September / October 2006
No Hidden Patient: Facility Design for Safety
Genesis of the Clinical Nursing Worktable
Jeff Hardy interviewed Valli Washburn, RN, director of emergency and intensive care services at Glendale Memorial Hospital and Health Center, a 334-bed facility in Glendale, California. Washburn led the planning process for designing what is now called the “Clinical Nursing Worktable” installed in the intensive care unit at Glendale Memorial Hospital. As a facility planning and design consultant, Hardy worked closely with Washburn to determine if the worktable would be applicable for greater use at all patient care centers. The following are excerpts of those discussions.
Hardy: Where did the idea for the clinical nursing worktable come from?
Washburn: About 10 years ago we had an opportunity to plan and design a replacement intensive care and cardiac care unit. Our first task was to list all the problems we had with our traditional intensive care units. For one thing, the nursing stations were enclosed — we couldn’t see the patients without looking around physicians and staff who were standing at the counters blocking our views. We had to walk around the desk and out to one of two side cutaways to reach a patient.
Furthermore, the stations were too small for anyone to work. Physicians complained about not having a place to sit and review patient charts. There was also concern there wasn’t enough seating for all the clinical nursing and clinical professional staff, such as the respiratory therapist, the pharmacist, the social worker, dietician, and so on, who were involved in the case. So physicians and staff took their charts wherever they could find a place to sit, which inevitably was somewhere away from the station and other clinical staff.
Hardy: What was the pivotal moment that led you to decide on the worktable design?
Washburn: Our biggest concern — at the top of the list — was patient safety. In the old unit, the difficulty was not only in seeing the patients from the station, but in not being able to talk with each other. Promoting communication is the biggest patient safety factor there is. The more we all communicate with each other, the lower the risk to patient safety. To do that, we have to be more accessible and less formal. Once we agreed on the general idea of the worktable, we spent nearly a year brainstorming the details — the shape of the worktable and where in the station to put the computers, the chart racks, the supplies, and so on.
Hardy: What are the greatest benefits of using the worktable?
Washburn: Nurses don’t have to get up and walk around a desk to get to their patients. It allows for a much more open, embracing environment. We can hear the patients in the nearby rooms and we can see across the top of the worktable and note immediately if any of our team needs help in a patient room. We can see at a glance if a patient is struggling to get up to go to the bathroom. Most important, everyone is face-to-face, not side-by-side or back-to-back, as with the traditional nurses’ station. We can have informal meetings more often, as patient care needs and regimens change from moment to moment. Nurses typically stand and walk a lot during their shifts, but here, when staff come out of a patient room, they can sit down right opposite the room to do their documentation and communication.
Hardy: Do HIPPA confidentiality regulations affect the design of the worktable?
Washburn: No more or less than traditional nurses’ stations do.
Hardy: Did you consider the popular “alcove charting area” design, locating nursing work stations between rooms?
Washburn: Yes. We toured many hospitals before coming up with our own design. We visited several patient care units where there was an alcove with a stand-up counter, a computer and charting table between every other room. The alcove charting areas were similar; nurses could chart and see through small windows that looked into the patient rooms from the alcoves.
We saw problems with that design, though. First, the alcove separates staff and automatically reduces communication among the team to levels well below what we felt were acceptable. Also, there wasn’t much room at the alcoves for two nurses, the assumption being that the nurse taking care of one patient will be always responsible for taking care of the patient in the adjacent room. This becomes a nurse-assignment nightmare. Either the nurse has to be assigned to patients based on room location, or there’s a lopsided scheduling of one nurse, for example, to one critically ill patient and one less severe patient. The nurse-assignment problem is compounded when multi-specialty patients reside on a single-patient care unit. Finally, the alcove is supposed to get the nurse closer to the patient — but when we want to be closer to the patient, we want to be right next to the patient. Florence Nightingale will never be wrong on that point.
Sidebar adapted fromÝ”‘No Hidden Patient'” by Jeff Hardy and Ron Lustig, Healthcare Design, Vol. 6, No. 4, July 2006. Used with permission from AIA.