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Has anyone moved away from decentralized nursing on IP units?

  • 1.  Has anyone moved away from decentralized nursing on IP units?

    Posted 10-26-2015 03:55 PM


    Penn Medicine is designing a new patient services facility. As is standard practice today we are designing around decentralized nurse servers on our IP units. In an effort to confirm that this current industry standard remains valid, I am asking if anyone knows of a patient care unit designed around distributed nurse workstations where the client questioned or became significantly dissatisfied with that element after occupancy. For any units where this was the case, did the institution modify the built environment to return to a more centralized nurse work environment? If so, how? Many thanks!

    ------------------------------
    Earl Marsh AIA
    Health System Architect
    Penn Medicine Real Estate, Design and Construction
    Philadelphia PA
    ------------------------------


  • 2.  RE: Has anyone moved away from decentralized nursing on IP units?

    Posted 10-27-2015 06:22 PM


    The article below discusses a situation where the team designed the space with decentralized nurse "work stations" and after it was built the staff created a workaround using folding tables to create some space for "inter-professional discussions".  I have kept this article because on one of my previous projects we had an Evidence Based Design consultant that was pushing for the elimination of this centralized nurse station but the nursing staff insisted it was necessary for their process and the space was added back into the program.

    At Bat: Nurses Step Up To Design Plate

    Healthcaredesignmagazine remove preview
    At Bat: Nurses Step Up To Design Plate
    The success of a healthcare construction project requires many participants and viewpoints. One voice that's getting more recognition is coming from nurses. "They have a very unique perspective on patient and family needs, therefore their informed voice at the design table is absolutely critical," says Jaynelle Stichler, professor emerita at San Diego State University, research consultant for Sharp Metro Campus, and co-editor of HERD Journal .
    View this on Healthcaredesignmagazine >
    ------------------------------
    Karl Person AIA
    Senior Architect / Healthcare Market Leader
    Schemmer
    Omaha NE



  • 3.  RE: Has anyone moved away from decentralized nursing on IP units?

    Posted 10-27-2015 06:57 PM
    We recently completed a post-occupancy evaluation of a new nursing unit with decentralized nursing areas between rooms.  We found that nurses were not using the workstations.  The need for team support appeared to be outweighing proximity to patients.

    --
    Frank Zilm, D.Arch., FAIA
    Frank Zilm & Associates, Inc.
    816-561-7186
    Frank@zilm.com





  • 4.  RE: Has anyone moved away from decentralized nursing on IP units?

    Posted 10-29-2015 01:25 AM

    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

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  • 5.  RE: Has anyone moved away from decentralized nursing on IP units?

    Posted 10-30-2015 05:41 PM

    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. 

     

    ---

     

    William W. Heun, AIA

    Principal

    williamh@mca-architecture.com

     

    Matthei & Colin Associates, LLC

    332 S. Michigan Avenue

    Suite 614

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  • 6.  RE: Has anyone moved away from decentralized nursing on IP units?

    Posted 10-30-2015 05:46 PM
    Molly M. Scanlon, FAIA, FACHA
    Sent from my iPad




  • 7.  RE: Has anyone moved away from decentralized nursing on IP units?

    Posted 10-30-2015 05:53 PM

    I think we need to remember the impacts of technology; years ago decentralized nursing stations were popular to place the nurse close to the patient for better observation; now there is much more sophisticated technology in place to handle some of that workload but not maybe all.  Nursing stress studies show that nurses need social support amongst their peers and that cannot be gained from patients or families.  Nurses need a balance of working at the bedside and dealing with issues as team members and not individual nurses assigned to observe a patient.  

    ------------------------------
    Molly M. Scanlon, FAIA,FACHA



  • 8.  RE: Has anyone moved away from decentralized nursing on IP units?

    Posted 10-28-2015 05:36 PM
    This has been coming up on our recent project discussions as well. We must ask nurses to "walk us through their shifts". There are many differences from one facility to another and from one specialty (geriatric, ortho, peds, icu, etc) in how care teams function, and therefore what kind of workspace supports that function. Some care teams round bedside, some do shift change in a centralized space. Mini nurse stations or decentralized nurse stations do not eliminate the need for a team space where nurses, respiratory therapy, specialists, and more can consult. They also don't replace central "home base" functions like bulletin boards or dry erase, alarm panel central location, charging stations and more.

    Sincerely,

    MICHELLE TEAGUE, AIA, LEED AP BD+C
    American College of Healthcare Architects Board Certified
    mobile 501.472.7297









  • 9.  RE: Has anyone moved away from decentralized nursing on IP units?

    Posted 10-28-2015 01:15 AM
    Totally decentralized nursing has proven very unpopular with most nurses. Decentralized charting areas combined with staff workrooms provide both quiet documentation areas and gathering spot(s) for interdisciplinary staff and medical providers. Increasingly, care is provided by teams rather than separate disciplines and it is essential to provide spaces large enough to support the team approach, both in inpatient and outpatient settings.

    Marjorie Serrano, RN, PNP, AIA, EDAC
    Health Environment Innovations
    3100 Main Street #178
    Dallas, TX 75226
    214-729-9742




  • 10.  RE: Has anyone moved away from decentralized nursing on IP units?

    Posted 10-30-2015 08:27 AM

    The question of centralized vs. decentralized caregiver areas needs to consider and evaluate three primary factors

    1. As Marjorie Serrano points out, patient care is done by teams not individuals and those teams require spaces to interact regardless of any commitment to decentralized nursing. The cluster or pod model can provide those spaces or they can be in one central location if there's tolerance for greater travel distances.
    2. IT & low voltage technology and equipment can have a huge impact on the success or failure of the decentralized model. The quantity of equipment and IT/LV  devices on patient units is proliferating faster than clinicians and Architects can find room for them. This equipment needs to be purchased and located thoughtfully regardless of what model is selected. If a decentralized model is to work, frequently used equipment and devices must be located at or near the bedside and the challenge is often to find the space for them.
    3. Decentralized nursing with it's intent to promote nurses spending more time at the beside with patients requires strong cultural support from the institution and nursing units particularly if the existing model has been centralized care giver stations.
    ------------------------------
    Sarah Simpson AIA
    Denver CO



  • 11.  RE: Has anyone moved away from decentralized nursing on IP units?

    Posted 10-28-2015 08:44 AM


    As a nurse, perhaps I can provide a different way to look at this as I believe there are two different issues being discussed.  

    The first issue:  The nurse's primary workspace in at the patient bedside.  Just like a professional working in an office, the nurse needs the equipment, supplies, and information to care for the patient at his or her primary workstation.  In a profession office where individuals are assigned to workstations, computers and all writing instruments would not be located at a central location.  Numerous recent studies on walking distances support providing the materials needed to care for the patient at the point-of-care.

    The second issue:  In professional workspaces, there are conference rooms and gathering places (i.e., water coolers).  Nurses also need these spaces BUT they are not in lieu of their primary workspaces.  It is not realistic for the nurse to walk to a central space to check an order on a computer, etc.

    I think this framework of thinking will help define what nurses need at the bedside and what is needed centrally.

    Joyce Durham RN, AIA

    Global Health Services Network

    Farmington, MI 

    PS- I am a contributing author to the book mentioned above "Nurses as Leaders in Healthcare Design: A Resource for Nurses and Interprofessional Partners".  It is an excellent resource and will be unveiled at HCD15.

    ------------------------------
    Joyce Durham AIA
    Prinicpal
    Ann Arbor MI



  • 12.  RE: Has anyone moved away from decentralized nursing on IP units?

    Posted 10-28-2015 09:13 AM

    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

     

    Perkins+Will  Ideas + buildings that honor the broader goals of society

    perkinswill.com | Blog | Facebook | Twitter

     

    Honored to be ranked among Fast Company's "Top 10 Most Innovative Companies in Architecture"

     






  • 13.  RE: Has anyone moved away from decentralized nursing on IP units?

    Posted 10-28-2015 01:42 PM


    Having both the roomside staff work stations and centralized work spaces allows for the different work models available with the EHR.  We are seeing  a clear desire and need to have the interdisciplinary team center. Several factors support the notion of an interdisciplinary team center. There is the need for socialization among staff. Knowing what one’s coworker’s kids did in soccer, or what new recipes they have tried are ways that humans bond together. When we know one another on a personal level, rock solid levels of trust can be built – trust that is the essential ingredient for critical task teamwork.As pointed out above, teamwork is the new care model. Furthermore, the team center is an ideal place for mentoring - where seasoned staff can freely speak with junior team members, while maintaining appropriate privacy. One more feature of the team center is the heightened opportunity for impromptu dialog between people of various disciplines. When the chance encounter between staff triggers a question about patient care, they need a environment in which discussion is spontaneously, yet discreetly conducted. 

    ------------------------------
    James Harrell FAIA
    GBBN Architects, Inc.
    Cincinnati OH



  • 14.  RE: Has anyone moved away from decentralized nursing on IP units?

    Posted 10-30-2015 02:09 PM

    Earl,

    One of our clients had decentralized nurse stations designed into their regional hospital along with traditional nurse stations for team discussions. Although the staff made efforts to work with this model, they reverted to using only the central nurse stations. Over time, the staff and administration saw these stations as space wasting pockets. However, this hospital saw an increase in the number of residents over the last several years and these decentralized stations have become useful again. They are now functioning as touchdown stations for the residents using laptops and tablets. I guess one lesson learned could be design for flexibility. As technologies changed they found a new need for these pockets. So much so that they asked us to find space for additional pockets throughout their entire IP unit.

    Hope this helps.

     
    ------------------------------
    Stephen Sgro AIA, LEED AP BD+C
    Senior Architect
    PS&S
    1909 Route 70 East, Suite 307
    Cherry Hill, NJ 08003



  • 15.  RE: Has anyone moved away from decentralized nursing on IP units?

    Posted 10-31-2015 08:24 AM

    I think the type of IP nursing unit has a heavy weight when considering centralized vs decentralized nursing stations. The nurse to patient ratio and hence level of attention and care would vary accordingly. In that respect, we will, and in my opinion, should, still design decentralized caregiving stations in units were high level of care is required near the patient at higher frequencies, ie in acute care nursing units. In chronic care areas I think nurses and nursing managers are correct in choosing the central configuration for better and more coordinated team efforts, except in situations where the unit is too large to fulfill the nurse to patient observation and response requirements, jeopardizing patient safety, then decentralization is a good solution. 

    ------------------------------
    Ahmad Jawhar, PE, AIA
    Managing Director
    Healthcare Consulting and Planning
    Beirut, Lebanon