Designing the ultimate nursing unit
Unfortunately, the above scenarios exemplify the paradox that exists on many nursing units in a variety of healthcare organizations across the country.
The challenge is to design a nursing unit that not only positively influences the guest's experience, but also meets the staff's needs. The paradox is that the nursing unit, as currently designed in many facilities, does neither.
In 2001, at the invitation of the American Nurses Association, a myriad of nursing organizations came together to discuss their vision for the future of nursing a critical need in this era of damaging shortages. These groups identified 10 distinct domains, or areas of focus, for their work, aimed at bringing about positive changes for nursing and the healthcare system. These domains were refined and narrowed during summit discussions, based on work done by other coalitions and from priorities identified in research literaturein particular, the Institute of Medicine study Crossing the Quality Chasm: A New Health System for the 21st Century. One domain identified was the work environment.
The objective for this domain, co-championed by the American Nurses Association and the American Organization of Nurse Executives, is as follows: “Members of the profession will work to improve nurses' work environments so that quality patient care is optimized and professional nursing staff is retained.” This objective has been described as being “basic to nursing's future.”
If the challenge of improving nursing's work environment is to be successfully met, I firmly believe that the following five standards should be incorporated into the design. Specifically, the ideal nursing unit/station should:
Express courtesy, caring, and respect for both guests and staff.
Be designed for peak efficiency.
Incorporate safety standards for the welfare of both guests and staff.
Comply with federal, state, and other regulatory agency guidelines.
Provide a place for staff to “go offstage.”
Taking this point by point:
1. Express courtesy, caring, and respect for both guests and staff.
This is paramount to the successful design of a nursing station/unit. It should meet the needs of all individuals and make resources conveniently available to all. For example, the regulation stipulating that countertops be low enough for wheelchair-bound guests is an element of courteous design. Figure 1 displays a traditional nursing-station counter, which is chest-high. Obviously, communication would be difficult, at best, for a guest in a wheelchair approaching this nursing station.
Figures 2 and 3 illustrate a new nursing station located on a 30-bed adult medical unit. The station was built with prefabricated, removable components. I call it the “barricade” nursing station. If a guest needs to find a staff member, he or she has to enter through a narrow doorway. The only visible opening to the general public is a small windowand, ironically in this case, the nursing staff placed a computer printer in front of the window, apparently to discourage contact with guests. This might increase staff productivity, but from a guest's perspective, this area gives the impression that it is a fortress, conveying a “do not bother me” message.
2. Be designed for peak efficiency.
Efficiency considerations are important in the design of the ideal nursing station. Traffic patterns, unit capacity, patient type, acuity of illnesses treated, and system processes all affect efficiency. Figure 4 depicts an entrance to the nursing unit of a NICU. The doorway leads to the medication room, supply room, unit-secretary station, and charting area. Since many staff members work in the NICU, that doorway will get plenty of traffic!
3. Incorporate safety standards for the welfare of both guests and staff.
The National Patient Safety Foundation, the goal of which is to measurably improve patient safety in the delivery of healthcare, has teamed with leading healthcare organizations in embracing safety as one of the top performance-improvement indicators. Recently, during the design of a women's hospital, consideration of infant safety emerged as being of primary concern. Figure 5 shows a postpartum nursing station. To enhance the staff's ability to monitor newborns and to thwart attempts at infant abduction, plenty of glass was installed.
4. Comply with federal, state, and other regulatory guidelines.
The need for a design to meet regulations goes without saying. However, designers should continuously attempt to improve current regulations by suggesting and implementing new and better ways to do things. For example, the Leapfrog Group (http://www.leapfroggroup.org), founded by The Business Roundtable with support from the National Health Care Purchasing Institute, and composed of more than 130 public and private organizations providing healthcare benefits, works with medical experts throughout the United States to identify hospital systems' problems that could harm patients, and propose solutions.
The previously mentioned National Patient Safety Foundation (http://www.NPSF.org) is another venue where designers can propose improved healthcare design regulations, as is the Joint Commission on Accreditation of Healthcare Organizations (http://www.jcaho.org).
5. Provide a place for staff to “go offstage.”
Last, but certainly not least, staff need a place to “go offstage.” It seems ironic for people comprising the largest workforce in healthcare to be relegated consistently to only limited areas for temporary respite from the public whom they serve. The nursing break room, or nursing conference room, is traditionally on the nursing unit, usually in the nursing station itself. I cannot think of any other public-oriented profession that doesn't have a specific place where workers can have some privacy. Teachers have the “teachers' lounge,” as well as recess periods and designated conference times; professional athletes have locker rooms and “closed” practice camps. Even in the Bible, Jesus left the crowds he was preaching to and went into the mountains for a peaceful “escape.”
In addition to “being offstage,” nurses, being predominately female, need the camaraderie of other women for mutual support. (Even though attempts are being made to increase the number of men in the profession through the Nurse Reinvestment Act, and media campaigns and initiatives by the American Association of Colleges of Nursing, men still comprise only 5.4% of the total registered nurse population, according to the U.S. Department of Health and Human Services Seventh National Sample Survey of Registered Nurses.) Nursing stations ideally should provide an area where this companionship can occur. Furthermore, research has shown that nurses frequently use the nursing report time between shifts as a time to offer support to one another.
In conclusion, the ultimate nursing station/unit needs to incorporate the five design standards discussed here. Through the embodiment of these standards, an organization can define its culture and shared values with immediate visual impact. Moreover, designing an environment conducive to nursing staff will improve nursing recruitment and retention. HD
Dore J. Shepard, RN, MS, is vice-president of Patient Services, Insytex, LLC, Healthcare Design Consulting Group.
The Patient's Wife
My husband and I finally made it up to the nursing unit at about 10 a.m. We had been in the emergency room for more than nine hours, waiting for the results of the MRI. At first I'd thought his headaches were just sinus-related, but when he passed out, I knew they must be something worse. The paramedics had been so nice, quickly responding to my frantic 911 call.
“How can my husband die on me?” I'd thought. “We've been together for more than 32 years.” I briefly recalled our wedding vows, spoken on that sunny October day: “For better or for worse, in sickness and in health.”
I had called our children on my cell phone as the ambulance made its way to the hospital. They are so far away. They said they could catch a plane in the morning. As I fought back tears, despair welled up in my body.
I felt so alone. I watched my husband's chest rising and falling with every respiration. Gently, I placed my hand on his chest. I hoped the oxygen was helping him.
It had seemed to take forever to get to the hospital, the monotonous siren wailing over and over as we sped through the dark night.
“Cerebral vascular accident, CVA, stroke.” Those words echoed in my mind like a coyote howling into the midnight desert air.
He'd never been sick a day in his life. My husband, my lover, my best friend.
My stretcher-bound husband and I, accompanied by transportation couriers, had entered the nursing unit through beige metal doors. As we walked down the stark hallway, passing room after room of bed-bound patients experiencing their own purgatory, I smelled the faint odor of rubbing alcohol.
Nursing staff moved quickly from one room to the next. I noticed they wore running shoes. What ever happened to old-fashioned nursing shoes?
We reached the front desk. The three of us, walking beside my husband on the stretcher, must have been invisible to the unit secretary on the other side of the mustard-colored countertop.
At least I thought she was the unit secretary. Her badge was too low for me to see her name, as it hung on the farthest end of a mauve WWJD identification rope. I thought to myself, “What would Jesus do?” I think he'd at least look up at us.
She had a phone to her ear, a computer on in front of her, and an old AM/FM radio to her left, crackling as it played “soft rock” favorites. Medical records were strewn across the countertop. The intercom light was flashing in time to a penetrating alarm.
Hospital staff sat laughing toward the back of the station. I got the impression they were talking about one of the patients. One drank a Coke. The others held Styrofoam cups. As if on cue, all three glanced up quickly and dispersed from the area, leaving their beverage containers behind.
I looked up at the slow, rhythmic movement of the second hand on the wall clock.
I felt so alone.
The Unit Secretary
I glanced up briefly toward the sound of an approaching gurney and noticed the outline of two navy-clad transporters and a third person. They moved quickly toward my mustard-colored desk.
“Must be the patient's wife,” I thought, turning my attention back to the edgy pharmacist on the phone.
“Are you still there?” he asked impatiently. Carefully enunciating every syllable, he barked, “I said I need to speak to the nurse caring for Mr. Smith. This is the second time I've called. If she doesn't come to the phone, I'll just have to call her manager.”
Scanning the handwritten nursing assignment sheet for the penciled name of the nurse taking care of Mr. Smith, I promised myself to stop by the drugstore on the way home to get a new pair of reading glasses.
The intercom light with the insistent alarm was demanding my attention, but I ignored it for the moment; I had a testy pharmacist to deal with.
I sat with another medical resident and a nurse in back of the nurses' station. Two hours ago, we had seen an elderly male patient's carotid artery burst. A cardiac arrest was called. The patient died. He literally bled to death from the cancer-ravaged artery in his neck.
Trying to come to grips with such a horrendous sight, I cracked a joke to ease the tension. We began to laugh but soon noticed the glare of several sets of eyes looking over the mustard-colored countertop into our refuge. Immediately, our smiles changed back to the professional expression society expects from us. We hastily left the remnants of the only brief lunch break we would have that day, as we fled our sanctuary.