If you were to ask hospital staff about a time when their hospital underwent a major renovation or transformation, they might praise the addition of new beds or the layout of the new space. But if you were to ask nurses, you’ll likely hear a different perspective. For many nurses, renovations often create new obstacles for frontline healthcare workers trying to do their jobs and deliver care. This can be traced back to nurses rarely being consulted during the design process.

Healthcare design leader Debbie Gregory, DNP, RN, understands this phenomenon completely. Eager to combine her career as a nurse with her interest in interior design, Debbie was excited to learn about the intersection between design and health outcomes after reading Florence Nightingale's Notes on Nursing[1]. However, she was disappointed to discover what a small role nurses played in the conversation. In 2010, together with her Vanderbilt Nursing School colleague, Laura Hayes Buchanan, BSN, RN, MBA, she founded the Nursing Institute for Healthcare Design, a nonprofit organization dedicated to engaging and integrating clinical expertise and planning into the design of healthcare environments.

Now a Senior Clinical Consultant at engineering consultancy Smith Seckman Reid (SSR) in Nashville, Tennessee and Co-Editor for the Health Environments Research & Design Journal, Debbie is leveraging over 35 years of experience as a nurse, 15 years as an interior designer and 10 years as a healthcare consultant to bring a unique perspective to healthcare design, and she hopes other nurses can be inspired to consider design as a career path as well.

The Johnson & Johnson Notes on Nursing team recently spoke with Debbie to learn more about the Nursing Institute for Healthcare Design and how nurses can play a larger role and help provide critical input in the design of health spaces.

J&J: What does “healthcare design” mean to you, and how is it different from other forms of interior design?

Debbie: I’ve always been interested in the function of spaces, and how design can influence people’s moods, behaviors and even health. As it turns out, healthcare design isn’t a new phenomenon. Its origins can date all the way back to Florence Nightingale, who is largely considered to be one of the first healthcare architects. After her experiences in the Crimean War, she understood and advocated for improved sanitary practices, as well as the importance of fresh air and natural light for better health outcomes.[2] To me, healthcare design is incorporating the principles of interior design, such as evidence-based design and form following function, to identify ways to improve the patient experience and make life easier for frontline healthcare workers.

I had the opportunity to go on a hospital tour and everyone was remarking about how beautiful the hospital was with brand new rooms and lighting. I went up to a nurse and asked how she liked the new hospital and she said it was a disaster. The designers had put the ice machine directly behind the nurse’s station, so it was loud and family members were constantly going up to the station and asking nurses for ice. This is a perfect example of a beautiful, but poorly conceived design because nurses weren’t consulted and as a result were inconvenienced. This is also a perfect example of why nurses should be consulted in all areas of healthcare design.

J&J: What motivated you in 2005 to pursue interior design after your career as a nurse?

Debbie: As a young child, I knew I either wanted to be a nurse or an interior designer. At that time, these careers were about as opposite as could be and no one saw the correlation between the two. I ended up choosing nursing because I believed it would be a more hands-on way of helping people, but after twenty years as a nurse I wanted to reinvent myself and explore the creative side of my brain. When I started to learn more about healthcare design it really spoke to me and helped me realize that I could really tap into both sides of my brain in order to help people. There was something incredibly appealing about being a leader in designing work flow and process improvements helping to shape the future of patient care delivery.

J&J: What motivated you and Laura to launch the Nursing Institute for Healthcare Design?

Debbie: Laura and I went to nursing school together at Vanderbilt University, and we both share a love of improving spaces. One day I sort of discovered evidence-based design when reading the Health Environment & Design Journal and quickly realized no one in our circle knew about it. Even today, there are only a handful of nursing schools and programs that offer a focus in design and innovation. Laura and I immediately knew that this was something that nurses should have a bigger role in, and our quest to learn more about healthcare design brought us to an evidence-based design conference. It was largely a healthcare environment, but we were shocked at the lack of nurses there. We ended up going to the front of the stage and handing the speaker a note asking him to invite all nurses in attendance to the back of the room. A handful of nurses assembled, and this began our first database of nurses in healthcare design.

We knew we needed to create an organization to help nurses who want to pursue this specialty, and that’s why we decided to create the Nursing Institute for Healthcare Design in 2008. When we were starting the institute, we felt pretty lonely trying to find nurses who shared our passion. But we kept on building our platform and our network and were motivated by knowing there were nurses out there who also felt alone and were looking for support. We made the institute into a non-profit in 2010, and over the years we have grown into our own entity with over 150 members from around the world, ranging from young clinicians to retired clinicians, and including architects and designers from other disciplines. I’m most proud that our organization has created a resource for nurse leaders in healthcare design and built a reputation in the industry as a champion of nurses having a seat at the table for design discussions. I’m also proud to now be a co-editor for the Health Environment & Design Journal that was such an inspiration to me.

J&J: How can the design of a space potentially have an impact on health outcomes?

Debbie: There are so many examples of healthcare design gone bad. Several hospitals also tested out decentralized nurse stations, designed to have nurses spend more time at the bedside and chart outside the patient room. However, this eliminated the central station where nurses would be able to convene, mentor and collaborate with each other. Nurses love to collaborate, and this is an example of a design without any evidence or nurse feedback that can have a negative effect on nurse wellbeing, and therefore patient outcomes.

I worked at a hospital that redesigned a ward like a racetrack with the medicine room in the middle but with only one door on one side. This meant nurses had to go all the way around the ward to access the medicine room, creating a waste of time and energy and a barrier to care. This could have been avoided by just one nurse looking at the floorplans of these designs, and eventually a nurse was able to advise on rectifying this design.

But I have also seen the potential for nurses to really lead in the field of healthcare innovation. Celeste Phillips is a nurse who is widely considered the “Mother of Family-Centered Maternity Care,” who advocated for a woman’s labor and birth to happen in the same room and with the same caregivers.[3] Cecelia Kirbin was the nurse behind the evidence-based solution to transition babies from open bay neonatal intensive care units (NICUs) to private rooms with their mothers, which has had an incredible impact on decreasing infections, improving sleep, making breastfeeding easier and reducing the amount of time needed in the hospital.[4],[5].There is incredible potential for nurses to play a key role in designing health spaces, but they need to know this door is available for them to open.

J&J: What role can nurses play in the healthcare design process?

Debbie: Having a clinician at the design table can create an incredible line of sight into the operation of a space, such as how equipment is actually used, what nurse work flows are like, the various steps nurses take to complete a task and what the greatest challenges are in their environments. Nurses can serve as vital liaisons and interpreters for architects and engineers. Most healthcare spaces have a nurse zone, patient zone and family zone, and nurses can provide insights into the correct positions and sizes for everyone to operate comfortably. Nurses are by nature patient-centered, so it’s like having a representative for not just nurses but patients in the design process.

J&J: Why do you believe nurses should have a voice in the design conversation?

Debbie: Nurses have an incredible ability to see the problems and solutions in their environment. A chef is at the center of baking – he or she makes sure they have the right tools and the right ingredients. Meanwhile, nurses are at the center of care. No one understands the hospital dynamics, family and cultural dynamics better than a nurse. Nurses are trained to adapt to their environments, and I believe they offer a vital perspective on how to transform spaces that can benefit patients, staff and hospital systems.

J&J: What would you like to see in the future for nurse-led innovation?

Debbie: My vision for the future is to create a culture of creativity and innovation that allows nurses to bring their ideas forward without shame or fear that they will be disregarded. I believe many nurses bring their ideas to the table, but don’t always hold onto them because they don’t understand the intellectual property process. I would love to see more programs and resources that can create a safe place for nurses to learn how to take their ideas to the next level and empower them throughout the ideation and implementation phases of their idea. I’m also passionate about advocating for nurse innovators in rural areas, who may not have access to labs and resources, and I would love to see something like a mobile invention van traveling the country and providing education, training and support to nurses on a national level.

J&J: How can nurses play a larger role in healthcare design?

Debbie: One of the best things nurses can do is become aware of the role of design in delivering care, and that just because something has been designed a particular way because it’s how it has always been doesn’t mean that it cannot be improved. Nurses are constantly doing “work arounds” in their role, and if they are more aware of the science behind evidence-based design they can be more empowered to advocate for change. As the profession closest to care delivery, I believe more nurses should take ownership of their care environments. Nurses should take the time to familiarize themselves with what healthcare design is and the impact it has on health and hospital outcomes. I would encourage nurses to learn more about design thinking and to be open to innovation opportunities when they arise. Nurses should know they are uniquely positioned to best transform healthcare spaces and that they deserve a seat at the design table.

From left to right: Oriana Beaudet, DNP, RN, PHN, Kay Rademacher, MSA, RN, NEA-BC, EDAC, Debbie Gregory and Anna Hayman from the Clinical Consulting Group at SSR.

Pictured in the beginning of the article is Debbie Gregory, DNP, RN, and Scott Johnson, Principal at SSR, reviewing design plans for a hospital project.

To learn more about the Nursing Institute for Healthcare Design, visit here.

[1]Nightingale, F. (1860). Notes on Nursing, by Florence Nightingale. Reviews and notices. London: Harrison & Sons.
[2] Richardson, R. (2010, November). Florence Nightingale and hospital design. Retrieved from https://kingscollections.org/exhibitions/specialcollections/nightingale-and-hospital-design/florence-nightingale-and-hospital-design.
[3] Zwelling, E. (2000). Trendsetter: Celeste Phillips, The Mother of Family-Centered Maternity Care. Journal of Obstetric, Gynecologic & Neonatal Nursing, 29(1), 90–94. doi: 10.1111/j.1552-6909.2000.tb02761.x
[4] Stichler, J. F., & Okland, K. (2015). Nurses as leaders in healthcare design: a resource for nurses and interprofessional partners. Zeeland, MI: Herman Miller.
[5] Buchner, J. (2017, November 17). Individual rooms are revolutionizing NICU care. Retrieved from https://www.todaysparent.com/baby/baby-health/individual-rooms-are-revolutionizing-nicu-care/.