Within six months of the Parker Adventist Hospital opening in Parker, Colorado, administrators noticed a significant increase in nurse turnover. The reason for the increase: the hospital's bed units were planned as acuity-adaptable units (figure). They revised that approach accordingly. Today, staff retention is up and the acuity-adaptable nursing model is out.

In the universal room at Parker Adventist Hospital in Parker, Colorado, medical gases on each patient bed provides easy access for caregivers, but…

Controversial findings about the universal room and the acuity-adaptable nursing model were disclosed during a recent exploratory study conducted by HKS and Herman Miller. The study, dialoguing with leaders from top community hospitals nationwide, found that implementing the acuity-adaptable nursing model has not been easy from an operational standpoint. A perception of inadequate care, an inability to maintain intensive care nurse competencies, and lack of adequate support space are just a few of the issues raised by the nurse managers, directors, and administrators interviewed.

Over the past decade, hospitals across the United States have invested millions of dollars in inpatient infrastructure that supports the acuity adaptable nursing model. Supporting the additional capital investment are a host of projected favorable patient and staff outcomes, including reduced patient transfers, medical errors, falls, patient dissatisfaction, and staff stress. The study's findings, however, advocate a rethinking of this model and the architectural design response that it requires.

Original adaptability thinking

Noted healthcare planner and registered nurse Ann Hendrich originated the acuity-adaptability model in the 1990s. The model is based on the concept of patients spending their entire length of stay, from admission to discharge, in the same room. Universal patient rooms were designed with sufficient space and provision for equipment, medical gases, and power capacity to accommodate any level of patient acuity.

This paradigm shift warranted a radically different approach to nursing. Since different acuity levels demand different levels of skill and expertise, implementing the acuity-adaptable nursing model was based on cross-trained registered nurses and a different type of patient room design.

As noted, several potential advantages exist favoring the acuity-adaptable nursing model over traditional models of care. Patient transfers, lengths of stay, and medical errors are reduced, while nurse and patient relationships are enhanced. Nevertheless, research suggests that pitfalls to implementing the acuity-adaptable nursing model may outweigh these opportunities. For example:

Cross-training staff. The acuity-adaptable model requires nurses who are cross-trained (or willing to be cross-trained) to address all levels of acuity. This is a challenge because nurses typically have preferences for a certain type of care environment, in level of acuity, as well as in type of illness or injury.

Collaboration, peer support, and mentoring. Intensive care requires teamwork and support at a moment's notice. A mix of cross-trained staff on acuity-adaptable units creates less opportunity for mentoring and support of other intensive care nurses. Intensive care patients are not congregated, but are separated from other intensive care patients, sometimes by six or seven rooms. As a result of the separation, intensive care nurses may not have the opportunity to support one another during a shift. Newer intensive care nurses are isolated from others who have the ability to informally mentor and support throughout the shift.

Physician's perception. In an acuity-adaptable model, intensive care patients can be located in any of the inpatient units within the hospital. However, physicians want their intensive care patients cohorted. In a dedicated intensive care unit, the physicians, especially intensivists, can readily build relationships with the intensive care nurses. There is a security in knowing that all the staff within the unit is competent and familiar with the challenges of caring for intensive patients.

Perceived workload. Acuity-adaptable intensive care nurses have appeared in studies to have less of a workload than typical medical/surgical nurses. However, while medical/surgical nurses care for five to six patients and intensive care nurses treat one to two patients, the acuity of their patients is significantly higher, requiring more care and supervision.

Equipment cost. The acuity-adaptable model requires access to critical care equipment on each unit. This entails increasing monitor capability and purchasing more IV pumps, ventilators, and other pieces of equipment required to support a changing acuity. The cost of maintaining critical-care equipment for all rooms that may not be used for critical care 24/7 can be prohibitive.

Physical design response. The patient room size and support space to house the acuity-adaptable model requires a larger floor plate. Decentralized workstations and satellite stations are added, increasing the unit size. All of this leads to longer walking distances between rooms and support spaces and creates isolation and lack of visibility among staff.

Maintaining staff competency and intensive care admissions. Maintaining intensive care nursing competencies may not be practical in an acuity-adaptable model. This is true especially in community hospitals, where the number of intensive care patient admissions may not be enough to maintain all of the competencies required by intensive care nurses. The hospital's ability to admit intensive care patients may therefore be limited.

More acuity-adaptability findings

In the study, HKS and Herman Miller found that many community hospitals were rethinking and reconfiguring, and in some cases rejecting, their universal rooms and acuity-adaptable nursing models. At Parker Adventist Hospital, for example, the decision was made to cohort intensive care patients, allowing dedicated intensive care nursing staff to provide care. The hospital added intensive care unit control-access doors, and its support core was reconfigured to house critical-care supplies and equipment.

Another example: By definition, universal rooms are designed to house equipment that accommodates all acuity levels. Because of the overwhelming equipment costs and maintenance involved, Clarian West Medical Center in Avon, Indiana, opted not to fully equip each of its universal rooms. To do this, management had to completely redesignate the inpatient unit's core support rooms, transforming supply rooms to equipment holding areas.

And another example: Staffing for the acuity-adaptable nursing model unit posed several challenges at St. Rose Dominican Hospital–Siena Campus in Henderson, Nevada. Because of the cross-training needed to staff the hospital, many nurses could not maintain their core intensive care competencies. Also, the uncertainty of intensive care admissions during any given shift placed undue stress on nursing staff and administrators, knowing that many nurses were not intensive care competent. To meet this challenge, the hospital dismantled its acuity-adaptable model altogether, opting for traditional inpatient care.

In addition to the HKS and Herman Miller study, the Healthcare Advisory Board Company (http://www.advisory.com), serving a membership of more than 2,600 leading hospitals, health systems, universities, and other mission-driven enterprises throughout the United States and, increasingly, worldwide, has also noted similar issues with universal rooms and the acuity-adaptable nursing model. According to its IC Business Brief, “Designing for Quality,” the pseudononymous Griffey Medical Center abandoned the acuity-adaptable nursing model after 12 months because of staffing challenges and clinician dissatisfaction.

After designing universal rooms for a decade, architects continue to gather more data about the pros and cons of the acuity-adaptable nursing model. Additional research and discussion must continue to involve both healthcare system planners and architects before committing to a full-scale design of this type. HD

Jennie Evans, RN, LEED AP, is an Associate/Clinical Advisor with HKS. With 19 years of nursing, process, and operations redesign, as well as management, experience, Evans, as a member of a hospital executive committee for a six-story, 132-bed pediatric expansion, has participated in medical equipment planning (including booms versus headwalls) and procurement, back-fill redesign and coordination, and nursing unit closures. She can be reached at

jevans@hksinc.com.

Debajyoti Pati, PhD, AIIA, is director of research for HKS's Clinical Advisory Group. He has more than 20 years of international experience in architectural practice, research, and education. His PhD degree has a focus in architecture, culture and behavior, and building technology. He can be reached at

dpati@hksinc.com.

Tom Harvey, AIA, MPH, FACHA, directs the HKS Clinical Advisory Group in addition to working on healthcare architectural projects. He has more than 30 years experience in strategic planning, functional and space programming, master planning and feasibility studies, facility design, and project management for healthcare clients, including 10 years of service as a healthcare consultant. He can be reached at

tharvey@hksinc.com.

For further information, phone 214.969.5599 or visit http://www.hksinc.com.

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