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BY: KATHY OKLAND, RN, MPH, EDAC

The ethos of nursing practice is both art and science. At the heart of holistic care, all who serve and support the patient are deemed agents and extensions of healing. This human-centered care philosophy has evolved in such a manner that multiple mediums are recognized as therapeutic modalities. They include choice, music, beauty, simplicity and the very environment where care and service is provided.

Although I have been a nurse for more than 30 years, it was not clearly evident to me that the care environment was a therapeutic modality until I found myself as chief nursing officer and the clinical leader for a greenfield hospital project. The term "greenfield" applies to construction and development of new land that has never been previously used and therefore requires no need to demolish existing structures. Indeed, my preoccupation always had aligned with the patient, the practice and the process of supporting care. This time, conversations with architects, designers and equipment planners quickly convinced me that my clinical and leadership acumen alone was not sufficient to represent the interests of the patients, providers and staff at the project planning table.

It became apparent I had a responsibility to learn as well as lead, to ask as well as answer, and discern as well as decide, on the important matters determining the future of care to be delivered in this place. "Humble thyself," I said to myself. And so I did. In retrospect, the gift amidst the experience was not knowing and somehow embracing that reality, accepting vulnerability with grace and remaining constant to the endeavor as the voice of patients, families and staff.

Many nurse leaders share a story like this, and we all agree that a construction project introduces a domain of practice and a learning curve like no other. Now that I have more experience, I can bridge matters of clinical practice, process and the place where care occurs to remind myself, "What element of health care delivery, from simple to significant, is not influenced by the environment?"

HEALTH AND HABITAT
Health and habitat are inextricably linked. Adjacencies, travel distance, noise, distraction, line of sight, privacy, storage, interruption — all have impact on human performance and the health care experience. Caregiver fatigue, patient confidentiality, end-user comfort, ancillary efficiency, delay, exposure — design decisions impact them all.

Make no mistake, a nurse will interpret and translate the attributes of space from his or her clinical insight and empathy acquired from a role that advocates for patient and family needs. Sacred to the nurse is the deeper understanding of the subtleties expressed and exchanged in caregiving. This empathic nature of nurses has earned the trust of patients, the honors of top Gallup poll ratings, and, in the health care industry, recognition as a legitimate voice of advocacy.

Also sacred is the space that supports and sustains care. As hospitals evolve to be less institutional and more hospitable, we can imagine metaphorically the patient room as a sanctuary. Thought of that way, how might patient room acoustics, views, colors and amenities differ? Utility is essential to safety, but beauty is essential to the human experience. Attention to beauty and utility is the designers' obligation when creating sanctuaries of care for those in health care environments, because beauty is essential to the human experience.

Think about a time when you experienced in full measure a sense of separation from the chaos of the day, peace, shelter and calm. Where were you? What were the attributes of those surroundings? What were the qualities of the space? And, how did you feel?

Think about this space and consider what similarities might exist within your facility's setting. In keeping with the philosophy that caregiving is a ministry, we should consider that the place where caregiving occurs has spiritual significance for those we serve and for those who serve. Lovely objects and sacred symbols can renew us by their appointment, placement and perfection.

My friend and colleague Ronn Goodnough RN, MN, who serves as Clinical Project Manager at Harrison Medical Center in Bremerton, Washington, put it like this: "What inspires me most in all of this and above all, is the thought that this space we are creating, a hospital, is sacred ground. People live and people die in these spaces. People experience all of these moments in our spaces, and I am inspired that these experiences can be honored by the design of a healing environment"¹

ENVIRONMENT OF CARE
Emphasis on the environment of care is not new, nor is emphasis on the environment as an essential requisite for optimal outcomes. The Greek physician Hippocrates (460 – 377 B.C.), known as the Father of Medicine, said health depends on a state of equilibrium of the body and mind, reached only when in harmony with the external environment.²

In the 1800s, Florence Nightingale was not only a trailblazing nurse, but her work in the British military hospital in Constantinople during the Crimean War gained her recognition as the first health care architect, statistician and epidemiologist. She demonstrated that for health and healing to occur, suitable conditions of sanitation, fresh air, light, hygiene and clean water were required, and her lengthy report and recommendations are credited with a restructuring of that military hospital system.

Nightingale's findings were foundational to modern medicine, yet today, fresh air is rare in our climate-controlled hospitals, natural light is sought after and sanitation is challenged. There are over 700,000 hospital patients who acquire at least one health care associated infection a year while hospitalized, and of those, 75,000 patients will die during their hospitalization.³

Similarly, in her book Notes on Nursing, Nightingale concluded, "the nurse's role was to manipulate the patient's environment to maximize healing."4 Yet the integration of nursing and the built environment as a premise of 150 years ago has not materialized until the recent decade. The recognized importance of integrating nursing with the built environment is credited to nurse pioneers Debbie Gregory, RN, DNP(c), as founder of the Nursing Institute for Healthcare Design (NIHD) in 2005, and Jaynelle Stichler, DNS, RN, NEA-BC, EDAC, FACHE, FAAN, co-editor of Health Environments Research & Design Journal, launched in 2007.

They are both known to have established a contemporary response to the foundational philosophies of nursing and the corresponding physical climate where nursing practice occurs. Through their advocacy for integrating nursing with the built environment, NIHD was founded on the beliefs that nurses bring an essential competency to the design of health care environments and that nurses can inform research and supporting evidence to shape the physical environment of care. Yet, suffice to say, nurses may be the most underutilized discipline and resource in planning and design. There are myriad influences that explain this, and to name a few: the dearth of resources (to include mentors) to adequately prepare clinicians to have an equal place at the planning and design table; disciplines and decisions that fail to recognize the value of clinical input to the process; not being recognized as experts to inform space planning; and at times being involved too late to effect meaningful design.

In an industry that strives to deliver on superior outcomes, exceptional patient and provider experiences and value, an emphasis on the influence of design has reached its time. In 2008, the Center for Health Design (www.healthdesign.org) launched the credentialing program Evidenced Based Design Accreditation and Certification (EDAC). The purpose of EDAC is to educate and inform, create awareness and establish a standard in the industry for the necessary knowledge in design, and supporting relevant research to contribute to a growing body of knowledge. The EDAC curriculum enlightens the student and correlates the attributes of space to health care outcomes. Today, more than 1,500 designers, architects, engineers, nurses and other interdisciplinary partners distinguish their knowledge and practice of evidence-based design in health care by the EDAC credential. Interestingly, evidence-based design has its beginnings in evidence-based medicine, which naturally aligns informed practice and informed design.

NURSING AND DESIGN
The role of nurses integrated in planning and design is a concept whose time has come. If bringing nurses to design discussions is long overdue, then what value does nursing as a profession bring to health care design?

• Nurses practice across the entire continuum of care and serve as translators for the needs of patients and families and the clinical work environment for providers.
• Nurses understand clinical workflow, bottlenecks and barriers as occupants and users of spaces where care is planned and delivered.
• Nurses have mastered the inherent complexity in the current healthcare milieu to manage patients' care including navigating constant change and the discourse required to integrate the input of multiple influencers in care delivery.
• Nurses possess an applied understanding of the interactions of time and resources.

Consider the constraints of our current state. We are challenged to do more, better, faster and with less. At the same time, those who serve (providers and caregivers) and those who are served (patients and families) understand that every therapeutic modality must be leveraged to positively affect health and well-being. At the same time, we understand that a hospital cannot heal on its own. As care moves from hospital to home, no space is exempt from careful considerations given to the corresponding effect of habitat on healing.

Having been a nurse for decades, I know the intimacy of caring for patients and those who love and nurture them as well as my own family. Nursing is both vocation and avocation. As does a nurse, space touches every patient with every diagnosis, and everyone in the space at every moment. When clinical leaders support space as an extension of healing, there is promise that people, process and place will be better aligned for health and for well-being.

KATHY OKLAND is a senior health care consultant for Herman Miller Healthcare and president of the Nursing Institute for Healthcare Design. She resides in rural Minnesota.

NOTES

1. Ronald Goodnough, "What Motivates and Inspires Me," in Nurses as Leaders in Healthcare Design: A Resource for Nurses and Interprofessional Partners, ed. Jaynelle F. Stichler and Kathy Okland (Zeeland, Michigan: Herman Miller Inc., 2015): 211.
2. Alan Bryson, Healing Mind, Body and Soul (New Delhi: Sterling Publishers Pvt. Ltd., 2000).
3. R. Monina Klevens et al., "Estimating Health Care-AssociatedInfections and Deaths in U.S. Hospitals, 2002," Public Health Report 122, no. 2 (March-April 2007): 160-166.
4. Florence Nightingale, Notes on Nursing: What It Is, and What It Is Not (Mineola, New York: Dover Publications, 1969).