Reducing Stress through Nursing Station Design People spend some of their weakest and most impactful moments as patients or support for friends and family in hospitals. Many of these moments have been made extra stressful and dreadful from the experience of the hospital. The physical setting not only can cause stress to the visitors but also workers, especially nurses who are involved with the patients, their family and friends, assistants, physicians, and other nurses. The nursing field’s main issue today is a shortage of nurses. Only 6% of the field are incoming nurses while 40% are about to retire (Zborowsky 20). Within those in the field, many have changed hospitals or left the profession due to stress and burnout (Rollins 338; Zborowsky 20). As more problems continue to arise in the health care field, changes need to be made. Though it may not solve all issues, rethinking the design of the built environment has proved to help reduce problems created by medical facilities. One patient’s son commented that “it is very clear that the quality of care that my mother got was in spite of the physical setting rather than because of it” (McCarthy 405). Many professional health care architecture firms have realized the importance in the physical hospital environment in terms of working efficiency and effectiveness in medical outcomes and so have started changing how they design hospitals. Because nurses work with patients, families, and other staff, providing an environment for nurses to work in that reduces stress is important in order for them to perform their best.
Architecture firms have started focusing more on the design of nurse stations as both centralized and decentralized and most recently have started to combine the two with the goal of creating the most successful nursing work process possible. Centralized Nursing Stations Throughout hospital history many hospitals have structured their patient wings around centralized nurse stations. In a centralized design all of the workstations are condensed at one designated, central space to all the patients’ rooms. Often this is at front of the entrance where people walk into the wings (Bromberg). It is helpful to have workers at the front desk area to direct people. One key element of centralized nursing stations is that the hub serves as a “home base” for all nurses and assistants on a particular wing (Brown). The design allows for collaboration among workers that encourages staff interaction and team work. A unified, close proximity work force provides opportunities for staff discussions that lead to less confusion between nurses, assistants, and physicians. There is also a great deal of learning by mentoring and shared discussion with random, impromptu meetings between staff (Bromberg). Having one central “home base” also makes it easier to find a certain nurse. Centralized nursing stations have a hierarchy in the layout of their design. It is important to implement an “us‐versus‐them” layout that is open while providing necessary privacy for staff (Brown). Three distinct work space hierarchies are created for the staff to work the most effectively. The “curbside” zone (1) describes the area where random meetings occur between the staff and with the patient or visitor. Design conditions include limited standing height work surfaces for a few people to gather along the main work floor. On the opposite side of the standing area are where nurses and assistants sit to help direct patients and visitor.
Here nurses are able to record something on a small work area with maybe only one phone and computer to assist them since there is little privacy. The “step in” space (2) becomes more private and does not allow for patients to physically enter though there are some visual connections. Here nurses have chairs to sit at small, more enclosed and protected workspace where they can chart patients information. They can have private discussions with other staff by the design of some acoustic privacy. Windows and doors to these spaces may be used as long as views to the main “on stage” zone is not obstructed. The most private space is considered the “immersive zone” (3). It lies beyond the desk zone. Multiple spaces make up this zone such as areas for large meetings, supplies and work tool closets, storage for paper charts and medication, and areas with access to more computers and phones (Bromberg).
Zone Layout As architects have started to change nurse station designs, it has become very evident that centralized nursing stations do not benefit certain aspects of nursing. Most apparent is the far distances between some patient rooms and the “home base.” The distance harms both the efficiency and effectiveness of how the nurses perform their work. Nurses spend too much time traveling between the patients’ rooms and their home base. Some studies show that
nurses walk more during one ten hour shift than they do through daily activities on days they do not work (Chow). Another study has shown that “only about 30‐40 minutes of [nurses’] shifts [are spent] actually giving care at the bedside” (McCarthy 406). Distances leave less time for nurses to spend with patients, making patients believe nurses are not attending them and that they do not get the proper care they need and want. Patients in rooms at the end of halls farthest from the station suffer the worst from this design (McCarthy 405). Wasted time walking is due to having to chart and gather supplies father away from patients’ bed. Another issue with distance is that often nurses forget specifics as they walk and make errors to patients’ charts and medications. The chaos and distractions often present at a centralized work station can cause errors (Rollins 338). They are usually crowded with noises also from alarms, overhead pagers, and nurses rattling through supplies or pushing carts (McCarthy 405). Some cases of noise are so extreme that in the rooms adjacent to these spaces noise levels have reached 113 decibels at morning beginning hours. If patients choose to move away from the noise they risk having fewer visits and assistance from their nurses (McCarthy 405). Example of Centralized Plan
Centralized Nursing Station at Nebraska Orthopedic Hospital The Nebraska Orthopedic Hospital recently designed by Altus Architectural Studios in Omaha, Nebraska incorporated a centralized nursing station plan. To help reduce the noise carpet was used around the nursing station to muffle sound. To create a comfortable space that informs patients and visitors of the us‐versus‐them hierarchy, the desk designs are interesting and are built of home‐like materials and are softly lit (Malkin 7.68). Decentralized Nursing Stations The decentralized nursing station has created a successful alternative option for a work environment. It has been made possible by advances in technology that allow for charting to be completed on computers rather than using paper records (Zborowsky 21). Decentralized nursing stations are smaller, organized nurse stations scattered along the wing or ward so that the entire work station is not concentrated at one center point. The stations are placed throughout the unit zone so that each station/nurse is in charge of two or three patient units (Lee). Displaced stations reduce time spent walking between the work stations and units by physical distance and the opportunity for distractions on the walk (Bromberg; Chlang 20). By spreading the main supply closets out in addition to the work spaces, nurses are always closer to their supplies. With less travel time to charting areas nurses are less likely to forget or mix up the patients details when charting. Also, there is less chance of error by having fewer
distractions with only one or two nurses at a given station (Bromberg). With fewer distractions and chaos and more personal work space and technology the nurses also benefit by being less stressed. Close proximity also allow for observation directly into each room. Nurses spend more quality time with their patients through decentralized nurse station plans and patients feel as if they are better able to be served and assisted quickly and whenever needed (Gurascio‐ Howard 52). Though decentralized nursing stations have greatly benefitted the nursing work system, key disadvantages can create problems. Since these stations only allow for one, maybe two nurses, there is less staff peer learning and mentoring between the nurses and other staff. Less discussion may lead to confusion between staff and they do not continually learn for the other’s experiences. In decentralized designs “nurses report feeling more isolated from their colleagues and losing the sense of team connection in comparison to centralized nursing stations… [implying] that there are important social behavior components of nursing station design that should be considered” (Zborowsky 38). When nurses need physical help or expertise it can be more difficult to find other nurses, resulting in long walks to the main front desk at the entrance of the wing. The hierarchy described relating to centralized plans is still important in decentralized plans. A front desk at the entrance or core of the wing is necessary to direct patients, visitors, and staff. The smaller nurse stations provide nurses with spaces to chart and work, but privacy is often compromised for views to patient rooms as the “step in” space directly is adjacent to the circulation. The “immersed zones” no longer are all at a central core to be efficient, but
rather need to be spread out so that at the very least common supplies is available throughout the floor plan (Chlang 21). 3D Plan of Patient Care Wing at Dublin Methodist Hospital Decentralized Nursing Station at Dublin Methodist Hospital The Dublin Methodist Hospital in Dublin, Ohio has successfully incorporated decentralized nursing stations into its patient wing plan. The hospital opened in 2007 with goals of building a facility that provides comfortable healing environment for receiving, supporting, and providing care in the space. Karlsberger Architects design of the wings allows for the individual nursing stations to be towards the core of the wing with other nurse’s rooms and support spaces. The stations are spread out evenly in distance and each serve three rooms. Each station is called a “perch.” There is standing and sitting space provided for nurses. The
space is obviously not for patients and guest to enter by markings by the materials and way the “perches” are designed. At the floor surface the carpet pattern forms circles around the station and overhead a lowered surface provides a sense of privacy. The floor plan is benefitted by not being a tight, enclosed layout, but rather a more open one with those spaces that need to be private enclosed and not accessed by the main circulation path. The architects also took other concerns into consideration, and so that nurses are not deprived of the natural environment a large atrium courtyard brings in natural light. This is also enhanced by the not tight, enclosed layout, but rather a more open one with those spaces that need to be private enclosed (Malkin 7.34). A Proposal of a Hybrid Both centralized and decentralized nursing stations benefit nurses through specific characteristics. Architects have started to look at blending the two to create a sort of hybrid that emphasizes these positive characteristics. A hybrid could consist of multiple, slightly smaller centralized plan nursing stations, fewer and larger decentralized nursing stations, or a combination (Bromberg).
For the social and learning aspects of nursing it is important that more than one nurse reports to a specific station, preferably three or four nurses with an assistant who remains at the desk permanently. This organization provides the nurses with sources to learn from and use when they need help or clarification. Also, with a permanent assistant, physicians can easily check in or discuss patient’s medical concerns with a staff member who constantly is in contact with a certain set nurses. Patients and visitors can also benefit from an assistant who is in constant contact with their nurses. An assistant would also be an available resource if patients need help while their nurse is occupied. Though creating a social space of three or four nurses may create some commotion, there would be less chaos and fewer interruptions than in a centralized nursing station, creating a more efficient work space for nurses. With fewer distractions nurses will benefit by being less stressed, reducing the likelihood that they will become “burnt out” from their career. Less nurse turnover would benefit the health care field by having a reliable nursing staff. By designing multiple nursing stations that each serve several nurses, walking distances could be significantly cut down. These nursing stations would be closer to patient rooms than in a centralized layout, allowing more time to be spent focusing on the patients. It would be very important that all rooms are visible from the nursing station. Both centralized and decentralized plans require a central station with permanent assistants at a front desk to help direct patients, visitors, and staff as would a hybrid plan. Having storage spaces at each nursing station would be efficient in terms of space and travel. Other private spaces, such as conference rooms and less used supply closets, would still be necessary at the core of the wing.
As technology advances, a hybrid plan may move some nursing duties that usually take place at the station, to take place in patient’s rooms. Some designs are putting small computers in rooms so that nurses may do charting directly in rooms during discussions and testing with the patient. Some are stationary and other can be moved directly in front of the bed so that nurses can talk and look at patients as they chart. This practice will reduce errors and make sure that all details are recorded properly. In room charting is easy for nurses and less stressful so that they do not forget or mix up any information by having to chart in the hallways or in nursing stations. Some detailed charting may still be completed outside of the room (Cahnman).
The Baylor Medical Center at McKinney, Texas provides a hybrid plan. Three nurse stations are spread out over the floor wings that have 48 rooms. Each of the three stations serve 16 rooms and are considered PODs. Views are provided into each room from the nursing station. As health care architecture sees the changes being made, influences are responsible for helping make decisions. Architects have been applying evidence based design (EBD) to their practices. EBD relies on using research from studies on the built environment to advise design
decisions to benefit health care. First instances of using EBD in hospital design began in the early 1990s. It has both improved the safety of the physical environment and the quality of the human experience as both workers and visitors (Zimring). Along with using EBD, architecture firms have turned to those who regularly experience hospitals to influence design decisions, such as staff and patients. Nurses are focused on the patient and provide insight to how nursing stations can assist them in assisting the patients. They are very willing to help architects so that the physical environment can also reduce the stress placed on them while working (Pecci). As technology and demand continue to change, health care design will advance and adapt. Looking at the two designs that are most currently used for nursing stations, the centralized and decentralized plans, it is evident that both have benefits and detriments. Hybrid design will become more popular to both assist the needs of nurses and the patients and guests if they continue to prove successful. The most successful medical facilities and health care architects will be those that use evidence based design (McCarthy 406), listen to those working and visiting medical centers, and keep up their knowledge of changing technology. The success then of the built nursing station system will be measured by the efficiency of the nurses’ time and practice and the effectiveness on the nurses stress level and outcomes of the patients’ recovery and care experience.
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