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Original Articles

Always a Nurse

The Nurse Architect

Felker, Tammy M Arch, BSN, RN, AIA, ACHA, EDAC, LEED AP

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Nursing Administration Quarterly: January/March 2020 - Volume 44 - Issue 1 - p 40-44
doi: 10.1097/NAQ.0000000000000393
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Before embarking on a career in architecture, I had an inkling that design was in my future. That's why family vacation itineraries were often dictated by visits to historical sites and buildings.

FROM NURSE, TO ARCHITECT, TO NURSE-ARCHITECT

When I was growing up, I was drawn to both art and science. But it was at the height of the ecology movement that my interest in environmental studies really began to blossom. That fascination took me down the path of studying and teaching Biology. Working as a Biology teacher at a private boarding high school in remote southwestern Virginia, the state board of education wanted to have staff on-site who had advanced First Aid or EMT training. Another teacher and I took an EMT course and, as a result, I ended up volunteering at a local hospital to understand more about the health care world. I had begun to look at graduate school and was interested in health care, as high school teaching did not seem to be a long-term career fit for me. The experience further solidified my interest in health care careers and eventually my decision to pursue nursing. Nursing offered many different venues and variety of practice options that I could explore. At that point in time, most of my experience was in the emergency department and the excitement of a high-acuity environment was intriguing but I really was open to any area of practice. I would also be able to utilize my teaching experience if I decided to pursue an advanced degree in nursing. The ability to make a difference in people's lives and always be learning and growing was very appealing as it was a career that I would always continue to improve in with more experience.

My very first job in caring for patients was on the weekend bed and bath team at the University of Virginia (UVA). At that time, the nursing model of care was transitioning from Functional Nursing to Team-based Nursing. I learned valuable lessons about providing care with dignity and respect as I “worked my way up” to become a nurse's aide. This was while I was progressing through nursing school. The summer between my junior and senior years in nursing school, I was selected for a critical care externship at the UVA Medical Center. This was a critical turning point in my career (no pun intended). This experience confirmed my desire to practice in a high-acuity environment as I had first experienced volunteering in the emergency department at a small community hospital years ago. I learned so much that summer working with 2 fantastic preceptors. They were compassionate and caring in addition to being skilled clinicians. They taught me to treat the patient, not the numbers, and to really develop a clinical assessment eye. I continued to work as an assistant nurse throughout my senior year and built my skills and showed that I was eager to learn and grow. As a result, I was offered a job upon graduation. Nursing school not only taught me about the art and science of the profession but also gave me an appreciation for the scholarly side of what we are and do. Consequently, during senior year at UVA, I was inducted into Sigma Theta Tau International Honor Society of Nursing.

Early in my career, I also learned the importance of including the family in the care of their loved ones. Soon after I graduated, I was working in the coronary care unit (CCU) and I had my plan for my patient care for the day outlined. I reviewed the patient Kardex for medications and treatments, physician orders for laboratory test results and other tests, and noted hour by hour these activities on a piece of 2-in wide waterproof tape I had placed on my charting station. The routine I had learned from my preceptors was to perform a head-to-toe assessment, administer medicines, draw laboratory samples, and complete am care first thing. As I was working through these tasks, the family wanted to visit my patient. This was back in the day when visiting hours in the intensive care unit (ICU) were much more tightly controlled, and I was feeling annoyed that they were wanting to come in early. They kept ringing the buzzer and I kept postponing their visit. This patient was a rule-out MI (myocardial infarction or heart attack) and confined to bed, so I needed to use that most basic nursing skill of changing the sheets of an occupied bed. Another nurse was assisting me and as we rolled the patient on his side he went into v-tach (ventricular tachycardia) and coded. We called the code and the code team arrived and tried to revive the patient. Unfortunately, the code was unsuccessful. I felt absolutely horrible as the patient's family missed seeing him before he died. The bed bath and sheet changing could have waited. I could have let his family in for a brief good morning visit and completed his am care a little later. It is unknowable if the ultimate outcome would have been different, but my patient could have seen his family one last time. Ever since that occurrence, I always tried to accommodate a patient's family and loved ones whenever I could, even if I was stretching the rules for visiting hours. To this day, I also always try to provide space for families to be welcomed and accommodated in the health care spaces I design, including in the ICU patient room. There are few things that are more meaningful to a patient than to have their family with them.

While I was working as a critical care nurse (CCRN certified) at UVA, my career intersected with architecture due to my involvement with the university's hospital replacement project. I was part of the clinical team that worked with the hospital design group. It quickly became apparent to me that health care design could benefit from a clinician's perspective. However, by the time I had an opportunity to provide feedback on the plans, the project was too far along in the process to have the impact I think would have resulted in a more clinician- and patient-friendly environment. I did, however, get to help transition the critical care department into the new building. That gave me influence on how the new space would be utilized to best support those who would use it. I worked in this building for several years, spending time in every type of ICU—SICU, MICU, TCVICU, Neuro ICU, and CCU. All the while, I continually tried to make physical and workflow improvements that would help ensure staff had what they needed to efficiently provide quality care. This was Lean operations way before anyone knew about the Toyota Way.

During this time, I realized how little details could have a significant impact on the efficiency and flow of work. The charting station, for example, was not large enough to fit the flow sheets that nurses used to document vital patient information—a key part of the nurses' job (before electronic record management was a thing). I realized that simply right-sizing the table would make this task much more efficient.

In 1993, I moved to Roanoke, Virginia, where I taught part-time at the Roanoke Memorial Hospital School of Nursing and I also worked in the cardiac thoracic surgery ICU. This was a great blend of work experience as I was able to draw on my prior teaching experience at the boarding school. During my time working as a critical care nurse at UVA, I had the opportunity to precept multiple undergraduate and graduate nursing students. I really enjoyed mentoring and teaching them. I realized that I really excelled in teaching and explaining complex concepts, and there was value in helping develop the profession. Nursing has had a reputation of “eating their young” and I had the ability to change that cycle. The teaching in the Licensed Practical Nurse school gave me a venue to explore this interest and determine whether I wanted to pursue an advanced nursing degree and join the academic world. It was a great experience, but other roles appeared on the horizon and I began to further explore those paths. At Roanoke Memorial, I had the opportunity to be involved in a critical care tower expansion project as a nurse on the planning committee. For me, a top priority was coming up with design solutions that would “engage families in the care process.” I believed (and still do believe) that providing families with their own space can make them feel welcome and involved in the hospital, not in the way of their loved one's care.

Throughout these years of giving direct care—and over the course of dozens of family trips to historic and architecturally significant buildings across the mid-Atlantic—my love of art and historic architecture was quietly but steadily growing in the back of my mind. I was considering either pursuing a master of nursing degree to continue teaching, or perhaps applying to medical school, when my husband encouraged me to examine where this attraction to architecture might lead.

After 12 years in patient care, I earned a master of architecture degree in 2001. I have worked in medical planning and design ever since. (I became a board-certified health care architect in the American College of Healthcare Architects.) Partway through my graduate program at Virginia Tech, I relocated yet again—this time to Seattle, Washington, with 3 young children in tow. I completed my master's degree at the University of Washington, along with a certificate in Historic Preservation. My master's thesis tied together my love of historic buildings and health care. The thesis was a plan to repurpose a historic lumber mill town (Port Gamble, Washington) into a Continuing Care Retirement Community. The project included a historic survey analysis, a master plan for new buildings including a skilled nursing facility, and my design project, which was an assisted living complex.

By 2007, I was a licensed architect and was also LEED certified (continuing to be interested in the environment and sustainable building design). I was designing hospitals around the country for Seattle-based firm NBBJ. One memorable project was the Charity Hospital replacement, now the University Medical Center, in New Orleans. Modernizing the overtaxed facility—which had also been severely damaged in Hurricane Katrina 10 years earlier—required significant operational changes, and I was tasked with developing a “user guide” for clinicians and staff. Leveraging my dual perspectives as both nurse and architect, I helped the team bridge between early planning and operational concepts and between medical planning and architectural design. My unique background and newfound position eventually landed me on the cover of ARCHITECT magazine. This was a recognition that the combination of 2 great professions—Nursing and Architecture—could make a difference in planning environments for the good of patients, families, and patient care teams. I discovered that returning to the bedside was like riding a bike. The basics of nursing care had not changed, though there was new technology and new procedures to learn.

In 2010, I decided to get my Washington State RN license. I reacquainted myself with the clinical environment as a nurse at VA Puget Sound in Seattle. I was offered job in the surgical ICU and, at same time, I learned about another architecture firm. I was torn between my 2 loves—and had to ask myself which one would make the most difference to those I want to serve?

I decided there are many great ICU nurses, but very few people who have degrees and licenses in both architecture and nursing. I could have a greater impact by remaining a health care architect. I have also since obtained my EDAC (Evidence-based Design Accredited Certification) to further support the practice of evidence-based health care facility design.

NARROWING IN ON BEHAVIORAL HEALTH

Over the course of both careers, I have seen a dramatic shift in the way hospitals and health care systems approach behavioral health. I saw this firsthand years ago, during a summer working as a nurse on a geropsychiatric unit at Catawba State Hospital in Virginia, a former TB sanatorium. Compared with other health care facility types, I believe the physical environment of an inpatient behavioral health unit has the greatest potential to impact patient outcomes. When it comes to designing spaces for the greatest therapeutic benefits, I found that this approach, to introduce design interventions that promote a sense of normalcy and healing while balancing patient and staff safety considerations, was the one most appealing to the nurse in me. The spaces and rooms, the furnishings, the fixtures—they are all tools to help with healing, just like an IV pump in a medical-surgical unit. Presenting options for patients' choice of care, control of the environment, and interactions with others is really important as well. This can all be enhanced by the physical environment we create.

As an example, in a renovation project in the Seattle area, the design team inherited 2 floors of an existing hospital that would be renovated into a 22-bed space promoting recovery, mindfulness, and safety. Designed to simulate the activities of daily living, the facility includes private spaces for patient bedrooms, transitional zones, and communal spaces for dining, activities, and interactions with fellow patients and staff. This is in stark contrast to what I first encountered as an architect. Then, only prison-grade fixtures were available to those designing BHUs. This project incorporates wood, fabrics, wall coverings, Corian countertops, and even ceramic tile. These are familiar materials found in homes that also lend a feeling of sophistication. While elevating the experience for patients, these finishes also carry the dual benefits of safety and durability. Acoustical considerations also drove design decisions. As a nurse, I am very aware that noise can agitate patient populations.

Another key design driver for this project is the emerging trauma-informed model of care. To minimize the need to restrain patients—which can trigger memories of past trauma—the project includes calming rooms for de-escalation. The quiet spaces allow patients to change the color and intensity of lighting in the rooms, imparting a sense of safety and control. Patients also use them to meditate and practice breathing exercises, the kind of skills that can be developed in the inpatient environment to manage symptoms after being discharged. In common areas, tunable LED lighting helps synchronize patients' natural sleep-wake rhythms, marking the passage of time and providing a sense of calm as the day winds down. Again, my nursing education and experience contributed to how we designed the unit, both for acute care needs and to help prepare patients for their post–acute wellness.

What is really important is the message we send to patients, their families, and the community. Through the design, we are signaling that these are valued members of society and that the hospital and the organization have invested in these spaces to provide comfortable, warm, and therapeutic environments for their well-being.

What I have learned from my unique role is that architecture can have a profound impact on the way we provide care and how we provide care must inform how architecture is designed. Today, there are a handful of nurse-architects in the United States, leading the way toward better health care facilities for patients and their families, clinicians, and staff. We design spaces for the physical and mental health of patients, their families, and their caregivers. We are working to do our part to promote wellness and heal sickness. It is not hands-on nursing care, but it is in support of the team members who are direct caregivers. I am proud to say I am an architect, and I am proud to say I am (and always will be) a nurse.

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