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.