Arriving at the right unit size is a challenge. A greater number of beds in a unit improves staffing efficiencies. However, as hospitals transitioned to all single-patient rooms (2006 guidelines mandate private rooms), a greater number of beds has translated to larger floor plates, greater distances between destinations, and more nursing time wasted in nonproductive tasks. A recent archival study by Kurt Salmon Associates found that acute care units have increased in floor area by 118% over the past 20 years.

A mismatch between the physical transformation of inpatient units over time and the clinical processes that it supports has contributed to the nonproductive use of nursing time. In a 36-hospital time-motion study, a team from Ascension Health, Kaiser Permanente, and Purdue University found that the average total walking conducted by nurses ranges between 2.4 and 3.4 miles on a 10-hour day shift, and 1.3 and 3.3 miles on a 10-hour night shift. That translates to a higher extreme of about 4 miles on a 12-hour shift. These figures confirm some other studies that found similar long walking time for nurses.

Dr. Debajyoti Pati, FIIA, LEED AP
Dr. Debajyoti Pati, FIIA, LEED AP

Why is nurse walking time an issue? One perspective pertains to individual performance. With the median age of American nurses at 53 years old, one could argue that long walking distances, along with the mentally and physically demanding work that nurses conduct, could impact their stress, fatigue, and alertness-and, therefore, their individual performance.

Roomside charting alcove at Texoma Medical Center
Blake Marvin/HKS, Inc.

Roomside charting alcove at Texoma Medical Center

A second perspective relates to system efficiency, where unnecessary walking can be considered as waste. It is a type of nonproductive use of nurses' time, which is better utilized at bedside or other care tasks that add value to the services rendered. Distance walked and time spent in walking is considered an important metric in Lean operations design and intervention. Furthermore, the extensive time spent walking goes against the prevailing notion of patient-centric care, as it takes the caregivers away from the patient for prolonged periods of time.

As a result, many facilities are considering smaller units (such as 24 beds instead of 36 beds) to reduce nurse walking distance. That, in turn, poses the challenge of optimizing staffing efficiencies as well as maintaining an adequate level of peer support during night shifts.

The Summerlin and Texoma inpatient units

HKS designers confronted these challenges in the design of a bed tower addition at Las Vegas's Summerlin Hospital and at Texoma Medical Center in Denison, Texas, using four guiding principles:

  1. Proximity of services;

  2. Amenities for care;

  3. Decentralized nurses' station; and

  4. Computer logistics.

The underlying logic was that by focusing on the efficiency of flow, one can focus on patient-centric care and supply nurses everything they need without walking long distances. Both units were large-34 to 36 beds in size. It was hypothesized that by optimizing flow and reducing potential waste, the large unit would not result in walking distances that are substantially higher than the national benchmark. Similarly, it was hypothesized that how nurses spend their time would not constitute an outlier. In other words, if a unit is designed properly, a nurse will walk 2.4 to 3.4 miles (the latest data from the 36-hospital study) in a 10-hour shift, irrespective of the unit size.

“While the added square footage might intimidate even the most seasoned nurse, architects from HKS along with TMC management and nursing teams worked together to devise floor plans that maximized workflow,” says Belinda Wagner, RN, BSN, director, Oncology/Renal/Ortho/Med-Surg at Texoma Medical Center. “By distributing necessities such as supply and linen rooms throughout the units and providing corridor shortcuts, nurses now find workflow has actually improved in the new hospital. One of the greatest advantages for nurses is the strategically placed charting alcoves near the patient rooms, which enable nurses and other caregivers to quickly document care.”

HKS designers strategically incorporated decentralized nurse charting stations, located inside and outside of the patient rooms, as well as decentralized medication and supply areas that were all within 50 feet of any patient room. With an industry standard assumption that the average adult walks 150 feet per minute, all resources the nurses need for care delivery were designed to be located within 20 seconds from any patient room.

“One of the driving factors for the ‘50-foot rule,’ or the desire to get nursing support services close, came from a corporate pharmacy study,” says William Seed, vice president, design and construction, Universal Health Services. “It's human nature to create workarounds for time-intensive or difficult practices. Nurses who walk great distances to the medication station tend to collect drugs for multiple patients at one time. This can lead to drug errors. If we place the medication within 50 feet, it makes it easier to mandate a rule of one patient drug dispensing at a time.”

The postoccupancy study

Decentralized nurse unit at Texoma Medical Center
Blake Marvin/HKS, Inc.

Decentralized nurse unit at Texoma Medical Center

Data on walking distances and the way nurses spend their time were collected from both hospitals during the summer of 2010. The data collection lasted one week on each of the two units.

Walking distance data was collected using pedometers. Nurses wore the pedometers during their entire shift and recorded distance data at the end of each shift. Walking data was analyzed and compared to the findings from the aforementioned 36-hospital study. The distance data on both units were converted to 10-hour shift durations to enable comparison.

Time-motion data were collected using programmed PDAs developed by Rapid Modeling Corporation. The devices were programmed to randomly ring/vibrate 30 times in a 13-hour shift, with a minimum of 10-minute gaps between each ring/vibration. The PDAs include touch screen menus to allow the nurses to input data on their current location and activity at each occurrence of the random vibration. Compilation of the data across nurses provided a statistically robust distribution of the way they spent their time. Time-motion data from each unit was compared to the TCAB Time Study RN national database (Rapid Modeling), which includes data from hospitals across the nation.


Angela Lee, AIA, ACHA, LEED AP
Angela Lee, AIA, ACHA, LEED AP

The pedometer and PDA data confirmed the designers' hypothesis. At Summerlin, the mean walking distance during day/evening shifts was 3.2 miles, and the distance for night shifts was 2.1 miles. At Texoma, the mean night shift walking distance was 3 miles. All of these were within the 36-hospital benchmark data of 2.4 to 3.4 miles for the day shift and 1.3 to 3.3 miles for the night shift. Day shift walking for Texoma, at 3.5 miles, was marginally higher than the 3.4 miles upper value of the 36-hospital benchmark. However, this difference is not of much practical significance.

A similar finding resulted from the time-motion data. The TCAB Time Study RN national database has summary data available on key areas of interest, namely: value added, non-value added, necessary, direct care, indirect care, documentation, administration, medication, personal, waste, time in patient room, nurse station, and off unit. Among the areas of focus, none of the data points represented an outlier in comparison to other hospitals. In fact, all the data points were either within the second and third quartiles (middle 50%) or very close to the middle 50%.

These comparisons suggest that the unit operations and efficiencies are similar to those of other hospitals. While retaining these efficiencies in time distribution across activities and walking distances, the two units successfully incorporated a larger number of beds while reducing construction costs.

The bottom line: A healthcare provider can significantly reduce construction costs but operate with the same efficiencies. The case studies described are examples of how integrated decision-making with a primary focus on the efficiencies of flow can be used to address the seemingly difficult task of achieving larger inpatient bed units as well as efficient use of caregiver time. HCD

Dr. Debajyoti Pati, FIIA, LEED AP, is Vice President and Director of Research of HKS Architects and the Executive Director of the Center for Advanced Design Research & Evaluation. He can be reached at Angela Lee, AIA, ACHA, LEED AP, is Senior Vice President at HKS and can be reached at Healthcare Design 2011 February;11(2):32-38