Reimagining Medical Workspaces: Information Ecosystems for Future Nurse stations
The work of doctors and nurses demands intensive sharing of highly technical information throughout the long and varied workday, under highly stressful situations. Yet at the same time, they must remain emotionally engaged and empathetic. Working in partnership with furniture company Steelcase, a team of multi-disciplinary researchers at Virginia Tech examined how to integrate digital technologies with the design of the physical environment. The goal was to reduce clinician burnout by ensuring information flow that is accurate, current, and easily understood, especially during emergencies when stress and emotions are acute.
The innovation in our research-based design stemmed from the composition of a team that drew from departments across the university, and a design research strategy that employed multiple modes of observational studies and prototyping. Our team comprising human factors researchers, architects, industrial designers, and computer engineers collaborated with clinicians from Carilion Clinics and researchers of WorkSpace Futures at Steelcase. The complexity of medical workspaces required a team that can cross-examine problems through multi-disciplinary lenses. Our designs, which integrate technologies in the design of the environment to increase human communications, could only result from a synthesis of our expertise.
We conducted ethnographic studies through interviews and visual observation of clinicians at hospitals, a dispatch center, and a simulation center used to train clinicians. While shadowing them, we identified conditions that both aid and hinder their work flow. Based on our findings, we generated numerous design concepts for nurse stations at ICU, where clinician stress is extremely high and the need for team interaction is critical.
In one scheme, we reimagined the traditional U-shaped nurses' station that provides panoptic views of all patients. Inspired by a pilot's cockpit and an air traffic control center, the station becomes a central command center in which multiple display screens are arranged around the nurses' seats to reflect the plan arrangement of the patient rooms. Another was a decentralized, distributed nurses' station that reimagined the overbed side table found in patient rooms. The table not only held meal trays and personal belongings, but also functioned as a display screen with which clinicians can share information with each other or patients, and patients can hold Zoom calls with family or clinicians. In both schemes, the goal was to enable accurate and easy flow of information, and increase situational awareness among clinicians. We rapidly mocked up selected design schemes at full scale in foamcore that could easily be marked, taped, and modified. We engaged a range of stakeholders at each step of the process and imparted agency to a variety of users to intuitively grasp the design and provide feedback.
The wellbeing of clinicians is essential to the delivery of quality healthcare to patients in a timely, accurate, and caring manner. Our pre-design research with a multi-disciplinary team highlighted obstacle in clinician's workflow, to which we responded with designs that integrated information capabilities into the physical design of furniture and equipment, using full-scale mockups and digital simulations to seek further input to create an iterative design-input cycle.
CONTEXT – overview of the problems, goals, and process A multi-disciplinary team from Virginia Tech collaborated with office furniture company Steelcase to study the impact of medical workspaces on the clinician experience. Clinical care in acute care hospitals results in highly stressful situations on a daily basis. Clinicians work long, variable hours, complete complex technical tasks, and must also be emotionally engaged with patients and families to meet the caring demands of this profession. Repeated exposure to such acute stressors often results in burnout– a state characterized by the depletion of emotional, energetic, and coping resources that has long been present in healthcare professions. Our team identified conditions that could either aid or hinder their work flow using observations and interviews, then generated design concepts and tested them using digital and physical full-scale prototypes.
There were several innovation strategies in the project. One stemmed from the research and design process that capitalized on the depth and breadth of expertise, facilities, and technologies that are available at a research university and affiliated medical facilities. We began our process with a kickoff meeting with the research team and clinicians from Carilion Clinic in Roanoke, Virginia. Our literature reviews showed that there are three critical components to workflow in the Intensive Care Unit: communication, situational awareness, and access to contextual information. In order to understand how these three factors are linked to the design of work environment and information flow, our team examined both routine and acute work tasks and spaces by conducting interviews, and on-site shadowing and observation of clinicians at three locations. The first was the Carilion Clinic Transfer and Communications Center, a command center responsible for routine tasks of placing and transporting patients. The second was the Carilion Center for Simulation, Research and Patient Safety, where clinicians are trained for acute situations such as Code Blue (respiratory and cardiac arrests) using high quality simulation experience. The third was Intensive Care Units (ICU) at the Carilion Roanoke Memorial Hospital, to study both routine and acute situations.
Whereas architects and designers' observations are typically limited to patient spaces, our team studied how a network of people involved directly or indirectly in patient care affect information flow and situational awareness, and subsequently, the stress levels and burnout rates of clinicians. For example, ICU teams' interdisciplinary members are often located in different buildings or floors. Consequently, in order to have situational awareness, ICU teams rely heavily on technology to communicate with each other and to access information. This broader perspective on clinicians' work enabled us to examine how impediments in communication between clinicians can adversely affect patient care, both directly through degrading team performance and indirectly by increasing stress levels and fatigue. The ethnography highlighted complex communication issues on the ICU floors, so the team focused their attention on the design of centralized and decentralized, mobile ICU nurses' stations. Based on the analysis of our interviews and observation (summarized below), we generated and tested several design concepts through multiple iterations of sketching, prototyping using digital and full-scale mockups, and integrating stakeholders' feedback into the subsequent round of sketches. INNOVATION in multi-disciplinary team assembly The complexity of medical workspaces–involving stress, burnout, team performance, information sharing, and environmental design–required a range of perspectives to cross-examine problems through multi-disciplinary lenses of social sciences, technologies, and design. Both our research process and design concepts, which integrated technologies in the design of the environment to improve clinical team effectiveness, could only result from a synthesis of our collective expertise. Our team members met and discussed everyone's progress for thirty minutes weekly for two semesters. Unlike typical teams in which researchers from different disciplines work independently for weeks and meet only every few months, our team worked in a truly collaborative, interactive manner. This teamwork, in which questions, input, and critiques were freely exchanged, was crucial for researchers from different disciplines to share feedback that informed and improved each other's work.
INNOVATION in multi-modal ethnography Another point of innovation was the multi-modal ethnography conducted by a psychologist, an occupational therapist, designers, and engineers. We had a team member who was a PhD candidate in Psychology with a concentration in Occupational Psychology. She conducted sixteen hours of observations, eight hours of interviews with twenty people who have a voice in making design decisions in the hospital, including Medical Doctors, Vice President of Facilities, Infection Preventionist, and Nurse Practitioning Administrator. She began with the critical incident technique, asking such open-ended questions as, "tell me of a time when you and your team were in sync," "tell me of a time when you were unable to work with your team," and "what works well in your working environment, and what does not work well?". The designers interpreted the responses and sketched multiple design concepts, for which she also sought feedback through the design phase. For example, for one of the design concepts, a bedside table that could also function as a digital display surface, a doctor remarked, "The bedside table could be used to alleviate the workflow of clinicians when it comes to checking in with the patient; the clinical team could visit with the patient remotely or have an intern and a senior resident physically present, and the rest of the team is virtual. This could revolutionize how rounding is conceptualized and make it more efficient. Patient representatives or family members could be included in this process."
Furthermore, designers on the team had different but related modes of observations. We shadowed clinicians through their workday, and in addition to asking questions and listening to them describe their tasks and challenges, we sketched and photographed what we observed as pain points in workflow. We also drew on top of printed photographs taken on site, to highlight spatial configurations or objects in space that obstruct work or information flow. For example, in the ICU, we observed that clinicians work with highly limited space in both patient rooms and hallways, and that additional equipment and furniture are difficult to accommodate without becoming obstructions. We also noted that clinicians have challenges finding space and means of display to share information effectively, with each other or with patients. These observations were key to integrating display technologies with the physical design of the mobile furniture we later prototyped.
INNOVATION in multimedia prototyping The third innovation was in our prototyping methods. As soon as ideas were sketched, we built digital models as well as full-scale mockups. We iterated through "bodystorming"–a brainstorming process by which we act out with our bodies to understand the experience of others. We built prototypes with foamcore that could be cut and taped easily and quickly based on interpretations of feedback. Architects' mockups are often built with the actual construction materials at the end of or after the design phase for client's final approval prior to construction. However, we made mockups as sketches, out of materials that could be easily modified to iterate unreservedly during the early design phases. Furthermore, we incorporated cutting edge technology to enhance our simulation in bodystorming. Our team had a recent graduate of Virginia Tech's Creative Technologies program. He had experience and skills in projection mapping, a spatial augmented reality technique which can turn any object, with flat or complex curved surfaces, into a display screen for projected images or videos. He used projection mapping to simulate multiple display screens on a nurses station, including a camera view of the patient's room, their vitals, and a PeraHealth screen (a clinician surveillance information tool). This enabled us to not only bodystorm with full-scale furniture but also with digital displays that could easily be modified in proportion, size, and content.
We had access to another valuable resource that elevated our bodystorming capabilities: Carilion Center for Simulation, Research and Patient Safety, a facility that provides clinical simulation for training and assessment. Working closely with the center director, we enacted various scenarios in which the proposed overbed side table/display would be used, in the context of a patient room equipped with a hospital bed, monitors, IV poles, other clinicians, and other equipment–all of which must be managed while caring for the patient. According to literature on bodystorming, an effective bodystorming performed in the context of the space in which the product or technology will ultimately be used, can help us proactively identify points at which there are problems in the design. For example, by enacting a huddle in a replicated ICU room with projection mapping, we could assess whether the information displayed on the table could comfortably be read in a two- or a three-person huddle, and when the display becomes difficult to read, or becomes an obstruction in the room. Putting aside preconception and enacting scenarios placed us in the positions of patients and clinicians, to be empathetic and understand problems and solutions from their perspectives.