Put To The Test
Over the past decade, the nurse’s workplace has generated much interest from healthcare designers and facility managers alike. This interest, to a large extent, can be attributed first to the 2004 Institute of Medicine report “Keeping Patients Safe: Transforming the Work Environment of Nurses.” The design of these spaces, specifically, continues to be critical to a patient’s well-being and safety. Operational efficiency, staff satisfaction, and—more importantly—medical errors can be linked to workplace design.
Nurse walking is a key component of the workplace experience that’s been discussed at length in the research literature, too. A 2012 study led by Debajyoti Pati, professor and Rockwell Endowment Chair at Texas Tech University, shows that a nurse can walk as much as six miles during a shift, prompting researchers to examine how much of this walking is of value and how much time is being wasted in nonessential travel. While a strong body of research exists on nurse activity and walking distances, it’s evident that there’s a degree of variability between different delivery models and sites.
Walking distances can’t be estimated based on adjacencies and proximities of key areas alone; it’s imperative to understand the sequence of activities and the flow of work to adequately assess an optimal experience. It’s also important to put walking in the context of the overall care model in place to allow a robust investigation.
To achieve this goal, a research team developed a tool that over a course of 2.5 days does an intensive analysis of work process, space utilization, and user experience. The team included representatives from HKS and two of its internal specialty groups—LINE, its Laboratory for Intensive Exploration, and the nonprofit CADRE, the Center for Advanced Design Research and Evaluation—along with ProMedica Hospital in Toledo, Ohio.
The methodology includes shadowing, surveys, interviews, photo essays, collection of light and sound levels, and spatial analysis to assess proximities (resulting in a heat map of distances) and visibilities. One of the key deliverables of the diagnostic is translating the field research information into a parametric tool that allows designers to assess walking distances based on a sequence of activities rather than just spatial proximities. The tool can be plugged directly into building information modeling software, allowing streamlined integration into the design process.
The diagnostic was conducted in a medical/surgical unit at ProMedica, and HKS received an inaugural Environmental Design Research Association Certificate of Research Excellence award for the effort in 2015.
ProMedica is a nonprofit health system that serves 27 counties in northwest Ohio and southeast Michigan and is currently developing a new patient tower at its flagship hospital in Toledo. The project features a 615,000-square-foot patient tower addition and 120,000 square feet of renovations aimed at improving the care environment and patient and staff comfort as well as preparing ProMedica for the future. The 13-story tower will replace 308 adult inpatient beds, with the potential for 160 additional beds, and will be guided by patient-centered care.
ProMedica leadership identified the need to carefully study conditions in its existing medical/surgical and intensive care units (designed more than a decade ago) to inform design decisions in the new tower. There are two wings with four nurses’ stations and 20 rooms in each, two meds/supply rooms, a nourishment room (shared by both wings), two soiled-linen rooms, two equipment rooms, and four linen closets. The staffing ratio to number of patient rooms is as follows: eight registered nurses (1:5), four nursing assistants (1:10), two patient care supervisors (1:20), and two unit clerks (1:20). A nursing director oversees the unit. Additional staff members on the unit include physicians, respiratory therapists/occupational therapists, care navigators, social workers, dietary services staff members, transport staff members, and maintenance staff members.
The area studied was “first to fill,” so it was at full occupancy most of the time. Patient assignment was by block, although this could be changed if the high-acuity patient percentage increased on a given day. The core work area on each unit was the central nurses’ station, and off-stage areas weren’t visible from the corridors. All nurses and most nursing assistants used workstations on wheels (WOWs) for computers, with visitors assigned additional stations for use when needed.
The objective of the diagnostic was to study the workplace and identify suboptimal environmental conditions that could be improved in the existing space and also avoided in future design. The findings revealed that colocation of medications, supplies, and nourishment; accommodation for WOWs; and spatial and technological connectivity between care teams and patients should be considered while designing a medical/surgical unit.
Sound level captures showed the highest sound levels in the nurses’ stations that tend to serve as collaboration hubs (and showed the need for workplaces where decentralized units are offset with larger team areas). The most “wasteful” walk was identified as the walk to the nourishment room for a minor task such as getting applesauce that a patient may need to accompany meds. Conversations with staff members revealed that it’s not just the distance but also the perceived value in the walk that can impact satisfaction. Walking a full length of the unit for something as minor as applesauce is a dissatisfier. The notion of colocating nourishment areas with meds/supplies is a new one to the literature.
Other insights—such as the need for collaboration zones in addition to decentralized and point-of-use access, as well as flexibility to accommodate different work modes—complement the existing literature. However, the key innovation in this study is the methodology.
Results in use
The team used data from the observations to develop a simulation model that mapped key sequences of activities. The research team benchmarked field research results against findings from larger data sets of existing research. The simulation model analyzed optimal and suboptimal sequences. The ability to take data from field research and input that into simulation models allowed the design team to optimize throughout the process. After each design iteration, the design team ran the simulation and analyzed visibility and walking distances (based on optimized and actual sequences of activities). The final plan configuration resulted in reducing walking distances in half, even though the overall floor plate was larger.
Following are the key innovations in the design, based on the diagnostic and evidence-informed user interaction:
- Improved unit connectivity.
- A narrow and porous support core that allows for clear staff-to-patient and staff-to-staff visibility.
- Technology leveraged to enhance staff communication, such as mobile phones connected to the electronic medical record.
- Reduction of wasteful walking.
- An equal distribution and proximity of key support spaces throughout the unit, such as the colocation of nourishment and medication and supplies.
- The addition of point-of-care supplies with a double-sided nurse server stocked by materials management and the
- Accommodation of WOWs and mobile technology.
- The creation of workplace flexibility at the bedside, between patient rooms, and in collaboration hubs.
- Sound levels/noise reduction measures.
- Creation of collaboration hubs that allow for visibility but provide sound privacy.
- Alarm fatigue reduction through the use of colored LED lights to provide visual cues.
- Addition of a pink noise system to the unit.
- Unit integration and coordination.
- Creation of horizontal connectivity with the step-down unit.
- Interdepartmental integration through shared staff support spaces.
- Unit security.
- Ability for all units to be locked independently.
- Patient/family/staff respite.
- Sun room additions at the ends of each unit with views of the park and the community.
- Creation of “point of pause” locations within the unit for ambulating patients and families.
- Staff and family lounges with access to natural light and views.
The validation of these simulation results is planned in a post-occupancy diagnostic after the new unit opens in 2019.
The HKS design team also used other user engagement tools such as full-scale mock-ups, virtual walkthroughs, and evidence-based design decision-making tools that brought together the existing evidence base and context-specific insights from the diagnostic. This multilayered approach levels the playing field and allows all key stakeholders to understand the design, independently of their architectural and design knowledge.
Through this study, design and research teams were able to work in concert with the owner to transform the design process and develop informed, context-specific solutions. Information from the research was also used to develop simulation tools that informed the design process throughout.
Camilla Moretti, AIA, ACHA, LSS CE, LEED AP BD+C, is an associate at HKS. She can be reached at email@example.com. Upali Nanda, PhD, Assoc. AIA, EDAC, ACHE, is associate principal/director of research at HKS Inc. She can be reached at firstname.lastname@example.org.