Healthcare Design - October 2015 - 54

R RESEARCH | 10.15
Does decentralized nursing deliver?

After more than a decade of industry adoption, it may be time to look back before navigating ahead
By Debajyoti Pati and Pamela Redden
The decentralized nursing operations and physical design model was introduced to inpatient units
more than 10 years ago, with a number of expected
positive outcomes for staff. Those include reduced
nurse walking distances, more time at the bedside,
less stress, improved productivity, and enhanced
collaboration, among others. In essence, it was anticipated that the move would improve efficiency and
safety, workplace condition, and care quality.
Since adoption began, at least six studies have
examined whether these hopeful outcomes have
been achieved (see sidebar for more information).

Areas of concern
The findings mentioned are good or, at worst, neutral
regarding the trend toward decentralization. However,
there are areas where the decentralized model was
found to perform worse than the centralized model.
One area of concern is walking distances. Of three
studies that measured walking, one reported a reduction, whereas two showed an increase. This goes
against intuitive logic, since the core goal of decentralization was to move staff closer to the point of care.
Why would walking increase? It could be unrelated to
unit design, for one. Policy changes related to patient

While not all studies posed the same set of questions, a review of the outcomes does provide some
interesting and important questions to ponder.

care-such as frequency of rounds-can impact
walking and, if effected during the transition to a new
facility, may result in an increase in walking distances
wrongly attributed to design.
On the other hand, the large footprints that are typical of decentralized units can also trigger additional
walking. This is exacerbated by varying requirements
for patient visibility: For example, acuity-based assignments, as opposed to geographic, will lead to
increased walking on large units to maintain necessary visual contact. Peer-to-peer visibility is also
an essential part of the nursing culture and staff
may walk to seek out consultation, mentoring, and
socialization. Additionally, while nurses' stations may
be decentralized, the support areas-such as linen,
supplies, and medications-may remain centralized
and result in more travel.
The second issue that emerged pertains to
medication. Two studies measured nurses' time in
medication rooms, both reporting longer time spent
on decentralized units. It's possible that nurses are
collaborating or socializing while in the medication
rooms in order to mitigate the lack of a centralized
gathering space. However, there are also policies and
procedures that may affect time spent in medication
rooms. For example, some medications may require
"two-nurse checks."
All six studies measured some aspects of the
broader construction of staff interaction-consultation, collaboration, or social engagement-and all reported a reduction. Only in a team-based care model
(one study), which mandates interactions between
the RN and his or her assistants, was a reduction not
observed. This reduction has occurred even though
the decentralized units were designed with infrastructure to support collaboration and teamwork. There's a
growing body of literature demonstrating the positive

The good news
Patient satisfaction is higher in decentralized units,
according to two studies. While some may attribute
this to the halo effect of new facilities (one's impression about a hospital is influenced by the newness
of a space), one of the studies reported improved
scores for nurse response time to patient calls, too.
It's intuitive that response time would be quicker,
thanks to the proximity of caregivers to patients in a
decentralized model, and that fact may also explain
a reduction in fall rates (found in a different study),
as well. Patients typically fall during solo trips to
the bathroom, either owing to a false confidence in
their physical abilities or a delay in nurse response
time, or both. Nearby location of staff can improve
vigilance as well as reduce response time, thereby
reducing fall events. Additionally, a lower level of
distraction during work was self-reported by staff in
one study.
Interestingly, some outcome areas demonstrated
few differences between centralized and decentralized units. Those include sound levels (two studies),
perception of the work environment (two studies),
self-reported productivity (one study), and clinical
outcomes (one study).
There are inconsistent findings in some areas,
too, where decentralization has either demonstrated
good outcomes or no difference. An increase in time
with patients was shown in one study, whereas no
difference in nurse/patient interaction was reported
in two other studies. Inconsistent findings were also
observed in staff well-being, including levels of acute
stress and energy, in two studies.
54

HCDmagazine.com 10.15

Debajyoti Pati

Pamela Redden

http://www.HCDmagazine.com

Healthcare Design - October 2015

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