A Family Affair
Hospitals have designs on healing environments that meet needs of staff, patients and loved ones

By Cathryn Domrose
April 2, 2002

Two years ago, a cardiac care unit at an Indianapolis hospital unveiled what its vice president for patient care services calls "the patient room of the future."

Critical patients stay in the same private room from admission to discharge. The 425-square-foot rooms have ample space for families, complete with desks, pullout beds and mini refrigerators. Acuity-adaptable headboards can be closed down and hidden as a patient recovers.

The nursing station has disappeared. Instead, nurses work at computers outside each room. They have everything they need-medications, supplies, equipment-within six to eight feet of the patient's bed.

But the most radical change has been in the attitudes of caregivers. Critical care nurses and medical nurses now work side by side on the same unit, as partners with patients and their families. They no longer treat families as visitors, but as valued members of the health care team.

"It was really difficult for me, initially. The only thing I'd ever done was ICU," said Kimberly Browder, RN, a charge nurse on what now is called the cardiac comprehensive critical care unit on the Methodist campus of Clarian Health in Indianapolis.

Many nurses on the new unit couldn't handle the change and quit. But Browder and others who stuck it out have seen how families appreciate being able to help turn a wife or shave a husband in the morning; how comfortable patients seem to feel in the presence of friends and family and how they seem to recover more quickly; and how the unit has learned to work together as a team, not just of nurses, but also of support staff, including housekeepers.

"Now, I love it," Browder said. "I wouldn't work anywhere else."

In past years, rules and practices at many hospitals dictated that caregivers took care of patients while families sat in coldly lit waiting rooms, paced corridors or waited by the phone. But spurred by demands of patients and families, shortened hospital stays that mean families must do more home care and increasing evidence showing the importance of family support during recovery, a growing number of facilities such as Methodist are throwing open the doors to patient rooms and telling families, "Come in. We want you. We need you."

More hospitals are consulting staff, patients and families when they design new hospitals and units. They're creating comfortable patient rooms with extra beds and storage spaces that encourage family and friends to stay for as long as they and the patient wish. They're building gardens and respite areas and putting art on the walls. They're providing resource rooms, staffed by a designated family helper, where patients and families can look up information about a disease, find a nearby restaurant or hotel room or check in with the office.

"The norm has changed in that we ask parents about changes that we're making rather than assuming we know what they want," said Lynel Westby, RN, director of patient and family support services at Children's Hospital and Regional Medical Center in Seattle.

For most of the last century, patients and families considered physicians and nurses the experts, said Nancy Hogan-Baur, MSN, RN, a partner in 5THink, a health care consulting firm in Pasadena, Calif., that works with architects and hospitals. They expected to be told what to do. "It was an element of a parent-child relationship. We [caregivers] didn't concern ourselves with the family in the same way."

Now, patients' rights groups and organizations that promote partnerships between clinicians and families, such as the Institute for Family-Centered Care in Bethesda, Md., hope to persuade caregivers that times have changed and that health care consumers-patients and families-prefer hospitals that allow them to be involved in care.

The Center for Health Design in Pleasant Hill, Calif., is gathering data to show that the "healing environments" favored by many family-centered hospitals are not luxuries-elements like inspiring art, soft colors and lighting, waterfalls and live plants help sick people get better faster.

In hospitals with healing environments, soft colors and textures, natural and subdued light, carpets and cell phones or beepers have replaced institutional lighting, Formica and noisy overhead paging. Patients have private rooms with ample space for both the clinical team and families and friends. Some rooms resemble mini-suites, with refrigerators, couches, tables and reading lamps.

At the new Little Company of Mary Hospital in Torrance, Calif., set to open this month, patients will feel they are in a healing place the minute they walk in the door, said Kathy Harren, MHA, RN, the hospital's senior vice president for patient care services. Waterfalls in front of the lobby, a self-playing grand piano and a reflective garden planted with olive trees will give sick patients and stressed family members a sense of peace, she said. "You don't feel like you're walking into a hospital."

Creating a healing environment doesn't cost any more than building an institutional one, said Houston architect Kirk Hamilton, who is president of the American College of Health Care Architects and serves on the board of the Center for Health Design.

He became involved in designing healing environments partly because some early unpleasant experiences made him fear long hallways and the smell of disinfectant. At first, he began sneaking gardens and other elements into his hospital designs. Then, as the movement toward healing environments grew, he began to specialize in what he calls "evidence-based design," based on research that shows what satisfies patients and seems to help in their recovery.

For instance, instead of linoleum hallways, which look cold and echo noise, he would choose a synthetic carpet that resists microbes. The carpet costs the same or less than linoleum and is as easy to clean, he said. But it also absorbs noise so patients can sleep better, and it looks more welcoming.

Before Methodist remodeled its cardiac care unit two years ago, the ICU looked pretty much like any other, Browder said. "It was drab."

In the step-down unit, as in any medical/surgical unit, nurses spent a lot of time walking between the nursing station, patient rooms and a supply room. Transferring patients between the two units could take as long as half a day, said Ann Hendrich, MSN, RN, senior vice president for patient care services at the Methodist campus of Clarian Health.

As a clinician, Hendrich had always been frustrated by the amount of time she spent away from patients. She has conducted time and motion studies, showing how nurses spend many hours on documentation and seeking information rather than in patient rooms. Eliminating transfers and changing the design of the unit so nurses didn't have to travel long corridors or walk back and forth from a station would give them more time to spend educating and working with patients and families, she reasoned.

A good healing environment takes into account the needs of the staff as well as patients and families, architects and administrators said. With staff input, architects are designing spacious, naturally lit staff lounges, waist-high wall sockets and places to store supplies and medications inside patient rooms.

At Childrens Hospital Los Angeles, a new facility will feature mostly private rooms with clinical space at the entrance and family space at the far end, said Mary Dee Hacker, MBA, RN, vice president for patient care services and chief nursing officer at the hospital.

The clinical area will include sinks, flat countertops that are easy to clean, dressing changes, gloves-everything clinicians need, she said. The far end of the room will have a real bed for parents, shelves for storage and soft, domestic lighting. Parents in focus groups specifically requested a place to plug in computers and chairs big enough to hold their children on their laps. Staff members wanted enough space for a clinical team to surround the bed, room for equipment at the foot of the bed and bathrooms with entryways wide enough for wheelchairs, Hacker said.

Because the staff was heavily involved in designing Methodist's new ICU, what happened after the unit opened came as a surprise to many. About 60 percent of the nurses-mostly in critical care-quit. "Everything that the nurses knew, changed," Hendrich said. Some said they did not want so much family contact. "It broke my heart," she said, "but that's what they said."

Browder believes many who left wanted to be strictly critical care nurses, instead of sometimes attending to noncritical patients. She and other intensive care nurses also were nervous at first because they were working with nurses who were not trained in critical care, she said. At times, Browder said, she wanted to give up, but she had promised to give the new unit at least a year.

The shock of changing to family-centered care, especially in an area like critical care, where family visits are often limited to 15 minutes, can be difficult even for nurses who believe in the concept, consultants and administrators said.

"What we've found is that it's not enough to just go in and change the environment," said Sara Marberry, director of communications at the Center for Health Design. "Unless the culture of the place supports that, it doesn't work."

Nursing leaders at hospitals who make a change to family-centered care must realize that nurses will face huge changes, said Beverley Johnson, RN, president and CEO of the Institute for Family-Centered Care. Moving from a central nursing station to a workstation outside the bedroom, for example, may save a nurse some time, but it also limits contact with co-workers.

"What we're finding is that nurses like the privacy, they like the quiet and the families, but they really miss the socialization," Johnson said. Hospitals must address this need, she said, perhaps with a large, pleasant employee lounge or other gathering place.

Clinicians often are afraid that families may get in their way or ask questions they have no time to answer, Hogan-Baur said. "It's almost easier to address the physical part than it is to address the changes for the staff."

Nurses must realize that they can politely tell families they have to do something that requires all their concentration and will be happy to answer questions later, or that they can ask a belligerent relative to leave, Johnson said. "You have to draw some limits."

As time went by, Browder learned to trust the medical nurses-now called comprehensive care nurses-many of whom were cross-training in critical care. In turn, they taught her how to organize her time in caring for three or four noncritical patients, instead of the one or two critical patients she was used to. She also receives support from patient-visitor representatives, social workers, unit technicians, housekeepers, chaplains and patient care coordinators.

Because most of the nurses work all the time on the same unit, they have come to know and trust each other in a way that never happened on the old unit, she said. "We have an outstanding team. I can't applaud them enough. I've never seen such a big group of nurses work so well together." She also has found that families seem much less nervous when they understand what is going on. "We're teaching them constantly," she said.

Once, Browder overheard some family members trying to explain to other relatives what a balloon pump did. "They had no idea what they were talking about," she said. She stepped in, taped a balloon pump to a cardboard cutout of a human figure and asked if they wanted to see what that noisy machine was doing. "In five minutes, they knew what it was and why it was needed," she said. "It was so comforting to them."

It's important for families to understand how nurses are caring for their loved ones, Harren said, because often they will be taking care of the patient at home in a few days. Her hospital sends home 150 patients a month with home care and 120 to post-acute facilities.

"Families have to be a part of understanding the care pathways so they don't have to turn around and ask 100 questions" when the patient gets home, Browder said.

Although hospitals that have embraced family-centered care and healing environments have a lot of anecdotal evidence that the practice not only makes patients feel good, but also helps them get better, research to support those anecdotes is still ongoing. The Center for Health Design has a number of hospitals collecting data for its Pebble Project, which will show how much healing environments affect outcomes.

So far, the biggest concrete measurement is patient satisfaction. "Patient satisfaction is outstanding" on the new unit, Hendrich said. "It's the largest increase we've ever seen in such a short time for one unit."

At Unity Hospital in Fridley, Minn., which also combined its ICU and step-down units, patient satisfaction has increased notably, said Kathy Wilde, MA, RN, vice president for patient care services at Unity and Mercy Hospital in Coon Rapids, Minn.

The Barbara Ann Karmanos Cancer Institute in Detroit has always offered family-centered care, but recently redesigned two "institutional" oncology units to create a healing environment, said Dore Shepard, MS, RN, nurse manager at Karmanos. The institute is collecting data for the Pebble Project.

Since the new units opened, patient studies have shown a significant decrease in the dosage of self-administered pain medication, Shepard said. Although lengths of stay have remained constant, variable costs of care per patient for at least one procedure dropped by more than 25 percent, Shepard said. Methodist, which is also participating in the Pebble Project, reports a decrease in falls and medication errors as a result of eliminating patient transfers. Staff turnover, which seemed to rise so sharply at first, is now less than it was on the old unit.

Based on the patient satisfaction and outcome data, Hendrich is convinced that eventually health care consumers will demand healing environments and family involvement in almost all aspects of their care. Given the nursing shortage and a growing baby boom population, "we're going to have to involve families more and more in patient care, and find more efficient and safe ways to care for patients," she said.

Family-centered care already has become standard practice in pediatric hospitals, Johnson said. She sees encouraging signs that adult health care is going the same way.

Marberry estimates that many hospitals have embraced the concept of healing environments. "It's a growing movement," she said, "but it's certainly not mainstream yet."

Browder's satisfaction with the new unit has increased beyond her expectations. She gets to know families well, talks to patients who can talk back and watches people go home who came in very sick-rewards she almost never knew on the old intensive care unit.

She recalled one man who came in after a massive heart attack. No one thought he would make it. She got to know his wife, who stayed by his side almost the entire time. Browder remembered the joy she felt as the patient slowly recovered, how moved she was the day he left, when his wife hugged her and he thanked her, tears of gratitude in his eyes.

"I love the kind of care we give here," Browder said. "It's a different kind of nursing. If anything happened to one of my family members, this is where I'd want them to be."