Mountain West Nurse Designers Create Environments of Care for Patients and Staff

(As seen in NurseWeek Magazine)
March 12, 2007
By: Melissa Gaskill

In patient rooms at Banner Estrella Medical Center in Phoenix, wall connections for data and electrical outlets are all at least 24 inches high. In the facility’s intensive care unit, electrical and data connections are on the corridor side of patient beds.

“You have to understand how a nurse works in a room in order to design it well,” says Banner Health system’s clinical director of design and construction, Susie Faz-McCann, RN. With more than 15 years of experience in critical-care nursing, she knew that equipment is brought into ICU rooms from the corridor, and that having connections on that side of the room means nurses don’t have to maneuver equipment around the patient bed.

Design affects care, caregivers
Design is more important in a healthcare environment than almost anywhere else, say those who are involved in it. “If a healthcare environment isn’t designed well, then it won’t work at all, and may even be harmful,” says Sharon Woodworth, AIA (American Institute of Architects), a former nurse and now an architect with Anshen+Allen architects in San Francisco. “If a church, museum, or even a factory is designed poorly, the impact isn’t as negative. Most people in a healthcare environment are not freely entering that environment. They don’t want to be there. There’s no other facility in which a human being is there because they’ve been told to be there, and are ill. There are few buildings that operate 24/7. That leaves less room for error when putting the pieces together.”

Only nurses understand the whole dynamic, Woodworth says. “When you ask a nurse what size a door should be, for example, he or she will consider not just the nursing needs, like change of shift, but also function, such as the fact that there is now more equipment going through that door for portable chest X-rays, and that this is a teaching hospital, so rounds gather right outside that door, and a window in it would be good.”

A nursing background brings an understanding of healthcare environments at a basic level, says Terri Zborowsky, RN, MSc, director of healthcare education and research at Ellerbe Becket, a design and construction firm in Minneapolis. “Being a nurse gives me a way to dialogue with clients that is unique. There is nothing like ‘been there, done that’ for understanding. I can understand the client and know what the appropriate questions are. I may ask more questions. I understand the role of the nurse in the hospital environment, which is really instrumental. Nurses manage and organize the patient care.”

Nurse involvement ensures that important issues are on the design table. “It is very hard to translate to anyone outside of nursing how difficult the job really is, and how important it is to consider everything, even what seems minor to a non-nursing person,” says Marjorie Serrano, RN, PNP, Associate AIA, clinical planning specialist at HKS, Inc., a Dallas-based healthcare design firm that has completed projects in Utah, Nevada, Colorado, Oregon, and Washington.

“Things like moving patients and infection control are so challenging and so labor-intensive, it is hard to translate that to someone who hasn’t worked in the area. Nurses have first-hand knowledge of things like how many steps it takes to do a task and how far you have to go to get supplies. So many times, the design of a space can save a huge amount of energy for nurses. I am always bringing that to the forefront and reminding the designer what something will mean to those who are working there. If you haven’t worked in health care, you can’t really know how the space is used,” she explains.

Not only does involving healthcare workers throughout the process ensure that the space will work for them, but it also allows them to change processes to work in a new space, says Serrano, who worked as a pediatric nurse and nurse practitioner for 20 years before studying for a master’s degree in architecture. “You can’t just change the space without changing the process. It is important to have nurses involved in order to take into consideration those processes, the way you change your daily work to fit into a space. It takes a lot of planning and forethought. We’ve never approached a project as ‘Just design a space and the people will make it work.’”

For the new Children’s Hospital in Denver, user groups representing each unit were integrally involved in design. A core group of mostly volunteers looked at a number of other hospitals, says Susan Koch, RN, MS, director of clinical planning. “We tried to look at not just how big a room was and where you put the bed, but also the workflow, how you would get supplies and meds, what is close to the room and far away, and flow of communications. We were really guessing about stuff that was three or four years down the line, and we guessed wrong in some aspects and right in others,” she says.

There were also philosophical decisions about aspects like where people congregate, and how to create appropriate places where they could. “You want to encourage that, but also make staff as physically available to patients and families as possible,” Koch says, adding that the team also considered ergonomics issues and the aging workforce.

“You have to involve other departments. We talked about getting people through the hospital, from patients to staff and even flower delivery, before we put in stairs and elevators and things like that. We tried hard to have our med/surg floors be as similar as possible, to make the building really flexible and still meet needs of the populations,” she says. The team made cardboard mockups of a rehab floor to get a clear idea of the space, whether there was enough room, and if things were in the right places. Staff input also extended to how staff would get from the parking lot to the hospital and the location of time clocks and locker rooms.

At Banner Estrella, nursing worked closely with information technology and tech management during design. “I could say, as a nurse, ‘I want to be able to stand here and find someone on the unit,’” Faz-McCann says. “Technology is now driving our work flow, and you have to work with those departments to get positive results.” That cooperation is where design improvements like the corridor-side outlets in ICU came from, she adds. Internal research at the facility is already showing that, thanks to design elements like decentralized nurses’ stations and careful placement of technology access, nurses are spending more time with patients, and both medication errors and falls have decreased. The Children’s Hospital design followed a number of guiding principles, such as family-centered care, flexibility, and timelessness, which included using a natural palette rather than trendy colors and creating rooms that could be used for infants, toddlers, or adolescents. Then there were tenets for various spaces, like a certain number of isolation rooms. “It was really figuring out philosophically how we wanted to deliver care,” Koch says. “We had an infection control committee and a standards committee for ancillary spaces such as linen rooms.”

Planning for the future
Flexibility in design also allows future changes without major room reconstruction. For example, in Banner’s emergency department, Faz-McCann says, there are no longer rooms dedicated to specific functions such as ultrasound and cath. “We designed where you can do any function in any room, because once you start dedicating rooms, you’re running into situations like holding patients outside the rooms, not using rooms for things they were dedicated for, and having to reconstruct.”

Another reason to involve those with a clinical background, Zborowsky says, is they can better assess healthcare design trends. For example, two years ago her firm began to consider the idea of what an increase in the morbidly obese population means from a design standpoint. She is also managing an independent study on the impact of centralized versus decentralized nurses’ stations on culture of nursing as well as patient care.

“The evidence-based design trend is a huge initiative,” Zborowsky says. “Research is really important to the healthcare design practice. It’s a trend that I think will grab hold of our industry and transform the way we do design.”

Projecting future needs and accommodating growth are also important. “It’s always an educated guess,” Serrano says. “Making the budget and the goals of the facility fit are another challenge. Many times what is efficient design-wise and cost effective is not what makes the space work well. But something that saves time and energy and stress for the staff is a positive for the patient, as well, in almost all cases.”

Budget considerations at Children’s Hospital forced a decrease in size of the building grid, which defines where the walls will go. “We had to do it,” Koch says, “but once it is set you can’t get that space back. It’s important to try and maintain a good size for the room.”

Levels of nurse involvement
Clearly there is much potential for nurse involvement in design, Zborowsky says, and a number of important skills that nurses bring to the process. The possibilities range from a staff nurse providing input, to a nurse working at a design firm, or a nurse who has become a designer or an architect. In some firms, nurses do master planning, looking at the layout of an entire hospital campus, perhaps for full renovation of a hospital, where all the different departments are going to be and accommodating future growth.

Zborowsky often uses change-of-shift meetings to gather input from nurses. “Hospitals should set up a process that is inclusive of staff if there are design changes coming,” she says. “The process works best if everyone has their interests addressed in the design process. Not everything is possible, of course, but it is really important for people to have a voice and to talk through those issues. It really improves design; it has never detracted from it.”

Faz-McCann agrees: “If we design without nursing involvement, we are just repeating the same mistakes we’ve been making for ages and ages. That is certainly recognized within Banner, and I think is becoming more recognized across the country.”

It is not yet a given, however, that a nurse or clinical person will be involved from the beginning, Woodworth says. “A healthcare organization is a political business and so is healthcare architecture, and that’s just part of the game. Nurses have to be empowered to have their voices heard. Sometimes decisions are made before nurses even know the project is on. The staff might make a proposal to participate in the process on their own time. It takes a tremendous amount of time, but it is so rewarding.” She does see nurse involvement happening more often, and an increasing degree of respect for what nursing brings to the table. “I think it is an important expectation for nurses to be involved in new design and construction.

“As a nurse, you impact individuals’ lives quite strongly,” Woodworth adds. “You’ve saved their life or educated them or helped them make a change. As an architect doing healthcare work, some of your decisions affect thousands of lives — not just one patient and family, but all the staff who work in that environment.”

Melissa Gaskill is a freelance writer for NurseWeek. To comment on this story, send e-mail to editormtw@nurseweek.com.
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