Nursing unit design has always fascinated healthcare architects. Not just because it's an interesting design problem with inherently competing needs and conflicting goals, but also because a quick study of the evolution of the nursing unit reveals that we have struggled mightily with it for many decades. No solution has competently balanced the requirements of all the users.

Until now. The flexible-core inpatient unit puts to rest the decade-by-decade iteration of designs that solve one problem only to create others. Based on balance, not compromise, the flexible-core design serves the needs of all users, breaking the now century-old paradigm of acute-care facility design evolution.

When Florence Nightingale described her vision of nursing units in the 1850s, she revolutionized the quality of care. We also know that she was an overworked nurse responding to the critical needs of too many patients while making life and death decisions. (Not much has changed, has it?) The significant thing was that Florence felt empowered to change her environment to suit her needs.

Through the years, others have felt empowered, as well, but most often they addressed one need at the expense of others. Entering the 20th century, nursing units were arranged as wards, which solved the issue of the nurse's proximity and visibility to multiple patients. The open ward transformed into the simple rectangle of semiprivate rooms that maintained nurse/patient proximity, but did not allow for storage or much privacy. In 1946, the federal government seeded the nation with this design, courtesy of Senators Hill and Burton.

For the next 50 years, we can trace the struggle between the two great nursing unit contenders—providing enough storage in the right location versus shortening the nurses’ daily path—in the architectural artifacts of the floor plans. In the 1950s, we witnessed the advent of the racetrack rectangle: patient rooms around a core that began to address storage and staff space needs but consequently lengthened the caregiver pathway. Several varieties of cross-shaped plans—simply, rectangle units with more expansion potential—were introduced in the 1960s. The 1970s brought us circular arrangements (shorter pathway, not enough storage) that led to the triangle units of the 1980s (still a short path and no storage, but less quirky in room layout). The 1990s gave us a little bit of everything.

During the last decade, the patient leapt from being an unnoticed competitor for space and architectural attention to becoming the dominant focus. Suddenly, we saw bigger patient rooms, decentralized nurses’ stations, clustered rooms to reduce isolation, various floor-plate shapes, and architects beginning to design like we gave a damn. (What took us so long?) And while all this is great and very necessary, in reality, it simply added one more contender struggling to win dominance. Now there are three competing interests—pathway length, storage, and patients—and no referee. And that means constant compromise.

So we've decided to throw away decades of space programs, to let go of the baggage of past designs, and revisit fundamental questions: What are the goals of each person using this space? What does it take for each person to optimally perform? What attributes within each space can maximize the return on the investment of energy by each person? How do we create collaborative, flexible spaces that are malleable in response to the various needs of both the group and the individual?

The answer is developing the form of the flexible-core inpatient unit. Imagine any nursing unit without the core (but leave the space). That's right, take out all that stuff packed in the center of the nursing unit and put it somewhere else. In a merciless sweep of the space program, remove anything not directly associated with patient care from the center of the patient floor (think exit stairs, elevators, mechanical shafts, data rooms). Then on to the next level: staff offices, staff lounges, stat labs, satellite pharmacies, housekeeping—

everything that may be needed close by, but not in the center of the patient unit.

For the needs that do belong in the center of the unit, the core stays open. The flexible core is composed of modules of space delineated by system office furnituremoveable partitions designed to adapt readily to different needs and various configurations. Inside these modules can be equipment storage, nurses’ stations, and patient support spaces in whatever ratio the service line requires. The staff can easily adapt the different spaces to their various needs throughout the shift, the month, or the year. Patients and families can move furniture around in their “living rooms,” just like at home. It's a veritable laboratory allowing care teams and patients to experiment with ways to customize their environments to achieve their goals, rooted in the knowledge that having control of your space is a basic tenet of evidence-based design and healing environments.

By opening up the core and allowing easy passage in any direction through it, the care team path shifts from being lengthened by and contained within a corridor, to being transverse across the core. So, one nurse may handle four patients across the unit (shortening the daily commute), and on that pathway are equipment and supplies (in optimally located storage). Daily-use supplies are kept bedside in the large, acuity-adaptable rooms, complete with family space. Visibility is maximized, while privacy for focused activity is optimized. Multiple connectivity venues—power and communications ports—are available for adaptability, and the system furniture partitions keep it all organized, contained, and defined.

Is it perfect? Not yet. But it is a revolutionary first step in balancing the needs of all users of the nursing unit. Florence Nightingale responded to her war-torn world by taking control of her space. Bravo for her. Today's care teams are just as much under the gun. Let's see what they do with their space when they at last feel empowered.

After all, healing environments aren't just for patients anymore. HD

Janet Paden Faulkner, AIA, LEED AP, is a Principal and leader in the healthcare design studio at Callison. Callison's flexible-core inpatient unit design at St. Charles Medical Center, Redmond, Oregon, has reduced nurses’ time spent searching for supplies by 40%, achieved the highest satisfaction ratings given by the facility's patients and their families, and has led St. Charles to be specified as a facility of choice by regional physicians. She can be reached at

Janet.Faulkner@callison.com.

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