The healthcare environment is inherently stressful. Staff are working long shifts, rotating shifts, and are dealing with life and death every day; they must be error free in every action they take and every medication they administer. COVID-19 has intensified this stress. Short-staffed facilities are relying on the same staff, shift after shift. Nurses are taking on more jobs and activities ranging from patient care to cleaning patient rooms. The added burden of wearing PPE makes a twelve-hour shift, in which nurses typically walk four to five miles, even more physically exhausting.
Studies have shown that fatigue impacts a caregiver’s physical health, because of the increased risk for needle stick injuries, and mental health, because of sleep deprivation and psychosocial functioning; and that, in turn, affects patient outcomes. Caregivers working twelve and a half hour shifts or longer have increased risk of committing a healthcare error, yet little has been done in the built environment to mitigate fatigue and enhance wellbeing.
Initiatives have sprung up around the country to try to improve the work environment for staff. Some of these strategies include hiring dedicated staff to cover breaks and providing structured restorative break activities like yoga and meditation. There has even been legislation to enforce breaks for staff. What has not really been addressed by the design community is the environment for staff breaks. Studies have examined the physical environment and impact on healthcare outcomes but only focus on the patients. There is some research on other environments that may be applicable to the healthcare setting, but to date, little has been done focusing on staff. These interventions include access to nature, daylight, and fresh air.
Are your Caregivers Hungry, Angry, Lonely, and Tired?
An approach that is being studied to help support staff and minimize fatigue and medication errors is HALT: Hungry, Angry, Lonely, Tired. An initial small-scale study showed a decrease in medication errors by thirty one percent over two months. However, it did not address where the activities should occur to mitigate HALT. From my own clinical experience as a nurse and now as an architect, I’ve taken the approach that supported and cared for staff will provide supportive care to their patients and the built environment should enable that and help to further mitigate HALT.
Here are some of the simple strategies I’ve implemented over the years working with clinical teams:
Decentralize Small Break Spaces and Place Them Close to Nurse Stations
Staff are reluctant to go far from their patients and often don’t have more than five minutes to have cup of coffee or eat a snack. The reality is that food and beverages often end up in the nurse station, especially on the night shift. By providing a dedicated space that is easily accessed near the point of care allows staff a place to step aside, have a cup of coffee or a granola bar, and reboot. Providing distributed break nooks or rooms, large enough for a couple of people, close to the areas of work for brief nourishment breaks addresses the Hungry. Hydration is even more important with COVID-19 and extended wearing of PPE leads to dehydration and more fatigue.
If there is room in the existing nurse station to carve out a small nook as a decentralized break space, do it
If not, try to find another small office or storage room and set it up close to the nurse station where staff can go sit down with some privacy and have a ten-minute break for coffee or to rehydrate and refuel
Furnish the spaces with a small café table and a couple of chairs or a pair of lounge chairs with a table arm for someone to sit at with a beverage
These simple changes will send the message that you are taking care of them in the flow of their workday.
Update Your Staff Lounge
The staff lounge is the only code-required support space for staff. Unfortunately, they often fall into “leftover” space during planning and placed in a landlocked area that has no access to daylight, views of nature, or the outdoors. As a result, it is a dismal and depressing space and not a welcoming or supportive environment. Staff comment that they are the lowest priority when healthcare facilities are planned. Staff spaces should be required to include windows, daylight, and ideally located in a more discrete part of the patient care environment. Privacy from family and visitors should be provided, as a dedicated lounge and not serve multiple functions like a training room, locker room, or someone’s workspace. In an ideal world, all staff lounges would have direct access to an outside space.
When you can’t start new, update your staff lounge by:
Cleaning it up using the 5-S method: Sort, set in order, shine, standardize, and sustain
Giving it a fresh coat of paint, new furniture, and remove work related material
Removing notices of in-services and other work information. Post these in another location and make this space an oasis that staff can utilize to refresh and reboot.
Providing healthy snacks. This an investment by leadership to maintain healthy behaviors in this stressful time
Adding images of nature on the walls if it is an interior location
Assuring the mechanical system is properly balanced to quickly dispersed any food odors
Removing the TV and add soothing music. At the very least, turn off the news, it is overwhelming, and your staff are living the news real time, twenty-four hours a day, every day.
The lounge should be a respite from the unit and the rest of the world.
Provide Respite Rooms
Providing Respite Rooms for calming and destressing is necessary to address the Angry and Tired components of HALT. Some clients have dubbed this space the “Zen Den” or “The Oasis” and have used aroma therapy, visual and audio distraction, and massage therapy to de-stress. This is especially important now with the amount of deaths and patient volumes staff are experiencing because of COVID-19. They need a place to go cry or scream or just de-stress. Look for an office or small storage room in your patient care environment that can be temporarily or permanently relocated to create a respite space.
It doesn’t need to be large, eight by ten feet can work
Repaint, add dimmable lighting, and furnish with a comfortable lounge chair.
Provide music or other positive sensory elements
Plants or images of nature can be calming and restorative, especially if the room does not have a window
Add acoustic seals to the doors to provide additional privacy and translucent film on any windows from the corridor into the space
Avoid the temptation to combine this space with the decentralized break room; these spaces serve different functions and address different needs
Another alternative is to take a larger space and subdivide it into two spaces, one for a decentralized break space and one for the respite space
While it is still unusual to find Respite Rooms, they are used by some facilities as nap rooms and furnished with a recliner, thus addressing the Tired. They should be located on the unit and easy to access, but in a quiet area.
Make the Conference Room a Sharing Room
It is important to have space for staff to debrief, review incidents, hear the experience of their colleagues, and share feelings in a space like a conference room. It’s critical to let the staff know they are not alone and that others are feeling the same stressors. This debrief process helps to mitigate the feeling of being Lonely.
Schedule regular debriefs with the staff
Give them a forum to share their thoughts, feelings, and emotions
Make it a safe space to be honest and open. Bring in therapists to run the discussions and try to have them on all shifts, not just weekdays.
During this time of COVID-19 staff are feeling overwhelmed and often unsupported. Studies are underway to assess the impact of the pandemic on healthcare workers, and information from other countries who are ahead of us have revealed disturbing trends. Frontline providers are experiencing higher rates of distress, anxiety, and sleep disturbances. They can also feel isolated as many are staying away from families from fear of infecting loved ones. Sharing coping strategies with others, taking breaks, eating healthy, and minimizing alcohol or drug use are all recommended by the World Health Organization (WHO).
Stress has always been part of the healthcare working environment, now critically amplified because of the pandemic. The simple interventions recommended here can be implemented with minimal cost and provide staff with the physical spaces to implement the recommended WHO strategies and cope with these stressful new working conditions.
Image courtesy Adobe Stock.