Original Research

Multioccupancy hospital rooms: Veterans' experiences and preferences

Abstract

Abstract

BACKGROUND:

Although common, multioccupancy hospital rooms have long been criticized for concerns about safety and privacy. In 2006, despite limited evidence, the Health Guidelines Revision Committee recommended to eliminate them entirely from U.S. hospitals. We used a survey to evaluate patients' experiences and preferences regarding room type in order to help inform public policy decisions.

METHODS:

Medical service inpatients at the Washington DC Veterans Affairs Medical Center were asked upon discharge to complete an anonymous written survey containing questions about privacy, nursing availability, loneliness, fear of death, interactions with roommates, and room preferences.

RESULTS:

Of the 162 patients who completed surveys, private room patients were more likely to report adequate privacy (92% vs. 53%; P ≤ 0.01) and available nursing (79% vs. 64%; P = 0.025) than shared room patients. There was no difference in reported loneliness or fear of death. Most shared room patients (59%) indicated that they enjoyed speaking with their roommates, and 35% reported receiving help from roommates. The overall preference strongly favored private rooms (79%), most commonly for the sake of privacy. Patients who preferred shared rooms most often cited a desire for conversation.

CONCLUSIONS:

Patients felt that privacy was inadequate in the shared rooms, and a strong preference was found for private rooms. For those who preferred shared rooms, positive aspects of the experience included exchange of conversation and assistance between roommates. Journal of Hospital Medicine 2009;4:E22–E27. © 2009 Society of Hospital Medicine.

Copyright © 2009 Society of Hospital Medicine

Originally championed in the form of large multibed wards by Florence Nightingale in the nineteenth century, multioccupancy hospital rooms have recently been criticized for concerns about their cost, safety, lack of privacy, and unpopularity among patients.13 Specifically, they have been linked to longer hospital stays and the morbidity that those stays produceinfections, falls, and medical errors.13 In 2006, the Health Guidelines Revision Committee, the body that establishes guidelines for the construction of healthcare facilities in the United States, moved to a position recommending private rooms as the minimum standard for medical/surgical and postpartum hospital beds. The evidence supporting their position, however, has remained limited. Given the substantial cost and effort involved in converting hospital rooms, it is important to understand the impact of such policies on patients.

In a recent literature review by van de Glind et al.,4 the authors were able to identify only 4 randomized controlled trials comparing private and shared rooms. While they found that private rooms had a moderately positive impact on patient satisfaction and privacy, data on infection control was mixed, and data on patient safety was lacking.48 Though suggested, the association between private rooms and shortened hospital stays has not clearly been shown.13, 9 Certain advantages of shared rooms, such as decreased loneliness and increased patient social interaction, have also been identified.10 In addition, specialized multioccupancy wards for dementia and delirium have been demonstrated to be useful in the management of inpatients with those conditions, partly because of increased nursing presence.11 Finally, an additional theoretical benefit of shared rooms is the possibility of assistance between roommates in emergency situations.

For the sake of providing high‐quality patient‐centered care, patient concerns and preferences are also important to consider when establishing health policy regarding rooms. Previously, patient surveys and interviews have been helpful in identifying issues of concern to patients and understanding their preferences. Kirk12 identified privacy, quiet, improved sleep, and ability to have a family member stay in the room as reasons why 18 of 24 hospice patients preferred private hospice rooms.12 Conversely, in a 2002 Welsh survey of palliative patients, 68% wanted to be in an open area (4‐bed bay), identifying companionship as the major reason.13 Most recently, palliative care patients in the United Kingdom expressed a preference for shared rooms while well enough to interact with others but preferred private rooms when very ill or dying.14 These findings, given the lack of solid medical justification for 1 room type, raise multiple concerns about whether universal adherence to 1 room type will lead to the best patient care in the United States, and more specifically the veteran population. First, nearly all of the preference data described has been collected outside of the United States and veteran's populations. Second, studies have targeted highly‐specialized patient populations, and their applicability in a general medical/surgical population is unknown.10, 1217 Finally, the diversity of preferences exhibited in these studies underscores the difficulty in applying preference data to outside populations, such as the veteran population.

With 7.8 million patients enrolled in its healthcare system and operating 153 medical centers, the U.S. Department of Veterans Affairs has a large interest in the ongoing debate about shared vs. private hospital rooms. Because veterans share a common military background, they may place a higher value on companionship relative to privacy, and so they are an important group to study separately from the general U.S. population. To date, we have been unable to identify any studies that have looked at veterans' experiences and preferences in regards to room type. Through an anonymous survey, we sought to learn about these experiences and preferences and assess whether previously found advantages of each room type (eg, companionship in shared rooms, privacy in private rooms) could be confirmed in the veteran population. By doing so, we also aimed to better inform public policy about a general continued role for shared hospital rooms in the United States.

Methods

Our study used a point prevalence survey to examine patient preferences and experiences with shared (2‐person or 3‐person occupancy) vs. private rooms.

Design

From September to November 2007 patients admitted to the Washington DC VA Medical Center medical service (a tertiary care facility, with 76 beds on the medical service, 37 shared and 39 private) were asked to complete anonymous written surveys prior to discharge. Male patients were assigned rooms based on bed availability only, with the exception of those requiring isolation or those receiving chemotherapy, which mandated private rooms. Patients were not able to request specific room types. Planned patient discharges were identified daily by consulting each ward unit's central discharge list. One member of the research team not directly involved in the patient's care would approach the patient to see if he was willing to participate. Participants were asked to fill out the surveys independently, but those who were incapable of doing so due to physical limitations were allowed assistance by family, a member of the research team, or the nurse, if they so requested. Patients were asked to leave completed surveys in provided blank envelopes for pickup by a member of the research team. These were later marked as coming from either private, shared, or isolation rooms. Exclusion criteria included hospitalization for chemotherapy and female sex. Patients who were not able to complete surveys because of cognitive impairment were considered nonparticipants. Although data from patients in private contact isolation rooms was collected, it was left out of analysis, as assignment to these rooms was based upon medical condition rather than solely on bed availability. To account for patients who switched room type during their hospitalization, 1 survey question asked for their predominant room type. Power analysis suggested that a sample size of 70 patients per group would give 80% power to demonstrate differences of 20% (estimated difference expected for key measures) between the groups at a 95% confidence level.

Data Collection

The survey instrument was designed for the purposes of this study as no suitable existing tool could be found. Questions were drawn from issues identified in the literature on loneliness, fear, and anxiety, as well as author hypothesis about potential social benefits of having roommates.1013 Questions included demographics (age, race, education, household income); hospital experiences including adequacy of privacy (Do you feel that the privacy in your room is adequate?), nursing availability (Have you felt that a nurse was available when you needed one?), loneliness (Have you been lonely during this hospital stay?), fear of death, interactions with roommates (Have any of your roommates helped you in any way [like calling for a nurse]?); and private vs. shared room preference. Except for 1 open‐ended question asking the reason for room preference, questions were yes/no.

Data Analysis

Chi‐square testing was performed to determine whether there were any baseline differences between the private vs. shared groups in terms of demographic variables and length of stay; whether room type was associated with differences in perception of privacy, nursing availability, fear of death, and loneliness; and to determine differences in room preference with regard to demographic variables. Fisher 2‐tailed exact testing was performed to evaluate differences in room preference based upon room type, as the sample sizes for this comparison were small. For the open‐ended question, responses were coded into categories by 1 research team member (W.E.) and reviewed by another team member (K.C.). Consensus was reached through discussion.

The protocol received exemption from Institutional Review Board oversight and approval from the Research and Development Committee.

Results

A total of 162 surveys were completed with a participation rate of approximately 73%. Eighty three patients (51%) reported a shared room stay, while 70 patients (43%) reported a private room stay (17 of which were isolation). Nine did not report room type (Figure 1). Excluding isolation patients and those respondents who did not indicate room type, 5% of respondents reported age less than 45 years, 56% between 45 and 65 years, and 39% greater than 65 years. Sixty percent of patients identified themselves as African‐American, 28% as white, and 5% as other (7% did not answer). The majority (56%) reported having some formal higher education after high school. Median total household income was between $11,000 and $20,000.

Figure 1

Flow diagram of patients through the study.

Private vs. Shared

Comparison of demographic information between the private and shared groups revealed no significant differences in age, race, education, or income distribution (Table 1). There was also no difference in reported length of stay. Because some respondents failed or declined to answer certain questions, the number of responses reported for each category varied. Notably, 79% of patients staying in private rooms reported that they had been in shared rooms before, while 78% of patients in shared rooms reported that they had been in private rooms before, indicating that both groups were familiar with each type of room.

Population Characteristics
Private (n = 53) (%)Shared (n = 83) (%)P Value*
  • NOTE: Not all percentages add up to 100% due to rounding.

  • P value based upon chi‐square testing.

  • Previous stay in a shared room for private room patients and vice‐versa

Age (years) 0.63
<453 (6)4 (5)
45‐6532 (60)44 (53)
>6518 (34)35 (42)
Race 0.80
Caucasian15 (28)23 (28)
African‐American34 (64)48 (58)
Other2 (4)5 (6)
No response2 (4)7 (8)
Education 0.67
4 (8)10 (12)
High school16 (30)26 (31)
Some college20 (38)31 (37)
College4 (8)10 (12)
>College6 (11)5 (6)
No response3 (6)1 (1)
Annual household income 0.17
<$10,00010 (19)21 (25)
$11,000‐$20,00016 (30)19 (23)
$21,000‐$35,0004 (8)19 (23)
$36,000‐$60,0009 (17)12 (14)
>$60,0006 (11)6 (7)
No response8 (15)6 (7)
Length of stay (days) 0.90
<535 (66)52 (63)
6‐1012 (23)21 (25)
>105 (9)9 (11)
No response1 (2)1 (1)
Previous experience in opposite room type 0.73
Yes42 (79)65 (78)
No10 (19)18 (22)
No response1 (2)0

In describing their experiences, patients in private rooms were more likely to report adequate privacy (92% vs. 53%; P 0.01) and available nursing (79% vs. 64%; P = 0.025) than patients in shared rooms (Table 2). There was no difference in the amount of reported loneliness or fear of death. For patients with roommate interactions, 66% replied that they enjoyed talking with their roommates (Table 3). A minority (31%) indicated that they had been bothered by sights, noises, or messes made by their roommates. A majority of patients reported giving help to roommates (59%), and a substantial percentage reported receiving help (35%).

Comparison of Patient Experiences in Shared and Private Rooms
Private (n = 53) (%)Shared (n = 83) (%)P Value*
  • P value based upon chi‐square test.

Privacy adequate49 (92)44 (53)<0.01
Felt nurse was available42 (79)53 (64)0.025
Felt lonely11 (21)18 (22)0.913
Had fear of dying5 (9)13 (16)0.309
Experiences of Patients with Roommates (n = 104)
Yes (%)No (%)N/A or Missing (%)
  • NOTE: Includes patients with a primarily private room stay who had roommates for part of their stay (ie, spent most of their time in a private room but at some point were in a shared room). Not all percentages add up to 100% due to rounding.

  • Abbreviation: N/A, not available.

Enjoyed conversation69 (66)15 (14)20 (19)
Bothered by roommate32 (31)70 (67)2 (2)
Received help from roommate36 (35)65 (63)3 (3)
Gave help to roommate61 (59)39 (38)4 (4)

Patient Preferences

Of the 117 patients who expressed a preference for a private or shared room, 92 (79%) stated that they preferred private rooms (Table 4). Patients in shared rooms were more likely to prefer shared rooms than patients in private rooms. Race did not impact preference. Patients older than 65 years were more likely to prefer shared rooms than patients younger than 65 years (31% vs. 15%; P = 0.042), although the preference for private rooms persisted across all demographic groups.

Room Preference Responses
Prefer Private (%)Prefer Shared (%)P Value*
  • P value based upon chi‐square test, except in comparison by current room status, where Fisher 2‐tailed exact test was used due to small sample size.

Total (n = 117)92 (79)25 (21)
Comparison by race
Caucasian (n = 31)25 (81)6 (19)0.60
African‐American (n = 75)57 (76)18 (24)
Comparison by age (years)
Age >65 (n = 45)31 (69)14 (31)0.042
Age <65 (n = 72)61 (85)11 (15)
Comparison by current room status
Private (n = 43)41 (95)2 (5)<0.01
Shared (n = 71)50 (70)21 (30)

Ninety‐two patients responded to the open‐ended prompt to state reasons for these preferences, most commonly citing privacy and peace and quiet (Table 5). Other reasons included worrying about germs, being unwilling to share the television, wanting a private bathroom, being bothered by smells, feeling a lack of security, and wanting to have space for family. Patients who preferred shared rooms most commonly cited a desire for companionship.

Patients' Reasons for Room Preferences and Frequency with Sample Quotes (n = 100)
  • NOTE: 92 patients responded, some listing more than 1 reason.

Private (80)
Privacy (33): privacy, like to be alone
Peace/quiet (28): snoring roommates, sleep better
Room amenities (7): television sharing, bathroom is within
Germs (6): germs, diseases
Security (2): security, belongings
Family (2): daughter had to sleep in lounge
Smells (2): smells
Shared (14)
Company (13): someone to talk to
Safety (1): safer, someone to look out for you
Neutral (6):
No preference (5): doesn't matter, what's available
Depends on circumstances (1): depends on sickness

Discussion

In this observational study of U.S. veterans, we found that patients in private rooms were more satisfied with privacy than their shared‐room counterparts, a finding consistent with previous studies.4, 5 We also found that private room patients were more likely to feel that nursing was available, a finding that had not previously been reported. Although increased loneliness and fear of death had been noted in private room patients before, our study did not support such findings.10 We found a strong overall preference for private rooms, adding to previously mixed evidence about patient room preferences.10, 1217 Although we had hypothesized a substantial demand for shared rooms among veterans based upon their common military experience, we found the demand modest at best.

The increased satisfaction with privacy among private room patients was expected.4, 5 That nearly one‐half of the patients in shared rooms found the privacy to be inadequate, however, was a strong finding that points to a fundamental problem with these rooms. That private room patient also felt more that nurses were available was surprising, since the higher number of patients in shared rooms might have been expected to generate a more visible nursing presence. Whether this finding is reproducible and whether it is based upon an objective difference in nursing behavior is something that should be studied further. It may simply have been a marker of increased satisfaction among the private room patients.

Although loneliness and increased fear of death had previously been identified as possible drawbacks of private rooms, our survey found no such suggestion.10 This may have been because our survey instrument simply asked patients to answer yes or no whether they had experienced the particular feelings; the previous study had used interviews. A more sensitive survey instrument would be needed to investigate questions of loneliness and fear of death further.

Except for the problem of privacy, the shared room experience generally appeared to be a positive one for patients, particularly in the exchange of conversation and help. A genuine value of these interactions to the patients was suggested by the finding that patients in shared rooms were more likely to prefer shared rooms than patients in private rooms. It is possible that once in them, patients found shared rooms to be better than expected, or that they warmed to them as a matter of resolving cognitive dissonance between their preconceptions and their placement. Although peace and quiet was a frequently cited reason for preferring private rooms, relatively few patients reported being bothered by their roommates. The high rate of assistance among roommates was perhaps the most surprising positive about the shared room experience, even if patients recalled helping others more than they remembered being helped themselves.

Preference for private rooms was greater than that found in previous studies, and appears to have been based largely upon concerns for privacy.1217 We suspect it may reflect changing societal values that have placed an increased priority on personal privacy; this is suggested by the greater willingness of elderly patients to stay in shared rooms. Whether the preference for private rooms is even higher in the general nonveteran population is something that should be assessed with future studies.

Our study was limited by a number of factors. While room assignments were based on bed availability, it is possible that patients requested particular rooms or were moved due to other factors. By selecting a study population of male veterans of the armed services, we limited the extent to which our results can be generalized. However, this particular population is an important one to study due to the size of the VA healthcare system, the prevalence of shared rooms in VA hospitals, and the unique cultural values of veterans. We were unable to obtain information from approximately 27% of our target population because they were unable or unwilling to participate, thus excluding a population subset from analysis and potentially biasing our results. Although a high prevalence of preference for private rooms was seen, the strength of the preference was not assessed, and patients were unable to convey if they had no preference regarding room type. The survey instrument was designed for the purposes of this study and has not been validated. Some patients were assisted with filling out their surveys and may have responded more positively about their roommates if they thought their roommates could overhear their answers to questions. Because patient enrollment was slower than expected, fewer patients were enrolled than planned and the power achieved was insufficient for detecting differences of 20% or less between groups. This is unlikely to have affected our positive findings, but may have prevented us from detecting additional differences among the study groups.

Our data shows that for a population of veteran patients, private rooms are preferred, and that increased privacy is a primary advantage. It also demonstrates that multioccupancy rooms have several positive aspects. Given the need for sound public policy in regard to this issue, further research is needed to better evaluate objective outcomes of room type, such as fall rates, nosocomial infection rates, and lengths of hospitalization. In the meantime, efforts should be taken to address some of the known problems of shared rooms. For instance, establishing more substantial dividers between beds would be an intervention that could increase privacy, reduce noise, and minimize unwelcome smells. Additionally, given that patients have a wide variety of feelings toward multioccupancy rooms, incorporating patient choice into room assignments when logistically feasible is a step that could lead to increased patient satisfaction with hospitalization.

References

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