Does The Decentralized Nursing Model Deliver?
The decentralized nursing operations and physical design model was introduced to inpatient units more than 10 years ago, with a number of expected positive outcomes for staff. Those include reduced nurse walking distances, more time at the bedside, less stress, improved productivity, and enhanced collaboration, among others. In essence, it was anticipated that the move would improve efficiency and safety, workplace condition, and care quality.
Since adoption began, at least six studies have examined whether these hopeful outcomes have been achieved (see sidebar below for study details). While not all studies posed the same set of questions, a review of the outcomes does provide some interesting and important questions to ponder.
The good news
Patient satisfaction is higher in decentralized units, according to two studies. While some may attribute this to the halo effect of new facilities (one’s impression about a hospital is influenced by the newness of a space), one of the studies reported improved scores for nurse response time to patient calls, too. It’s intuitive that response time would be quicker, thanks to the proximity of caregivers to patients in a decentralized model, and that fact may also explain a reduction in fall rate (found in a different study), as well. Patients typically fall during solo trips to the bathroom, either owing to a false confidence in their physical abilities or a delay in nurse response time, or both. Nearby location of staff can improve vigilance as well as reduce response time, thereby reducing fall events. Additionally, a lower level of distraction during work was self-reported by staff in one study.
Interestingly, some outcome areas demonstrated few differences between centralized and decentralized units. Those include: sound levels (two studies), perception of the work environment (two studies), self-reported productivity (one study), and clinical outcomes (one study).
There are inconsistent findings in some areas, too, where decentralization has either demonstrated good outcomes or no difference. An increase in time with patients was shown in one study, whereas no difference in nurse/patient interaction was reported in two other studies. Inconsistent findings were also observed in staff well-being, including levels of acute stress and energy, in two studies.
Areas of concern
The above findings are good or, at worst, neutral regarding the trend toward decentralization. However, there are areas where the decentralized model was found to perform worse than the centralized model.
One area of concern is walking distances. Of three studies that measured walking, one reported a reduction, whereas two showed an increase. This goes against intuitive logic, since the core goal of decentralization was to move staff closer to the point of care. Why would walking increase? It could be unrelated to unit design, for one. Policy changes related to patient care—such as frequency of rounds—can impact walking and, if effected during the transition to a new facility, may result in an increase in walking distances wrongly attributed to design.
On the other hand, the large footprints that are typical of decentralized units can also trigger additional walking. This is exacerbated by varying requirements for patient visibility: For example, acuity-based assignments, as opposed to geographic, will lead to increased walking on large units to maintain necessary visual contact. Peer-to-peer visibility is also an essential part of the nursing culture and staff may walk to seek out consultation, mentoring, and socialization. Additionally, while nurses’ stations may be decentralized, the support areas—such as linen, supplies, and medications—may remain centralized and result in more travel.
The second issue that emerged pertains to medication. Two studies measured nurses’ time in medication rooms, both reporting longer time spent on decentralized units. It’s possible that nurses are collaborating or socializing while in the medication rooms in order to mitigate the lack of a centralized gathering space. However, there are also policies and procedures that may affect time spent in medication rooms. For example, some medications may require “two-nurse checks.”
All six studies measured some aspects of the broader construction of staff interaction—consultation, collaboration, or social engagement—and all reported a reduction. Only in a team-based care model (one study), which mandates interactions between the RN and his or her assistants, was a reduction not observed. This reduction has occurred even though the decentralized units were designed with infrastructure to support collaboration and teamwork. There’s a growing body of literature demonstrating the positive effects of collaboration and teamwork on quality, efficiency, safety, and innovation, and in this context, the reduction noted should be of major concern.
As patient care increasingly moves to outpatient locations, the inpatient acuity level is increasing, requiring the ability for nurses to consult on clinical problems, teach new nurses, and rely on teamwork in acute situations.
Striking a balance
The key challenge that’s emerged from this review is how to retain the benefits of decentralization while improving on the areas of concern. Does the solution lie in operational interventions or in physical design? If a larger footprint is one of the culprits, the solution may be to reduce unit size and number of beds. However, that may pose a challenge to operational efficiencies.
In addition to acuity-based patient assignment, higher patient–to-nurse ratios will affect operations more on a decentralized unit, as a higher number of patients assigned means more walking and to multiple rooms. Both of these factors could provide subjects for new hypotheses related to centralized versus decentralized design. Is the decentralized model superior only with lower nurse-to-patient ratios and higher patient acuity? What role does geographic patient assignments play in the efficiency of unit operations?
Before pointing a finger at either physical design or operations, it’s crucial to underscore that changes in the former or the latter alone may not produce desired outcomes. Physical design interventions must be accompanied with a firm commitment to operational and cultural changes. Regardless of the unit design, these formalized processes must be implemented and sustained to realize successful outcomes in any model.
Debajyoti Pati, PhD, FIIA, IDEC, LEED AP, is a professor and Rockwell Endowment Chair, Department of Design, Texas Tech University (Lubbock, Texas). He can be reached at email@example.com. Pamela Redden, MS, BSN, RN, EDAC, is director of clinical operations development at MD Anderson Cancer Center (Houston). She can be reached at firstname.lastname@example.org.
The six studies referenced are as follows:
- “An Empirical Examination of the Impacts of Decentralized Nursing Unit Design,” by Debajyoti Pati, Thomas Harvey, Pamela Redden, Barbara Summers, and Sipra Pati. In HERD, Volume 8, No. 2, 2015.
- “Centralized vs. Decentralized Nursing Stations–The Impact on Staff Perception of Communication, Teamwork, and Quality of Care,” by Sherri Ewing, Karen Richey, and Huong Mai. A paper presented at the 2014 Healthcare Design Expo & Conference, San Diego.
- “Effects of Nursing Unit Spatial Layout on Nursing Team Communication Patterns, Quality of Care, and Patient Safety,” by Ying Hua, Franklin Becker, Teri Wurmser, Jane Bliss-Holtz, and Christine Hedges. In HERD, Volume 6, No. 1, 2012.
- “Impacts of Architectural Design on Communication Among Hospital Staff,” by Chia-Hui Wang. A paper presented at the EDRA 42 Conference, Chicago, 2011.
- “Centralized Vs. Decentralized Nursing Stations: Effects of Nurses’ Functional Use of Space and Work Environment,” by Terri Zborowsky, Lou Bunker-Hellmich, Agneta Morelli, and Mike O’Neill. In HERD, Volume 3, No. 4, 2010.
- “Centralized and Decentralized Nurse Station Design: An Examination of Caregiver Communication, Work Activities, and Technology,” by Linda Gurascio-Howard and Kathy Malloch. In HERD Volume 1, No.1, 2007.