Bedside to Blueprints: The Role of Nurses in Hospital Design

Frontline Nursing Staff

Nurses provide more direct patient care in the context of the built environment of an inpatient hospital unit than any other staff member. Their workflows and processes are created, molded, and shaped by the layout of the facility. When asked about the importance of frontline staff involvement, all participants agreed that their input is highly regarded as valuable information when creating new workspaces, as they have first-hand knowledge of the current workflow processes, the needs of their patient population, and current operational inefficiencies that result from the physical design.

The involvement of frontline staff is often project-specific and can vary widely based on the size and scale of the endeavor. A similarity found across disciplines was that ideally nurses should be involved in the early stages of unit layout design; however, those interviewed identified a number of barriers preventing optimal involvement during the design process. The two most common obstacles identified across all interviews were nurses' apprehension to innovative change and challenges related to interdisciplinary communication when working with frontline staff.

Changing a work process is a difficult concept to envision. When involving frontline staff and engaging in discussions regarding their visions of a new unit, nurses often default to that with which they are familiar and comfortable despite prior identification of inefficiencies within the built environment. A recurring perception among those interviewed was the difficulty frequently encountered when trying to generate innovative ideas from bedside nurses, who many times have little experience outside their “home” unit for the greater part of their careers. Limited exposure to different and possibly superior design features may hinder their ability to visualize how proposed design schemes for a new built environment could contribute to higher quality patient care and greater efficiencies in their own work. In addition, nurses are keenly aware of their own processes, but are only one of many end users of the built environment and may have limited knowledge of the effect of their decisions on other disciplines, such as dietary or physical and respiratory therapy. One nurse consultant described the benefits of constructing a mock-up room as a means to address this issue. This physical space where multiple disciplines can brainstorm and work through issues related to the built environment together can allow issues to surface and be resolved prior to construction of the building.

Nursing workflow is guided by its own systematic process and language to practice and communicate efficiently and effectively. Similarly, architects use their own strategic process from concept to occupation and employ a language specific to their profession. Blueprints, design concepts, and square footage may be foreign concepts to frontline nursing staff, leaving encounters between disciplines vulnerable to frustration and miscommunication. Additionally, many of those interviewed suggested that miscommunications happen as a result of limited understanding of the nursing role and workflow of the nurse. One nurse architect in particular advised that work processes of the end user be constructed first to avoid creating design features that result in permanent inefficiencies. Another healthcare architect suggested identifying a nurse “champion” who is interested, motivated, and invested in the hospital to work alongside the facility manager, assist communication, and function as the voice of the frontline staff for the project. Essentially these comments support the idea that nurses as the end users are important team members at the front end of the design process.

Nurse Leaders

Patient population and nursing processes differ from unit to unit and workflows need to be communicated to the project team for optimal design layout. Nurse leaders play a different, yet important, role in the design process. As the link between frontline staff and decision makers, it was commonly noted across interviews that the nurse leaders' presence and input is valued when received. However, the involvement of hospital nurse leaders in the process is often limited and sometimes nonexistent. Their level of participation is dependent on both size and scope of the project as well as the culture and structure of their facility. As with the frontline staff, communication across industries can be frustrating, leaving nursing vulnerable to being circumvented altogether if leadership allows for that to happen.

On the other hand, some nurse leaders are very involved in the design process. In addition to creating teams and disseminating information, nurse leaders are found at the table on the business end of the design process. They assist in evaluating project recommendations and making budget and service line decisions. The skill mix of nurse leaders is unique in that they have intimate knowledge of the organizational culture and nursing care process, and can translate nursing input into executive language when they are present and participatory in unit design discussions. With this unique skillset, nurse leaders are poised to protect the frontline staff's input and defend their judgment to the decision makers.

External Nurse Consultants

Many nurses interviewed directed their interest in healthcare design into project leadership on facility construction as a member of the hospital's administrative staff. Using this experience, these nurse leaders transitioned out of the hospital and into an external consulting role. Many pursued formal and informal education outside of nursing but within the realm of healthcare design, creating a unique combination of knowledge and skills and making them a useful and valuable asset to the design team.

Hospital renovation or reconstruction occurs only once or twice throughout the length of an executive or employee's career. Therefore, it is understandable that hospital decision makers may elect to obtain guidance from external sources to ensure they integrate the most innovative and financially feasible decisions. Many of the architects interviewed have sought out nurses to be on design projects in a consulting role either as independent consultants or employees of architecture firms to assist design team members throughout the process. Among the many roles they assume, nurse consultants function as a liaison between the architects and clinicians, translating the languages and processes of the two professions. Most remain active in research and current with the evidence to provide sound guidance to architects and hospital decision makers as a facility proceeds along the continuum of the design process. While there are only a handful of nurses who have elected to work in healthcare design, their unique combination of disciplines yields valuable contribution to healthcare design.

Current Trends and Future Forecasting

One of the current movements in hospital design is the implementation of the patient-centered care (PCC) model for healthcare delivery in the inpatient setting (Nelson, West, & Goodman, 2005). The PCC model integrates aspects of the medical, emotional, and spiritual needs of the patient and family. Design concepts encompassed in the PCC model include single-occupancy rooms, larger inpatient rooms, designated family areas, natural light, noise reduction, art, and gardens (Mroczek, Mikitarian, Vieira, & Rotarius, 2005; Nelson et al., 2005; Trochelman, Albert, Spence, Murray, & Slifcat, 2012; Reiling, Hughes, & Murphy, 2008) The landmark report To Err Is Human commissioned by the Institute of Medicine (1999), coupled with the recent adjustment of Medicare reimbursement for preventable adverse events, shifted the spotlight to patient safety and quality outcomes (Thompson et al., 2012; Sadler et al., 2011). Hospital administrators and design teams are looking to the built environment as a means to improve safety and quality in the inpatient setting. Improved ventilation and filtration systems, design features that facilitate hand washing, assistive devices in patient rooms, and antimicrobial surfaces are innovative design concepts that project teams currently incorporate into the built environment with the intent to decrease adverse patient outcomes (Reiling et al., 2008).

A growing body of literature highlights many of the effects of the organizational and architectural design on patients, families, and staff members. (Sadler et al., 2011; Nelson et al., 2005; Ulrich et al., 2004). Project team members look to other facility designs as well as present research to make the best decisions possible for their current project. The lifespan of a building can be many decades, so while current research is of great importance, it is also important to incorporate design ideas today that are capable to support future medicine and healthcare. When asked about the future of healthcare, many of those interviewed referenced the Patient Protection and Affordable Care Act (PPACA). The PPACA of 2010 intends to make vast changes in the healthcare deliver in the United States by increasing the number of individuals with health insurance and creating alliances among providers to improve continuity of healthcare (Schultz et al., 2013). An overarching commonality across many interviews regarding the future of healthcare and the built environment is that many of the effects PPACA on healthcare delivery remain somewhat unknown; therefore, it is important to forecast as accurately as possible when the decisions made today are comparatively permanent for the life of the building.

Considering the unknown future of healthcare, those interviewed suggested that emerging hospital design incorporate an element of flexibility into patient room design and unit floorplans, which allows the facility to change as healthcare delivery changes, stay ahead of the curve, and avoid costly future renovation or reconstruction. While buildings are cemented in one place for decades, medicine and technology are not, and the responsibility falls to the organizational leadership and project team to incorporate the mission and vision into the built environment as they construct a facility that will serve the organization through the lifespan of the building.

Implications for Nursing

Many of those interviewed have observed that nurses are becoming increasingly involved with design projects in a variety of functions, but with little preparation or education for these roles. As increased evidence regarding hospital design emerges, a high-level understanding of research, interpretation of data and its implications for their facilities would better equip nursing leaders to participate as active project team members. A strong theme among interviews across disciplines was the need for inter-professional collaboration and education enabling each discipline to have an understanding of the others' profession. To facilitate the growth of interdisciplinary learning and collaboration, a number of resources exist to encourage the sharing of information and innovation and are recommended for those interested in learning more about the industry.

The Center for Health Design (www.healthdesign.org) is a not-for-profit organization that operates as the information hub for healthcare design. Embedded in their website are a number of valuable resources for professionals interested in current research, events, certifications, and ongoing projects related to healthcare design. This organization creates a forum for interdisciplinary collaboration and information sharing and is open to all participants of healthcare design regardless of profession or level of experience.

In recent years, the Evidence-based Design Accreditation and Certification (EDAC) exam has been offered to members of the healthcare design community. The three-volume set of study guides available from The Center for Health Design for the exam contain information to learn about design, research, healthcare, and more. This certification is unique in that it brings together multiple disciplines working toward the same goal and encourages interdisciplinary collaboration.

The Nursing Institute for Healthcare Design (NIHD) is another professional organization run by nurses with a diversity of expertise in healthcare design (http://nihd.affiniscape.com). Many nurses involved in NIHD have pursued further education in a design related field and offer their knowledge and experience through the organization. They provide educational webinars, research, events, and open discussion forums to provide a means to facilitate discussion and learning from the experience of others. While NIHD is composed mainly of nurses, membership is open to anyone interested in healthcare design, regardless of their profession. Both The Center for Healthcare Design and NIHD actively work toward closing the knowledge and communication gap and create an opportunity for nurses to envision nursing practice outside of their current processes and setting to achieve improved patient and staff outcomes.

Jennie Evans, Vice President and Operations Specialist with the international architecture firm, HKS, Inc., and President of NIHD, identified another opportunity for nurse leaders to include frontline staff in the design process through the journey of Magnet® designation. Magnet® status encourages nurses to step outside their bedside roles, learn additional skill sets and seek higher education to improve nursing practice and patient outcomes. The American Nurses Credentialing Center (ANCC) highlights five components that organizations must strive for to achieve excellence: transformational leadership, structural empowerment, exemplary professional practice, new knowledge, innovation and improvement, and empirical outcomes (Wolf, Riolo, & Ponte, 2008; Luzinski, 2011; ANCC, 2008). Striving for the coveted Magnet® status can create an opportunity for nurse leaders to encourage frontline staff to participate in healthcare research and project design as a member of the interdisciplinary team.

Additionally, conferences across the nation function as an avenue to foster networking and innovative ideas to improve hospital design and functionality. Participants gain knowledge of the latest research, new technologies, current events and facility experiences in seminars, small group discussions, and interactive events. Examples of these conferences include the annual Healthcare Design conference, American Society for Healthcare Engineering conference, Healthcare Facilities Symposium, and the Health Facility Planning, Design and Construction Summit.

Conclusion

Nursing as a profession has historically had little involvement in renovation and reconstruction projects, but this has recently changed. Nurses have been recognized as important members of the design team who provide valuable input into the design process, and nursing continues to have an increasingly important role in facility design (Stichler & Gregory, 2012). Nursing is continuously evolving and with resources more widely available and the assembly of the right team members across disciplines, visions of innovative blueprints can become the future of patient care.

Implications for Practice