Blog Contribution by NIHD Board Member for Education Elizabeth Johnson, PhD, MS-CRM, RN, Assistant Professor at the Mark and Robyn Jones College of Nursing - Montana State University.

A recent Forbes article written by Jens Martin Skibsted titled, ‘Why ‘Diversifying Design’ is More Crucial Than ‘Designing for Diversity’ highlighted the significant need for creative approaches to design, achieved through including a variety of methods and specialties. As Skibsted notes, ‘design needs diversity to thrive.’ The development and cultivation of functional, interdisciplinary teams has been a proven method to sparking innovative design. Effective teamwork particularly across design disciplines requires a solid foundation in the art of working together. The concept of working together centers on the necessary elements: collaboration among team members, compromise between ‘wants’ and ‘needs’ of the organization, and consideration of each project stakeholder. These elements take time and experience to develop, however introducing the significance of each early in an individual’s career yields opportunities for amplification of a designer’s inclusion of new methods and approaches to complex projects.

Particularly in rural areas, diversifying design is critical to the survival of critical access hospitals and clinics, particularly in states which serve frontier areas and under-served populations. The buildings and care delivery workflows must reflect the needs of the communities and be flexible to future adjustments in needed service lines and capacity requirements. When financial resources are few, there are little options to correct poor design decisions or universal designs which are not congruent to the rural or frontier community culture. Design slights, such as lack of access to natural light, significant amounts of unnecessary traveling by staff to complete tasks, and neglecting technology integration needs drives providers and patients away from the accessing healthcare, which can lead to shuttered facilities.

Montana ranks 49th of all US states in terms of healthcare value, reports most counties in a healthcare provider shortage, and 1 in 4 hospitals closing or at imminent risk of closure.

At Montana State University, we see opportunity in the midst of the maelstrom of healthcare constraints. An interprofessional graduate-level course titled, “Design of Healthcare Delivery Systems’ is part of the program of study for graduate students from the College of Engineering and College of Nursing to progress the notion of diversification of design by beginning collaborative behaviors and attitudes early into careers. This course is crafted to bring engineering and nursing students together in the same course offering to gain differing perspectives of how the built environment and organizational management are approached across specialties. Industry guest speakers supplement course learnings once monthly during the semester, further lending students valuable insights and lessons learned from design professionals. Examples of guest speakers include architects, design consultants with nursing backgrounds, art advisors, and representatives from engineering firms. These voices influence students to consider fresh approaches to rural healthcare design challenges, which directly can support the well-being of the communities they call home.

Shared Goal, Different Languages

The frustration is heard all too often: healthcare providers feeling their facility was designed with little reflection of what their jobs actually entail. Design slights such as outlets in the wrong locations or computer stations too far away from care set the stage for workarounds and ineffective care delivery. How these missteps originate and become part of the final design is multifactorial, but one truth persists: we need more healthcare providers well-versed in design terminology and depiction of their systems of care to translate needs to design teams in a way that is well understood and actionable. As with learning any new language, you begin with basic structure and visual representations that convey an idea. For our nursing students, this equates to Lean methods and tools so that their worldview becomes quantifiable, objective, and measurable. Nursing students learn value stream mapping, Pareto analyses, swim lane diagrams, and flow charts as they align to different tasks or situations they encounter every day. For example, nurses will create a value stream map of a patient’s admission or discharge or a Pareto analysis of supply management issues. Visual figures are created with complementary narratives to further describe potential solutions to the issues identified with evidence-based rationales derived from academic literature or facility/design guidelines.

Engineering students who take this course are typically specialized in industrial, mechanical, or healthcare management systems. Efficiency in workflow is high priority in their training, but they may have little experience as to how the humanness of healthcare delivery is integrated into their models or proposed designs. The chaos of overcapacity, on-the-spot decision-making, and messiness of healthcare is hard to convey if only relegated to textbooks and discussion boards. Foundational to this course are the clinical observation hours for engineering students, where they embed themselves into healthcare systems, public health departments, and community clinics to interview providers, witness the delivery of care, and compare their assumptions to the reality of what patients and providers experience. Engineering students also utilize Lean methods and tools to describe their observations, however they also receive feedback from their nursing peers as to the accuracy of what is depicted in the visual representations of the system (such as a value stream map or swim lane). This churn of feedback between engineers and nurses creates opportunity for compromise (how to convey recommendations in a constructive way) and collaboration.

Focus on Commonalities and Celebrating Differences

One way to celebrate creative design differences is to share a common experience. In this course, the students read a book together and post reflections on targeted chapters in their online learning space. The Great Indoors, by Emily Anthes, provides tangible examples of how the built environment shapes our mental and physical wellbeing with corresponding research from across the globe. Chapters range from the effects of cool light on productivity to use of artificial intelligence in care delivery. Students then interpret the case studies Anthes provides as to how it may be considered in their personal practice. For example, for the chapter describing disaster preparedness of hospitals, students review their own organizations’ policies and protocols for scenarios such as wildfires, floods, and patient capacity surges of displaced persons. The posted reflections and new learnings of their own facilities creates a permeability across disciplines in their awareness of design issues in their own backyards.

Opportunities to Get out of the Classroom

The runner-up student team proudly displaying their facility design at the 2023 PDC Summit Student Design Challenge.

Organizations such as the Nursing Institute of Healthcare Design (NIHD) become critical lighthouses for budding designers and healthcare system leaders. Scholarships and funding for opportunities such as the PDC Summit and AIA/AAH Student Design Challenge, and attending the Healthcare Design Conference + Expo act as a launchpad to transition students to professional life after graduation. Members become role models and templates for students seeking to break the mold and push boundaries of what is possible with resources at hand and communities counting on access to care. By the end of the course, we produce engineers who have first-hand experience walking in a nurse’s shoes and nurses who can represent their systems using Lean methods and tools. These students become valuable assets to their employers and communities as professionals who are bi-lingual in design terminology and clinical voice. Working together becomes co-creation of new methods, approaches, and ways to deliver care that will be instrumental to the agility of our healthcare system for future challenges in the decades to come.

Application opportunities are key to solidify learning into practical experiences while also giving students a safe environment to engage with other specialties, think ‘big,’ and experience the joy of interactive design. A group of graduate nursing students from Montana State University recently competed in the annual 2023 PDC Summit and AIA/AAH Student Design Challenge, which provided not only a pressure-test of a 48-hour charrette but also initial exposure to architecture students and the integrated work of mechanical and construction engineering roles as part of the design team. The nursing students, all of whom completed the interprofessional design course prior to the competition, were tasked with creating staffing models, operational budgets, and informing the design decisions for a clinical nurse wellness facility in the greater Phoenix area. The grand challenge of this charrette hit home for these nurses: address the mental health crisis among nurses amid a crippling national nursing shortage. The facility’s environment was to support nurses to care for themselves, de-stigmatize mental health treatment, and focus on caregiver wellbeing.