What is the Aim
Despite considerable discussions on flexibility in professional literature, empirical research on the flexibility of inpatient units is not widely published. Moreover, the notion of flexibility from different stakeholders’ perspectives at the inpatient unit level is, at this moment, not well understood. As a result, design ideas aimed at promoting flexibility are randomly being incorporated into designs with these ideas based on untested hypotheses, applying the assumption that the concept would accommodate necessary adaptation for appropriate care delivery in the long run.
To address these challenges, this study aims to articulate the notion of flexibility in inpatient care and to identify attributes and elements of the physical environment that facilitate or impeded flexibility during the useful life of unit design. This research is intended to inform decision-making in the design of inpatient care units that will maximize flexibility for implementing changing unit operational models while minimizing physical design change/redesign costs, improving or maintaining efficiency over time, and lengthening economic life of inpatient care units. To address these issues, this research focused on the following questions:
- What does flexibility mean to different stakeholders of care delivery in hospital inpatient care units?
- What physical design variables do stakeholders identify as the critical dimensions of inpatient care unit architecture that influence their flexibility?
- What elements of the designs of inpatient care units promote or hinder unit flexibility?
This study focuses on adult medical-surgical inpatient units, which typically comprise 25-30% of the physical area and capital cost in healthcare facilities and are the most common inpatient units across all hospital types.
In-depth, semi-structured interviews were conducted with the management, nursing and support staff at six not-for-profit hospitals across the United States in order to understand their interpretations of flexibility and attributes of physical design in adult medical-surgical units that facilitate or impede flexibility. All six hospitals were, at the time, new construction, designed by HKS, Inc., and were selected through purposive sampling to maximize variations in physical attributes including unit size, unit shape, circulation type, and location. At each hospital, participation was solicited from selected stakeholders in patient care services and services that support nursing care delivery including respiratory therapy, dietary services, environmental services, materials management, and pharmacy. The volunteering participants were interviewed individually for one hour by the same two research team members on site, a registered nurse and a doctorate-level architect. Interviews were guided by a plan of inquiry, prepared and tested before the site visits. Brief facility tours, photography, and annotations on floor plans were also conducted to aid in the process of understanding, interpreting and articulating the interviewees’ perspective.
What We Found
The researchers first identified key operational challenges faced by caregivers, including management as well as direct caregivers such as nurses and non-nurse caregivers and support staff. The stakeholders were also asked to define their interpretation of flexibility. Despite a variety of responses based upon the individuals’ roles, most responses focused on being able to provide optimum service to the patients, or to the direct caregivers who take care of patients. From these interviews, this research was able to determine that the physical environment could play a decisive role in facilitating the individual/operational/ organizational attributes yearned for by caregivers.
Researchers identified several attributes of the physical environment that influence flexibility needs on medical-surgical units. Principal among these are:
- unit size
- unit shape
- design of support core area
- room design
- inter-unit/departmental circulation
As such, this research suggests that the physical design plays a crucial role in facilitating or impeding human adaptability to changing workload demands, staffing patterns and operational situations. The physical environment, in both its real and its perceived state, regularly influences human performance and adaptability.
The data collected in this study suggests that there are certain attributes of the physical environment that need to be ‘static’ to enable personnel and operations to be flexible in an inpatient unit over time. Attributes include:
- multiple division/zoning options
- peer lines-of-sight
- patient visibility
- centrality of support
- resilience to move/relocate/ interchange units
- multiple administrative control and unit spread options
- ease of movement between units and departments
This research therefore captures a notion of flexibility, in essence, that constitutes a type of ‘adaptable’ flexibility from a clinical operations perspective—the ability of an inpatient unit to accommodate diurnal, short and long-term changes in census, staff, and other vital aspects of the clinical operations without any change in the environment itself; a view which also introduces an issue in physical design that adds a new perspective to the traditional notions discussed in professional literature.
From these interviews, this research was able to determine that the physical environment could play a decisive role in facilitating the individual/operational/ organizational attributes yearned for by caregivers.
What the Findings Mean
The findings of this study suggest that adaptable flexibility at the inpatient unit level can be enhanced during design by evaluating the design against a checklist of desired environmental characteristics. To aid in this process, the study provides a suggested checklist for designers.
Despite these very informative findings, this study is essentially exploratory in nature and the sample consisted of designs from one design firm, and, hence should be considered with an appropriate understanding of these limitations. Future studies should consider expanding the sample for greater generalizability as well as more objective assessment of flexibility needs in inpatient care units, based on the findings of this study. Moreover, this document is intentionally limited to discussions on bed units. Future studies could and should begin to link micro and macro flexibility needs and design issues arising out of such needs.
Thomas E. Harvey Jr.
Dr. Debajyoti Pati
Laurie T. Waggener
Carolyn L. Cason, Ph.D., Professor, School of Nursing, University of Texas, Arlington, Texas
Doug Bazuin, Researcher, Herman Miller, Zeeland, Michigan
AIA Research Grant 2006
Herman Miller Grant