (FLOURISH): a pilot study

Background and Aims: Good workspace design is key to the quality of people’s work, safety, and wellbeing (happiness, health and productivity), and yet the healthcare workforce is rarely consulted about how workspaces should function. Consequently, we lack vital knowledge about optimal hospital design in line with workforce need, to impact positively on employees’ safety and good care delivery. Hospitals are currently designed more according to Work-As-Imagined (WAI) than Work-As-Done (WAD). WAI is based on a managerial understanding of how work is performed, whereas WAD is what actually happens in the workplace. This innovative study aimed to examine WAD and the effect of workspace-use on healthcare professional practice, health and safety, and productivity.
Methods: Between June 2018 and April 2019 a textual and visual qualitative, in-depth assessment took place of one Australian, private, university hospital’s gastroenterology surgical unit. It involved 50 hours of observations and informal interviews with employees and patients crossing hospital spaces (mobile methods), and the interpretation of five architectural plans and 45 photographs of spatial use. Researcher fieldnotes were analysed thematically, and visual data were analysed using a predefined visual taxonomy. Overarching themes and categories were considered in combination to build an iterative and dynamic picture to address the study aims around workspace-use, spatial management and workforce experience, including people’s perceptions of health, safety and productivity.
Results: Drawing on a mobile methodology, the innovative, qualitative study revealed spaces that both support and hinder WAD. In this study, fit-for-purpose spaces allowed effective doctor-patient communication to take place, and for people to work and function in relative comfort and privacy, harmoniously through a shared understanding of each other’s roles and responsibilities, while high-quality care and the maintenance of sterile practices could be upheld. Unfit-for-purpose spaces, characterised by cold temperatures, crowded and uncontrolled surgical areas, and the lack of private space resulted in physical discomfort for staff, disrupted work practices and threats to the maintenance of sterile spaces and practices and team collaboration and harmony. Despite this, most staff creatively found ways to manage unfit-for-purpose spaces, adopting new habits and approaches – ‘workarounds’, and accommodating one another, while altering clothing to keep warm and purposefully bounding spaces, according to their body-language and spatial management, to ensure they were perceived by others as ‘private’.
Conclusion: Arrangements of fit-for-purpose and unfit-for-purpose workspaces, and their effects on health, wellbeing and productivity, as well as their impact on safety, workspace-use and experience highlight important considerations in hospital workspace design. In this study the gastroenterology team’s use of surgical theatres, clinical and non-clinical spaces were illustrative of the way that people manage their working lives. The study data indicated how people can be negatively affected by unfit-for-purpose spaces, with workarounds demanding more time and ingenuity to carry out even the most routine functions. Results also indicated the need to creatively expand spatial options, so that alcoves become offices and theatres become walkways, not only to ease surgical patient throughput but also for more general professional access, enabling people to function effectively while moving fluidly from one space to another.
While new habits and approaches can help staff circumvent the negative implications of unfit-for-purpose spaces and inappropriately-placed objects within them, they can also lead to unexpected consequences. These include staff regularly ‘rewriting the rules’, talking during difficult operations, crossing sterile boundaries and sharing confidences in unexpected ways. This can lead to staff going ‘rogue’ – making autonomous decisions, reinventing spatial layout, and redesigning the functionality of different spaces, adapting clothing for more sustained precision medicine practices, such as those taking place in the operating theatre. Only through adaptation and flexibility, within the setting where unfit-for-purpose spaces abound, can everyday working practices be maintained.
Recommendations: We offer three recommendations to ensure the reduction of unfit-for-purpose spaces and the growth of fit-for-purpose spaces across both clinical and non-clinical areas: 1) the inclusion of small, private spaces on surgical wards aligned to operating theatres to ensure people have the necessary privacy to function effectively, and more consideration of privacy within shared spaces, where people react according to their close proximity not only to the work in hand, but also to one another; 2) hospital clothing that is well-maintained and suitable for the purpose for which it was designed (this will reduce the opportunity of contamination across sterile and unsterile spaces and lead to greater pride in group identification); and 3) better ergonomic use of objects in spaces, (the implications of which need further thought), to ensure the workforce are able to conduct their work in comfort, harmoniously, and to the benefit of both the team and the patients under their care. We recommend this report is shared for greater awareness of vital improvements to spatial use and function, with the aspiration that fit-for-purpose, high-quality and safe spatial practices can be increased in these critical theatre areas.
Reducing waste and reconsidering what might be inappropriate spatial use, according to team functioning and group and personal wellbeing, will improve the safety of patients and staff. This is particularly evident when staff attempt to operate on patients in cold spaces that lack clear boundaries between sterile and non-sterile spaces. Furthermore, beyond the operating theatre, when privacy is lacking and personal space is makeshift and tenuous, this has ramification for reduced productivity and wellbeing, with the potential to lead to more strained interactions with others.
The three recommendations we outline above include the need to construct smaller, more adaptive and protected workspaces within surgical units, to make adjustments to the design of hospital attire to suit theatre temperatures and to consider which are the sterile spaces and how sterile practices could conform better to those sterile spaces, such as the need to relocate air-conditioning units. This study also illustrates how innovative, mobile methods are an effective tool for investigating WAD. Mobile methods offer a clear understanding of what workforces are actually achieving in hospitals as different groups of people situate themselves within or across different types of clinical and non-clinical spaces, while data captured using mobile methods can enable the formulation of recommendations for hospital designs that have the potential to transform hospitals into better-quality, safer places for all concerned.