Improving Staff Outcomes in Inpatient Units—A Canadian Context
As reported in the CHD Research Report in the June 2012 issue of HEALTHCARE DESIGN, the design features of the new wing at Trillium Health Centre-Mississauga site, which include decentralized nurses’ stations, larger patient rooms, and wireless technology, were evaluated for their impact on patient safety, staff outcomes, cost effectiveness, and improvements in overall patient and staff satisfaction.
Trillium wanted to test the improvements in the quality of nurses’ work life by ensuring they had access to frequently used supplies, communication devices, and quiet spaces for medication dispensing and documentation. The new wing was built on the premise that the average age of the nursing staff will become increasingly older, based on demographic projections by human resources.
Ergonomic considerations such as large uncluttered rooms and ergonomically placed electrical outlets (waist high)—virtually stopping the need for kneeling and crawling—were critical to ensure enhanced staff safety and satisfaction.
The quality of the nursing environment was tested using qualitative interviews, retention rates, and reported sick time. The study measured the impacts of the new environment on staff safety, satisfaction, and turnover. A comparison of data from the traditional patient unit with data from the new decentralized units found statistically significant changes in pre and post measures for staff outcomes, including:
- A decrease in nurse walking time and trips to obtain supplies;
- A decrease in nurse call-response times; and
- An increase in nursing availability and direct patient care time.
Studies have shown that poorly designed workspaces can often lead to inefficient patient care as clinicians’ time is spent “hunting and gathering” information (Hendrich 2006, Ulrich et al. 2008). There are correlations between the work environment and nurse satisfaction. Nursing satisfaction, in turn, directly impacts patient outcomes (Hendrich, 2006). In hospitals where nurses experience high job satisfaction, patient outcomes such as quality care and patient satisfaction scores are often positive (Hendrich, 2006).
In the new wing’s decentralized nursing environment, process inefficiencies such as response times should be minimized because nurses are closer to their patients. Clinicians are able to update patient records right at the bedside and communicate directly with their patients and colleagues in a timely manner. In decentralized environments where nurses can work in stations placed closer to their patients, one finds that patient care is enhanced and staff satisfaction is increased (Ulrich et al., 2008).
Nurses are able to spend more time caring for their patients and are in a position to respond in a timelier manner to their patients’ needs. The decentralized environment has also been correlated with improved patient satisfaction. In their study that compared the benefits of decentralized environments over centralized environments, Howard and Malloch found that patient perception of response to calls was more favorable in a decentralized medical surgical unit (Howard and Malloch, 2007).
Staff safety and physical demands
Nurses have the highest number of lost work days and the highest percentage of lost time attributed to illness and injury. Most of these injures are musculoskeletal. Causes of musculoskeletal injuries include awkward postures for sustained periods of time and repetitive loading or lifting. For musculoskeletal disorder (MSK) cases involving patient handling, almost all (99%) were the result of overexertion. Sprain, strain, or tear was the type of injury incurred in 83% of the MSK cases involving patient handling (U.S. Bureau of Labor Statistics, 2011).
The hypothesis was that staff safety would be improved in the new wing through reduced MSK injuries due to improved bed mobility and room access, proximity of patient care equipment, and ergonomically placed electrical outlets. Pre-move data was documented on the physical demands required to perform essential nursing tasks. The physical demands required to perform essential tasks on the new unit were analyzed post-move with a specific focus on patient handling activities. The pre-move physical demands data was compared to post-move data for the same units that now occupy the new wing.
A physical demands analysis (PDA) of the RN position was completed for the 4B medical unit in the “old” building prior to the move to the J wing. Following the move, a new PDA was completed for the RN position on the J wing medical unit. A comparison of the frequencies that specific physical demands were performed pre- and post-move was completed using the hospital standard PDA forms.
The comparison was based on frequencies for 8- and 12-hour shifts. A standard frequency rating scale was used (see Table 1 and Table 2 below). The documented rating was based on the cumulative time for which that physical demand is performed over the course of a shift. This was established through observation and use of a stopwatch. Additional tools used as required were a force gauge (to measure push/pull forces) and a weigh scale.
Most of the environmental changes implemented in the new wing were to ensure better working conditions for the nursing staff. According to Rashid (2007), betterstaff working conditions are created by:
- Flexible patient charting locations (inside and outside the room);
- Adequate work surface and space at nurse work stations; and
- Proximity of nursing stations to patients.
The hypothesis was that staff satisfaction would improve because of the wing layout design: proximity of supplies as well as proximity of patients. Additionally, the integrated technology would allow clinicians to effectively communicate directly with their patients and other staff members. This was measured through rates of staff turnover, as research has shown that turnover rates are tied to the environment and job satisfaction.
The data used for the analysis includes the total number of staff and the number of staff who left the job for each five-month period from May 2006 to March 2009 (pre-move) and November 2009 to March 2010 (post-move). Statistical analysis indicated that the five-month turnover rate decreased from 3.38% to 1.76%, with significant results at the 95% confidence level (0.025<0.05).
Direct time in care
Physical features of inpatient facilities can obstruct efficient nursing work and diminish patient safety. Poorly laid out inpatient units contribute to a decreased amount of time available for nurses to spend on direct patient care. Numerous studies have shown that nurses spend a significant portion of their time in activities that are inefficient and reduce the amount of time they have available for direct patient care.
The hypothesis was that the decentralized environment and the enhanced communication technologies in the new wing will lead to an increase in the percentage of time a nurse is spending in direct patient care time over a traditional inpatient unit with a centralized nurses’ station (Hendrich et al., 2004).
“Releasing Time to Care” is a licensed product from the National Health Services (United Kingdom) that provides a lean guide to improving bedside nursing care. “Activity Follows” is a methodology that permits understanding of what nurses are doing—minute by minute. One of the indicators is direct time to care, and the other is the number of interruptions (due to
poor physical layout and access to supplies, for example).
Using this methodology, the new wing showed evidence that nurses provide more direct care time in the new wing versus the old wing (see Table 4). There were fewer interruptions in their workplace, as well (see Table 5).
Two medical-surgical units were monitored for 64 hours of nursing time over eight days. Observers documented how nurses spend their time. Analysis of the time and motion study provided insight into how the environmental design (traditional versus decentralized) of the nursing unit can affect nursing workload by tracking excess motion, inefficiencies, amount of direct patient care time, amount spent dispensing medications, and documenting charts.
Although significant initially, the organization has adopted lessons from the new wing into the old wing. These adoptions have increased direct time to care at the bedside and helped to reduce interruptions. An example of this includes frequently used supply carts now dispersed throughout the unit and decentralized workstations installed wherever possible.
As online medical records become more common, we see more opportunities to create decentralized environments bringing nurses closer to their patients.
Data from the two medical-surgical units show that nurses on the new wing spend more direct patient care time than nurses on the old wing. Tables 4 and 5 illustrate the amount of patient care time and the number of interruptions nurses faced on both units during the observation period.
The decentralization of supplies dramatically reduced the time staff spent “hunting and gathering” or interrupting each other. The decentralized unit also allows nursing staff to be closer to patients, and the end result is a much calmer environment that increases staff morale and is comforting to patients. HCD
Note: On December 1, 2011, Trillium Health Centre merged officially with The Credit Valley Hospital. The Credit Valley Hospital and Trillium Health Centre is one of Ontario’s largest community-based academic health networks, serving the communities of Mississauga, West Toronto, and the surrounding regions. For more information, see www.trilliumhealthcentre.org and www.cvh.on.ca.
Patti Cochrane is Vice President, Quality and Patient Safety and Chief Nursing Officer at Trillium Health Centre site of The Credit Valley Hospital and Trillium Health Centre; Juliet Nishimura is a Quality and Patient Safety Advisor at Trillium Health Centre site; Gary Spencer is the Director Decision Support at Trillium Health Centre site; and Ellen Taylor is Director of Pebble Projects for The Center for Health Design. Joseph Szmerekovsky, PhD, provided statistical analysis.
Hendrich A. (2006). Hospital Work Environments: Implications for Nursing Practice and Patient Care Quality. In proceedings of Healthcare Environments Research Summit 2006:Developing the Research Roadmap. February 8-9, 2006: Georgia Tech, Atlanta
Howard, L., and Malloch, K. (2007). Centralized and Decentralized Nurse Station Design: An Examination of Caregiver Communication, Work Activities, and Technology. Health Environments Research & Design Journal, 1(1), 44-57.
Ulrich, R. S., Zimring, C., Zhu, X., DuBose, J., Seo, H.-B., Choi, Y.-S., Quan, X., et al. (2008). A Review of the Research Literature on Evidence-Based Healthcare Design. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL, 1(3), 61-125.