Learnings from Sweden on designing for staff wellbeing

The hospital environment is not often considered in terms of its impact on staff wellbeing. Most staff support policies are associated with mental health, flexible work, food provision, and protected breaks, rather than the work environment itself. However, there is a correlation between staff stress and satisfaction and patient satisfaction — if staff satisfaction is high, then patient satisfaction will also be higher; if staff are unhappy, patients are unhappy.

Current staff space provision across the NHS is generally poor. Facilities are institutional, uncomfortable, and frequently over-occupied (consider that the NHS full-time staff count has increased by 92,000 since July 2019, while staff areas have not increased, and administrative spaces are frequently repurposed for additional clinical requirements). Typically, the priorities are functionality and durability over comfort and respite.

Built environment’s impact on the workforce

At a time when NHS staff have never been more dissatisfied, and with over 40,000 nursing vacancies to fill, it is essential that Trusts up and down the country consider the role and impact of the built environment on the workforce. Estates managers, Capital Projects directors, architects, and designers need to work together to implement powerful interventions. Wholesale redesign is not always required — there may be small interventions that can have a big impact.

What, however, do we know about designing for staff in healthcare settings? There is appetite within the NHS to improve staff wellbeing; it is explicitly mentioned in the Elective Recovery Plan (February 2022) and the NHS health and wellbeing framework (November 2021), but it is not often linked to the built environment. The framework discusses the environment in terms of safety, while the Recovery Plan indicates that supported staff are more able to innovate. The NHS has already implemented policies to support staff mental health, but the spaces in which staff work and rest also need to be considered for the greatest effect.

Numerous studies have revealed the impact of workplace design on employee attraction, productivity, satisfaction, and retention. These studies have informed the WELL Building Standard, and have also helped companies understand the importance of the work environment on their bottom line.

Focus on traditional office jobs

This research has been overwhelmingly focused on traditional office settings and desk jobs. While there are some studies on healthcare work environments, they tend to be small, survey a specific user group, and are rarely conducted within the NHS. Although basic biophilic principles of daylight, nature, and circadian lighting are transferable from office to healthcare workplaces, healthcare staff are often placed under significant emotional and physical strain, and require some other, more specific features and considerations. The following are key features that could have a big impact, based on studies undertaken so far:

Outdoor space: Garden breaks for hospital staff have been found to be significantly more impactful for reducing sadness and stress than indoor breaks.
Resilience rooms: ‘Wobble rooms’ have been found to reduce emotional distress in users by up to 50%. However, they were found to be least impactful for staff who already self-reported the highest levels of burn-out, suggesting that early intervention is required.
Visual privacy: While having facilities on or near a ward/department is beneficial for access, ensuring visual privacy from patients and their families is vital to prevent pressure to return to work too quickly and not take the full deserved break.
Acoustic privacy: Acoustic design is important to prevent the intrusion of departmental noise and hinder the ability to properly escape and switch off. ‘Switching off’ has been found to benefit staff health, and lower fatigue levels and emotional exhaustion, while high noise levels have been shown to negatively impact healthcare staff stress and satisfaction across multiple studies.
Soft furnishings: Comfortable and non-institutional furnishings to provide a sense of home enable a complete escape and mental break from the pressures of the job.
Facilities for food preparation and eating should be provided proportional to the number of staff using the space.

Incorporating these (sometimes fundamental) elements can reduce staff stress, sickness, and turnover, while improving retention. In addition to improving the wellbeing of NHS workers, there is also an argument that implementing these interventions will have benefits for patients. Research conducted by the NHS in 2016 found that staff pressure, stress, and satisfaction (among other things) are predictors of overall patient satisfaction.

So, while it is understandable and even admirable that patient care and wellbeing have historically been the priority, when thinking about the built environment, it is equally important to invest in staff areas to support their wellbeing.

Examples from Sweden

Healthcare staffing shortages are not an issue unique to the UK. The WHO estimates a projected shortfall of 10 million health workers by 2030, and emphasises that countries at all socioeconomic levels face difficulties. Sweden is no exception. Official data reports that there are nursing shortages across 80% of the healthcare sector.

My Scandinavian colleagues report that staff wellbeing in the workplace is taken very seriously, and carefully addressed in most healthcare projects. This is due to Health Regions (equivalent of NHS Trusts) being aware of the huge challenge they face with regard to staffing, especially in more remote regions, and that workplace design can form part of the solution. Meanwhile, most regions are also struggling with financial issues; the ROI is always at the forefront of design decisions.

In this context, architects at White undergo extensive co-design processes with users to ensure that staff, as well as patient, needs are taken care of. The following examples from across Sweden demonstrate how staff spaces have been considered and designed in contemporary healthcare settings.

Huddinge extension

The Karolinska University Hospital, Huddinge, is a 30,000 m2 extension comprising 23 operating theatres, eight interventional rooms, and a new imaging department, as well as an 8,000 m2 redevelopment of the existing pre- and post-operative care facilities. The project placed a significant focus on the working environment, on the understanding that it would be crucial in attracting and retaining motivated and competent staff. Daylight, views to nature, and integration of artwork, were emphasised throughout the facility, with all staff areas looking out over the surrounding park. The acoustics of staff working areas were also carefully considered in an attempt to reduce burn-out and absenteeism in a challenging and physically demanding role.

Memory clinic’s access to outdoor space

Minneshälsan is a memory clinic affiliated with Skåne University Hospital within a 16,000 m2 mixed use development in central Malmö. The memory clinic staff were very keen that their patients and staff should have access to outdoor space while there. Together with a team of researchers from the Swedish University of Agricultural Sciences, psychologists, doctors, and other healthcare professionals from the Minneshälsan clinic, White Arkitekter created a unique therapeutic roof top garden. It was important that several people could use the garden while maintaining privacy and solitude. The design therefore provides a variety of secluded spaces using planting and built elements of varying characteristics. The garden can also be used for therapeutic yoga, stress management, and therapeutic cultivation. It is an excellent example of what can be achieved in a dense urban setting with some creative thinking and ambition.

The 35,000 m2 state-of-the-art extension to the existing Queen Silvia Children’s Hospital in Gothenburg included a new surgical department, expanded intensive care unit, and additional single-patient rooms. The new building features a separate area for staff to rest, but also to carry out non-patient-focused work, providing opportunities for collaboration, meeting, and research. There are staff provisions within the departments, but staff have indicated appreciation of having the option to choose where to go depending on their time, need, and preference. All the staff areas are filled with daylight, include natural materials such as timber panelling, and soft furnishings, to create a non-clinical atmosphere and promote rest and recovery for staff.

The new Psychiatry Clinic at Södra Älvsborgs Hospital in Borås comprises an emergency unit and inpatient beds for adults, adolescents, and children. It was designed to protect patient integrity and create a calming workplace for staff. The clinic features a range of spaces for staff use, including lounges, dining areas, calm rooms, outdoor terraces, and balconies, and a library space with coffee facilities. When asked for feedback, staff have indicated that they appreciate the option of being able to leave the clinical areas and work away from patients on the non-patient focused tasks. Having this variety and choice is widely valued — staff feel appreciated and taken care of.

Anecdotal feedback only

Unfortunately, the feedback we have on these projects is anecdotal since — as with the architecture industry in the UK — post-occupancy evaluations (POEs) are not standard, and getting fees for the work required is typically difficult. However, these examples are promising, and what these projects repeatedly indicate is that staff appreciate choice — of the type of space in which to work, of being indoors or outdoors, in a busy space or calm space, and to retreat or join in.

POEs are important, as they can contribute evidence to support the value of these different options. The more POE we do, the more we’ll be able to distinguish the needs of different user groups and provide exactly what is needed. It would also help Trusts to apply limited funds with precision, as it would be easier to predict which design choices would have the greatest impact on staff wellbeing, performance, and retention.

White Arkitekter is also working in the UK on multiple projects, including the new Velindre Cancer Centre in Cardiff, where staff wellbeing has been at the heart of the design from day one. ACORN, a consortium with White Arkitekter as the lead designer and led by developer and investor Kajima, has been selected to deliver the Velindre Cancer Centre, which is set to become the UK’s most sustainable hospital. Our approved proposals for the project were developed to ensure that it provides a practical, elegant facility where patients, staff, and the local community can feel welcome and unrestricted, while having the minimum impact on the surrounding environment of Cardiff’s Northern Meadows.

The Velindre University NHS Trust has a range of policies and provisions to support staff wellbeing — including encouraging and enabling staff networks for minority groups, wellbeing support, and complementary therapies, as well as access to a range of digital information and support. The Trust has made it clear that in the new facility, spaces to enable and support these activities are critical, and that their design should be at the heart of the project, not an afterthought.

Staff provision will include both departmental and centralised refreshment rooms, rest rooms, and lounges, a staff wellbeing room for yoga, meditation, and group counselling, and small individual therapy rooms. In addition, active transport will be supported with dedicated, secure, staff bike storage and changing facilities. There will also be a roof terrace, accessible from the first floor, providing an alternative break space for staff in addition to the wider accessible landscape.

In each of these spaces we are paying close attention to the interior design. Furnishings and finishes are being selected to contribute to a relaxing and non-institutional environment, prioritising natural materials wherever possible, the acoustic design will provide privacy, while views to nature and access to outdoor space are emphasised.

Staff survey results

The Velindre University NHS Trust 2020 staff survey results indicated that staff engagement was relatively high but — as with the rest of the NHS staff surveys — respondents are not questioned about their views on their work environment or staff facilities within the hospital. Therefore, in preparation for the POE, we added some supplemental questions to start gathering data on the existing facility. This will be used as a baseline for the new centre. Not only will this research support the Trust in delivering the best support for their staff, but it will also contribute to the body of research on how healthcare staff wellbeing, sickness, and burn-out are affected by the work environment.

Conclusion

There are many issues relating to the healthcare workforce, and we cannot fully address them from within our siloed professions. The hospital environment needs to be considered holistically, as a workplace, as well as a place for patient care, to ensure that staff wellbeing is supported. We know that in looking after the staff, we look after the patients. It is not a case of choosing one over the other.

Currently, staff facilities are frequently institutional, uncomfortable, and over-occupied. There are relatively small interventions and features that we can prioritise to improve this — including providing access to the outdoors, ensuring acoustic and visual privacy, incorporating homely furnishings, and facilitating choice. Further study on the impact of these, and other features, will only strengthen the business case. The NHS is aware of the workforce challenges it faces; including the built environment in its arsenal of solutions is critical to its long-term success.