Optimizing Nurse Workflow Efficiency: An Examination of Nurse Walking Behavior and Space Accessibility in Medical Surgical Units

Abstract

Objective:

This study aimed to investigate the effect of spatial adjacencies on nurses’ walking patterns and the subsequent impact on staff satisfaction with perceived accessibility and adjacency-related issues.

Background:

Recognizing the crucial importance of spatial adjacencies in healthcare facilities is essential, as they significantly affect staff morale, fatigue management, operational efficiency, error reduction, and overall patient care excellence, highlighting the need for objective assessments to evaluate the impact of facility layout and space configuration on workflow patterns and staff satisfaction in patient care units.

Methods:

Integrating on-site observations with survey data, we explored how spatial adjacencies affect staff walking behavior and satisfaction in two med-surgical unit floors.

Results:

The findings highlighted a significant frequency of movements between nurse stations, patient rooms, and medication areas. Regression analysis identified several contributing factors to staff satisfaction, including the proximity of supplies, team visibility, ease of access across departments, and the location of equipment rooms. Specifically, satisfaction with the proximity of supplies was positively associated with increased provider satisfaction with workflow, quality of care, and workplace. Additionally, valuable feedback from staff revealed concerns regarding break room placement, medication area functionality, and disparities in the availability of supplies.

Conclusion:

This study highlighted the critical need for carefully planned spatial adjacency strategies to enhance workflow efficiency and raise clinical staff satisfaction within healthcare facilities. The actionable insights gleaned from this research offer valuable direction to architects, healthcare administrators, and design professionals, enabling the creation of environments that positively resonate with healthcare providers and improve healthcare operations.

Keywords

medical surgical unit design nurse walking distances space adjacency healthcare planning staff satisfaction accessibility

Nurse walking behavior within healthcare environments has garnered significant attention due to its wide-ranging impact on patient care and nursing staff well-being (Cai et al., 2023; Chappel et al., 2017; Choudhary et al., 2010;Hendrich et al., 2009; Liao et al., 2022; Ma et al., 2021; Sagherian et al., 2023; Watkins et al., 2012; Zadeh et al., 2012). Extensive research has been dedicated to understanding the considerable distances nurses cover during their shifts, highlighting the physical demands of their role (Chang & Cho, 2022; Hendrich & Chow, 2008; Hendrich et al., 2008; Pati et al., 2008, 2012; Yu et al., 2020).

Walking and running are fundamental physical actions necessary across all nursing units, happening while moving between the patient’s bed and the nursing station (Acar & Butt, 2016; Hendrich & Chow, 2008; Hendrich et al., 2008; Nanda et al., 2015; Shepley & Davies, 2003). Given that the extent and intensity of physical involvement during work impact nurses’ well-being, notably their musculoskeletal health, undertaking physically demanding responsibilities while in an unsound condition might result in the accrual of fatigue, potentially compromising patient safety (Cai et al., 2023; Chappel et al., 2017; Liao et al., 2022; Ma et al., 2021; Sagherian et al., 2023).

A consistent theme across the literature is the inverse relationship between nurse walking time and time spent on direct patient care (Choudhary et al., 2010; Hendrich & Chow, 2008; Hendrich et al., 2009; Shepley & Davies, 2003; Watkins et al., 2012; Zadeh et al., 2012), highlighting the critical importance of thoughtfully designing spatial layouts to optimize nurses’ time allocation toward patient-focused activities. The configuration of the healthcare environment plays a crucial role in determining nurse walking distances and overall workflow efficiency. Various unit shapes and sizes have been investigated for their impact on nurses’ walking behavior and efficiency (Choudhary et al., 2010; Hendrich & Chow, 2008; Hendrich et al., 2009; Lee et al., 2020; Shepley & Davies, 2003). For instance, Shepley and Davies (2003) compared two nursing units, one with a rectangular 24-bed layout and another with a radial 10-bed layout, revealing a statistically significant difference in walking patterns between the units. Nurses in the rectangular configuration averaged 7.9 steps per minute, while those in the radial configuration averaged 4.7 steps per minute. Similarly, Lee et al. (2020) conducted an agent-based simulation study that found triangular layouts of inpatient units, with nurse stations (NSs) positioned closer to patient rooms, led to a reduction in nurse travel distances of over 15%.

The physical attributes of a patient unit, including linear integration, visual connectivity, and step depth, have been identified as factors influencing walking behavior, peer awareness, and time spent with patients (Cai & Zimring, 2012; Hendrich et al., 2009; Hendrich et al., 2008; Rafeeq & Mustafa, 2021; Seo et al., 2011; Shepley & Davies, 2003; Yi & Seo, 2012). Linear integration measures how well a space, such as a patient room, is connected to potential movement paths represented by straight lines, with greater integration indicating higher centrality (Hendrich et al., 2009). Step depth, on the other hand, quantifies the accessibility between points of interest by measuring the number of turns needed to traverse between locations within a plan (Cai & Zimring, 2012). For instance, Hendrich et al. (2009) conducted a study tracking the movements of 767 medical-surgical nurses in 36 hospitals, revealing that spatial attributes of assigned patient rooms significantly influenced nurses’ movement patterns. Units with higher average integration values were associated with increased visits to both patient rooms and NSs.

The relationship between spatial design and nursing behavior is further elucidated by studies examining specific unit layouts and their impact on nurse activities. For example, Cai and Zimring’s (2012) investigation of intensive care units (ICUs) highlights that a greater distance between NS locations negatively affects nurses’ peer awareness and contributes to a heightened sense of isolation. Additionally, Seo et al. (2011) compared nurses’ medication procurement trips in different ICUs, revealing that factors such as visibility, nurse substation location, and medication distribution locations influence walking behavior and interaction patterns among nurses. These findings underscore the intricate interplay between spatial configurations and nursing activities within healthcare environments.

The arrangement of spaces and features within healthcare units significantly shapes nurses’ walking distances and overall workflow efficiency (Acar & Butt, 2016; Copeland & Chambers, 2017; Nanda et al., 2015; Nazarian et al., 2018; Pati et al., 2008, 2012, 2014). These findings are consistent with studies that have established an increase in nurse walking distances when patient rooms are situated outside the central circulation of a nursing unit and when patient assignments involve multiple corridors (Acar & Butt, 2016; Hendrich & Chow, 2008; Lee et al., 2020; Nazarian et al., 2018; Pati et al., 2008). Additionally, the configuration and location of NSs within patient units influence nurse walking distances, peer communication, and operational efficiency (Cai & Zimring, 2012; Copeland & Chambers, 2017; Gurascio-Howard & Malloch, 2007; Lee et al., 2020; Nanda et al., 2015; Seo et al., 2011; Watkins et al., 2012). For instance, Cai and Zimring (2012) note that in ICU units, nurses seated in alcoves are effectively connected to the community, leading to increased awareness of patient conditions and a greater likelihood of being recruited for assistance. Similarly, an observational study by Acar and Butt (2016) found that during a 12-hr shift, nurses spent 34.5% of their total travel time moving between the NS and patient rooms.

Various studies have yielded contradictory findings regarding the optimal design of NSs aimed at minimizing walking distances (Fay et al., 2017; Lee et al., 2020; Pati et al., 2015; Watkins et al., 2012). In their simulation study of inpatient units, Lee et al. (2020) found that the placement of NSs in a symmetric layout with the NS in the center reduced the walking distances of nurses. Pati et al. (2015) observed that transitioning from centralized to decentralized stations in inpatient units increases walking but enhances efficiency and reduces self-reported collaboration. In contrast, Watkins et al. (2012) indicated that a higher concentration of documentation activities at centralized nursing stations correlated with longer walking distances for nurses and reduced time with patients.

In their pre- and postoccupancy evaluation of ICU units, Fay et al. (2017) discovered that decentralized nursing stations led to increased visits to patient and medication rooms, quicker responses to patient calls, and enhanced patient visibility. However, they also observed reduced communication and collaboration among staff, diminished patient or peer-to-peer visibility, and fewer opportunities for mentoring and networking, potentially impacting care process efficiency. Conversely, the centralized model showed advantages in nursing peer support, socialization, mentoring, and consultation with other providers. Nevertheless, centralized nursing stations were associated with increased walking distances, unproductive use of nursing time, and heightened stress levels. Interestingly, the study found no significant change in staff satisfaction with the unit’s design or its impact on the sense of well-being. Similarly, in a pre–post quasi-experimental study, Copeland and Chambers (2017) compared the effects of centralized versus decentralized NSs and support spaces on nurses’ walking distance and satisfaction for acute care inpatient units. Findings show that the decentralized NSs and careful consideration of support spaces decreased walking distances, maintained nurse job satisfaction, and reduced falls in medical–surgical environments.

The strategic placement of support spaces within healthcare units is a critical factor influencing nurse walking behavior and overall workflow efficiency. Multiple studies emphasize the significance of arranging support spaces in a manner that reduces staff fatigue, improves efficiency, and minimizes the likelihood of errors (Cai et al., 2023; Chaudhury et al., 2009; Gurascio-Howard & Malloch, 2007; Nanda et al., 2015; Pati et al., 2014; Yi & Seo, 2012). Pati et al. (2012) employed a simulation-based experimental approach and task frequency data from a nationwide sample of 700 nurses, exploring the impact of nursing support spaces on a 30-bed medical–surgical unit. The findings indicate that total walking time can be reduced by up to 67.9%, highlighting the potential for improving care quality and efficiency through appropriate levels of decentralization. A literature review by Chaudhury et al. (2009) suggests implementing pods with 8–12 patient rooms with their medication rooms to reduce walking-related fatigue and errors. The authors conclude that efficient travel paths from patient rooms to medication rooms are essential for achieving optimum travel distances. Yi and Seo (2012) found that the proximity of the medication supply room to the central nurses’ station in ICU units influenced nurses’ interaction frequency and led to deviations from the shortest, retracting, and most efficient path while administering medication (0.6, 73.3, and 109.0 feet, respectively). These insights underscore the strategic importance of spatial layouts in minimizing unnecessary travel and optimizing time spent on patient care.

Nanda et al. (2015) conducted surveys and shadow data analysis to identify spaces frequently visited by nurses during their shifts in a 40-bed medical–surgical unit. Findings showed that patient rooms, assigned NSs, clean supply and medication rooms, and corridors were the primary areas navigated by nurses. Notably, the co-location of medication and supply spaces emerged as a favorable attribute. This arrangement streamlined workflows, significantly reducing the need for extensive walking to gather essential items, thereby enhancing overall efficiency. The findings highlight the preference for double-loaded corridors over single entry from staff areas, underscoring the influence of support space and corridor layout in shaping nurse walking behavior. This preference vividly illustrates that well-thought-out configurations of these areas have the potential to optimize nurse movements, ultimately leading to improved efficiency.

Amid the challenges posed by the COVID-19 pandemic in healthcare, fatigue became prevalent among nurses (Liao et al., 2022; Sagherian et al., 2023). Environmental factors, including nurse distance, spatial crowdedness, adequate break rooms, and the availability of visible hand hygiene stations (HHS), were identified as contributors to nurses’ fatigue (Cai et al., 2023; Liao et al., 2022; Ma et al., 2021). For instance, Cai et al. (2023) revealed that nurses facing a scarcity of visible and accessible HHSs in their work environment had heightened odds of experiencing moderate to higher fatigue levels. These findings underscore the critical role of environmental considerations in addressing and mitigating fatigue among healthcare professionals.

In essence, these findings underscore the pivotal role of thoughtful spatial planning in shaping nurse movements, optimizing workflows, and ultimately improving staff satisfaction and quality of patient care. Continued research on healthcare design and nurse walking behavior is imperative to refine evidence-based principles that optimize environments for efficiency and patient care. Addressing these gaps will contribute to a nuanced understanding, fostering the development of innovative design strategies that prioritize the holistic well-being of healthcare professionals and patients. Subsequently, this study seeks to investigate the influence of spatial adjacencies on nurses’ walking patterns and their subsequent impact on staff satisfaction, focusing on perceived accessibility and adjacency-related issues. The research questions are structured as follows.

How does the spatial configuration of a medical–surgical unit influence the walking patterns of nurses during their assignments, and how can these insights inform the optimization of design for enhanced efficiency?

What specific environmental factors, with a focus on perceived accessibility and visibility, contribute to staff satisfaction regarding workflow, safety, quality of care, department size, overall workspace, and reduction of walking distances within healthcare facilities? Accessibility refers to the ease of reaching and using various elements or features within a space, such as equipment, supplies, workstations, and patient areas, to perform tasks efficiently and safely.

Method

The study was conducted in July and August of 2022 within a significant healthcare system, focusing on a 46-bed medical–surgical unit spanning two floors in the postpandemic period. Initially, the unit’s layout featured two centralized nurse team stations supplemented by decentralized NSs outside each patient room. Additionally, there were two nourishment rooms located midway along the corridors adjacent to patient rooms, along with a single medication room nearer to the southern NS (refer to Figure 1 and Table 1). The updated layout aimed at significant enhancements to accessibility and process improvement. It introduced four large, centralized care team stations strategically positioned at corners to optimize access to patient rooms. Moreover, the redesign increased the number of medication rooms to two, ensuring improved accessibility from each NS. Nourishment rooms were relocated to offstage corridors, equally accessible from the internal corridor and NSs (refer to Figure 2 and Table 1).

Figure 1.

Level 3 layout showing the location of nurse station and clinical support areas (Copyright: Authors).

Table 1.

Comparison of Third and Fourth Floor Layouts.

Characteristics		Third Floor	Fourth Floor
Nurse stations	Quantity	Two central and 12 decentralized	4
Nurse stations	Distance between patient room to central nurse stations (center to center path of travel)	24′ (min) and 166 (max)	44′ (min) and 77′ (max)
Nourishment	Quantity	2	2
Nourishment	Distance between nourishment to central nurse stations (center to center path of travel)	105 (min) and 109′ (max)	14′ (min) and 67′ (max)
	Distance between nourishment to patient room (center to center path of travel)	27′ (min) and 184′ (max)	41′ (min) and 55′ (max)
Medication room	Quantity	1	2
Medication room	Distance between medication rooms to central nurse stations (center to center-off stage path of travel)	74′ (min) and 77′ (max)	41′ (min) and 52′ (max)
Position of WOWs or HER systems		Inside rooms	Inside rooms
Staffing ratio		Four to five patients to one nurse on day shift, and five to six patients to one nurse on nights	Four patients to one nurse on days and four patients to one nurse on nights

Note: WOW: workstation on wheels.

Figure 2.

Level 4 layout showing the location of nurse station and clinical support areas. As shown, nurse stations are distributed evenly and there is an additional midsection corridor to improve access to the support areas (Copyright: Authors).

The research methodology employed a combination of on-site shadowing and online surveys to gather data. The online survey included inquiries designed to assess staff satisfaction regarding various environmental factors within the department. The survey’s development prioritized content validity, achieved through a rigorous iterative process involving input from a multidisciplinary team consisting of researchers, planners, architects, and designers. Additionally, a comprehensive literature review informed the selection of specific physical environment attributes closely associated with clinical staff satisfaction. It is worth noting that the survey instrument had previously demonstrated efficacy in similar projects. However, due to budget and time constraints, formal reliability testing for the survey was not feasible. Nonetheless, a robust development process was implemented to maximize the survey’s reliability and validity within the given limitations.

It should be noted that the clinical institution did not require formal institutional review board approval; however, the survey underwent an internal informal review process by the quality improvement personnel. The collection of responses utilized a convenient sampling approach involving the electronic dissemination of the survey to all employees within Levels 3 and 4 of the medical–surgical unit (n = 458). This distribution was internally coordinated among the unit supervisors and spanned 3 weeks.

Assessed environmental elements included satisfaction ratings of ease of access across primary rooms described as: spaces serving essential and central components for patient care and treatments, such as patient rooms, operating rooms, treatment rooms, procedure rooms, and isolation rooms. To implement “ease of access,” the survey included questions regarding the satisfaction with the accessibility of medication, supply, equipment rooms, and signage. Furthermore, the investigation delved into the satisfaction levels concerning various outcomes, such as quality of care, departmental dimensions, the flow of medication, staff stress and anxiety levels, equipment flow, and overall staff satisfaction. Satisfaction with team visibility was operationalized by including an agreement to statements such as: Most communications among staff occur face-to-face in my unit; the type of nursing station in my unit mostly requires face-to-face communication; a centralized nursing station supports face-to-face communication. Further, an open-ended question was included in the online survey to capture design enhancements improving staff efficiency and areas of improvement.

It is essential to clarify that while staff perceptions play a crucial role in shaping the work environment, this article recognizes the importance of differentiating between operational factors and actual outcome measures. To address this concern, the authors delineate the role of staff perceptions as contributors to the overall healthcare environment and underscore the need for additional quantitative data or objective measures related to patient outcomes to strengthen the link between operational changes and their impact on patient care.

The survey was developed and distributed using the Qualtrics platform and later exported into Excel and JASP software for descriptive and statistical analysis. We performed t tests to ascertain any significant differences in average satisfaction levels across the two floors. Further, a forward stepwise regression analysis explored significant predictors for staff satisfaction of different qualities. For the regression analysis, the study pooled the data from both floors to present a broader perspective on the travel distances and provide a more robust and nuanced understanding of the study outcomes. Furthermore, the inclusion of data from both floors facilitated a more comprehensive examination of the factors influencing nurse workflow and satisfaction across different unit configurations. The open-ended responses were analyzed using a qualitative approach to gain insights into staff perspectives regarding the unit’s layout and accessibility. The qualitative analysis identifies and categorizes repeated themes in the open-ended responses, contributing to a deeper understanding of staff perceptions and concerns regarding spatial arrangements within the unit.

The shadowing method presented in this study served as a quantitative, unobtrusive observation tool to track and record nurse movements and all activities (excluding interactions and behaviors that occurred in patient rooms) without direct interaction with study participants. A structured observation schedule was established, delineating assigned NSs and floor plans for 2.5 days (7.5 hrs for both days; Figure 3). Nurses were randomly chosen based on their location in an NS on each floor. Before commencing any observations, the observer briefly discussed the study’s objectives with the nurse. The shadowing session was initiated upon obtaining verbal consent (45 min per nurse). The team conducted 10 separate shadowing sessions at various times and days, involving six observers from the architectural firm, resulting in 44 rounds of data collection (33 hrs of combined data).

Figure 3.

Research team’s schedule of behavior mapping and shadowing sessions (Copyright: Authors).

During observations, both hand-printed documentation and the Bluebeam software were employed by observers to trace nurses’ paths to specific locations. Sequential numbers and approximate end times were recorded, aligning with position numbers in the Zoo Monitor application (refer to Figure 4 for an illustrative example). Zoo Monitor, developed by Lincoln Park Zoo, is an application that allows users to capture animal behavioral data, visualize it, and export the information for analysis. In our study, we utilized this software for behavior mapping and shadowing purposes due to constraints in resources for digital recording and linking human behavior to the physical environment (visit: https://zoomonitor.org/). Duration of stay was systematically documented in the Zoo Monitor application at 45-min intervals. Subsequently, the data were exported in Excel format, detailing the type and duration of stay at various locations. Noteworthy comments were also annotated on paper or the Bluebeam interface during the tracking of paths.

Figure 4.

The Zoo Monitor application created a platform to describe and code for various behaviors. It also creates heatmaps for instantaneous behavior recording (Copyright: Authors).

In this research, our focus revolved around analyzing walking distances and spatial adjacency to determine optimal proximity. Paths of travel corresponded to distinct movements or interactions between locations or entities within the hospital premises (PT-Patient, SS-Patient, O-Patient, Med-Med, etc.).

Paths of travel were documented in the AutoCAD interface to measure distances across paths of travel accurately (refer to Figure 5). Each travel path entry included two critical pieces of information: the frequency, indicating how frequently that specific path was taken, and the average distance traveled for that path, measured in feet. To ensure a more representative analysis, extreme outliers were excluded in calculating average distances.

Figure 5.

An example of paths of travel distance calculation and annotated behaviors linked to the Zoo Monitor data report (Copyright: Authors).

After importing the data, we utilized bar charts to manage and exclude extreme outliers, which could potentially distort the calculations of travel distances. However, it is essential to acknowledge a limitation of this study: certain observers either forgot or were unable to document travel paths accurately on-site due to the rapid movements of individuals. Consequently, this missing recall information should have been incorporated into the calculations. It is worth highlighting that despite this limitation, the frequency data about travel paths remain accurate, as it was extracted from the site observations using the zoo monitoring system.

Results

Travel Distances

Figures 6 and 7 illustrate the typical pathways of the shadowed nurses. The data presented in Table 2 represent travel paths taken by hospital staff in an inpatient unit, the count of travel occurrences, and average travel distances in feet. The independent sample t test revealed significant differences in nurse travel distances between the two floors (t = 4.59, df = 157, p < .001). Specifically, the mean difference was higher for Level 3 (M = 76.85, SD = 43.70) than for Level 4 (M = 52.50, SD = 22.59). The data indicate that the “NS-Patient” route was the most frequently traveled path, traversed a total of 187 times.

Figure 6.

Cumulative layers of nurses walking behavior retrieved from the shadowing data of Level 3 (Copyright: Authors).

Figure 7.

Cumulative layers of nurses walking behavior retrieved from the shadowing data of Level 4 (Copyright: Authors).

Table 2.

Travel Paths, Counts, and Average Traveled Distances for Observed Nurses.

Row Labels	Count of ID	Average of Distance (ft.)
Clean-Med	3	93
Clean-Patient	17	72
Equipment-Med	1	37
Equipment-Office	1	59
Equipment-Patient	2	104
Med-Med	7	102
Med-Nourish	6	45
Med-Patient	25	101
Nourishment-Patient	3	83
Nourish-Patient	13	73
NS-Clean	14	38
NS-Med	27	79
NS-Nourish	13	21
NS-NS	30	68
NS-Office	2	53
NS-Other	3	80
NS-Patient	187	59
NS-Physical Therapy	3	55
NS-PPE	11	31
NS-Staff Support	17	59
Patient-Patient	27	53
Physical Therapy-Patient	4	164
Physical Therapy-Staff Support	1	31
PPE-Clean	2	53
PPE-Patient	8	40
Staff Support-Med	3	31
Staff Support-Patient	6	158
Grand total	440	65

Several paths have high-frequency counts, such as “Medication (MED)-Patient,” “Patient-Patient,” “NS-Medication,” and “NS-NS,” indicating areas with significant staff movement. Some paths have relatively shorter average distances, like “Med-Nourish” (Medical Area to Nourishment) and “NS-Nourish,” suggesting that these areas are near each other. Other paths, like “Physical Therapy-Patient” or “staff support-patient rooms,” have higher average distances, indicating potential areas for improvement in spatial arrangement.

The independent sample t tests conducted for pathways with adequate data revealed significant differences across the two floors in nurse travel distances. When traveling between the NS and patient rooms, there was a significant difference (t = 2.082, df = 49, p = .043), with nurses traveling, on average, 19 feet more in Level 3 compared to Level 4 (M = 69.043, SD = 45.646; M = 50.008, SD = 14.767, respectively). Additionally, a significant difference was observed when nurses walked between patient room assignments in Level 3 compared to Level 4 (t = 2.308, df = 11, p = .041) with mean distances of 67.825 feet (SD = 22.45) and 44.23 feet (SD = 14.741), respectively.

Survey Findings

A total of 143 individuals participated in the survey (31.2% response rate). Most respondents fell within the age brackets of 25–34 (n = 38, 26.6%) and 45–54 (n = 33, 23.1%). The participant demographic skewed predominantly female (n = 117, 81.3%). The respondent pool encompassed a range of roles, including registered nurses (n = 53, 36.8%), managers (= 15, 10.4%), support staff (n = 15, 10.4%), administrative personnel (n = 12, 8.3%), nurse technicians (n = 11, 7.6%), directors (n = 10, 6.9%), leadership roles (n = 9), and others (n = 19, 13.2%). Table 3 illustrates the counts, average, and median values for each variable accounted for in the regression analysis. The results of the one-way t-test analysis revealed no statistically significant difference in satisfaction levels among staff members on Levels 3 and 4 concerning both dependent and independent variables.

Table 3.

Counts, Average, and Median Values of Satisfaction Ratings in the Survey.

	Variable	Count	Average	Median
Satisfaction with environmental factors	Proximity of supplies	88	3.55	4
	Location and access to equipment	89	3.64	4
	Proximity of medication	65	3.77	4
	Ease of access to primary rooms	86	3.97	4
	Ease of access across departments	86	3.99	4
	Team visibility	90	4	4
Satisfaction with outcomes	Provider/staff flows	72	4.00	4
	Patient flows	65	3.91	4
	Patient safety	75	4.09	4
	Quality of care	72	4.10	4
	Department size	80	3.45	4
	Overall workspace	86	3.49	4
	Reduced staff stress and anxiety	77	3.09	3

The regression analysis demonstrated that the proximity of supplies was a significant predictor of provider flow satisfaction (β = .471, t = 2.934, p = .008). This finding signifies that a one-unit increase in satisfaction with the proximity of supplies corresponds to an expected increase of 0.471 units in provider flow satisfaction, F(2, 20) = 12.765, p < .001. Throughout this section, we will consistently clarify that a “one-unit increase” denotes a standardized change of one unit in the predictor variable. Additionally, team visibility positively affected provider flow satisfaction (β = .428, t = 2.667, p = .015). Patient flow satisfaction was significantly influenced by the proximity of supplies (β = .458, t = 2.601, p = .017) and ease of access across departments (β = .368, t = 2.089, p = .005; F(2, 20)= 9.192, p < .001).

Proximity of supplies (β = .328, t = 2.111, p = .048) and location and access to equipment (β = .586, t = 3.766, p = .001) were statistically significant predictors of quality of care, F(2, 20) = 19.446, p < .001. Satisfaction with patient safety was significantly predicted by satisfaction with proximity of supplies (β = .386, t = 2.419, p = .025) and location and access to equipment (β = .526, t = 3.30, p = .003; F(2, 21) = 23.25, p < .001).

Enhancing the proximity of supplies impacted workspace satisfaction (β = .631, t = 3.812, p < .001). This effect implied that a one-unit increase in the proximity of supplies led to an anticipated increase of 0.631 units in workspace satisfaction, F(1, 22) = 14.529, p < .001. Ease of access across departments played a substantial role in influencing satisfaction with department size (β = .631, t = 4.865, p < .001), underlining the importance of convenient pathways and connections between different departments, F(2, 20) = 23.614, p < .001. The regression analysis revealed that there were no statistically significant predictors identified for the staff’s perception of diminished stress and anxiety.

Open-Ended Comments

In the context of the unit’s layout and accessibility, four open-ended responses were gathered, unveiling valuable insights into staff perspectives. One staff member highlighted the geographical challenge of the break room’s location, expressing that its distance from the workspace makes it unwelcome and potentially inconvenient for staff to access. They mentioned, “Break room is far from the workspace and is not very welcoming.” A recurring concern emerged regarding the functionality of the medication rooms. One response pointed out an issue with the stocking of medications in each med room, leading to potential complications. The staff member noted, “The medical rooms have been an issue regarding what is stocked in each medical room. I have brought this up at the pharmacy many times. They say that they stock the med room for the patients nearby; however, if my assignment is split between their room cutoffs, I may have to go to two different med rooms to pull medications.”

Further observations highlighted discrepancies between the two available medication rooms. Despite having two medication rooms on Level 4, the medication inventory needed to be uniform to reduce potential walking inconveniences for nurses. The small size of these rooms was also noted as problematic, particularly when multiple nurses require access to patient medications, leading to challenges in supply accessibility. The need for space to accommodate a new disposal system is further emphasized these concerns. A quote captured this sentiment, “Two medication rooms are available. However, they are not necessarily stocked the same. The space is small, and it is difficult to access supplies when more than one nurse is waiting to access patient meds. It also needs space to accommodate a new disposal system.”

Despite having two medication rooms on Level 4, the medication inventory needed to be uniform to reduce potential walking inconveniences for nurses. The small size of these rooms was also noted as problematic, particularly when multiple nurses require access to patient medications, leading to challenges in supply accessibility. The need for space to accommodate a new disposal system is further emphasized these concerns.

Lastly, a call for enhanced patient accessibility emerged from these responses. The desire for improved access to all patients from both medication rooms highlighted the importance of streamlined layouts that facilitate efficient care delivery. The staff member’s remark encapsulated this sentiment, “I would like to have better access to all patients from both meds rooms.” These open-ended responses from staff members effectively illustrate their perspectives on the unit’s layout and accessibility. They underscore the significance of optimizing the spatial arrangements, particularly in medication rooms, to enhance staff workflow, streamline processes, and ultimately improve patient care delivery.

Discussion

In essence, the study’s identification of nurses’ walking distances and the influence of spatial factors on various satisfaction measures is corroborated by the existing literature. Previous studies have consistently underscored the extensive distances nurses’ traverse during their shifts, thereby shedding light on the physical demands of their roles (Chang & Cho, 2022; Hendrich & Chow, 2008; Pati et al., 2012; Yu et al., 2020). The correlations established in this study echo findings from previous investigations (Hendrich & Chow, 2008; Lee et al., 2020; Nanda et al., 2015; Nazarian et al., 2018; Pati et al., 2012), collectively highlighting the need for continuous optimization of nurse workflow efficiency and the crucial role of spatial design in shaping healthcare experiences.

The study’s findings suggest that the shift from two centralized care team stations to four on Level 4, along with the reconfiguration of corridors and support spaces positioned at approximately equal distances to NSs and patient rooms, likely played a significant role in creating a more efficient layout. By strategically placing centralized stations at corners on Level 4, it is presumed that nurse travel distances during routine tasks, such as moving between the NS and patient rooms or navigating between patient rooms, were minimized. This improved workflow on Level 4, as opposed to Level 3, highlights the positive impact of the design changes on day-to-day operational efficiency.

Aligned with prior research (Hendrich et al., 2008; Hendrich et al., 2004; Lu & Zimring, 2012; Shepley & Davies, 2003; Yi & Seo, 2012), findings from this study also highlight the intricate interplay between spatial arrangement and the way nurses navigate their surroundings, emphasizing the significance of design considerations beyond mere physical dimensions. This design-induced improvement in nurse travel distances highlights the crucial role of deliberate spatial planning and layout optimization in healthcare facilities. While Level 3 experienced increased travel distances, the updated design on Level 4 demonstrated enhancements, aligning with the overarching goals of improving accessibility and reducing travel distances for healthcare providers. These observed differences underscore the practical implications of layout considerations for the daily operations of healthcare units.

The identification of the “NS-Patient” path as the most frequently used route resonates with previous studies that emphasize the frequent travel between patient rooms and NSs (Acar & Butt, 2016; Fay et al., 2017; Gurascio-Howard & Malloch, 2007; Hendrich & Chow, 2008; Kim & Chai, 2018; Nanda et al., 2015; Nazarian et al., 2018; Pati et al., 2008, 2012; Seo et al., 2011). This finding underscores the importance of optimizing the layout to ensure proximity between patient rooms and NSs. Prior studies have indicated that patient rooms situated outside the central circulation of a nursing unit or farther from NSs result in increased walking distances for nurses moving between patient rooms and their workstations (Gurascio-Howard & Malloch, 2007; Hendrich et al., 2008; Pati et al., 2008). Further investigation and design recommendations are warranted to align the placement of patient rooms with nurses’ assignments, as this alignment could significantly impact travel patterns.

The identification of the “NS-Patient” path as the most frequently used route resonates with previous studies that emphasize the frequent travel between patient rooms and NSs.

The lack of significant differences in staff satisfaction and perceptions, despite increased walking distances between Levels 3 and 4, suggests potential factors contributing to a positive response to the redesigned healthcare facility. Staff adaptability, task flexibility, well-equipped facilities, the use of communication technology, practical training, positive workplace culture, and employee involvement in the redesign process collectively contribute to staff members navigating the changes with minimal impact on satisfaction. These findings underscore the complex interplay between spatial design, work style, and employee experiences, highlighting the importance of a comprehensive understanding of these factors in healthcare facility planning and management. Further exploration and consideration of these elements offer deeper insights into the dynamics influencing staff satisfaction within the context of spatial design changes.

The survey’s findings indicate that staff satisfaction with patient flow is closely linked to the ease of accessing supplies across different departments. Leveraging insights from observational data, it is recommended to establish optimized pathways connecting medication points, patient rooms, and NSs. This approach aims to improve communication, minimize travel distances, and ultimately enhance staff satisfaction. These implications are consistent with previous research suggesting similar enhancements (Acar & Butt, 2016; Chaudhury et al., 2009; Fay et al., 2017; Hendrich & Chow, 2008; Kim & Chai, 2018; Nanda et al., 2015; Nazarian et al., 2018; Shepley & Davies, 2003).

…it is recommended to establish optimized pathways connecting medication points, patient rooms, and NSs. This approach aims to improve communication, minimize travel distances, and ultimately enhance staff satisfaction.

Building upon prior research (Chaudhury et al., 2009; Nanda et al., 2015; Shin & Kang, 2016), this study underscores the step-by-step process of moving from patient rooms to NSs and medication rooms to obtain supplies, while also fostering communication among colleagues regarding patient status. Consequently, we advocate for the implementation of strategically positioned pathways linking patient rooms, NSs, and medication rooms to streamline workflow and promote effective communication among staff.

The correlation between supply proximity and workplace satisfaction highlights the importance of efficient spatial arrangements in promoting staff well-being and job satisfaction (Acar & Butt, 2016; Cai et al., 2023; Chaudhury et al., 2009; Copeland & Chambers, 2017; Kim & Chai, 2018; Nanda et al., 2015; Pati et al., 2014). This underscores the need to strategically position supply storage within inpatient units to alleviate staff fatigue and burnout, thus enhancing staff satisfaction. Additionally, the significance of this approach is further emphasized by feedback on medication room functionality and disparities between rooms, echoing previous studies highlighting the importance of well-stocked and efficiently placed medication rooms (Chaudhury et al., 2009; Nanda et al., 2015; Pati et al., 2014; Shepley & Davies, 2003; Yi & Seo, 2012). These findings suggest the importance of strategically locating and stocking medication rooms within inpatient units to enhance staff satisfaction and optimize patient care delivery.

These findings suggest the importance of strategically locating and stocking medication rooms within inpatient units to enhance staff satisfaction and optimize patient care delivery.

While the study’s findings highlight the importance of strategically placing nourishment spaces to alleviate staff fatigue and enhance operational efficiency in healthcare setting (Nanda et al., 2015), it also reveals a discrepancy in resource allocation within healthcare facilities, with less attention often given to staff respite spaces due to funding constraints, despite their limited utilization by patients. Insights from open-ended responses provided by staff further highlight concerns about the geographical challenges posed by the break room’s location, echoing the observational findings. In many instances, the allocation of resources within healthcare facilities tends to prioritize patient-related areas due to limited funding, leading to staff respite spaces receiving less attention. These areas, encompassing break rooms, staff toilets, or lounges, often take a back seat as patients rarely utilize them. Studies have demonstrated that break areas with improved accessibility from direct patient care areas and clinical support spaces are more frequently utilized (Nejati et al., 2016; Shukor et al., 2012; Zhu & Shepley, 2022). Therefore, future designs of inpatient units are recommended to allocate staff respite and support spaces in accessible locations to reduce fatigue and walking distances.

Insights from open-ended responses provided by staff further highlight concerns about the geographical challenges posed by the break room’s location, echoing the observational findings.

The study’s findings highlight the significant influence of supply proximity and team visibility on healthcare providers’ satisfaction with their workflow. These results are consistent with prior research emphasizing the substantial impact of spatial design and enhanced visibility on staff experiences, workflow efficiency, and the improvement of communication and collaboration (Cai & Jia, 2019; Fay et al., 2017; Hendrich et al., 2008; Nanda et al., 2015; Nazarian et al., 2018). Building upon these findings, previous studies have demonstrated that improved team visibility not only reduces walking distances for healthcare providers and enhances team communication (Hendrich et al., 2004; Lu & Zimring, 2012; Nanda et al., 2015; Shin & Kang, 2016) but also results in increased time spent on direct patient care activities (Hendrich et al., 2009; Hendrich et al., 2008; Nanda et al., 2015; Pati et al., 2008). These findings underscore the pivotal role of spatial arrangements in enhancing visibility for team communication and improved access to supply for inpatient units, thus contributing to provider flow satisfaction.

Finally, the correlation between ease of access across departments and satisfaction with department size underscores the significance of connectivity and pathways between different units, aligning with the emphasis on spatial configuration and its impact on nurse walking behavior (Choudhary et al., 2010; Hendrich et al., 2009; Hendrich et al., 2008; Lee et al., 2020; Nazarian et al., 2018). For instance, purposeful placement of the entrance and NS at the central point serves as a resilient design approach to minimize nurse travel distances and ensure ample visibility to the unit entrance (Lee et al., 2020). Future research could delve deeper into the nuances of space utilization within healthcare facilities, examining the efficiency of various layout configurations, assessing the impact of different departmental proximities, and exploring the potential of flexible spatial arrangements to accommodate evolving healthcare needs.

…the correlation between ease of access across departments and satisfaction with department size underscores the significance of connectivity and pathways between different units, aligning with the emphasis on spatial configuration and its impact on nurse walking behavior.

Conclusion

In conclusion, our study sheds light on the intricate dynamics between spatial design, nurse behaviors, and overall satisfaction within healthcare environments, highlighting a significant frequency of staff movement between NSs, patient rooms, and medication areas. Regression analysis revealed several contributing factors to staff satisfaction, including the proximity of supplies, team visibility, ease of access across departments, and the location of equipment rooms. Notably, satisfaction with the proximity of supplies was positively associated with increased provider satisfaction with workflow, quality of care, and workplace. Moreover, valuable feedback from staff illustrated concerns regarding break room placement, medication area functionality, and disparities in the availability of supplies. Given the study findings, Figure 8 displays the proposed adjacency matrix and bubble diagram for the inpatient unit spaces. These findings underscore the paramount importance of strategic spatial arrangements in streamlining nurse workflows and enhancing staff satisfaction, emphasizing the need for continuous optimization of healthcare facility layouts. Our study also highlights the complexity of the relationship between spatial arrangements and employee experiences, emphasizing the necessity for a holistic understanding of these factors in healthcare facility planning and management. Overall, our research contributes meaningfully to the discourse on optimizing healthcare environments, offering actionable insights to guide future efforts toward creating facilities conducive to both staff productivity and overall well-being.

Figure 8.

Adjacency matrix based on the shadowing findings (Copyright: Authors).

Future Research and Limitations

While this study provides valuable insights into nurse behaviors, spatial design, and their impact on healthcare provisioning and satisfaction, several limitations require consideration, opening avenues for future research to delve deeper into understanding the complexities of healthcare environments and their optimization. Firstly, the study focused on a specific inpatient medical–surgical unit, potentially limiting the generalizability of findings to other healthcare settings with distinct layouts, patient populations, and operational demands. Secondly, while the study observed nurse behaviors, it may only capture part of the spectrum of nurse tasks and interactions, neglecting the impact of nurse assignments or roles. Thirdly, the study utilized a cross-sectional design, capturing data at a single point in time, which hinders the ability to establish causal relationships between spatial design and outcomes and does not account for potential changes over time. Finally, the study does not consider external factors, such as patient acuity, staffing levels, staff years of experience, or technological advancements, potentially affecting nurse behaviors and satisfaction.

Given these limitations, we recommend that future researchers conduct similar studies across various healthcare settings, including specialties and facility types, to provide a broader understanding of the relationship between spatial design (unit square footage or number of beds), nurse behaviors, and patient outcomes. Furthermore, we suggest that forthcoming studies delve into the impact of different nursing roles—such as seasoned nurses, travel nurses, or new graduates—or nurse assignments on variables such as their familiarity with the unit, the duration of traverse, or specific travel paths. Incorporating the time factor and the nurse’s orientation into calculations would also be valuable for upcoming research. Furthermore, as we advocate for longitudinal studies to track changes in nurse behaviors and outcomes over time, it is crucial to consider the aging population’s impact on the accessibility of healthcare facilities. Thus, future research could investigate how the principles identified in this study can be tailored to accommodate individuals with varying levels of mobility, ultimately contributing to the creation of more inclusive healthcare environments. In conclusion, while this study has shed light on the crucial interplay between spatial design, nurse behaviors, and healthcare satisfaction, it is essential to acknowledge its limitations and pave the way for future research endeavors that can offer a more nuanced and comprehensive understanding of optimizing healthcare environments for both patients and staff.

Implications for Practice

Proximity of Supplies and Medication:

Position supply and medication storage spaces near patients for streamlined access and efficient workflow.

Integrate workstations with essential supplies to minimize staff travel and enhance accessibility.

Location of Equipment:

Centralize essential equipment rooms near patient beds or treatment zones to ensure swift emergency response and improved patient care.

Team Visibility:

Design an open inpatient unit layout using transparent partitions and glass doors to foster team visibility, communication, and rapid response to patient needs. Ensure visibility between NSs and patient rooms.

Med-Surgical Department Layout:

Adopt functional clusters grouping related spaces (NSs, medication rooms, supply areas) to streamline transitions and minimize travel.

Strategically locate and provide NSs near patient zones to optimize staff travel distances.

Ensure NSs are within sight of each other to enhance communication and reduce travel distances.

Establish a seamless layout interconnecting different departments for smooth transit for staff, patients, and visitors.

Provide staff respite areas close to patient rooms and in a central, easily accessible location.

Enhance efficiency by situating medical supply storage or carts near patient sections to reduce staff travel distances.

Locate nourishment stations near-patient and NS areas for the convenience of clinical staff.

Footnotes

Acknowledgment

The authors extend their acknowledgment and appreciation to Chase Miller, Kapri Ames, Allison Gasper, Kaitlyn Gardner, Joe Sagen, and Katelyn Vagedes for their significant contributions to both the data collection and diagram creation aspects of the study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Zahra Zamani, PhD, EDAC

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