The intense and stressful healthcare workplace environment continues to challenge healthcare leaders in their efforts to improve staff recruitment and retention. According to an April 2005 news release issued by the American Nurses Association (ANA), a report released in July 2002 by the federal Bureau of Health Professions indicates that if the nursing shortage goes unchecked, the demand for registered nurses (RNs) is expected to grow to 2.8 million by 2020—a 29% shortage. ANA also notes a Hospital & Healthcare Compensation Service survey conducted in 2003, which found the turnover rate for RNs is 14.6%. Moreover, in one of the largest samples of its kind exploring various components of job satisfaction among registered nurses (RNs), conducted through an ANA survey, 79% of all RNs reported they intend to remain on the same unit, while only 69% of RNs on step-down units and 72% of RNs on medical/surgical units intended to remain in the same job the following year—and 8% reported they intend to leave direct patient care or nursing entirely.

Certainly, operational changes can enhance staff recruitment and retention efforts. Effective, staff-focused design also offers positive solutions


Impetus for Innovation

Designing the hospital as a healing environment has been found to have a positive impact on patients' safety and well-being. Indeed, today's patients expect quality care and a comfortable environment. In upscale markets and certain specialties (e.g., maternity care), they are shopping around to find these attributes. They are becoming familiar with good design through contact with other community settings, such as libraries, hotels, corporate offices, airports, and public branding for major retail venues. Thus, they expect patient rooms designed for functionality, comfort, and convenience, with attractive, comfortable furnishings, accessible over-bed and bedside tables, telephones, computer ports, individual lighting and temperature controls, and provisions for family members to spend the night. Patients and their families also desire access to gardens and other healing spaces. As a result, healthcare leaders realize they need to focus on their healthcare environment and what it communicates about how the institution cares—both for patients and staff.

Environment and Retention

There is no doubt that the built environment is a key to nurses' productivity, job satisfaction, and stress levels. A good deal of emphasis has been placed on designing the work environment to enhance nurses' productivity and effectiveness. However, given the inherent stress involved in the practice of nursing in an acute care environment, nurses need opportunities to step outside the work environment for short periods to relax during the workday, so that they can return to patient care feeling renewed and refocused.

When asked to describe a restorative environment, nurses have stated that it is one that feels totally unlike the work space, according to results of focus groups led by Patricia Novick, PhD, DMin, a senior fellow at Harvard Divinity School and executive director of Alive, Ltd., a nonprofit organization with a mission of sharing restorative practices with individuals and organizations. Such an environment would facilitate reading, meditation, relaxation, and other short-term activities that would restore a sense of calmness and focus. This private space would be furnished and designed comfortably, based on themes of nature such as water and sky. Perhaps there would be views of a garden, wall and ceiling murals, or artwork depicting waves and clouds. A CD player would be provided for personal music. A private bathroom would complete the environment.

A Prototype Restorative Environment

Archeworks, an interdisciplinary design school that approaches design based on social need, has designed a prototype of a restorative space for nurses that can be incorporated into existing space within a hospital (figure 1). Archeworks based the restorative design on research obtained in tandem with Dr. Novick and Archeworks' on-site nurse research. The module features a translucent wall (figure 2); a wood-paneled wall with storage, phone, and computer connections (figure 3); a daybed and a lounge chair; adjustable lighting; and a private bathroom. The prototype aims to capitalize on the opportunity for design to support relaxation and rejuvenation. Designed with particular sensitivity to the impact of light and color within the space, the prototype facilitates restorative activities such as rest and reading. Materials were chosen to counteract the highly industrial and impersonal character of most hospitals. In addition, cabinetry was constructed in modular units to create the opportunity for nurses to tailor the environment to meet their collective needs and desires. This tangible idea contributes to a work environment that supports recruitment and retention.

A restorative space for nurses can be incorporated into a hospital's existing space, like this prototype by Archeworks.

Features such as the Archeworks prototype's translucent wall introduce ambient light and help to distinguish the restorative space from the nurses' work environment.

The prototype includes such amenities as storage space, phone and computer connections, and a daybed.

Practical Design Strategies

Few hospitals can afford to add space exclusively for restorative environments for their staff. However, every hospital has spaces within nursing stations designated for conferencing or break-out. Often, designated meeting rooms are used only for short periods each day. It is possible to “repurpose” these areas economically to accommodate a restorative space.

At the same time, practical design strategies can be employed throughout the hospital to create an environment that promotes staff well-being. Because hospitals often are homogeneous spaces without variation in the intensity of light and hues of color that create varying moods, the effective use of light and color is critically important to creating stimulating environments, such as in physical therapy rooms, and calm environments, such as in restorative spaces.

Hospitals also should consider opportunities to leverage amenities cost-effectively, such as on-site childcare, banking, retail space, food services (especially those that offer healthy alternatives to conventional menus), wellness centers, and walking trails for use by patients, visitors, and staff. Such amenities not only contribute to the hospital's ability to attract patients, but also its ability to recruit and retain staff. Some of these services even can be developed as profit centers.

Hospitals today face enormous challenges in recruiting and retaining qualified professional staff—especially nursing staff. Implementing practical, staff-focused design strategies to create a restorative environment for nurses can help them to meet those challenges. HD

As Design Principal of Perkins+Will's Branded Environments discipline, Eva L. Maddox, FIIDA, Assoc. AIA, LEED AP, focuses design on alternative learning processes, restorative/green spaces, and the integration of community/cultural interpretations within corporate, education, and healthcare environments. She is a member of the Perkins+Will board of directors. She founded the discipline of Branded Environments to assist clients in communicating their brand, and is a cofounder of Archeworks, Chicago's alternative design school.

Jean Mah, AIA, FACHA, LEED AP, is the National Market Sector Leader for Healthcare and directs this $3 billion practice at Perkins+Will, specializing in leading project teams for health science centers, teaching hospitals, and academic medical centers worldwide. She also serves on the firm's board of directors. She can be reached at 213.270.8447 or