In a recent survey of nurses, 67% said that their workload has increased over the past six months. Fifty-nine percent reported burnout.

Nursing is hard work, physically and emotionally. Days are long—40% of nurses today work shifts of more than 12 hours. The stress of caring for higher acuity patients, using increasingly complex technologies, also contributes to staff fatigue and burnout.

Caregiver work environments need to be designed with sustainability in mind. In this case, creating places that sustain the energy, spirit, and productivity of the staff is the goal. A safe and efficient working environment will help to reduce travel distances and streamline processes and, in so doing, reduce caregiver stress and fatigue. Staff-sustainable environments will also play a key role in attracting new talent and retaining valued caregivers.

Thinking Lean

Staff fatigue and burnout result from many factors, but helping to alleviate some of the causes can be addressed in the design of the caregivers' work environment. If the design enables caregivers to work more efficiently by reducing travel distances and the time spent “hunting and gathering,” then caregivers should have more time to spend in direct patient care activities.

The first step to creating such a place is to perform a thorough, methodical, and objective examination of all aspects of the staff work area. This assessment should cross departmental boundaries to identify dependencies, bottlenecks, and barriers to efficient patient care. Thinking Lean is a first step.

Lean thinking helps you identify waste and minimize the consumption of resources. Removing waste—in other words, getting rid of anything that does not add value—means more time and energy can be directed to patient care. Applying Lean thinking to healthcare delivery can also be profitable, since you get rid of the things that don't add value. Analyzing the thousands of interactive processes involved in patient care to identify wasted effort and resources will ultimately improve safety and reduce stress for patients and caregivers alike.

Applying Lean thinking is not a one-time exercise: it is a process of continuous improvement that requires the involvement of every staff member.

Identifying waste

To understand how Lean thinking can be applied to healthcare delivery, consider the nursing unit floor plan depicted below:

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Figure 1. Traditional racetrack configurations distance staff from their patients and one another and increase time spent on non-patient activities.

This typical configuration, in which a caregiver work environment with centralized support rooms creates a racetrack design that literally keeps staff running back and forth between patients and supplies. Centralized spaces for equipment, supplies, and medications require nurses to constantly backtrack in inefficient work patterns that add miles to their days and pull them away from their patients. The result: wasted motion.

Wasted motion is a significant drain on a caregiver's time and energy. A recent study showed that 50% of nurses’ work time involves transport, motion, and delay. Locating equipment, supplies, and medications close to the patient in order to reduce travel distances and eliminate the need for hunting and gathering is a top priority.

Inventory is another form of waste if it means storing more than is needed and storing items that are rarely used. In those cases, inventory wastes space. Another form of inventory waste is hoarding. It is a behavior most of us are familiar with, and it typically happens because caregivers lack confidence that they'll have what they need when they need it. But hoarding isn't efficient. It takes up space and doesn't create a purposeful and organized approach to inventory.

Adding value

Lean processes identify opportunities to fine-tune operations. Facility redesign offers opportunities to embed efficiency into the work environment. Let’s look at how the nursing unit might be reconfigured to reduce wasted time, motion, and resources.

Creating spaces that are inherently flexible and dynamic has benefits. Continuous improvement is enabled by adaptable environments.

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Figure 2. Adaptable spaces create efficient workplaces that can change as processes and requirements change.

This design provides multi-use space at the patient room, which gives it the ability to adapt and flex as needed. Unlike an environment where all architecture and furnishings are dedicated and static, these flexible spaces can be used as locations for supply storage, direct observation and charting, or “front porches” that provide a place for patients and their families to rest and interact during early ambulation. Multiple use spaces are one way the design of the environment can become more flexible and efficient.

Another feature of an adaptable nursing unit is the inclusion of an equipment closet in every patient room versus storing equipment in a centralized location. Locating an equipment closet in every room keeps caregivers in closer proximity to their patients. By stocking these closets with the equipment most needed by patients—IV poles, pumps, walkers, and commodes—a significant amount of wasted motion and time can be eliminated. Turning over the patient room and its equipment at the same time eliminates the multiple steps of moving items to a soiled storage area, then to central supply, then back to the unit, and finally back to the patient room.

Keeping equipment at the patient room also minimizes the risk of transferring potentially contaminated items and infectious bacteria throughout the hospital.

Patient supplies can be similarly decentralized to eliminate wasted steps. One hospital designed spaces to accommodate patient supplies within the patient room and calculated that the new design saved every nurse six trips on average to the supply room. This translated into 18 minutes of saved time per nurse—time that can be returned to direct patient care.

The floor plan (figure 2) also incorporates support pods of clean and soiled utility rooms, nourishment, and the linens and trash that serve four to six patient rooms. Decentralizing support spaces further reduces staff travel distances.

Decentralizing equipment and supplies alone will not realize the full benefit of reducing staff travel distances. Distributing medications to the patient rooms or to a support pod adjacent to a group of rooms will reduce staff travel distances and eliminate time wasted waiting for access to centralized meds. A more decentralized medication distribution process may also improve patient safety by reducing the occurrence of a caregiver retrieving medications for several patients at one time—and thereby reducing the potential for medication errors.

A staff-sustainable environment

Note how Figure 2's layout improves staff work patterns and work flow and reduces travel distances when compared to Figure 1. Figure 2 also addresses the issue of single patient rooms resulting in longer corridor length. In order to prevent wasted motion and energy, design cross-corridor circulation patterns as this figure demonstrates.

Every nurse travel mile saved by the new configuration returns 20 minutes of caregiving time to direct patient care. Giving nurses more time for patient care leads not only to reduced medical errors and improved patient safety, but also to reduced stress and improved job satisfaction for caregivers. It gives them back their profession's goal: to care for patients.

Studies show that nurses who stay in the profession at least three years are likely to remain for their entire careers. Considering that it costs a hospital $90,000 to $145,000 to replace one RN, the benefits of providing safe and efficient work environments that enhance caregivers’ effectiveness and satisfaction can have an enormous impact on the bottom line as well.

A staff-sustaining, adaptable nursing unit creates an environment that responds to the needs of caregivers. Visibility throughout the unit keeps caregivers connected to each other and aware of the activity on the unit. Decentralized support pods for supplies, equipment, and meds provide greater efficiency, managed inventory, less time wasted in travel and searching, and, ultimately, more time available for direct patient care. Designing caregiver environments that sustain the activities and spirit of caregivers and patients is immeasurable.

In Part 1 of this two-part series, the author presents ideas for designing flexible work centers and respite areas that can enhance caregiver recruitment and retention.

A healthcare consultant with Herman Miller Healthcare, Kerrie Cardon worked as a registered nurse for 14 years before becoming an architect specializing in healthcare design.