What Have We Learned About Hospital Design in 165 Years? 

I’d like to pose a question: what have we learned about building hospitals over the past 165 years? The answer is thankfully a great deal. Yet, despite this progress, we still get it wrong. The environments we create can inadvertently make working and healing more difficult than necessary. I would argue that we are still in the early stages of designing hospitals that are starting to support both patients and staff in doing the right thing.  

There are many papers which describe good practices. They describe methods which can be employed during planning, during the design process and also considerations for during the delivery phase. When the build is delivered, there are descriptions of managing risks and hazards and learning to work within an environment. So, do we routinely engage with these practices? I would suggest that most teams do little if anything. Why? Cost, lack of knowledge, lack of skill, lack of time, burnout or just a feeling that the architects know best. Perhaps a mixture of all of these.  

From Scutari to the Present 

In 1854, Florence Nightingale arrived in Scutari to find appalling conditions: a shortage of medicines, poor hygiene, and inadequate facilities for food preparation. These factors led to widespread infections and high mortality among wounded soldiers. In response to her appeals, a sanitary commission was dispatched. They flushed the sewers and improved ventilation interventions that dramatically reduced death rates. 

Fast forward to 2019, when an interim report from a hospital inquiry revealed that issues such as inadequate ventilation in critical care areas and water contamination were still compromising patient safety, postponing the opening with over 2255 appointments rescheduled, and costing over £16.8 million. Despite the 165 years between these events, we continue to face similar challenges. How is it possible that we are still designing hospitals with the same fundamental flaws? 

The Evolution of Hospital Design 

Hospital design has undergone significant transformation, shaped by societal needs, medical advancements, architectural trends, and, more recently, formal guidance such as Health Building Notes (HBNs). These documents, first introduced in 1961 following the creation of the NHS, now number 119 active publications, supplemented by Health Technical Memoranda (HTMs). Whilst a very valuable resource and guide, as with books, perhaps when published these are already slightly out of date when relating to updated best practice.  

Despite these resources, the 2013 Francis Report into failures at Mid Staffordshire NHS Foundation Trust highlighted persistent environmental issues: poor ward visibility, remote and office-bound leadership, and inefficient spatial configurations. These factors were not merely aesthetic concerns they had direct implications for patient safety. 

Evidence-Based Design: What the Research Tells Us 

There is a growing body of evidence linking hospital environments to patient outcomes. For example, single-family rooms (SFRs) in neonatal intensive care units (NICUs) have been associated with reduced infection rates, shorter lengths of stay, and potentially improved neonatal morbidity and mortality (O’Callaghan et al., 2019). However, outcomes can vary depending on how these designs are implemented, and understanding of the specific population needs and the work practices that accompany them - the “work-as-done.” 

Staff visibility and efficiency also play a critical role. A 2010 paper in Healthcare Design found that reducing the distance nurses walk during a shift led to less fatigue, more time with patients, and improved safety. These findings underscore the importance of aligning design with real-world workflows. 

Work-as-Judged vs. Work-as-Done 

Erik Hollnagel’s concept of the "built environment" describes a technical system designed to support specific activities. These designs often rely on assumptions about how work is performed, what Shorrock’s calls "work-as-judged." In reality, tasks are frequently adapted in practice, creating a gap between design and actual use.  

Natalia Ransolin’s 2010 study showed that ICU staff had to adapt their workflows due to mismatches between the built environment and real-world needs. This highlights the importance of functional analysis and stakeholder engagement in the design process. Meaningful engagement to gain a true understanding of the “work-as-done” takes time and effort, observation, interviews and experts – something the NHS doesn’t necessarily support.  

If we don’t fully understand how work is performed in practice, how can we design environments that support it effectively and safely? This disconnect can result in buildings that are beautiful on paper but flawed in function, buildings where no one asked knows how to turn to lights on, or which doors open automatically and which way - fairly fundamental design features for everyday use!  

Designing for Resilience 

The new NICU being built at Alder Hey, in partnership with Liverpool Women’s Hospital, is due to open later this year. Its design has been informed by HBN 09-03, which includes research on the average space required for an individual NICU cot 13.5 m². This figure was derived from simulations of common tasks, conducted by ergonomist Sue Hignett. In a SFR this space increases to 20 m2 – a size we have already compromised on with rooms being 18-19m2. Such work requires a deep understanding of both patient and staff needs and can be time-intensive to complete. Do I think this is enough? The rooms may end up being big enough for day-to-day tasks, but I am still questioning whether I will have enough space to safely perform future beside operations. I am also questioning whether we will have we enough axillary spaces. Is the pharmacy close enough for the nurses? Where is the equipment stored? Have we got our staffing models accurate for the reduced visibility? Will our technology work to enhance this or detract from it? 

Healthcare is one of the most complex socio-technical systems, constantly evolving in response to new evidence. During the construction of the new NICU, for example, infectious disease specialists raised concerns about water and wastewater safety. Fortunately, prior task analysis had already indicated that removing sinks from patient areas would have minimal impact on essential functions, an insight that allowed us to adapt without hopefully compromising care. This decision is however against current guidance within the HBN.  

Despite extensive pre-design visits to innovative units worldwide, thorough literature reviews, early engagement with an ergonomist for stakeholder meetings to inform design, and adherence to Health Building Notes, will our new neonatal unit be perfect? No. 

Should we have conducted more functional analysis and considered its implications for design decisions? In my opinion, yes. Staff working within healthcare will adapt/ change how they deliver care. This is not because they are bad, lazy or stupid but because they adapt their working to achieve the best and safest care for their patients. If we engage the most senior staff in designing our buildings they may not have worked in a clinical environment on the front line for several years, so how can they inform the design for clinical work? You need the subject matter experts involved throughout. They however also need to be informed and consider how they complete tasks when reviewing the plans.   

Saying this, with thoughtful preparation, and a commitment to bridging the gap between design and reality, we can move closer to creating environments that support safe, effective, and compassionate care. It requires flexibility, engagement and understanding.  

Conclusion:  

So, what have we learned about hospital design? A great deal. But we still have much to learn about creating resilient spaces that promote health and wellbeing for both patients and staff. Until we truly understand how work is done shaped by local practices, culture, and existing environments we cannot effectively translate those needs and explain them to our colleagues who will create the architectural plans. We are still a team, just a different one from which we work in during the day, with a different language. We don’t need a translator to work effectively together, just a slightly different way of explaining what we do every day, and what we need to do this. A great starter read for those interested is the 2025 publication of Human factors and ergonomics in health and social care by Sujan et al 2025, courses such as building blocks for clinicians, or if you are really interested perhaps join the chartered institute of ergonomists or attend a conference, European healthcare design or resilient healthcare!  

Can we do this in the cash strapped, time poor NHS? Short term pain for longer term gain? What would it really cost? If there were ever a time to rethink how we design healthcare environments this is it. Surely helping people work and be cared for safely is not a luxury. The built environment will impact patient safety so we should try! As Brene Brown says, ‘effort + courage to show up = enough’. Perhaps………it certainly is a good start. So am I happy with my engagement with the new NICU – no, for many reasons. Have I stopped trying – no! 

CLICK HERE to visit the RCSEd Patient Safety Group Page.