We all know that hospitals are complex places, unpredictable and chaotic. A variety of professions are represented within the facility, and each has distinct needs, goals and motivations. Yet this complex hospital environment is also an interconnected web of workflow, processes, products and people. Understanding how these interconnections influence decisions is crucial to improving health care delivery.
To that end, Herman Miller Healthcare partnered with InSight Product Development of Chicago, a health care design and product development group, to focus on the clinical caregiver, perhaps the most visible and recognized profession within a hospital environment. Our goal was to better understand a day in the life of a caregiver.
More importantly, we wanted to identify the specific needs, goals and motivations of caregivers that determined how they do their work. We started with no preconceived notions. We wanted fresh eyes, fresh views. We hoped to see how the design of caregivers' work environments supported or derailed their work processes. Over the course of three months, we visited nine hospitals across the country.
What we quickly realized was that it is impossible to isolate problems and solutions within a complex hospital environment to a single group of people, a single process or a single location. The interconnectedness of people, place and process creates ripple effects. Change one thing and six other things are affected.
A Hierarchy of Needs
Our research yielded a new way of looking at caregiver needs—a Maslow's hierarchy of needs, so to speak—from a caregiver's perspective. We call it the Caregiver Goal Prioritization Pyramid.
The Caregiver Goal Prioritization Pyramid outlines the hierarchy of caregiver needs. It helps us understand why caregivers behave as they do and how they navigate the complexity of hospital environments and respond to challenges. It also can inform decisions on work process and facility design, since environments that recognize caregiver needs will help promote a more productive and compromise-free workplace.
From basic needs to preferences, caregivers move through a series of primary, secondary and preferred goals. These goals must be met in order, from the bottom of the pyramid to the top. The first primary goal must be met before the second primary goal can be reached, and so on. Each step influences the decision-making process caregivers follow as they navigate their complex environments.
Basic—or primary—goals are about safety, both for the caregiver and the patient. The fundamental goal of caregiving is to "do no harm." Caregivers need to prepare themselves so they can stay focused and safe while caring for their patients.
Caregiver safety: Caregivers are trained to consider personal safety as one of their primary goals. One of the caregivers we spoke with put it this way: "We work in a risky environment, so we are obligated first of all to take care of ourselves." In an emergency situation with a patient bleeding, for example, caregivers first put on gloves, then attend to the patient. Now the caregiver's primary goal of safety has been met.
Caregiver accuracy and safety: Caregivers need to provide safe and accurate clinical care to their patients. Once personal safety is achieved, the caregiver can focus on delivering accurate and appropriate care to the patient. "If a patient goes into cardiac arrest," said one nurse we interviewed, "I'm going to forgo concerns about patient privacy and HIPAA. My primary focus is on keeping the patient alive, period." Accurate caregiving needs to be achieved before any additional goals are considered.
Now the caregiver can move to the secondary level of the pyramid, which focuses on the caregiving environment and work processes. In order, these goals are visibility, communication, efficiency and privacy.
Visibility of patient: Caregivers articulate a strong preference for direct visual access to their patients so they can track their status. Visibility ranked highly in conversations with caregivers. It was among the most desired characteristics of the work environment. Caregivers told us that greater visibility improves work processes and the quality of caregiving. It improves the exchange of information and promotes better and more regular communication among staff.
Communication: Supporting caregivers by providing both written and spoken communication to team members is critical. Visibility and communication keep caregivers connected to each other and to their patients—essential for assessment, information and directions. Our earlier example of a patient going into cardiac arrest underscores the need for visibility and communication. The staff sees the emergency situation. The attending caregiver communicates that help is needed.
Visibility and communication can be enhanced through the design of the caregiver's work environment. So can efficiency, which is the next goal.
Efficiency: Caregivers always are looking for ways to save time in their jobs, as efficient performance is rewarded in the hospital environment. Efficiency is essential to caregivers, since workload and stress levels can be high. The tools of caregiving should not add difficulty to their work. A wireless "dead zone" means that a nurse's laptop loses network connection in one area of the unit. A new type of IV bag that doesn't fit correctly in a cabinet requires more time and energy from a caregiver and takes away time spent with a patient. Efficient work environments can enrich the caregiving experience for nurse and patient.
Time is also a factor when caring for critically ill patients. If a caregiver needs to update family members on a patient's changing condition, he or she may not have the time to find a private area to do so. We observed many hallway conversations as busy caregivers moved quickly from one patient room to the next. Efficiency will trump privacy in the caregivers' hierarchy of needs.
Privacy: Caregivers need to maintain the confidentiality of their patients' personal information—both written and spoken—at all times. Privacy was not as valued a need as communication, according to caregivers. They weren't discounting privacy, but it was considered more a preference than a need. If patient safety is an issue, explained one nurse manager, then communication is always more important than privacy: "Communication is an essential ingredient in delivering accurate care."
Yet, caregivers should have the opportunity to find areas for private or quiet consultation with peers and families. Caregivers also will benefit from places where they can work privately, with limited distraction.
Having to make choices or sacrifice one thing for another can compromise the quality of care delivery. The ideal caregiver work environment will provide both communication and privacy.
Safe and accurate caregiving is the primary goal. Providing care in a place that allows for visibility, communication, efficiency and privacy enhances the quality of care. Once those goals are met, caregivers can tend to higher goals. These preferredgoals—ease of use and comfort—enhance the caregivers' experience at work.
Ease of use and caregiver comfort: Caregivers prefer products and solutions that they find intuitive or seem familiar. They also want to ensure their physical, mental and emotional comfort for improved outcomes and work satisfaction. Comfort is both a physical and psychological goal. Caregivers frequently mentioned that the conditions in which they worked provided little physical comfort. In our interviews, we often heard about missing a meal, working in areas without daylight or good ventilation, and even being unable to take a bathroom break.
When people aren't comfortable, they get distracted more easily and have a harder time focusing. Addressing physical needs can make a difference in a caregiver's attention to the work at hand. Caregivers also will be more comfortable doing their work if the supplies and equipment they use are intuitive and familiar and don't impede on the processes and time-sensitive nature of patient care.
Preferred goals also provide a measure of emotional support and psychological comfort. A comfortable work environment, for example, can influence the way caregivers feel about their work in general. Do they look forward to working with their peers? Do they feel like part of a care team?
We spoke with one nurse who, in her 20 years of practice, has come to value teamwork in the caregiving process. She commented how individual work processes and roles come together, and how the caregiving team works comfortably and as one unit. Providing emotional and peer support is incredibly important to building a team experience.
Putting the Pyramid to Use
Considering the hierarchy of caregivers' goals can help the clinical staff sort through the interconnectedness of the hospital environment and uncover issues with a new process or protocol. The pyramid uncovers ripple effects and introduces a broader perspective to decision-making, whether considering a new infusion pump, a patient chair, a change in policy or the redesign of a nursing-unit support core.
How might we design a support core, for example, that integrates the entire patient floor? How do we as an organization approach issues that could affect individual groups differently? Will a new monitor integrate with the other equipment in the room? The pyramid also keeps all aspects of caregiving—large and small—in mind.
The primary goal of safe and accurate caregiving must continue to drive every other decision or action. But in a complex environment, such as a hospital, many other things will impact and sometimes derail that basic goal. The pyramid helps keep those things in mind.
The Caregiver Goal Prioritization Pyramid can be used to understand why caregivers behave as they do, why challenges arise and how the complexity of the hospital environment can be navigated. This tool also can be used to develop solutions that satisfy all goals on the pyramid and avoid the compromises and loss of connectedness that can occur in the busy and stressful world of caregiving.
The pyramid can become a tool for keeping the focus on caregiving—from safety to comfort—and ultimately improving patient care and the professional satisfaction of a valued staff.
Doug Bazuin is a senior researcher at Herman Miller Healthcare, a division of Herman Miller Inc., Zeeland, Mich.
The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.