Talk Back

There are no comments posted for this article.

Post a comment

RSS Feed

Add BD&C Headlines to your
RSS Reader

Healthcare Boom: Nursing Stations for the 21st Century

The U.S. healthcare sector will exceed $36 billion this year, with exciting new developments in the design of nursing stations, acuity adaptability, digital technology, and infection control.

By Larry Flynn, Senior Editor

February 1, 2005

Building Design and Construction

In recent years, advances in information technology have enabled nurses to move away from traditional centralized paper-charting stations to smaller decentralized stations and charting substations located closer to patient rooms. Now, wireless phones, notebook computers, and handheld devices are making nurses even more mobile.

But even as technology enables the nursing function to become more decentralized, standards-setting entities like the Joint Commission on Accreditation of Healthcare Organizations are pushing for more collaborative care between nurses, doctors, and support staff. "Healthcare has become a multidisciplinary practice," says Tammy Felker, RN, medical planner with NBBJ Architects, Seattle. "Nurses, doctors, respiratory therapists, pharmacists, and clergy all need a place to interact. But nurses' stations, as we know them, have not been equipped to serve these needs."

In terms of nursing station design, then, what's it to be? Centralized? Decentralized? Something in between? Or some combination of elements?

Designs solutions run the gamut, says Philip Tobey, FAIA, FACHA. While the trend is toward team-oriented care, "we're tending to see fewer stations, more strategically located," says Tobey, national health practice leader for Detroit-based A/E SmithGroup. "In other cases, stations are centralized, but smaller. Still others are central and larger."

It may sound trite, but the solution depends on the situation, says Chuck Eyberg, AIA, senior project manager, HMC Architects, Ontario, Calif. "Decisions about which nursing station approach to take reflect each hospital unit's management and communication style or culture," he says.

To learn first-hand about the culture of hospital units, design firms are going beyond the usual planning meetings with hospital staff. At Providence Holy Cross Hospital in Mission Hills, Calif., nursing consultant Christy Frecerri, RN, donned scrubs and walked the hospital's floors with the nurses for two days in preparation for HMC's design of a three-floor, 80-bed medical/surgical and obstetrics addition.

The existing units, which were built in the 1970s using a Gordon Friesen theory of decentralized nurses stations, had no centralized stations, so nurses and physicians would meet in hallways, within earshot of patients. To reduce the noise levels in the hall and improve privacy, administrators recommended a centralized nursing station design for the new units. But out on the floor, Frecerri found that "the nurses really liked the decentralized aspect and didn't want it to change."

The solution, according to Beth Radovanovich, healthcare practice leader in HMC's Sacramento office: Retain the decentralized nurses' station format to keep the nurses close to their patients, but provide a central station where private consultations and greater collaboration could take place.

This "hybrid" nursing model "is a balance of nurses at the bedside and collaborative spaces," says NBBJ medical architect Kerrie Cardon, RN.

But decentralizing has its downside, too. It tends to distance nurses from their colleagues. "The traditional station allows them to share professional expertise with each other and with physicians," says Sharon Woodworth, senior associate, Anshen+Allen, San Francisco. There's also a socialization aspect, which is crucial to engendering team spirit among nurses.

At Sutter Roseville Medical Center in Roseville, Calif., the horseshoe-shaped decentralized stations in the medical/surgical and oncology units left nurses feeling "too isolated" and unable to "pitch in" for each other, says Julie Hebert, clinical manager for the surgical unit. The stations were "so decentralized that we wouldn't know if everyone showed up for a shift," she says.

With Hebert's concern in mind, Dallas-based A/E HKS came up with a triangle-shaped decentralized station design for the medical/surgical unit's new four-story, 90-bed tower. The floor plan calls for three stations per triangle, 10 beds on a side, with a 1:5 nurse-to-patient ratio. (The current standard for new healthcare facilities is 1:6 in the U.S., but pending legislation in California will require a 1:5 ratio.) Located in the center of the nursing triangle are a work room, patient support, supplies, pantry, and break room. "Everyone will go to the same place to get supplies, and we'll all have a place to get together," Hebert says.

Designers are finding that the physical appearance and use of the decentralized substations is changing as nurses become more mobile. "Alcoves with built-in casework that introduced nursing subcharting stations have now evolved into docking stations for lightweight portable computers or for 'computers on wheels,'" says Sam Burnette, AIA, senior project designer with Earl Swensson Associates, Nashville, Tenn.

The decentralized nurses' substation component of the hybrid nursing model being developed for Lancaster (Pa.) General Hospital will use "computers on wheels" — portable substations known as COWs — to enable nurses to roll their substations from room to room. While many nurses find COWs cumbersome, NBBJ's Cardon says they are "a necessary evil" today: "They're preferable to being tethered to the nurses' station," she says.

Decentralized charting substations are transforming into charting "islands," using partial walls to shield furniture systems and the COWs and delineate spaces between patient rooms as the nurses' zone, says NBBJ's Felker.

As for centralized nursing stations, they are no longer the central command centers of the early 1990s, says Todd Robinson, AIA, senior designer/principal with Earl Swensson. "Successful central stations today serve more as information centers for traffic control between units," he says.

Central nurses' stations in design for the Lancaster General Hospital by Baltimore architectural firm RTKL will function essentially as data centers, says VP Scott Rawlings. The data centers will house computers, data retrieval stations, printers, phones, dictation stations for physicians, medicine-storage rooms, and nourishment facilities.

Flexibility keys collaboration

The design of nursing stations is also being influenced by the need for greater physical flexibility in the use of space. The high price of hospital real estate is a major factor. "It's so expensive that we're trying to build more rooms that can be used in multiple ways," says NBBJ's Felker.

Adding to this problem is the aging of the nursing population: the average age for a nurse in the U.S. is 48, making the move toward team care and improved ergonomics a necessity, says SmithGroup's Tobey.

To design greater flexibility into nursing stations, architectural firms are teaming with furniture manufacturers to develop centralized nursing stations that provide both good ergonomics and flexibility. This "constant drive toward flexibility" in hospitals is punctuated by the growing use of flexible furniture systems in nursing stations that provide greater ability to change quickly with changes in technology, says Tobey.

Seattle's NBBJ is using its Clinical Integration Center (CIC) concept in the nursing stations on the fourth-floor medical/surgical unit of a new tower at St. Joseph's Hospital in Bellingham, Wash. The CIC incorporates "flexible furniture to accommodate group discussions and provide access to technology for immediate charting and patient information," says NBBJ's Felker.

Flexible furniture, adjustable-height chairs, tablet armchairs, computer workstations, and alcoves with phones provide comfort and support to older caregivers. This is especially crucial for critical care nurses, who frequently engage in "curbside consults," says Felker.

As healthcare technology and patient-care strategies evolve, space needs for patients and caregivers will have to change as well. In order to win projects and satisfy the ever greater demands of hospital owners, Building Teams will have to be even more engaged and in tune with those at the front-line of care, the nursing staff.

Changing face of nurses' stations

Greater mobility enhances bedside nursing.

Wireless notebook computers and cell phones are allowing nurses to deliver more bedside care.
'Computers on wheels,' rolling substations known as COWs, enable nurses to conduct patient charting and deliver care on the move.

Designs fit station functions.

Decentralized nursing station alcoves located in corridors in between rooms are evolving into docking stations for portable computers and COWs.
Traditional centralized nurses' station is transforming into data centers, housing data retrieval stations, dictation stations, medicine rooms, and nourishment centers.
Emphasis on coordinated, collaborative patient care among nurses, doctors, and support staff results in larger, centralized stations with dedicated workspaces for all.
Flexible furniture (chairs, screens, partitions) enables design of multi-use space that allows facilities to conserve floor area, adjust environment to rapid advances in technology, and improve comfort for older nurses.
Use of screens, partitions, and translucent and clear glass improves privacy for caregivers, while still enabling them to be connected to patients and family.

Taking some of the drudgery out of nursing

Healthcare designers are addressing the comfort and well-being of caregivers as well as patients by designing "places of respite," such as the room below designed by Seattle's NBBJ Architects. With fewer nurses caring for higher-acuity patients during shorter hospital stays, the nursing environment is "so much more stressful than it used to be," says NBBJ medical planner Tammy Felker, RN.

"Our hospital clients realize that their nurses need personal support spaces to recharge their batteries," says Todd Robinson, AIA, of Earl Swensson Associates, Nashville, Tenn.

These "healing environments" for nurses are also a good recruitment and retention tool, says Felker's colleague, medical planner Kerrie Cardon, RN.

While these places of respite are not revenue-producing spaces, they still need to be located near nurses' working areas, says Robinson.

Another way hospital designers are reducing stress on nurses is by providing more convenient location of linen storage, supply closets, and medicine rooms on in-patient floors, thus reducing the sheer amount of walking nurses have to do.

The floor plan (right) illustrates one of four models of nursing support centers designed by Earl Swensson to increase nursing efficiency, says the firm's Sam Burnette, AIA. They were originally developed for a 180-bed tower addition at the Villages (Fla.) Regional Hospital, which opened in 2002 with 60 beds. The hospital selected the model shown here.

Designed to be centered between patient rooms, each of the four support centers includes an automated pharmaceutical dispensing station, a charting/work area, a soiled-linen holding area, storage space for bar-coded medical supplies that can be scanned as they are dispensed to patients, clinical work space, and nourishment storage. Located in the middle of each patient wing, each model occupies about 500–600 sf of space, an area the size of two patient rooms.

Missing links in acuity adaptable design

Faced with slim budgets and staff shortages, hospitals are constantly looking for new ways to reduce expenses, maximize staff efficiencies, and provide a better healing environment.

The acuity adaptable model is one design approach that has gained popularity during the past several years. The scheme permits an individual patient room within a nursing unit to be reconfigured to meet the needs of any one of four acuity levels: intensive care, step-down, observation, and acute care. This approach allows hospitals to not only utilize crossover of nursing staff, supplies, and equipment, but also drastically reduces patient transfers, according to Dan Noble, principal and director of design with HKS, Dallas.

Noble says the acuity adaptable model also provides hospitals with the flexibility to organize units by patient type — in addition to acuity level — to meet patient demand and take advantage of staff crossover. For example, a hospital can configure an entire unit or floor to serve all cardiac patients across all acuity levels, says Noble.

While the acuity adaptable model has been hailed as wildly successful in hospitals across the nation, Noble has observed one common flaw in numerous designs: The geometry of the unit often fails to fully support the nursing needs throughout the complete acuity spectrum, specifically intensive-care requirements.

Double-loaded or "race track" corridors, for example, obscure views into patient rooms and require nurses to walk long distances.

"It's a waste of money to design an acuity adaptable room along a double-loaded corridor, because the hospital will never be able to use it as an IC unit," says Noble. He says intensive-care practice is better suited to more of a "fishbowl" layout, where nurses can see into many rooms from a single point.

Other common mistakes, according to Noble: Patient rooms that are remote from charting or support areas, and rooms that are too small to accommodate equipment required for different types of care.

Noble points to Parker (Colo.) Adventist Hospital as an example of a facility with a "truly adaptable nursing unit." The 210,000-sf, $52 million hospital, which opened last February, features a triangular-shaped, 36-bed unit that, at any given time, can be reconfigured to serve any acuity level.

The unit is currently configured with an eight-bed ICU area, serviced by a dedicated nursing station. The remaining 28 beds are a mix of step-down, observation, and acute functions, serviced by three nursing stations, according to Terry Ritchie, director of nursing.

Initially a skeptic of the acuity adaptable model, Ritchie says she was convinced of its benefits a month after the hospital opened, when the condition of a patient admitted to an acute-care room suddenly deteriorated. Instead of having to move the patient to intensive care, an ICU nurse was simply reassigned to the patient. "Within a matter of five minutes, with no patient transfer, the nurse was giving one-on-one care to the patient," says Ritchie.

Ritchie says the layout has resulted in a reduction in patient transfers, saving staff time ("an average patient transfer takes up to eight hours of staff time") and minimizing costly medical errors. "Anytime there's a handoff in care, it's an opportunity to lose a critical piece of information," she says. "You also lose continuity of care."

More than 75% of the hospital's intensive care patients remain in the same bed during their recovery, tended to by the "same caregivers that they have bonded and developed trust with," says Ritchie.

The configuration also makes life a bit easier for the nursing staff (average age: 45). ICU nurses routinely assist medical/surgical nurses during periods of patient influx. Also, the unit's triangular shape and localized supply cabinets and medicine drawers cut down the distances the nurses have to walk.

There are additional upfront costs associated with acuity adaptable design, says Noble. Each patient room and support areas must be designed to meet ICU requirements and code (e.g., smoke compartmentalization and medical gasses on alarms), including additional storage space for ICU-related equipment and larger patient rooms and nursing stations.

But Noble suggests that it's money well spent, considering the reduction in patient transfers and crossover in staff, supplies, and equipment. "The additional capital cost is usually surpassed by savings in operational costs in less than five years," he says.