Four Ideas to Improve Hospital Work Environments To Help Combat America’s Nursing Crisis

Hospital design experts Teri Oelrich and Bryan Langlands explore ways to improve the efficiency and experience for nurses in hospital settings

March 14, 2022

Partner, NBBJ

A version of this piece originally appeared on Forbes. It was co-authored by Bryan Langlands and Teri Oelrich.

 

Two years into the Covid-19 pandemic, frontline nurses report feeling overworked and burned out—and the US is in the throes of a nursing crisis. While the pandemic has undoubtedly contributed to nurses’ stress and fatigue, the nursing population is unique, as are the factors contributing to the staffing shortage. A significant segment of the nursing population is nearing retirement age, while changing demographics signal a need for more nurses to care for an aging society. And while nursing school applications are up—a positive trend—enrollment is still not growing fast enough to meet the projected demand. Lastly, nursing has one of the highest turnover rates in the medical profession, with 16.5% of all nurses employed in hospitals quitting their jobs within the first year, costing hospitals $4 to $6 million annually.

“The nation’s healthcare delivery systems are overwhelmed, and nurses are tired and frustrated as this persistent pandemic rages on with no end in sight. Nurses alone cannot solve this longstanding issue. If we truly value the immeasurable contributions of the nursing workforce, then it is imperative that HHS utilize all available authorities to address this issue,” says American Nurses Association President Ernest Grant.

While we as designers are removed from administrative or policy decisions, we can create environments that improve operations, efficiency and working conditions. Here are four ideas to consider when planning and designing better work environments for nurses and other staff on inpatient bed units.

Plan for Efficiency

To achieve an efficient nursing unit, it is important to focus on the number, type and location of specific rooms; provide adequate support space; plan layouts and grouping of patient rooms that align with nurse-to-patient staffing ratios; and provide space and features that support and welcome non-dedicated staff.

Understanding how nurses work and allowing that to inform the layout of a nursing unit results in a better-functioning care environment. On average, nurses spend only 31% of their time with patients, while the remainder of their time is dedicated to activities such as waiting for lab data responses, patient transfer, searching for required equipment and documentation. For example, aside from patient rooms, the rooms most frequently accessed by nurses are medication, clean and soiled rooms—so, the number and placement of these rooms are critical to allowing nurses to spend more time with patients.

An effective nursing unit design solution is called “open core.” In an open core hospital design, patient rooms are located on both sides of a central work zone corridor, eliminating physical imped­iments within the areas of direct care. Between the banks of patient bedrooms, anything not related to direct patient care (such as elevators, mechanical shafts, stairs, electrical closets, offices, and toilets) is removed, leaving an unobstructed area to create an effective care team workplace. The standard eight-foot-wide corridor seen in many hospitals is doubled to sixteen feet. This accommodates circulation a clinical zone that houses decentralized team workstations, and supply and equipment alcoves stocked with the most frequently accessed items by staff. In addition, this layout creates neighborhoods for caregivers that locate nursing staff near patient rooms and supplies, with greater access and visibility to both.

An example of an open core hospital design at Mount Carmel Health System’s East campus in Columbus, OH. The design features double-width corridors and caregiver “neighborhoods” that place nurses in closer proximity to both patient rooms and supplies.

 

Select Finishes, Fixtures and Equipment That Improve Working Conditions

The Covid-19 pandemic highlights the limitations of many design elements that have been used for decades, and positively reinforces design advancements introduced on newer nursing units. One example is the advantages of glass over solid doors. Feedback from nursing staff on older units with traditional solid wood swing doors to patient rooms indicates that these types of doors contribute to staff isolation and compromised communication. Full-height glass doors, whether swing or sliding, allow for greater situational awareness, the ability to nurse from outside the room, maintain sight lines to patients, improve visual communication, increase natural light to the support areas, and reduce social isolation.

Motorized overhead patient ceiling lifts are another example of a solution that can be included at the beginning of a project. However, these lifts are often one of the first things to go when construction projects are over budget. While removing these pieces of equipment results in initial savings, injured staff and days away from work may end up costing hospitals far more in the long run. According to a 2018 article published by the Bureau of Labor Statistics, overexertion and bodily reaction as a result of excessive physical effort (bending, twisting, lifting and repetitive motion) accounts for 45.6% of all injuries occurring to nurses, and work-related musculoskeletal disorders resulted in 8,730 days-away-from-work among nurses in the private industry. To reduce occupational hazards and benefit nurses, patients and the healthcare system, keeping ceiling lifts in the project is optimal. Another solution is to provide the infrastructure—structural support and tracks—so ceiling lifts can be added in the future.

Embrace Technology to Save Time and Enhance Communication

Service robots, or automated guided vehicles, can make life better for nurses and staff working on units by performing simple yet time consuming tasks like delivering supplies directly to the unit, the room and even the patient. On many nursing units, technicians meet robots outside patient rooms, where they unload nurse carts and put away supplies, while new robots pick up the empty carts and quickly flip them for their next use. They can also keep workers safe by transporting supplies in areas where pathogens are a risk—an added benefit discovered during the pandemic. Other healthcare technologies like radio frequency identification and real-time location systems minimize time lost looking for equipment and can lead to an overall reduced inventory need.

In addition, nurse call systems now offer digital wall staff terminals which enable nurses and housekeeping staff to indicate whether a room needs servicing or has already been serviced—and what specifically is needed—by simply tapping a screen. Similar technology puts the control in the hands of patients and their families with digital tablets. These tablets can be used to control lights, temperature and window shades in patient rooms while also allowing patients to order meals, watch educational material customized to their ailment and recovery, and even FaceTime with friends or family members.

Finally, wearable devices allow nurses to communicate without having to leave the patient room, and more easily and accurately request help. These types of communication devices can also contribute to reduced noise and disruption to patients as they eliminate the need for overhead intercom systems.

Bring Amenities to the Unit to Reduce Stress

Like airports—which provide a variety of dining and seating options, Wi-Fi and computer access, and amenities like massages or yoga immediately adjacent to the gate—bringing amenities onto nursing units allows nurses and other staff to refresh and regroup “off-stage” without the stress of leaving their post. In a virtual roundtable with leaders from healthcare systems in the U.K. and U.S., participants noted that on-unit staff support spaces and convenient access to things like lactation rooms, showers and healthy food made a tremendous difference in quality of life for frontline caregivers. These amenities are also scalable, with some requiring little added space or cost. For example, small scale solutions like the creative use of small alcoves or leftover spaces such as the informal opportunity areas off stairwells or corridors, improvements to shared spaces like bathrooms or common areas, healthy food delivery or grab-and-go options, or the installation of rest pods are easier to implement than a large, centralized café, gym or wellness space—and are often more useful given the close proximity to nursing units.

Recently, institutions have started providing other concierge services to staff with the goal of increasing employee happiness and satisfaction and improving retention and recruitment. While amenities like staff retail pharmacies have been in existence for years, healthcare institutions are now incorporating services like day care, pet care, dry cleaning, salon services and made-to-order food to take home after a shift.

America’s nursing crisis is complex, and the staffing shortage may seem dire, especially amid the Omicron surge and the continued exhaustion felt by nurses and healthcare workers alike. Design solutions, technology and services that improve working conditions and prioritize efficiency, well-being and satisfaction can help to attract and retain nursing talent and create a better experience for nurses and staff.

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Strategies to Reduce Embodied Carbon in the Built Environment

February 8, 2022

Principal / Sustainable Design Leader, NBBJ

@MargaretMontgo1

This post was co-authored by Peter Alspach and Margaret Montgomery

Editor’s Note: As we work with our clients to improve the health of people and the planet, addressing carbon emissions from the built environment is imperative. In this series, we focus on the ethics and economics of carbon-based decision-making, as well as actionable steps to reduce both embodied and operational carbon. The first post served as an introduction to carbon reduction in the built environment. A version of this piece also appeared in The Architect’s Newspaper under the title, “Op-ed: Strategies to reduce embodied carbon in the built environment.”

 

A growing consumer demand for transparency—especially around sustainability and environmental practices—has implications for industries from apparel to healthcare products. Mars Inc. recently released a cocoa sourcing map to tackle deforestation and increase accountability, and the Fashion Transparency Index pushes apparel companies to be more forthcoming about their social and environmental efforts.

Now it’s time for the building industry, characterized by a lack of information around the materials and practices used in construction and throughout a building’s lifecycle, to catch up. The cost of inaction is too high to ignore. That’s because buildings account for 39 percent of total global carbon emissions. Traditionally, most carbon reduction efforts in the building sector focus on operational carbon—a building’s everyday energy use, which accounts for roughly 28 percent of emissions. The remaining 11 percent comes from what is often ignored: embodied carbon.

Embodied carbon consists of all the emissions associated with building construction, including extraction, transportation, manufacturing and installation of building materials on-site, as well as the operational and end-of-life emissions of those materials. It is also largely “upfront” carbon—the greenhouse gas emissions that are released in the early phases of a life cycle—which means that its negative impact now cannot be reversed later. Most importantly, the magnitude of embodied carbon emissions between now and 2030 dwarfs the incremental impact of operational carbon, therefore, the immediate focus for embodied carbon reductions must be on the next decade.

To reduce embodied carbon in the built environment, the following strategies should be applied across building typologies and sectors.

Select Low Carbon Materials

According to Architecture 2030, concrete, steel, and aluminum are responsible for 23 percent of total global emissions. There is great opportunity for embodied carbon reduction in these high-impact materials through policy, design, material selection and specification. A McKinsey report on embodied carbon in buildings explains, “Two materials may look identical, cost the same amount, perform to the same standard—but have totally different embodied carbon characteristics. For example, a 100 percent recycled-steel beam produced using renewable energy may appear identical to a virgin-steel beam produced using a coal-fired furnace—but have significantly different levels of embodied carbon. Where each steel beam came from and how far it was transported add further complexity.”

Using fewer materials without compromising quality and selecting the right building materials with recyclable content is important to achieving embodied carbon savings. For example, use of recycled aggregates, greener concrete options, reclaimed structural steel, FSC certified timber, or other innovative carbon-negative materials such as plant-based insulation help to sequester carbon and reduce the measured materials’ embodied carbon content. Certified sustainable materials should also be sourced from supply chains that have committed to transparent environmental product declarations and operate a net zero carbon business.

While it can be difficult to discern the embodied carbon in a specific material, certain materials have inherently lower embodied carbon, such as mass or cross-laminated timber (CLT). The use of CLT in healthcare buildings is especially advantageous, as demonstrated in the new Ohana Center for Behavioral Health in California. While hospitals are typically some of the most energy-intensive buildings on the planet due to the use of specialty equipment and the need to operate 24/7, they can benefit from CLT’s low carbon impact and its anxiety-reducing biophilic properties. CLT also lends itself particularly well to modular construction and offsite assembly, which is often faster, more cost effective and more sustainable than traditional methods of building.

The Ohana Center in Monterey, California, redefines the behavioral healthcare environment with natural, cost-effective materials like cross-laminated timber. As one of the largest healthcare buildings to use CLT, the facility benefits from its low carbon impact, its modular components that can be assembled off-site to reduce cost and schedules, and its anxiety-lowering properties. 

Perform a Whole Building Life Cycle Analysis

Life cycle analysis refers to the quantification of an entire building’s potential environmental impact. Conducting a whole building life cycle analysis after material selection allows design teams to spotlight potential environmental issues and identify more sustainable alternatives. Life cycle analyses involve compiling an inventory of relevant material inputs and the associated environmental outputs (for example, climate change) associated with a building, evaluating the potential impacts of these inputs and outputs, and interpreting the results to make environmentally responsible decisions.

As the importance of addressing embodied carbon gains momentum, methodologies and protocols on how to measure embodied carbon in a standardized way continue to emerge. For example, publications that give guidance on and suggest benchmarks and targets for assessing the embodied carbon of buildings and construction materials, or digital tools like Tally, OneClick LCA, EC3, or Athena that can help to accurately calculate embodied carbon. To bring better carbon education and awareness during the earliest phases of our projects, our firm designed Zero Guide, an internal tool that estimates the carbon equivalent of emissions associated with all aspects of a project, providing educated recommendations for how to lower its carbon footprint.

Implement Low Carbon Procurement Policies

For some major materials—for example, concrete—designers can request the embodied carbon footprint information of the mix designs, of which there are many that can meet the design intent if specified by performance requirements. Then, the compliant bid can be selected based on carbon footprint as well as cost, resulting in significant savings. The Embodied Carbon in Construction Calculator (EC3)—a free database of construction environmental product declarations (EPDs) and matching building impact calculator for use in design and material procurement—is intended for this purpose. For example, Microsoft’s commitment to becoming carbon negative by 2030 means a reduction in emissions across operations, from buildings to datacenters. The new headquarters in Redmond, Washington, employs innovative energy-saving techniques such as geothermal wells and serves as a pilot program for EC3.

The Thermal Energy Center at Microsoft’s headquarters in Redmond, Washington, powers the campus almost entirely through electricity provided by geothermal energy exchanges. The project acts as a pilot program for the Embodied Carbon in Construction Calculator (EC3), a free database of construction EPDs and matching building impact calculator.

Invest in Carbon Offsets

In addition to offsetting the ongoing emissions of building operation, the embodied carbon from construction of new buildings or renovations can be offset through a one-time purchase to zero out the construction emissions. Transparency, however, is a critical prerequisite to selecting, analyzing, purchasing, and offsetting embodied carbon.

To effectively reverse climate change and create a healthier planet, carbon-based decision-making is critical. By addressing operational carbon and then embodied carbon in the built environment through low carbon materials, building lifecycle analysis, low carbon procurement policies, and investing in carbon offsets, we can minimize the built environment’s carbon footprint and spark meaningful change.

 

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Through Their Eyes

How Computer Simulations of Vision Loss Create More Empathetic Buildings for the Visually Impaired

February 2, 2022

Senior Associate, NBBJ

This post was co-authored by Alex Almerico and Brian Uyesugi

 

More than 2.2 billion people in the world are visually impaired, while at least half of these cases—1 billion— could have been prevented or have yet to be addressed. In addition, blindness is expected to double in the U.S. by 2050 due to chronic diseases, like diabetes. For children and adults alike, loss of vision has significant effects on daily life, from accomplishing day-to-day tasks like reading and learning, to overall quality of life and mental health.

To fight against vision loss—and end preventable blindness—the new Oregon Elks Children’s Eye Clinic at the Casey Eye Institute in Portland, Oregon,  includes a pediatric eye clinic, as well as centers for retina services, vision rehabilitation, ophthalmic genetics, age-related macular degeneration and clinical trials.

When it came time to design the clinic, the NBBJ team first shadowed patients and interviewed staff about diagnostic conditions in collaboration with OHSU and Casey Eye Institute researchers. The team then used this research to develop custom simulations early in the process that allowed them  to input a specific eye condition and then view proposed designs through that lens.

For example, the models simulated what clinic spaces would look like to young patients with cataracts, diabetic retinopathy and glaucoma, as well for older adults with age-related eye conditions such as macular degeneration. Together, these research techniques were essential to support an empathetic design process that resulted in targeted design solutions to create an intuitive and visually comfortable environment.

The design team used staff and patient research to develop custom simulations to view clinic spaces through the lens of different eye conditions such as cataracts, glaucoma, macular degeneration and monochromacy and achromatopsia. This approach resulted in a more empathetic design process.

Here is a look at four challenges identified from our research and how the design responds accordingly.

Difficulties with Low-Contrast Colors

Challenge: While patients with macular degeneration, diabetic retinopathy and low vision have different vision conditions, a heightened sensitivity to low-contrast environments is a common challenge. This means greater difficulty in visually distinguishing colors that are next to one another on the color wheel, or different tints, tones or shades of colors. For example, combinations of red and orange, blue and purple, or dark green and light green, can be more difficult to differentiate for these young patients.

Solution: Enhanced Contrast. To improve navigation and orientation, the clinic utilizes high-contrast materials and colors. For example, design elements like rubber flooring and tile transitions are exaggerated with contrasting colors and textures to distinguish walkways from seating areas. In addition, public spaces such as elevators and bathroom doors are lighter in color to adjacent dark walls, signaling a destination or a public path of travel. Meantime, exam room doors are further accentuated with contrasting, built-in “door mats.” Furthermore, in the entry lobby the greeter desk is cloaked in a high-contrast color, which enhances visibility. The desk also anchors the space with an integrated guide rail that low vision patients can use to navigate to the elevators around the corner.

Bold graphics and contrasting colors and materials—such as high-contrast color combinations and rubber flooring with tile transitions—make it easier for patients to navigate the clinic.

Unclear Signage

Challenge: Navigating the existing clinic was difficult for patients, and it was especially challenging to find the bathroom among a sea of white doors and walls. Patients struggled to read signage and would frequently ask passersby for directions to or assistance with the elevator.

Solution: Bold Graphics. To improve visibility for patients, especially from a distance, signage throughout the clinic is large and high contrast, while graphics and numbers are bold and distinct.  For instance, the optical shop showcases a feature wall, which hosts a welcoming mural with the clinic’s friendly “Casey” mascot, that can be seen from the lobby. A frit pattern on the shop’s glass storefront also helps to indicate the glass enclosure as a barrier and guide patients to the shop entry.

Light Sensitivity

Challenge: The team found patients whose eyes were dilated for their exam waited with their heads between their legs to shield their eyes from daylight and stark white walls.

Solution: A Customizable, Calming Oasis. To provide a soothing, choice-driven experience for patients dilated during their visit, the new clinic features quiet spaces with dimmable lighting. For instance, sub-waiting zones in the children’s exam corridor are programmed with adjustable light settings and gentle, darker colors. Unlike the typical clinic, daylight is minimized throughout and limited to primarily public and staff spaces. The team considered acoustics as well, as patients with eye conditions and patients undergoing dilation can be more sensitive to sound. Playful acoustic panels in sub-waiting zones and in the cafe are inspired by ophthalmological “visual field” diagrams provided by OHSU. Seating areas also feature a dividing wall that creates quiet and active zones, and even hosts a whimsical child-sized opening for young patients to explore.

Dimmable lights and acoustic panels in sub-waiting zones provide a calm and soothing experience for patients undergoing dilation.

Wayfinding Issues

Challenge: The existing clinic lacked a sensory-rich arrival experience to help orient and calm patients, so it was key to create a welcoming entry sequence that offers both a sense of inviting familiarity as well as engaging novelty.

Solution: Textural Variety. A restorative garden adjacent to the clinic drop-off encourages a multi-sensory experience for young patients and their loved ones via textural changes and a tactile wall.  Landscape elements were also selected to build on other senses in lieu of vision. The garden includes a diverse array of fragrant and tactile plants to provide sensory interest—as well as welcoming familiarity—throughout the year. In addition, the team removed all vertical exterior pathway elements such as signs and bollards to create a barrier-free entry, while materials were specified to enhance visibility. For instance, the project uses a darker than typical sand finish to reduce glare and light levels for patients.

By designing with empathy grounded in research that considers  the unique needs of people with eye conditions, we can help our clients better care for patients as individuals—and provide a welcoming and safe space to support them—by first seeing the world through their eyes.

 

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