Good spatial design can boost the efficiency and well-being of nurses by reducing the challenges posed by physical configurations that can lead to fatigue and errors, says a study published in January by Cornell University in Ithaca, New York.
As poor floor design, storage closet clutter and crowded corridors contribute to fatigue and cause distractions, the study offers a design tool to increase efficiency in acute care settings by matching spatial design with caregivers’ workflow.
Rethinking Efficiency in Acute Care Nursing Units: Analyzing Nursing Unit Layouts for Improved Spatial Flow looked at floor plans and work patterns of five medical-surgical units at hospitals in the United States. In some hospital wards, main clinical spaces, such as nourishment rooms, are located far away from a nurse’s typical path. Congested patient-care corridors create excessive noise while high foot-traffic increases the potential for interruptions.
Rana Zadeh, assistant professor of design and environmental analysis in the College of Human Ecology at Cornell University, likens a nurse hunting for supplies stocked in various rooms to a pilot scouring the entire cabin looking for the tools and controls needed to steer the flight. “New medical practices and technologies have emerged during the past decade and facility design should adapt to these changing practices so that caregivers can perform better on their critical tasks,” she says.
The Cornell study cites findings from an earlier research paper indicating that almost 24 per cent of nurses’ time was spent walking to various destinations — making it the second most time-consuming activity during patient care. “Hospital layout and built space contribute to operational efficiency and safety,” the study says, noting that many errors are built into routines, systems and settings.
Apart from hurting patient care, errors also cause escalating distress and burnout in caregivers, who are described by the study as “second victims.”
Jeff Pajot, regional consultant with the Public Services Health and Safety Association in Peterborough, Ontario, highlights the importance of recognizing the connection between employee health and safety and patient safety. “The two are not mutually exclusive but rather interconnected in an overall culture of safety.”
A slip, trip and fall hazard affects employees, patients and visitors alike while an infectious agent can cause harm to anyone in the facility. “Health care organizations that use proper design, such as workplace layout to improve worker health and safety, will have spin-off benefits of improving patient or visitor safety and improve health care outcomes,” adds Pajot, who is also a certified ergonomist with experience in hospital layout design.
Vicki McKenna, first vice-president with the Ontario Nurses’ Association and a registered nurse in Toronto, can relate to the challenges posed by less-than-optimal design in health care facilities. “When things are designed poorly and people cannot get to them, that is why they overextend themselves.”
She cites carts stacked with medical supplies negotiating through narrow corridors, linens sitting precariously on bedside tables and nurses reaching for sheets placed high and deep in shelving units. “We have falls in some of our workplaces because of poor design and poor storage planning,” McKenna adds.
That challenge is compounded by the physical constraints commonly found in older hospitals. In some cases, beds that are too big for the doorway have to be disassembled before a patient can be moved to another unit for a medical procedure, and then reassembled to get the bed back into the room. “I know of a hospital where the operating room’s doorway is too small and they could not get patients in and out of those operating rooms on a bigger bed,” McKenna says. “They had to redo all the doorways.”
Michael Keen, senior director of planning and development with St. Michael’s Hospital in Toronto, says the spatial challenge posed by older facilities is a tough one. “Corridors are smaller, spaces are smaller — they were not designed to incorporate this intense amount of equipment [use].”
Keen is also the chair of the Canadian Standard Association’s (CSA) technical committee for health care facilities, which developed the landmark CSA Z8000 Health Care Facilities Standard launched in November of 2011. It is the first comprehensive national standard to address the complex nature of planning, design and construction of hospitals and health care facilities.
Prior to that, each health care facility building project undertaken in Canada relied on the knowledge and resources available to the architects and consultants engaged. While there are technical standards on lighting, electrical and plumbing, “there was no real document to tie everything together,” Keen notes.
While the CSA Z8000 standard, which sets out requirements and addresses concerns specific to health care facilities beyond what is contained in building codes and guidelines, is voluntary until adopted by the code, Keen says it becomes recognized as the industry standard once published — even if it is not mandatory.
David Jensen, media relations co-ordinator with the Ontario Ministry of Health and Long-Term Care in Toronto, says it is the responsibility of hospitals to produce a plan that meets the design principles captured in the OASIS principles, which stand for operational efficiency and effectiveness, accessibility, safety and security, infection prevention and control, and sustainability. “The OASIS principles can also be found in the new CSA’s Z8000 Canadian Health Care Facilities [standard].”
BACK TO THE DRAWING BOARD
Before the floor plan of a hospital can be drawn up, a thorough evaluation of the tasks and work flow; types of equipment used, moved and stored; patient and visitor activity; reaches and clearance requirements; and health and safety risks must be conducted, says Jeff Pajot, regional consultant with the Public Services Health and Safety Association in Peterborough, Ontario.
The evaluation should solicit inputs from front-line staff in the earliest stages of planning, design and implementation of the floor plan. Designers must also work closely with the staff and clients using that space so that health and safety considerations can be incorporated into the architectural floor plan.
Provision of adequate space to store and stage equipment, and having appropriately-sized rooms that can incorporate the use of these equipment are “all big factors in determining, from an ergonomic standpoint, where all the equipment [is placed] and how it interferes with the flow,” says Michael Keen, senior director of planning and development with St. Michael’s Hospital in Toronto.
Jensen adds that the ministry now requests planners to use a workshop process when evaluating the proposed design of a hospital. Designers and users are asked to simulate and measure the most critical tasks performed throughout their working day. By having them walk through the seven flows of health care identified in the Lean process methodology, which encompasses family, staff, medications, equipment, supplies, information and process engineering, designers can better understand the processes and improve the design.
“This method is not yet a specific document or tool, but the exercise is structured by the seven flows of Lean process methodology, which is well-understood by health care planners,” Jensen says.
Poor workplace layout can create problems for health care workers, such as musculoskeletal disorders, infection and fatigue. The Cornell study associates noise in clinical environments with increased errors, stress, burnout, perceived work demand, loss of control and poorer communication quality. It also results in occupational stress causing emotional exhaustion and burnout in critical-care nurses.
On average, registered nurses have a cognitive ‘stacking load’ of 15 activities for about 17 per cent of the time. Nurses had an average of 10 or more tasks awaiting completion and an average of 3.4 interruptions per hour.
“They rarely get a chance to sit down and that is for a whole bunch of reasons. Some of them certainly have to do with layout,” McKenna says. For nurses who respond to hospital emergency codes, “those are the teams that are not just walking — they are running.”
One of the downsides of poor layout is walking distance. “The amount of distance a nurse has to walk on any given day certainly has an impact overall on the fatigue factors,” Keen says. Reducing steps increases operational efficiency and creates an improvement from an oh&s standpoint, he adds.
Pajot says poor floor design in health care settings is common. Evidence-based design, which has only been introduced to health care facilities in the last decade or two, remains in its infancy and is not widely incorporated into the new design of health care facilities. “Although many books and even CSA standards are available, many barriers exist.”
Examples include patient rooms that are hard-wall built and the set width of corridors. “To change the floor, you have to gut the whole floor,” Keen says. “Sometimes, the footprint does not allow for it.”
That said, small changes can make a significant difference to outcomes. Renovations to convert multiple-patient rooms to single-patient rooms, installing overhead mechanical lifts in rooms to reduce clutter from storing portable mechanical lifts in hallways, redesigning storage areas for better organization and adding sound-dampening material to reduce noise are some of the measures, Pajot says.
While the remediation measures can vary widely depending on the configuration of respective work environments, “in some cases, costs do not have to be exorbitant,” he adds.
Working with storage design specialists to tailor a cart storage system that suits the specific operational needs of a particular unit, and getting health care workers to walk through and discuss where things could be located and the times of the day in which they are needed are also recommended. “Sometimes, it is not that hard because we have mobile equipment,” McKenna says. Equipping rooms with observation windows also allows nurses to monitor their patients without having to physically enter their rooms.
Patient flow can also be improved by repurposing existing space. Jensen cites the example of designating a fast-track area in an emergency department by using space that is no longer required for original purposes. “There is a wide range of actions that can be taken to improve safety that do not require a major overhaul.”
Apart from physical modifications, a number of emerging trends in the health care sector are also helping to reduce the amount of walking required of nurses. The shift towards more ambulatory procedures in medical work spaces are giving rise to decentralized workstations, which enable nurses to tend to patients without having to constantly walk back to their workstations.
“That ability to decentralize medication is a huge one in reducing the number of steps and increase the amount of time nurses spend with patients,” Keen suggests. The new standard for in-patient care in single-patient rooms also reduces the frequency of patient transfer to avoid infection risks, he adds.
Senior management and hospital planners should also involve frontline health care workers as early on in the hospital design process as possible. Otherwise, “you have gone too far in the structural design to make changes that will be effective,” McKenna says.
Jean Lian is editor of OHS Canada.