Academy of Architecture for Health

For what it is worth, I have seen the same response by nurses in US and international projects. In one USA project which we toured ( but did not design) they had several generations of decentralized work spaces which the staff refused to use because they did not like to be isolated and wanted to work with others at the central location. In China, we have heard the same thing: Nurse Mangers feel that they need to closely supervise all nursing staff in one location, and in one new hospital we visited ( but also did not design) the decentralized charting locations were never finished or occupied. The Nurse Managers there were unconcerned about staff walking distances, charting close to patient locations, or visibility of anything except the entrance to the unit.

I worked with a previous design firm, Rosenfield Partnership,, about 25 years ago which strongly believed in decentralized nursing which seemed to work only if very well supported by the Director of Nursing. These nursing executives strongly felt that they wanted nurses spending time either at the bed side of close to it and visible to patients; there was some post-occupancy done at the time which showed that the decentralized units had higher patient satisfaction, fewer falls, and fewer nurse calls. These projects were built around the idea of "cluster nursing" which was a Rosenfield specialty, with rooms and nurse work areas in pods or groups, a nurse call system which did not allow 2-way voice communication which forced nurses to go to the bedside every time, and strong staff training around these ideas. The built projects were at Hackensack (NJ) University Hospital, Rochester  (NY) General Hospital, and Kimball Medical Center, Lakewood NJ. All of these hospitals I think have done subsequent nursing unit projects which did not continue this idea after new Directors of Nursing came in.

So, my observation would be that unless Nursing Management is strongly dedicated to the benefits of decentralized nursing and trains staff around that idea,  the Central Nursing Station will persist.  People like to work in groups if left to their own devices. The planning question would be who is advocating for this different nursing practice model, and how deep is the institutional commitment to it?

Richard Sprow, AIA

Principal/ International Health Care

Perkins Eastman

HUAI HAI PLAZA, SUITE 3803, 1045 HUAIHAI MIDDLE ROAD

SHANGHAI, People's Republic of China 200031

T.  +86 21 6252 1040

F.  +86 21 6473 6190

M. +86 181 2102 7006

E: r.sprow@perkinseastman.com

WWW.PERKINSEASTMAN.COM

Culture, leadership and bad design can and will beat our best intentions.

We have seen decentralized stations work very successfully.  The key is to provide visibility and options and not isolate the staff.

Key questions:  How fragmented and decentralized is the correct balance?  How can we provide opportunity for meaningful interaction between the caregivers?  How invested are the administration, managers and staff in whatever solution is being created?

As with all of these things everything old is new again.  I made a lot of money removing nurse servers in hospitals all around the country and now all the consultants are touting the value of nurse servers and we are building them into new bed towers.  Centralized vs decentralized nurse stations are the same thing.  Every decade one is touted over the other as the next best thing.  Program and design either one well and it works.  Do it poorly and it won't. 

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William W. Heun, AIA

Principal

williamh@mca-architecture.com

Matthei & Colin Associates, LLC

332 S. Michigan Avenue

Suite 614

Chicago IL 60604

mca-architecture.com

312.784.9016 direct

312.953.9927 mobile

312.939.8164 fax

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For what it is worth, I have seen the same response by nurses in US and international projects. In one USA project which we toured ( but did not design) they had several generations of decentralized work spaces which the staff refused to use because they did not like to be isolated and wanted to work with others at the central location. In China, we have heard the same thing: Nurse Mangers feel that they need to closely supervise all nursing staff in one location, and in one new hospital we visited ( but also did not design) the decentralized charting locations were never finished or occupied. The Nurse Managers there were unconcerned about staff walking distances, charting close to patient locations, or visibility of anything except the entrance to the unit.

I worked with a previous design firm, Rosenfield Partnership,, about 25 years ago which strongly believed in decentralized nursing which seemed to work only if very well supported by the Director of Nursing. These nursing executives strongly felt that they wanted nurses spending time either at the bed side of close to it and visible to patients; there was some post-occupancy done at the time which showed that the decentralized units had higher patient satisfaction, fewer falls, and fewer nurse calls. These projects were built around the idea of "cluster nursing" which was a Rosenfield specialty, with rooms and nurse work areas in pods or groups, a nurse call system which did not allow 2-way voice communication which forced nurses to go to the bedside every time, and strong staff training around these ideas. The built projects were at Hackensack (NJ) University Hospital, Rochester  (NY) General Hospital, and Kimball Medical Center, Lakewood NJ. All of these hospitals I think have done subsequent nursing unit projects which did not continue this idea after new Directors of Nursing came in.

So, my observation would be that unless Nursing Management is strongly dedicated to the benefits of decentralized nursing and trains staff around that idea,  the Central Nursing Station will persist.  People like to work in groups if left to their own devices. The planning question would be who is advocating for this different nursing practice model, and how deep is the institutional commitment to it?

Richard Sprow, AIA

Principal/ International Health Care

Perkins Eastman

HUAI HAI PLAZA, SUITE 3803, 1045 HUAIHAI MIDDLE ROAD

SHANGHAI, People's Republic of China 200031

T.  +86 21 6252 1040

F.  +86 21 6473 6190

M. +86 181 2102 7006

E: r.sprow@perkinseastman.com

WWW.PERKINSEASTMAN.COM

For what it is worth, I have seen the same response by nurses in US and international projects. In one USA project which we toured ( but did not design) they had several generations of decentralized work spaces which the staff refused to use because they did not like to be isolated and wanted to work with others at the central location. In China, we have heard the same thing: Nurse Mangers feel that they need to closely supervise all nursing staff in one location, and in one new hospital we visited ( but also did not design) the decentralized charting locations were never finished or occupied. The Nurse Managers there were unconcerned about staff walking distances, charting close to patient locations, or visibility of anything except the entrance to the unit.

I worked with a previous design firm, Rosenfield Partnership,, about 25 years ago which strongly believed in decentralized nursing which seemed to work only if very well supported by the Director of Nursing. These nursing executives strongly felt that they wanted nurses spending time either at the bed side of close to it and visible to patients; there was some post-occupancy done at the time which showed that the decentralized units had higher patient satisfaction, fewer falls, and fewer nurse calls. These projects were built around the idea of "cluster nursing" which was a Rosenfield specialty, with rooms and nurse work areas in pods or groups, a nurse call system which did not allow 2-way voice communication which forced nurses to go to the bedside every time, and strong staff training around these ideas. The built projects were at Hackensack (NJ) University Hospital, Rochester  (NY) General Hospital, and Kimball Medical Center, Lakewood NJ. All of these hospitals I think have done subsequent nursing unit projects which did not continue this idea after new Directors of Nursing came in.

So, my observation would be that unless Nursing Management is strongly dedicated to the benefits of decentralized nursing and trains staff around that idea,  the Central Nursing Station will persist.  People like to work in groups if left to their own devices. The planning question would be who is advocating for this different nursing practice model, and how deep is the institutional commitment to it?

Richard Sprow, AIA

Principal/ International Health Care

Perkins Eastman

HUAI HAI PLAZA, SUITE 3803, 1045 HUAIHAI MIDDLE ROAD

SHANGHAI, People's Republic of China 200031

T.  +86 21 6252 1040

F.  +86 21 6473 6190

M. +86 181 2102 7006

E: r.sprow@perkinseastman.com

WWW.PERKINSEASTMAN.COM

There are two distinct issues: stuff and staff.

The big issue with decentralized stuff is that many institutions are using Pyxis, OmniCell or other expensive equipment to track supplies and medications. I have had many clients centralize supplies in order to manage the cost of inventory control. A hybrid approach was taken by one hospital to have one supply room and one medication room (with PTS) for every 10 beds (or 2 nurses for acute care). The degree to which supplies are decentralized needs to be coordinated with materials management, infection control, and nursing. The degree to which medications are decentralized needs to be coordinated with pharmacy and nursing.

The big issue for staff is that in a teaching hospital, in particular, there are many specialists on the floor. As information has become more easily accessible throughout the unit, there is still a need to coordinate patient care with the intensivist/hospitalist, pharmacist, nutritionist, social worker, etc. I have designed several facilities with distributed nurse workstations, however, many of them were never occupied. One major concern I hear at a teaching hospital we are currently designing is that "staff need to be able to find other staff members". I would be careful of the terminology: NURSE work areas can be very decentralized (assuming that documentation in the patient health record is the main task), but STAFF work areas need a "main" area (where nurses can find specialized staff) and areas distributed conveniently throughout the unit where staff of all disciplines can coordinate patient care without violating patient privacy. This is a balancing act.

Roland Binker, AIA, LEED AP

Senior Medical Planner, Associate Principal

1250 24th Street, NW, Washington, DC 20037

t 202.624.8350  m 202.487.5257  Roland.Binker@perkinswill.com

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