In her book Notes on Nursing, originally published in 1859, Florence Nightingale stressed the importance of a number of environmental factors that are now understood to be critical to patient care, such as cleanliness, noise control, natural light and views of nature. Nurses have long understood that “good design is good medicine,” says Jennie Evans, R.N., senior vice president and associate principal for Dallas-based architecture firm HKS Inc.
Despite their intimate knowledge of the patient care environment, nurses have not always been integral to the design of health facilities. But more and more, health care organizations, design firms and nursing groups are recognizing the value nurses can bring to facility design. While nurses feel the health care field has far to go to ensure that all nursing professionals are allowed to contribute meaningfully to the design of facilities, many nurses are helping to create — and even leading the design of — innovative health care spaces.
This input often ensures that nurses’ workflow processes are not interrupted and helps to avoid significant additional project costs. In one hospital project, designers planned to place sinks in a location that would have required caregivers to have their backs to the patient while performing hand hygiene, an action correlated with lower patient satisfaction scores. But because input was provided early in the process, additional costs were avoided. In another case, nursing staff input led to a reduction in departmental size that contributed to more than $1 million in cost savings.
Nurses’ central role in patient care makes them uniquely qualified to provide constructive input on facility projects.
Mary Hubenthal, R.N., facilities operations program director for Phoenix-based Banner Health, is a former director of critical care and progressive care who is overseeing the design and construction of a 17-story patient tower atop the new emergency department at Banner–University Medical Center Phoenix. The project will bring the hospital’s total bed count to 764. “With my background in nursing and knowledge of overall ancillary department support services for nursing, physicians and patient care, I can recommend design changes and really make a difference in influencing how we care for patients and care for our teams as we move forward,” says Hubenthal.
Pamela H. Redden, R.N., executive director of clinical planning and development for the University of Texas at Austin’s Dell Medical School, says, “The nurse is the coordinator of care for the patient, so that makes it important that the nurse have input into the facility design process.”
“Hospital operations link to the built environment, and the physical layout has got to be in sync and aligned [with operations],” says Debbie Gregory, S.N., senior clinical consultant for the technology group at engineering design and facility consulting services firm Smith Seckman Reid Inc., Nashville, Tenn. Because they’re involved in the full continuum of care, “nurses are probably the best source for that type of operational alignment,” she says.
The 24/7 nature of their job gives nurses insight into how a health care space functions at all times, notes Teenie Bracken, R.N., clinical health care planner in the Philadelphia office of design firm EwingCole. “They also understand several scenarios that can play out in the space. They’ve lived through the ‘what-ifs,’ ” she says.
Nurses can help to establish and maintain design and construction project priorities. “We understand hospital revenue matters. We understand administrator pressures, clinical pressures, quality pressures. We’re really savvy about these issues,” says Susan R. Silverman, president of the Nursing Institute for Healthcare Design and senior vice president and national director, project and development services, health care, for commercial real estate firm Jones Lang LaSalle in Chicago.
When difficult value engineering decisions need to be made, the perspective of nurses can be especially useful, says Evans. “They will help the leadership identify the clinical priorities and help them understand what the staff can live without or what they absolutely must have,” she says.
Evans describes an ED design project during which cost constraints compelled nursing staff to choose between installing telescoping doors in the department or placing imaging equipment in all three trauma bays. “They chose the doors,” says Evans. “They knew what they could live with; they’re in and out of those doors every day. Nurses know how these decisions impact workflow.”
Nursing requires innate problem-solving skills that design projects can tap into, notes Kathy Okland, R.N., senior health care consultant for design and manufacturing firm Herman Miller Inc. in Zeeland, Mich. Nurses are trained to assess, plan, design and implement solutions as caregivers, a skill set that easily transfers to health care design, says Gregory. The collaborative aspects of nursing also are relevant to the design process, Silverman says. And, Bracken notes, nurses respect the literature and research involved in evidence-based design, since much of their own work is similarly based.
Given the characteristics of nurses and nursing operations, “you draw the conclusion, ‘How could a nurse not be involved in the design of environments?’ ” says Okland.
“Unfortunately, currently, nurses are not always at the table” when facility design decisions are made, says Gregory. As a result, project teams sometimes develop designs that negatively impact nursing care.
Gregory says that while data demonstrate the value of nurses at the bedside, the move in many facilities to fully decentralized nurse stations limits opportunities for nurses to collaborate with one another or mentor less-experienced colleagues. Redden says: “While decentralized nurse stations on patient units are good things, they’ve been implemented in a very narrow way so that the old centralized stations got eliminated. The workflow processes were not thoroughly evaluated to the point at which we got the best outcome from that design.”
Hybrid nurse station designs, which provide space for collaborative work on the patient unit, appear to be an improvement, Gregory says. “I think that facilities have evolved over time, in a good way,” says Redden. “And I think a lot of that has had to do with nursing influence. Nurses are being asked more. If you look around the health care industry, you see architectural firms employing nurses. Hospitals are employing nurses to work in the facility design process.”
Says Silverman: “I think times are changing. Nurses are getting to the table sooner. The message is getting out there, but slowly.”
Kathy Harper, R.N., was formerly vice president of clinical coordination for Parkland Health & Hospital System, serving during the design and construction of the system’s new 2.8 million-square-foot campus in Dallas. “Nurses like that there’s more clinical input [on design] than 15 or 20 years ago,” she says. “They have a voice they never had before.” But, she adds, nurses don’t like the design process at all when they’re not involved, and their involvement varies from institution to institution. In the industry “as a whole, nurses’ opinions are not considered,” she says.
Bonnie Sakallaris, R.N., vice president for Optimal Healing Environments at the Samueli Institute, a health care research organization headquartered in Alexandria, Va., says: “When nurses don’t have enough knowledge about the process and the budget, they feel like they have to accept less than optimal design decisions. If they get involved very early on, that doesn’t happen, and the project is much more likely to come in on time and on budget.”
In the design drawings for a cancer center project on which the Samueli Institute is consulting, the handwashing sink in each exam room was originally positioned so that providers would need to turn their backs on patients to use the sink. “If your back is to the patient when you do that, your Patient Experience of Care scores are automatically lower,” Sakallaris explains. Because the plumbing design had not yet been finalized, the exam room layout could be revised at no additional cost. “It’s just knowing when in the process things can be changed without costing extra funding. That makes a difference,” says Sakallaris. “Nobody wants to be the person who causes something to come in late or out of budget. So, I think nurses want to know — they want to know what the process is, and then they want to be a partner in that process.”
Despite the challenges, nurses have been responsible for some recent disruptive innovations in health care design, says Joyce M. Durham, R.N., senior partner and executive vice president for health care management and consulting firm Global Health Services Network, Farmington, Mich. Durham notes that Celeste Phillips, R.N., pioneered single-occupancy maternity rooms for labor, delivery, recovery and postpartum care; Cecelia Kirvin, R.N., devised the design of private rooms for neonatal intensive care units; and Anne Hendrich, R.N., led the design of the acuity-adaptable patient room.
On the Parkland hospital project, nurses were involved starting at schematic design — an early stage in any project — Harper says. Gay Chabot, R.N., now retired after 25 years at Parkland, served as a program director and clinical liaison on the project. She says that nursing representatives at all levels — aides, technicians, clerks, staff nurses, managers and other supervisors — provided input on design mock-ups, from cardboard facsimiles of health care spaces to fully fitted-out replicas. “It was invaluable to our project,” Chabot says.
Based on this input, the project team eliminated nearly half the equipment and much of the cabinetry originally slated for the hospital’s 10 trauma rooms, which Chabot says saved the project several million dollars.
Nurses also were instrumental in the design of the patient room headwalls, which feature medical gas and electrical outlets on both sides of the bed. The outlets are raised as high off the floor as allowed by code. With this design, multiple people, such as a nurse and a respiratory therapist, can care for a patient at the same time without crowding one another or feeding a line over the bed, and nurses don’t have to bend over or crawl under a bed to plug in or unplug equipment. The design “just made more sense,” says Chabot. “You know, steps are time, and time is money. In the long run, if you can save a few steps, then you’re more efficient.”
In addition, nurses helped to determine where bedside computers would be placed in Parkland's patient rooms. They evaluated a variety of wall-mounted, adjustable arms for the monitors, ultimately selecting one that reaches almost to the patient and turns sideways so caregivers can chart without turning their back to the patient and family. “That was another thing that was important to nursing,” says Chabot.
Nurses helped to design the arrangement of computer monitors in the scheduling area of the surgery department, too. “Operating 27 operating rooms simultaneously is like traffic control,” says Harper. “I think they did a very, very good job of laying that out based on what they thought their needs were going to be.”
Evans says that in the design of Akron (Ohio) Children’s Hospital, the project team was fully engaged with the “Lean” principle of bringing frontline staff into problem-solving discussions. Nurses were among those invited to participate in the development of full-scale departmental mock-ups of the ED, ambulatory surgery department and neonatal ICU. As a result of staff feedback, Evans says, the architects were able to redesign the ambulatory surgery prep/post-anesthesia care unit three times in one day; they also decreased the ED square footage by 11 percent, for a savings of more than $1 million. The design of the ED triage area, in particular, was refined several times, according to Evans, to improve patient safety and throughput.
The University of Texas MD Anderson Cancer Center in Houston solicited nurses’ opinions about the design of inpatient units on the first five floors of an eight-story patient tower to enhance the design of the remaining three floors, which originally were shelled for future use. Over about three years, MD Anderson spent “tons of hours” researching how the design was working for nurses on all shifts, says Redden, who served as the center’s director of clinical operations development. Information was gathered through several means, including interviews, surveys and job shadowing.
The design of the last three floors, now underway, incorporates several changes based on this information. According to Redden, changes include the elimination of pass-through nurse servers to store supplies at the patient room — they were deemed too noisy — the addition of more work space for allied health professionals on the unit and more storage for patients’ personal items in the patient room. Also, the design of the patient bathroom was rearranged.
“Nurses spend the most time with the patient,” says Redden. “We have the responsibility to be the voice of the patient, public, family and each other.” Investing in nurses’ ability to contribute to design “will pay you back 100 times,” she says. “Facilities are so expensive. What’s a few thousand dollars to get the best outcome?”
“Our business is in patient care, and providing the best possible patient experience and best possible patient outcomes. If we don’t have the supporting structures in our buildings to provide that, we’re not meeting our vision and mission,” says Hubenthal. Of her facility design work at Banner Health, she says, “It’s just been wonderful to see how you can change the face of the future.”
Amy Eagle is a freelance writer in Homewood, Ill., who specializes in health care-related topics.
Groups promote role of nurses in design
The American Organization of Nurse Executives, a subsidiary of the American Hospital Association, developed its “Guiding Principles for Building the Hospital for the Next Generation” to identify what the organization considers valuable assumptions and principles for stakeholders involved in designing and building hospitals, such as the idea that operations and facility design must be mutually supportive.
“The way you design a facility has a significant impact on the way you’re going to deliver patient care, and the ability for nurses — and all health care providers — to work effectively,” says Pamela Thompson, R.N., of AONE and senior vice president of nursing/chief nursing officer for the AHA.
When nurses and designers work together, “you end up with just such a better product,” Thompson says. “It’s the blending of two areas of expertise: one that knows the work that’s going to take place in the building and the other that knows how to build a building. If you have one without the other, you run the real chance of designing a building that no one can use.”
The Nursing Institute for Healthcare Design is a leadership, education and advocacy group founded specifically to promote the integration of clinical expertise into the design of health care environments. The institute conducts educational events, such as a monthly webinar series; provides grants for studies that include nurses on the research team; partners with others in the health care design and construction industry; and produces material related to nurses’ role in facility design. In conjunction with Michigan design and manufacturing company Herman Miller Inc., NIHD recently published Nurses as Leaders in Healthcare Design: A Resource for Nurses and Interprofessional Partners. The book, co-edited by Jaynelle F. Stichler, R.N., and Kathy Okland, R.N., is available online via Herman Miller.
“We advocate that from the beginning [of a design project] you’ve got to have the right people in the room,” says NIHD president Susan R. Silverman. “That’s what we’re trying to do with this book. We’re trying to say, bring in nurses early, educate them in the design process and use them appropriately in this process. We want a dialogue. We want to assure that the priorities of the project start with the patient and the family. We want to make sure that all the right voices are heard.” — Amy Eagle