The United States is facing the worst nursing shortage in history. Not enough young nurses are entering the workforce, while baby boomers are aging and requiring more and more medical care. According to the U.S. Department of Health and Human Services, a registered nurse's average age is 46.8 years. This aging population is dealing with increasingly long hours and growing patient-to-nurse ratios, leading to stress, injury, and reduced quality of care. Using innovative solutions to workplace problems, healthcare architects are working to reverse these trends.

Nurses leave because they are dissatisfied with working conditions. Not surprisingly, a growing body of evidence suggests that hospitals with lower nurse-to-patient ratios have more adverse events than hospitals with higher nurse-to-patient ratios. The same study indicates that higher nurse-to-patient ratios result in a shorter length of stay for patients. Everyone wins when there are more nurses: patients' quality of care increases; hospitals have a higher turnover rate and are able to care for more patients; and nurses experience less stress, fewer injuries, and more job satisfaction.

Retaining older nurses, recruiting experienced RNs, and attracting young graduates are all critical means of addressing the nursing shortage, so naturally, hospitals and treatment centers are searching for ways to improve the working conditions for nurses. By providing a safer and more appropriate work environment, healthcare architects can effectively help battle this crisis. Experience-based design provides clarity to these challenges and allows the architect to formulate alternative design solutions to enhance nursing staff performance and comfort. This is a process in which we believe strongly because it has proven invaluable to our firm's healthcare design practice.

Lighting the way

When the net effect of the nursing shortage is an aging nursing population, a variety of factors have an impact-for example:

  • the number of steps to patient beds, supply closets, and support spaces;

  • ergonomic seating (or lack of it);

  • computer screen size and height of keyboard;

  • availability of private staff lounge areas;

  • patient beds and equipment that might aid nurses in lifting; and

  • proper lighting and the ability to control lighting easily.

Indeed, lighting is a major issue in the nurses' work environment. Eye fatigue in nurses, especially on night shifts, can be exacerbated by inappropriate lighting for computer usage, in patient rooms, in nursing stations, and in supply closets, causing eye strain and raising the risk of medical error. During the day, it is comfortable to shift one's eyes from a computer screen to a fluorescent-lit hallway to a sun-lit patient's room. But at night, the patient's room is typically dark while the corridor is startlingly bright, causing substantial eye fatigue when the nurse moves from one to the other repeatedly.

“One of the many stressors of the hospital stay from the patient perspective is ‘being stuck,’ whether it is for lab draws or IVs,” says Myra Gray Fouts, RN, MSN, vice-president for medical affairs, Aptium Oncology, Inc. “Creating an environment that is patient-centered includes the right kind of lighting to make these procedures as quick as possible. Poor lighting can impair the nurses' vision to the point that multiple sticks can be necessary, creating anxiety, pain, and future apprehension for the patient. The quicker one is able to focus and complete the procedure, the better.”

The design solution? Lower the levels of corridor brightness. The central nursing area can be quite bright, but at night, the hallway outside the patient rooms should be dim so as to ease the strain on nurses' eyes when transitioning from light to dark (figure 1). The insertion of a lighting control system with automatic dimmers is a simple, hands-off solution that also conserves energy. Design that lets in abundant natural light and uses multizone lighting control systems and dimmable lighting in corridors and nursing stations improves the work environment immeasurably (figure 2).

Within the acuity-adaptable room, thoughtful light allows for less eye strain for nurses

Access to daylight helps alleviate nurse eye strain

The text on computer screens and patients' charts is small, and the text on medicine packages is smaller still, so task lighting must be bright, particularly in the medication room. Thoughtful design can reduce the potential for error by creating medication dispensing areas in closed rooms or quiet alcoves with high lighting levels and sound dampening systems. Since the text on medication can be so small, providing fixed, adjustable magnifying instruments can greatly reduce mix-ups in medication dispensing and aid immeasurably in easing nurses' eye strain.

Acuity-adaptable care

Acuity-adaptable care concepts bring the required level of care to patients while they remain in one room throughout their entire hospitalization. An acuity-adaptable care delivery model reduces inefficiencies and enhances patient safety, since the level of care changes rather than the patient's location.

In a typical setting, transferring a patient from an intensive care setting to a step-down unit to a telemetry floor can involve multiple staff members with different levels of education and skills from various clinical and ancillary areas. With this large number of staff involved, the potential for miscommunication is high and can result in errors. Reducing or eliminating transfers significantly decreases the potential for medication errors, lost belongings, patient uneasiness, and staff confusion. Acuity-adaptable care can reduce the length of stay, free up capacity, and minimize the need to fill vacant nursing positions.

Acuity-adaptable design allows for greater exposure to other skill sets and provides a high level of cross-skill-level collaboration. This aspect of acuity-adaptable care provides an informal classroom that opens the door to mentoring and apprenticeships. Therefore, in the best-designed facilities, healthcare architects locate classrooms for continuing education adjacent to staff lounges. In these classrooms, “lunch and learn” sessions where new products or techniques are demonstrated draw the staff together and encourage personal and team advancement.

There is controversy surrounding acuity-adaptable care, however, and it is two-fold. Not surprisingly, one issue is cost. Hospitals hesitate to invest in multiple, fully-equipped critical care rooms in lieu of a standard patient room. Administrators shudder to think of a patient who may be going home tomorrow lying in bed surrounded by expensive equipment suitable for the highly acute. Results from existing facilities, however, indicate that hospitals get a return on the investment through occupancy, the rate of which is typically 75 to 85%.

A stickier issue involves the nursing staff. Acuity-adaptable care involves pairing nurses with basic skills with highly-skilled nurses so as to increase their ability level. The problem is that there are not enough critical care nurses to aid in training the lesser skilled, and nurses are divided among those who want to care for the seriously ill and those who do not. Asking nurses to treat patients from the beginning to end of their hospital stays may run counter to nurses' desires.

At our acuity-adaptable project at Geisinger Medical Center in Danville, Pennsylvania, nurses move from room to room within the unit. For every 10 patient rooms there is a nursing pod, outside of every two rooms there is a decentralized nursing station, and the classroom is located in the unit. The result is that nurses have easy access to relaxation, information, education, and (one hopes) greater job satisfaction.

Close at hand

Perhaps the greatest environmental issue facing nurses today is the number of daily steps required to reach their patients, supplies, and medicine. By merely reorganizing staff routes, blending centralized and decentralized nursing stations, designing supply shelves and closets to be within 60 feet of patient care delivery points (figure 3), and siting the parking lot near the facility for nurses and late-shift workers, facility design can reduce walking distances, greatly impact safety and energy levels, and improve patient care. Also, using adjustable chairs and counters and placing storage at appropriate heights can decrease absenteeism due to injuries.

Work areas are spaced within the unit so nurses do not have to walk more than 60 feet to get medication, supplies, or support

Bar code technology

Technology is a major factor in the modern healthcare delivery system, and merely rethinking a facility's use of technology can contribute to nurse retention. Architects are considering technological factors, such as the weight of hand-held equipment and the impact of computers on wheels, and they are finding solutions that do not involve adding to the nurses' existing burden. These solutions include avoiding heavy portable equipment, providing wall-mounted, fixed computers in numerous locations, and consolidating all pagers, door swipes, telephones, e-mail correspondences, and personnel location devices into one lightweight piece of equipment. With the number of wall-mounted computers growing, the need for a quick method to retrieve and input data is required. Biometric or card swipe access to ensure patient information safety is critical today. The card around their necks, that with one swipe, gives access to patient records, should be paired with a communication device that nurses use to call one another if they need help.

Strength in numbers

Reducing walking distances, designing user-friendly ergonomic stations, improving technology, and providing proper lighting influence a nurse's health and quality of care delivery, but the architect must consider the physical burdens of a nurse's daily activities as well. Patient lifting and transferring can place great strain on a nurse's back with increasing pressure on his or her mobility. Bariatric patients present an especially difficult situation. Healthcare architects are using mobile and fixed bariatric lifts and bariatric-approved rails to aid with this dilemma.

Debra J. Mensch RN, BSN, operations manager, Patient Transfer and Lift Team at Geisinger Medical Center, notes that “patient handling and movement tasks are physically demanding, performed under often difficult conditions and are often unpredictable … The implementation of the Patient Transfer and Lift Team will significantly reduce the risk of injury for the direct patient-care workforce-nurses, nursing assistants, etc.-thereby improving staff retention and recruitment through improved satisfaction. Patient handling injuries and the costs associated with those injuries will decrease by 30% after the first operational year.”


By 2014 it will be necessary to recruit more than 400,000 new RNs just to replace those older than 55 who are expected to retire from active nursing practice. The latest estimates developed by the Bureau of Labor Statistics indicate that the United States will require 1.2 million new RNs by 2014 to meet the nursing needs of the country, 500,000 to replace those leaving practice, and an additional 700,000 to meet growing demands for nursing services. Through effective and efficient design, architects can guide facilities toward solutions to retain staff and help counter this nursing shortage crisis, and perhaps reduce these daunting numbers. HD

Natalie Miovski, AIA, LEED AP, is a principal with EwingCole, based in Philadelphia, Pennsylvania, where she plays a key role in leading the firm's healthcare architecture efforts. She can be contacted at 215.923.2020 or at

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Healthcare Design 2009 August;9(8):66-69