Designing the nursing wards for a university hospital: a multifaceted approach on how architecture can stimulate care, education and research

Type of the Paper: Peer-reviewed Conference Paper/ Short Paper

Track title: Future-proofing

Designing the nursing wards for a university hospital: a multifaceted approach on how architecture can stimulate care, education and research

Klara Geltmeyer¹, Tineke Brits², Lynn Pieters², Rik Verhaeghe^1,3, Veerle Duprez¹ and Simon Malfait ^1,3,*

¹ Ghent University Hospital, Nursing Department

² Ghent University Hospital, Infrastructural Team

³ Ghent University, Faculty of Medicine and Health Sciences

* Corresponding author; simon.malfait@uzgent.be

Keywords: Nursing organization; ward design; hospital architecture; co-design process

1. Introduction

In 2029, the Ghent University Hospital aspires to complete a new hospital building that houses all nursing wards (with the exception of pediatric care, medical revalidation and psychiatry). However, it was unclear what the layout, format, and size of these nursing wards should be, and it was difficult to base the plan on international literature. While the international literature on the architecture of nursing wards provides some indications on preferable elements, no conclusive advice can be found. The absence of a comprehensive body of knowledge on this is mainly the result of the fact that (1) hospitals are not often built, meaning that research is scarce, and (2) when hospitals are finally built, the architecture may already be outdated in comparison to new technologies and insights (Pilosof, 2021). Moreover, while the body of knowledge about evidence-based design (and architecture) is structurally increasing due to a surge in hospital building in the USA (Ulrich et al., 2008), these ideas are, to a lesser extent, adoptable to European healthcare systems with a different form of funding. Solely turning to the literature in order to design the new hospital and its ward proved insufficient. Other approaches had to be searched for. One of the adagio’s that is often referred to in building design is that “we shape our buildings, and afterwards our buildings shape us." While not covering the entire truth, it has to be acknowledged that culture, structure, and strategy are closely intertwined with the environment in which they take place (Miller, 1993). Therefore, it was concluded that the design of the nursing wards and the overall hospital layout should be based on a theoretical idea about how nursing will be performed in the future. In other words, in order to determine this design layout, the future nursing care delivery model is to be seen as a primordial choice.

Determining this future nursing care delivery model does, however, not stand on its own. First, the model should be future-proof, taking into account possible evolutions and developments in the nursing profession. Second, there are both legal and environmental boundaries to the possibilities. Third, the nursing care delivery model should interlock with the strategy of the hospital. Fourth, any knowledge about evidence-based design concerning nursing ward architecture and layout should be taken into account. Based on the fact that different elements are to be taken into account in a systematic manner, it was decided that an evidence-based process had to be developed and executed to determine the nursing ward design and hospital layout.

2. Theories and Methods

The designing process consisted of five phases, showing similarities with the concept of co-design. In the concept of co-design, a systematic approach is used to bring together different perspectives from different levels (base or corporate) on the same issue, gradually building towards a widely supported idea, resulting in the development of a plan that takes into account all or most of the demands from the different stakeholder groups in the trade-off towards the final plan (Castro et al., 2018). The difference with the regular process of co-design is that in this case, the different groups did not consist of patients and healthcare workers but consisted of people who focused on the same subject. Several scientific approaches to guide these phases were used: systematic literature review, expert panels, focus groups, brainstorm sessions using the thinking aloud method, and peer review. An overview of the process is given in Figure 1.

Figure 1. An overview of the co-design process towards the final nursing ward layout.

In phase 1, several literature reviews and systematic analyses of documents were made by separate content groups consisting of different people (‘young potential’ nurses, ward managers, staff members, etc.). There were eight groups in this phase: (1) theoretical nursing models; (2) safe staffing; (3) skill mix; (4) nursing ward architecture; (5) future challenges for nursing; (6) legislation and accreditation; (7) strategic choices; and (8) non-negotiable choices. In phase 2, several groups were brought together in expert panels to combine their findings into overall propositions concerning their themes. Several alternative propositions were formulated. Groups (1), (2), and (3) were combined in an expert panel concerning nursing care delivery models. Groups (4) and (5) were combined into a group about the future of nursing. Groups (6) and (8) combined their findings to define the boundaries between which the plans should take shape. Group (7) remained aside and did not undertake any action in this phase.

During phase 3, a single focus group was formed in order to determine the final

theoretical characteristics of the nursing ward design, taking into account the compatibility of all the propositions made by the expert panels. The focus group consisted of different stakeholders, such as physicians, head nurses, the ‘construction’ team, and members of the board of directors. Several meetings were held, using a qualitative content analysis approach (White & Marsh, 2006). First, the propositions of each expert panel were presented and discussed. Second, choices were made, resulting in a checklist of the main characteristics of the ward design. This list was sent to the architects in order to design a plan for the nursing wards. Phase 4 consisted of several brainstorming sessions using the thinking aloud method with the members of the focus group to evaluate the plans made by the architects. Architects based their plans on former experiences and examples of ward designs from other hospitals. Plans were either rejected, adapted, or withheld until a single plan was accepted by all members and fulfilled all the demands of the identified characteristics. In phase 5, the finalized plans were peer-reviewed by a number of stakeholders in the hospital. These stakeholders included, amongst others, the board of directors, the physicians, and the head nurses. The design process took place from January until May 2020.

3. Results

The results from phases 1, 2, and 3 are reported together due to their connectedness. The results focus on the process for acquiring data and the main characteristics that were taken into account to design the wards. In the results of phase 4, the actual ward design and hospital layout are reported.

3.1. Phase 1, phase 2, and phase 3:

In order to determine the input for the nursing care delivery models, a mapping review (Geltmeyer et al., 2024) was undertaken about theoretical nursing care models (e.g., how nurses work together), the needed skill mix in the team (e.g., composition of different degrees in nursing), and nurse staffing (number of beds per nurse). A broad search was executed on Pubmed, CINAHL, and Web of Science, resulting in 7517 papers, of which, after screening, 326 were included in the review. Overall, from the available data, the nursing care delivery systems of primary nursing (Adams, Bond, & Hale, 1998) and modular nursing (Magargal, 1997) were withheld, but no definite choice could be made. The design should therefore be able to support both decentralized and small units that could be clustered. Based on the literature concerning safe staffing, the units should be sized with a minimum of 12 beds as the smallest piece of the puzzle. Skill-mix did not influence the architecture. A centralization of administrative functions (e.g., role head nurse, research, etc.) is added to make these systems of nursing possible (Mannekens et al., 2022). An explorative review concerning the design of nursing wards and its impact on nursing, as well as a search of the gray literature concerning future evolutions, resulted in an additional 4020 papers to screen. Concerning the design of the ward, radial layout, open nursing stations, increased visibility, and acuity-adaptable design were put forward. Moreover, in order to stimulate flexibility and transferability, a single-unit design was advised. When it comes to future evolutions, work health promotion (short running lines, minimal lift environment, and healing environment), technology (remote monitoring, telemedicine, central telemetry, wearables, robotics, and augmented reality), and patient and family participation should be facilitated. This is translated, amongst others, into broad hallways with room to implement new technology, a new design of the mobile nursing workstation, and a minimalization of separate desks (Van Meenen, 2021). The results of the above-described reviews, executed by the expert panels, were then discussed in focus groups. A hospital layout with 192 beds on each floor was chosen, taking into account legal and environmental registration. The 192 beds are clustered in four areas (48 beds), each comprising four units of 12 beds. Overall, the strategic choice of the hospital is to focus on specialized, high-quality, highly differentiated, and highly technological care, differentiated by the hospital's unique position in education and research, leading to innovation. All the elements above are directly linked to these strategic choices. Small units enable the hospital to provide highly differentiated care (focus), change fast (innovation), and enable a nursing care system that can focus on specialization, training (education), and research in a highly controlled area. By using technology, high staffing ratios, and open space, time is created for both patients and their families.

3.2. Phase 4: brainstorm sessions

In order to finalize the final design of the nursing wards, all the essential elements as decided upon in the focus group were used. In total, three elaborate brainstorm sessions took place in which designs were proposed, discussed, evaluated based on the recommendations made, and rejected, adapted, or withheld. The final layout of the nursing ward design and the overall layout of the hospital can be found in Figures 2 and 3.

Figure 2. The layout of the nursing ward, consisting of four units of 12 beds (1: patient rooms, 2: technical areas; to be determined, 3: central area; to be determined)

Figure 3. The overall hospital lay-out (preliminary)

3.3. Phase 5: peer review:

No additional suggestions or remarks were made in this phase, meaning that the overall plans for the ward design did not need any alternations. The layout of the patient room, however, needed further refinement. This was explored, discussed, and designed in another process (De Meester et al., 2022).

4. Discussion and conclusions:

Due to the absence of a comprehensive body of knowledge on evidence-based design concerning nursing wards, other sources had to be consulted in order to design the nursing wards in the new hospital at Ghent University Hospital. A systematic, evidence-based approach was used. From the start, it became clear that no clear-cut answer could be found in the literature. Most of the extensive studies on which the choices were made had to be done by the research team themselves and could not be found in the literature. This was the case for almost all the topics and elements included in this study. This provides two insights. First, because each hospital has its own focus and identity, the questions posed are unique. Therefore, investments are needed. Second, there remains a lack of knowledge on many topics related to nursing ward design. This should be addressed. Also, this case study showed, in contrast with some points made in this discussion, that each hospital should focus on creating its own design. This means that a universal truth about the best nursing ward design (within a time and context) is perhaps not possible and even not needed nor desired. It also seems important to provide the possibility to scale up if needed or change the care trajectories of patients in a fast and fluent manner (i.e., in the case of a pandemic) (Brambilla et al., 2021; Geltmeyer et al., 2022). Due to the extensive work done by the hospital itself, the specific focus of the studies, and the fact that most studies are not yet published and therefore lack peer review, a form of bias is a possibility. Moreover, this also compromises the transferability of these insights. However, apart from the created content, this case study shows that it is worthwhile to invest in an extended, systematic, evidence-based approach to design nursing wards. If any lessons can be learned, the presented approach could be an inspiration for other hospitals. In the future, there should be contemplation of creating a learning network in Europe and worldwide about the design of nursing wards. The focus of such a network should be on pro-actively sharing insights and conducting research on nursing linked to specific ward designs. As was learned throughout this case study, there should be an ever-remaining focus on the theory of nursing, both in design and overall. The process does not end with the finished design of the hospital. The hospital layout will also be evaluated after realization. Possible methods could be tracking nurses’ ‘walking lines’, tracking the time spent with the patient, and patient- and staff satisfaction.

Overall, three conclusions can be drawn based on this case study. First, there is no clear-cut answer to which design is best for the nursing ward of the future. Based on their experience, each hospital should look for a design that articulates the strategic choices of the hospital concerning nursing care. Second, vision should be placed before design. Before designing a nursing ward, the main principles and core values about care need to be determined in order to facilitate decision-making about a definitive design. Third, most of the knowledge needed to make a well-informed choice has to be created by the stakeholders themselves and is difficult to find elsewhere. This means that the process of designing a new hospital starts long before the actual drawing of the plans.

Data Availability Statement: Some of the studies to which there are references in this paper have not yet been published. Readers who would like to gain more insight into these results can contact the corresponding author. The authors are more than willing to share any available draft papers.

Contributor statement: All authors contributed significantly to the conception of this paper. SM, KG, and VD completed most of the study, which SM also supervised. TB, LP, and RV contributed significantly to the content in the process.

Acknowledgments: The authors would like to thank the scientific fund of the Ghent University Hospital for providing the necessary funds for conducting this study. The funds had no involvement in the design, conception, or execution of this study. Furthermore, the authors would like to thank all the employees of the Ghent University Hospital who participated in this process.

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