1. Watson, Carol A. PhD, RN

Article Content

The American Organization of Nurse Executives (AONE) recently released its education and research priorities for 2005.1 The 3 priorities guide AONE and its members in decisions about funding for research and about education programs. The priorities complement AONE's strategic plan and encompass the areas of: (1) serving as stewards of leadership, (2) visioning future patient care delivery models, and (3) creating positive and healthy work environments.


The articles in this edition of the Journal of Nursing Administration support the AONE education and research priorities, further expanding the knowledge base for nurse leaders. Three articles by Bolton et al, Leach, and Manojlovich examine strategies that are important to nurse leaders as stewards of leadership. The other 3 by Dougherty and Larson, Ruggiero, and Lynn and Redman explore factors that are important in creating positive and healthy work environments.


While the information addressed in each of the articles is valuable, the breadth of nursing administration research must include a stronger emphasis on technology and facility design. All of these articles and nursing administration research in general focus primarily on the providers of care, leadership skills, and work processes. Nursing administration research should incorporate more investigation on the impact of technology and the physical environment in leveraging the work of nursing and creating safer and healthier environments for patients and nurses.



AONE includes technology as an important focus in all 3 of its education and research priorities. The use of technology is acknowledged in the priorities as an important component to assist nurse leaders in carrying out their work and in the design of patient care delivery models. AONE supports research initiatives that evaluate the use of technology to diminish the work burden for nurses and enhance patient safety.


Much of the technology in healthcare is directed at the diagnosis and treatment of disease, with only occasional introduction of breakthrough technologies that transform the work environment for nurses. The shortage of nurses and the looming expansion of that shortage with the retirement of the baby boomer nurses make advances in technology that leverage the work of nurses imperative. Reliance on increasing the number of nurses as essentially the sole strategy to respond to the ever-growing demand for patient care can no longer be sustained. The dialogue about and evidence for specific technology strategies must have greater visibility within nursing administration research.


Nursing is predominantly about information handling. It's about getting the right information to the right person at the right time. Slowly, hospitals are becoming wired but lag behind other industries in adopting wireless technology. Less than 3% of hospitals have wireless platforms, and it will take 3 to 7 years for healthcare to catch up technologically.2


A wired hospital creates a patient-centered, point-of-care environment that enables a mobile workforce, such as nurses. It allows interactions to be performed either at or far separate from the point-of-care and brings together voice, video, physiologic, data, and diagnostic information through a plethora of mobile devices appropriate to the work demands.


A survey in 2001 of more than 300 companies with more than 100 employees, which included healthcare, explored the relationship between a wireless environment and productivity of employees.3 The survey found that employees working in wireless environments stayed connected to their companies' networks 13/4 hours per day, which translated into a daily savings per employee of 70 minutes. That's a 22% improvement in productivity. The impact of a wireless environment on productivity in healthcare was even greater.


Research that demonstrates the benefits of technology is important to nurse leaders, such as the study conducted by the First Consulting Group evaluating the impact of a wearable, hands-free, wireless communications system on nurse productivity.4 The communications system features a small, lightweight, and voice-activated device that is also a full-functioning phone. The device can be interfaced with a nurse call system, making communication with patients, physicians, other nurses, and departments within a hospital immediately available to nurses, wherever their location may be. The study demonstrated measurable and significant time savings and workflow improvement for the nurses.


Another example of research evaluating a technology with promise for changing the work of nurses is a study examining the impact of medication bar code scanning system. The scanning system uses a handheld, wireless, point-of-care device. The purpose of the study was to determine if medication administration, documentation accuracy, and nurse satisfaction with the medication use process improved using the wireless technology.5 The overall reduction in the medication error rate was 87%, with a 42% improvement in nurse satisfaction with the medication use process.


The importance of decisions about technology adoption will only grow, so selecting technologies that offer the greatest improvement in quality and safety must be evidence-based. But, evidence-based technology decisions are only one area that has not received adequate attention in nursing administration research. The other area is facility design.



Many US hospitals were built in the 1960s and 1970s and do not incorporate the most recent evidence-based facility design features. Providing care in 20th century facilities is shortchanging nurses and adds to their work burden. Renovation and construction projects in much of the 1980s and 1990s focused on outpatient but more from the patient perspective than the nurse perspective. Inpatient facilities received little attention.


Many hospitals are now involved in construction projects to expand, redesign, or build new inpatient and outpatient facilities. This is an unbelievable opportunity to create 21st century facilities that are healthier and safer for patients and nurses; involvement of nurse leaders is imperative. Evidence is mounting that facility design has an impact on patient and staff outcomes; however, most of that information is found in healthcare administration and architecture and design resources, not in nursing administration research.


The push for an entirely different approach to the physical environment is growing, with the centerpiece of the 21st century facility being private patient rooms. The American Institute of Architects recently released the 2005 proposed guidelines for the design and construction of hospitals and healthcare facilities6 that recommends private rooms for patients. The Center for Health Care Design is a research and advocacy organization. It is comprised of healthcare and design professionals committed to improving healthcare through architecture and design of physical environments that contribute to health and enhance outcome. Its initiative is called the Pebble Project.7 The Robert Wood Johnson and the Center for Health Care Design convened healthcare leaders from a variety of organizations to discuss the state of the US hospitals and the vision of the future.8 The focal point of the discussion was a new analysis of more than 100 research studies and the publication of recommendations linking patient health and quality of care with the way hospitals are designed.


Nurse leaders must be involved in the growing dialogue to define the physical environment in which nurses work. The design decisions are not just about patient rooms but also the support space for nurses. Redesign of patient rooms and the adjacent support space is an opportunity to create strikingly different environments to enhance patient safety, quality of care, and productivity of nurses.


New construction or extensive renovation is costly. With limited resources, justification of the financial and clinical benefits is imperative to ensure that changes made transform the work environment and are not just cosmetic. While the return on the investment is financial, the more striking improvements are in patient safety, quality, and productivity.


Evidence-based facility design is not about just designing a physical environment but a delivery model and philosophy of care.9 If the focus is just on the physical design, the design is about the status quo. The involvement of nurse leaders is critical to expanding the focus from just facility design to creating healthier environments that support new models for care delivery.



A brief review of some of the evidence is helpful in understanding the transformational opportunities available through evidence-based facility design. Improved patient outcomes fall into the categories of safety, quality, and satisfaction. Two frequently cited studies report reductions of 62%10 and 70%,11 respectively, in medication errors-a significant improvement in patient safety.


Improvements in quality occur through decreased use of narcotics, fewer healthcare-acquired infections, and shorter lengths of stay. The use of fewer narcotics by patients has been attributed to a quieter, less stressful environment that translates into less pain and a decreased need for narcotics. Bilchik reports a 54% decrease in narcotic use and up to 6 fewer healthcare-acquired infections per month.10 Patient satisfaction increases with private rooms12 but tends to moderate over time as the novelty of private rooms wears off. As private rooms become the standard, patients once again focus on care and compassion of nurses, quality of the food, and cleanliness of the environment, reinforcing that the emphasis on the physical environment alone is not transformational.



Private rooms do improve nurse productivity. A major impact on productivity comes through decreased patient transfers. One study estimates that an average unit transfers around 12 to 14 patients daily,13 with every patient transfer estimated to cost $500 to 1000.14 Hendrich et al report a 90% decrease in patient transfers with private rooms.11 Imagine the impact on staff productivity-nurses, housekeepers, laundry, etc-if 90% of these intradepartmental transfers were eliminated.


Private rooms also improve patient flow. It is much easier to get a patient room ready for another patient when it is a private room. Private rooms accommodate a 10% higher patient occupancy than other room types.13 In semiprivate rooms, beds are held vacant to handle the isolation needs, roommate incompatibility issues, or just the desire of staff to give patients private rooms when possible. A private room gives hospitals significant additional "hassle-free" capacity and easier placement of patients. Private rooms also improve overall nurse productivity and morale.15 One study describes a 14% improvement in productivity.16 Hendrich et al report a return to the 1997 level of productivity.11 Lost productivity due to turnover is reduced.17


Much of the research on facility design focuses primarily on the design of patient rooms but support space, such as the size of the medication preparation areas and decentralization of equipment and supplies, is equally important in improving patient and nurse outcomes. And, a true healing environment does not exist unless it exists for everyone in the facility. Nurses need space to rest and recover from some of the most physically and emotionally exhausting work that anyone can do, so sound design principles need to be incorporated in break rooms as well as clinical and support space.



The integration of technology and facility design to create healthier, more positive environments for patients and nurses is an exciting opportunity for nurse leaders. But it means that nurse leaders must be aware of the available evidence and incorporate this information into decision making about work environments. Nurse leaders must continue to evaluate the impact of facility and technology design on patient and nurse outcomes and communicate the evidence of their investigational work to transform not only the physical environment but also the models of care delivery.




1. American Organization of Nurse Executives. AONE 2005 education and research priorities. December 4, 2004. Available at: Accessed February 1, 2005. [Context Link]


2. Gillette B. Wireless technology serves as next logical step in care service. Managed Healthcare Executive. June 2004. Available at: Acces-sed February 1, 2005. [Context Link]


3. NOP World-Technology. Wireless LANS Benefits Study. September 2001. Available at: Accessed February 1, 2005. [Context Link]


4. First Consulting Group. Vocera Communications: Vocera benefits study at St. Agnes hospital. February 2004. Available at: Accessed February 1, 2005. [Context Link]


5. Rough S, Ludwig B, Wilson E. Improving the Medication Administration Process: The Impact of Point of Care Bar Code Medication Scanning Technology. ASHP Best Practices Award in Health System Pharmacy. Bethesda, Md: American Society of Health-System Pharmacists; 2003. [Context Link]


6. American Institute of Architects. Guidelines for design and construction of hospital and health care facilities (proposed 2005). Available at: Accessed February 1, 2005. [Context Link]


7. The Pebble Project. The Center for Health Design. Available at: Accessed February 1, 2005. [Context Link]


8. Designing the 21st Century Hospital: Serving Patients and Staff. Washington, DC: Robert Wood Johnson Foundation and The Center for Health Design; June 2004. Available at: Accessed February 1, 2005. [Context Link]


9. Lowers J. Improving quality through the built environment. Qual Letter. August 1999;8:2-9. [Context Link]


10. Bilchik G. A better place to heal. Health Forum J. 2002;46(3):10-15. [Context Link]


11. Hendrich AL, Fay J, Sorrells AK. Effects of acuity-adaptable rooms on flow of patients and delivery of care. Am J Crit Care. 2004;13(1):35-45. [Context Link]


12. Wellness LLC. The Wellness Room(TM) Pilot Study (2000). Available at: Accessed February 1, 2005. [Context Link]


13. Hospitals discover cost efficiency of private rooms: new analysis reinforces advantages of private rooms. Exec Solut Healthc Manage. 2000;3(1):7-8. [Context Link]


14. Hamilton D. Design for patient units. Healing by design: building for health care in the 21st century conference. McGill University Design Centre. September 20-21, 2000. Available at: Accessed Feb-ruary 1, 2005. [Context Link]


15. Coile R. Competing by design: healing environments attract patients, reduce costs and help recruit staff. Physician Exec. July-August 2002;4:12-16. Available at: Accessed February 1, 2005. [Context Link]


16. Critical care update. Facil Design Manage. 1998;17(10):48-49. [Context Link]


17. McKesson Provider Technologies. A structured approach: how bronson healthcare group is building better health. Answers. 2004;12(1):2-5. [Context Link]