1. y,1981.
t Care of
:eds and
t,4144.
PartfV
tological
t.
rse Con-
1971.
Flacilitating
zrm Care
's.
and the
Battle Professional
ting: an
tological
re of the
Nursing Practice
in insti-
r elderly
416.
.setting:
is/, June
Nursing,
in long-
.H., and
rns with
Geronto-
t, inThe
ct of the
198r.
qn Care:
)rnment

2. 13
Decirsion Making
in Clinical Settings
Florence M. Johnston
The purpose of this chapter is to examine decision making as a
fundamental, generic component of nursing administration. Nurse
administrators must balance clinical and organizational impera-
tives in managing the professional practice environment. On com-
pletion of this chapter, the reader will be able to:
l. Discuss decision making within a clinical and administrative
framework.
2. Describe the components of the decision process'
3. Explain "satisficing" as a descriptive model for decision mak-
ing.
4. Relate decision techniques to problem identification.
5. Describe the importance of quantitative analytical methods
in clarifying decision problems and expected outcomes.
Shall we implement an all-RN staff? Should we purchase a computerized
staffing and scheduling system? If so, which one? Which candidate for
the assistant director position is likely to be most satisfactory? Is the
existing clinical nurse specialist role appropriate with our new organ-
izational structure? How many nurses will we need for the new outreach
program? What marketing strategies should I recommend for nursing?
And the list goes on, leading some people to say that the work of man-
agement is decision making. Whether or not one wishes to support this
view, it is clear that the quality of the decisions made by managers is
critical to the well-being of any organization. In the case of health care
organizations, managerial decisions not only promote and maintain the
organization itself, but also promote, channel, or constrain the effec-
tiveness, humaneness, and safety of the client care provided by the or-
ganization. Nursing administrators with skills and knowledge in both
173

3. l74 iAqrlIIAING r&qlqqsler14! iru&slxc r&4ErlcE
clinical and managerial decision making can balance clinical and or- DECII
ganizational imperatives to ensure that one is not consistently promoted
to the detriment of the other. In thin
Nurses, throughout their basic education and clinical practice, develop procesr
and hone their knowledge and skills in making clinical decisions. Similar interre
formal, supervised training in managerial decision making is seldom As sucl
provided. Types of decisions, techniques of decision making, and the lectual
context of decision making in health care organizations are seldom ana- procesr
lyzed and taught in schools of nursing, except in some graduate programs process
in nursing administration. Although the information required for clinical often v
decision making and that required for managerial decision making are Coml
different and techniques may vary widely, the nature of the underlying underlS
decision process and its use in health care organizations is similar. derived
Alternative choices of action bridge the gap between a problem and a ratior
a goal. The generation of alternative problem solutions assists in for- the infc
mulating a plan of action. It is a rare problem that has only one solution, prescril
although people sometimes believe that problem solving means looking in arriv
for the right answer or the correct or logical solution. Basically, decision
making is a cognitive process of choice that precedes the chosen behavior.
Nurses in all settings exercise decision making in: 1. Recc
cisio
l. Personal actions. 2. Ident
2. Care of a single patient or groups of patients. 3. Detet
3. A nursing unit. and l
4. A division of nursing. 4. Selec
5. A school of nursing,
6. Other organizations. While
making,
Although everyone is programmed to make decisions of little conse- makers .
quence on a regular basis, the decision making of the nurse administrator decision
in rapidly changing health care settings is becoming increasingly com- cision rr
plex. According to Ackhoff (1), there is no such thing as a single problem. influent
Problems do not exist in isolation: they are elements of a system. Problem model rr
solving is not enough, for problems do not stay solved. Or they give rise cision pr
to new problems. of all avz
Ackhoff further defines a svstem in terms of four characteristics: but even
that voh.
1. It has two or more parts. tisficing.
2. Each part can affect the behavior or properties of the whole. is found
3. The parts are interdependent: the effect each part can have on the solution.
whole depends on at least one other part. satisficir
4. Any subgroup of parts yields subsets that have the same properties
as parts: each can affect the whole, and the effect of each on the whole 1. Recog
depends on the other subsets. cision

4. DECISION MAKING IN CLINICAL SETTINGS 175
rnd or- DECISION PROCESS
)moted
In thinking about decisions, it can be useful to differentiate the decision
levelop process from decision making itself. The decision process is a series of
Similar interrelated steps for systematically and logically coming to a decision.
seldom As such, it is analogous to other systematic processes that guide intel-
rnd the lectual work, for example, the scientific method, the problem-solving
rm ana- process, and the nursing process. Decision making is the point in the
ograms process at which the choice, or selection, of alternatives is made and is
clinical often viewed as the culmination of the decision process.
:ing are Components of the decision process vary, depending on whether the
lerlying underlying model is prescriptive or descriptive. Prescriptive models are
ilar. derived from economic theories of choice. They rest on assumptions that
em and a rational decision maker strives to reach optimal outcomes and that
; in for- the information necessary to determine these outcomes is available. A
rolution, prescriptive decision process includes the steps that should be followed
looking in arriving at a decision:
decision
ehavior.
l. Recognition and analysis of the problem or situation requiring a de-
cision
2. Identification of all feasible alternative solutions
3. Determination of potential favorable and unfavorable consequences
and their likelihood for each alternative
4. Selection of the alternative that will result in optimal outcomes
While the prescriptive model could serve as a general guide to decision
making, it is apparent that, except for very simple problems, decision
[e conse- makers have neither the time nor the information to seek optimizing
nistrator decisions. This fact led to the development of descriptive models of de-
gly com- cision making, based on how decisions are actually made. The most
problem. influential of these has been formulated by Herbert Simon (2). This
Problem model rests on the assumptions that for most reasonably complex de-
give rise cision problems, not only is it impossible to generate an exhaustive list
of all available alternatives and their positive and negative consequences,
stics: but even if this could be done, human decision makers could not process
that volume of information. So, what is actually done Simon calls "sa-
tisficing." This is, the decision maker searches for alternatives until one
le. is found that provides an acceptable solution rather than the optimal
solution. Steps in a decision process based on the descriptive model of
ve on the
satisficing include:
rroperties
the whole I . Recognition and analysis of lhe problem or situation requiring a de-
cision.

5. T76 FACILITATINGPROFESSIONALNURSINGPRACTICE
2. Development of criteria for an acceptable outcome. possib
3. Identification of alternatives. to the
How
4. Evaluation of whether the alternatives will lead to acceptable out-
r
traver
comes.
problr
5. Selection of a satisfactory alternative: each alternative may be iden- propel
tified and evaluated sequentially until the first one is found that is use, lT
expected to produce an acceptable outcome, or several alternatives Forr
may be identified and evaluated before selecting from among them. techni
itored
Other, less formal decision processes are frequently used but are con- the pr
sidered less likely to consistently produce good decisions. One such pro- proble
cess could be called the stimulus-response decision process. In this sit- inform
uation, the steps of identification and evaluation of alternatives are So, alti
omitted, and the decision maker goes directly from identification of the many
problem to the choice of solution, which has usually been predetermined. and th
This process can be useful for simple, repeated, and structured decision compl<
problems that can be handled through procedures, rules, and policies require
but is unlikely to produce high-quality outcomes in administrative de- Probl
cision situations that are complex, novel, and ill-defined. relies r
Another decision process has been labeled the "Oh, hell!" decision (3). reports
In this process, the decision maker either bypasses or ignores the in- sonnel
formation from a systematic decision analysis and makes a decision and tre
based on intuition or instinct-a tempting but dangerous method for nursing
busy, overloaded decision makers. and me
Often, two additional steps are included as components of the decision of ident
process: implementation of the decision and evaluation of decision out- and the
comes. No decision process is considered complete without these final One c
steps, including feedback loops to earlier steps' However, the imple- informa
mentation of change in organizations and the evaluation of organiza- ministri
tional performance are also major, generic administrative responsibil- gossip, i
ities within a broader context than decision making and the decision the adm
process. The old
the grou
Factor
TECHNIQUES the psyc
pect the<
Various techniques have been developed to assist in carrying out the and anti
basic steps of the decision process, although some steps have received ployed i
much more attention in the literature than have others. The first step, this wor
the identification and analysis of the problem or situation requiring a is of pot
decision, has received relatively little attention, in view of its importance sought o
for all subsequent work. The decision maker must first be sure that he alternati
or she is answering the right question by ascertaining, to the extent Hower

6. DECISION MAKING IN CLINICAL SETTINGS I77
possible, whether the problem as first stated defines root aspects, central
to the situation, or whether it is primarily a symptomatic statement.
How often have we responded to a problem such as a shortage of in-
le out- travenous infusion pumps by purchasing more pumps when the root
problem was the distribution system, frequent breakdowns due to im-
e iden- p.op". use or inadequate maintenance, or some combination of number,
that is use, maintenance, and distribution of pumps?
ratives Formal techniques for problem definition are few. Quality control
;them. techniques, in which specific performance standards are set and mon-
itored and exception reports produced when performance falls below
re con- the predetermined level, can be of assistance in identifying decision
ch pro- problems. However, such techniques usually rely heavily on automated
his sit- information systems and require quantifiable performance standards.
i/es afe So, although they can be helpful at least as indicators in some situations,
r of the many critical decision problems in nursing administration are novel
'mined. and thus not captured by routine monitoring of standards, or are too
ecision complex or unquantifiable for the kind of measurable standard setting
rolicies required.
:ive de- Problem identification, although assisted by exception reporting, often
relies more heavily on the manager's own monitoring of management
ion (3). reports, such as financial statements, patient activity reports, or per-
the in- sonnel data, to identify significant variations and to look for patterns
ecision and trends. Nursing administrators need to define relevant reports for
hod for nursing, such as trend reports for such incidents as patient accidents
and medication errors. Kepner and Tregoe (4) have outlined some ways
lecision of identifying problems through a search for factors that have changed
on out- and the conditions of the change.
se final One of the most useful sources for early problem identification is the
imple- informal communication network within an organization. While the ad-
ganiza- ministrator who relies on the informal network of casual conversation,
cnsibil- gossip, and rumor for problem definition is likely to be in trouble, so is
Lecision the administrator who ignores these sources for problem identification.
The old heuristics of keeping your "finger on the pulse," "your ear to
the ground," and "all your antennae out" are exceedingly useful.
Factors in framing the decision problem have received attention by
the psychologists Tversky and Kahneman (5,6). In initial work on pros-
pect theory, they have found that the order of presentation of alternativcs
out the and anticipated outcomes, positive and negative, and the language em-
'eceived ployed in stating them have subsequent influence on choice. Although
:st step, this work has not yet been tested in organizational decision making, it
uiring a is of potential importance, especially when consensus decisions are-
)ortance sought or when the administrator seeks support for his or her chosen
that he alternative solution.
l extent However, even without formal, well-defined techniques for problem

7. 178 FACILITATINGPRoFESSIoNALNURSING PNNCTICE
definition, a systematic analysis of a problem using the steps suggested lems ti
by Behn and Vaupel (3) would provide an improved information base not usr
for the rest of the decision process. Anol
Similarly, little attention has been devoted to the design of alternatives (MAUl
in decision problems. Alexander (7) has developed a model for analyzing plicate
the design of alternatives in organizational contexts and discusses both termin
the creation of new and innovative alternatives and the search for ex- signed
isting but unidentified alternatives. Although creating new alternatives alterna
and identifying existing ones are similar processes, the domains searched criteria
are different. The act of defining two separate domains helps clarify the
The f
activity, although the same techniques may be used to design alterna- to assis
tives. Usual techniques include brainstorming, lateral thinking, nominal theory,
group technique, and the Delphi technique (8). Also useful are searches analysir
of the literature or of the experience of colleagues and the use of analogies analyti,
or other simple heuristics, such as "working backwards." In this heu- quences
ristic, one begins with the desired destination and works backwards, consequ
step by step, identifying the various activities or pathways that lead to compar.
the desired result. ternativ
With the evaluation and selection of alternatives, it is not the paucity, tir.'eness
but, rather, the plethora, of techniques that is a problem. Although a as disab
complete listing of techniques and tools is beyond the scope of this pressed
chapter, some examples illustrate the range available. Examples of avoided.
qualitative approaches include values clarification (9,10) and ethical but are r
analysis (ll,l2,l3,l4). These qualitative analyses are most useful when
the decision problem itself contains significant intangible, unquantifi-
able components. Such decision problems, however, often include some MAKIN
aspects amenable to analysis through quantitative techniques. Much of
the power of quantitative models is the promise of concrete, clear-cut Once the
solutions, often achieved by assuming away the cloud of intangibles also has been
influencing the situation. The systematic use of qualitative analysis in remain. i
concert with quantitative methods can help to achieve a more balanced cess in re
evaluation. In his critical analysis of quantitative methodology, partic- oroblems
ularly in relation to "squishy," partially quantifiable problems, Ralph decision-
Strauch (15,16) reminds us that most models are only perspectives on support)
a situation and that their uncritical use as surrogates for a complex Vroom
problem is fraught with peril. alternatir
Nevertheless, despite such caveats, quantitative analytical methods :om an i
have great power to clarify decision problems and expected outcomes. of arrivir
The use of such a tool as a decision tree, also called a decision-flow
diagram, maps the problem in a series of chronological steps of choices ' Autocra
controlled by the decision maker and choices determined by chance, indeper
with associated probabilities of occurrence (17). Each branch of the tree ' Autocra
ends with a numerical statement of expected value, or utility, of the ordinatr
outcome. Decision trees can be useful analytical tools for nursing prob- Subordi

8. DECISION MAKING IN CLINICAL SETTINGS I79
ggested lems that can be structured and specified in the necessary way but are
on base not used much in practice (18,19,20).
Another quantitative approach, the multi-attribute utility method
rnatives (MAUT), disaggregates and evaluates separately the elements of a com-
ralyzing plicated decision according to determined criteria (21). Weights are de-
;es both termined for criteria, and probabilities of meeting the criteria are as-
r for ex- signed to alternative solutions. The resultant expected value for each
rnatives alternative identifies the alternatives that maximize achievement of the
rearched criteria (22).
rrify the The field of operations research utilizes many mathematical models
alterna- to assist in managerial decision making, including queuing theory, game
nominal theory, simulation, and linear programm ing (23,24,25). Cost-benefit
;earches analysis (CBA) and cost-effectiveness analysis (CEA) are closely related
nalogies analytical techniques of comparing the positive and negative conse-
his heu- quences of alternative uses of resources (26). In cost-benefit analysis, all
kwards, consequences, that is, benefits, are valued in monetary terms. This allows
t lead to comparisons to determine whether benefits exceed costs and which al-
ternative produces the greatest benefits for the least cost. In cost-effec-
paucity, tiveness analysis, outcomes are measured in nonmonetary units, such
hough a as disability avoided or days of hospital stay decreased. Values are ex-
: of this pressed as cost (dollars) per day of hospitalization reduced or disability
nples of avoided. CBA and CEA are used extensively in public sector decisions
lethical but are only beginning to be utilized in nursing (27,28).
ul when
luantifi-
de some MAKING DECISIONS ABOUT DECISION MAKING
Much of
:lear-cut Once the need for a decision has been identified and the decision process
bles also has been accepted as a useful, systematic approach, two additional points
alysis in remain. Preceding sections have dealt with the steps of the decision pro-
ralanced cess in relation to substantive decision problems. Next, the substantive
', partic- problems must be examined in relation to the selection of an appropriate
s, Ralph decision-making style and to the amount of scarce resources (time, staff,
:tives on support) to be allocated to the decision problem.
complex Vroom and Yetton (29) present an algorithm for selecting among five
alternative styles of decision making. These styles range on a continuum
methods from an independent, autocratic style to a participative, consensual style
rtcomes. o[ arriving at a decision:
ion-flow
I choices ' Autocratic I: the manager solves the problem or makes the decision
chance, independently, using information available at the time.
the tree ' Autocratic II: the manager obtains necessary information from sub-
y, of the ordinates and then decides the solution to the problem independently.
ng prob- Subordinates may or may not be informed about the problem for which

9. 180 FACILITATINGPROFESSIONAL NURSING PRACTICE
information is sought. Their role is clearly that of providing infor- ' Certai
mation, not of generating or evaluating alternatives. clear i
. Consultative I: the manager shares information with relevant subor- signifi
dinates individually, soliciting individual suggestions; the manager 'Quant
then makes the decision, which may or may not reflect the partici- accur€
pation of subordinates. tance
. Consultative II: the manager shares the problem with a group of sub- ' Huma
ordinates, soliciting their collective ideas and suggestions; the decision high o
is made by the manager and may or may not be influenced by sub- cant r€
ordinates' suggestions. a redel
' Group II: the problem is shared with subordinates as a group; the a staffi
group generates and evaluates alternatives and attempts to reach con-
sensus on a solution; the manager participates as a group member and The m
accepts the decision of the group. decision
tient car
evaluatir
A series of questions based upon attributes of the problem and situ-
is the lil
ational variables from the algorithm that identifies the appropriate style
humaner
is developed. Examples of such questions include (29):
patient <
process.
' To what degree is the problem structured?
. Does the manager have sufficient information to make the decision?
. Is acceptance by subordinates critical to implementation? THE P(
The subs
A determination of resources to be allocated to any decision problem
decision
should be guided by an assessment of the imfortance of the decision to
incomple
the organization or its likely organizational impact. Decisions of lesser in the or
importance or impact do not require a highly detailed implementation political
of ill steps of the decision process, and simpler techniques can be em-
determin
ployed. Such decisions can often be delegated. High-impact decisions
Pfeffer
iequire a greater commitment of resources and a higher level of re- t
decisions
sources.
affect or
Factors to be considered in evaluating the importance of a decision
terdepenr
include (30):
The se<
ogenous c
. Size and length of commitment: decisions that are likely to require a levels of r
long-term commitment of a significant amount of organizational re- Scarcit
sources in order to be implemented also require a heavier investment scarcity ir
of resources in the decision-making process; examples include the de- Since a
velopment of training programs and the use of management contracts. care setti
. Flexibility of plans: decisions that, once made, offer little possibility necessary
of modification, with significant penalty, during the implementation alternativ
process require detailed attention to the decision process; typical ex- In addit
amples of this factor include construction decisions. ing goals,

10. DEClSION MAKING IN CLINICAL SETTINGS 181
g infor- . Certainty of goals and premises: when goals and premises are fairly
clear and accepted, a decision based on them, although it may be of
t subor- significant organizational impact, may often be delegated.
nanager . Quantifiability of variables: decisions based on variables that can be
partici- accurately quantified may require significant resources, if the impor-
tance to the organization is high, but may frequently be delegated.
r of sub- . Human impact: decisions that have high impact on personnel have
decision high organizational importance and require the allocation of signifi-
by sub- cant resources to the decision process; for example, decisions regarding
a redefinition of R.N.-L.P.N. responsibilities or the implementation of
)up; the a staffing and scheduling system merit detailed decision processes.
ach con-
rber and The most significant factor in evaluating the importance of managerial
decisions in clinical settings, is, of course, the anticipated effect on pa-
tient care. The above-mentioned variables are components of such an
rnd situ-
evaluation, but additional ones must be considered, for example, what
ate style
is the likely impact on such dimensions as continuity, access, safety,
humaneness? The greater the expected impact, positive or negative, on
patient care, the more resources should be dedicated to the decision
process.
ecision?
THE POLITICAL CONTEXT
problem The substantive decision problem, decision processes and styles, and
decision importance are all important components for analysis but are
cision to
incomplete without consideration of the political context of the decision
of lesser
entation
in the organization. Most organizational decisions are made within a
political framework, that is, in a context in which differential power
n be em-
lecisions
determines decision outcomes.
Pfeffer (31) lists three conditions for the use of power in organizational
'el of re- decisions. The first is interdependence, that is, the actions of one group
decision
affect or are affected by the actions of another in significant ways. In-
terdependence can be both cooperative and competitive.
The second condition for the use of power is the existence of heter-
ogenous or inconsistent goals among individuals or groups and at various
'equire a levels of the organization.
ional re- Scarcity is the third condition for the use of power; the greater the
/estment scarcity in relation to demand, the greater the conflict and use of power.
e the de- Since all three conditions are present for most decisions in health
ntracts. care settings, nurse managers must develop their political skills. It is
rssibility necessary, but not sufficient, that the nurse manager present decision
Lentation alternatives based on a systematic, well-documented decision process.
pical ex- In addition, preparatory identification of interdependencies, compet-
ing goals, and resource demands provides important information for

11. 182 nacILttlttNcpRopEssroNaLNunstNGpRACTrcE
selection and implementation of political tactics to be employed in in- 6. Kahn,
fluencing the decision. Nurse managers need to add such political skills risk. ,l
as negotiation, bargaining, persuasion, use of political language, com- 7. Alexa
study
promise, and coalition formation to their repertoire in order to maximize
8. Moscc
their power in the decision situation or to minimize the level of conflict reseal
that politicizes the situation. healtt
388-4
9. Kirscl
SUMMARY and a
114.
Decision making is a cognitive process of interrelated steps for system- 10. Steele
pleton
atically and logically coming to a decision. Decision making can be based
11. Holme
on a prescriptive or a descriptive model, and various decision-making Medict
techniques may be used. Competing goals and resource demands are 12. Institu
factors contributing to the political context of decision making. York:
13. Davis,
Applet
STUDY QUESTIONS 1.1. Frome
15. Strauc
1. Define decision making as a process. ences, .
2. From your experience, what kinds of problems are appropriately 16. Strauc
evaluated through a decision process? Winter
17. Raiffa,
3. What are three key factors in framing a decision problem? Readin
4. How do informal communication networks contribute to your un- 18. Aspina
derstanding and definition of problems? ing Res
5. Identify decision-making styles. 19. LaMon
Admini
6. What factors are used to assess the organizational importance of a 20. Taylor,
decision? of Nurs
7. How can knowledge of the conditions that lead to political decision 21. Edwarr
making be of assistance to the manager? to evah
Sage P
22. Posava
REFERENCES Engleu
23. Eden, (
Ackhoff, R. Beyond problem solving. Paper presented at the fifth annual York:
meeting of the American Institute for Decision Sciences. Boston: November l-1. Parker,
1973. policy
2. Simon, H. Administrative Behavior. New York: The Free Press, 1976. 389-42
J. Behn,R. and Vaupel, J. Teaching analytical thinking. Policy Analysls, Fall 25. Warner
1976,2(4),663-692. Admini
4. Kepner, C. H. and Tregoe, B.B. The Rational Manager. New York: McGraw- 16. Warner
Hill, 1965. Care. A
.5. Tversky, A. and Kahneman, D. The framing of decisions and the psychology 17. Stokey,
ofchoice. Science, January 30, 1981, 211(4481),453-458. 1 978.

12. DECISION MAKING IN CLINICAL SET]:INGS 183
ed in in- 6. Kahneman, D. and Tversky, A. Prospect theory: an analysis of decision under
risk. Econometrica, March 1979 , 47(2), 263-291 .
cal skills
ge, com- 7. Alexander, E. The design of alternatives in organizational contexts: a pilot
study. Administreftive Science Quarterb, September 1979, 24(3), 382-404'
naximize
8. Moscovice, L Armstrong, P., Shortelle, S. and Bennett, R. Health services
f conflict rcsearch for decision makers: the use of thc Delphi technique to determine
health priorities. Jountal of Health Politics, Policy and Law, Fall 1977 , 2(3),
38 8-4 I 0.
9. Kirschenbaum, H. Clarifying values clarification: some theoretical issues
and a review of research. Group and Organizational Studies , 197 6 ' 1(2) , 99-
1.14.
r system- 10. Steele, S. and Harmon, Y.Values Clarification in Nursing' New York: Ap-
pleton-Century-Crofts, 1979.
be based
11. Holmes, C. Bioethical decision making: an approach to improve the process.
r-making Medical Care, November 1979, 27(ll), 1131-1138.
,ands are 12. Institute of Society Ethics and the Life Sciences. Hastings on-Hudson, New
rO
'b' York: the Hastings Center. The Hastings Center Reports.
13. Davis, A. and Arosk ar, M. Ethical Dilemmas and Nursing Ptactice. New York:
Appleton-Century-Crofts, 197 8.
14. Fromer, M. Ethical Issues in Health Care. St. Louis: Mosby, 1981.
15. Strauch, R. E. "squishy" problems and quantitative methods. Policy Sci-
ences, June 197 5, 6(2), 175-184.
cpriately 16. Strauch, R. E. A critical look at quantitative methodology. Policy Analysis,
Winter 197 6, 2(1), l2l-144.
I
17. Raiffa, H. Decision Analysis: Introductoty Lectures on Choices Under Certainty.
Reading, Mass.: Addison-Wesley, 1968.
your un- 18. Aspinall, M. J. Use of a decision tree to improve accuracy of diagnosis.Nzrs-
ing Research, May/June 1979, 28(3), 182-185.
19. LaMonica, E. and Finch, F. Managerial decision r;raking. Journal of Nursing
Administration, MaylJune 1977 ,7(5 and 6),20-28.
ance of a
20. Taylor, A. G. Decision making in nursing: an analytical approach. Joutnal
of Nursing Administration, Novemb er 197 8 , 8(l l) , 22-30.
I decision 21 . Edwards, W., Guttentag, M., and Snapper, K. A decision-theoretic approach
to evaluation research, tn H andbook of Evaluation Research, vol. I . London :
Sage Publications, 1975.
22. Posavac, E. and Carey, R. Program Evaluation: Methods and Case Studies.
Englewood Cliffs, N.J.: Prentice-Hall, 1980.
23. Eden, C. and Harris, J. Management Decision and Decision Arzalysls. New
[th annual York: Wiley, 1975.
November 21. Parker, B. Quantitative decision techniques for the health/public sector
p<rlicy maker. Joumal ol-Health Politics, Policy and Lrnv, Fall 1978, 3(3),
976.
389,429.
25. Warner, D. M. and Holloway, D. C. Decision Making ttnd Control for Health
alysis, Fall
Administration. Ann Arbor, Mi.: Health Administration Press, 1978.
:McGrarv- 26. Warner, K. and Luce, B. Cost-Benefit and Cost-Effectiveness Analysis in Health
Care. Ann Arbor, Mi.: Health Administration Press, 1982.
27 Stokey, E. and Zeckhauser, R. A Primer for Policy Analysis. New York: Norton,
rsychologl
1978.

13. 184 FACILITATING PROFESSIONAL NURSING PRACTICE
28. Crabtree, M. Application of cost-benefit analysis to clinical nursing practice:
a comparison of individual and group preoperative teaching. Journal of
N ursing Administration, December 197 8, 8( 1 2), 1 l-1 6.
29. Vroom, V. and Yetton, P. Leadership and Decision Making. Pittsburgh: Uni-
versity of Pittsburgh Press, 1973.
30. Koontz, H., O'Donnell, C., and Weihrich, H. Management, Tth ed. New York:
u
McGraw-Hill, 1980.
31. Pfeffer, J. Power in Organizations. Marshfield, Mass.: Pitman, 1981. Fiar
Judith
The p
proces
care f
able tr
l.t
2.r
S,
3. I
n
4. I(
e'
Conceptu
ognition
human o:
nursing c
health ca
in facilitS
For an5
ministrat
tives, dete
that the d
skill requ
the desigr
thinking:
ning.
Strateg
an organi:
in more d
ment, strr
tion's mis

14. practice:
ournal of
Lrgh: Uni-
14
Iew York:
,l -
Fiacilitiesf@
Judith A. Bernhardt
The purpose of this chapter is to provide basic knowledge of the
process and content of planning the physical environment for health
care facilities. On completion of this chapter, the reader will be
able to:
l. Describe the phases of a facility planning project.
2. Discuss the nursing role in the facility planning process and
space management.
3. Describe the operational concepts that affect nursing in plan-
ning and designing facilities.
4. Identify resources and techniques available for making and
evaluating planning and design decisions.
Conceptualization of the physical environment has resulted in the rec-
ognition that staff functioning and patient recovery are affecled by the
human organization within health care facilities. Since the delivery of
nursing care extends into and is dependent upon all other areas in a
health care facility, the importance of effective nursing administration
in facility planning cannot be underestimated.
For any administrator, planning is an essential component of the ad-
ministrative process and includes the major activities of setting objec-
tives, determining policies and resources, making decisions, and assuring
that the desired outcomes are achieved. Planning is the first conceptual
skill required in an administrative role and is the dominant process in
the design and construction of health care facilities. A useful way of
thinking about planning is to consider both strategic and tactical plan-
ning.
Strategic planning encompasses long-range goals and objectives for
an organization, while tactical planning focuses on goals and objectives
in more detail and for a shorter time span. In the health care environ-
ment, strategic planning includes such tasks as describing an institu-
tion's mission and role, determining the scope of services and the level
185

15. 1E6 lacl_LII4.IINQ_lBqI_ES_spN4,L_Nrr&QINGrBAlT,rcE
of care to be provided, and choosing the site location and design for a whetht
new health care facility. Tactical planning includes budgeting, identi- portior
fying staffing ratios, and determining patient admission and scheduling the der
procedures ( I ). The function of facilities planning is to strategically con- For z
ceptualize and plan how an individual health care environment will eration
function in the future. To strategically plan facilities is to commit to repres€
the risk of conceptualizing about the future, since buildings are sub- staff ar
stantial investments that will stand for long periods of time. physici
Addi
world r
THE ROLE OF NURSING IN FACILITY PLANNING brings
unfami
Nurse administrators have a significant role in the facility planning minolol
process because of their clinical experience related to the technical and in orde
sophisticated nursing and medical services provided today. Nursing ac- formati
counts for more than 50 percent of a hospital's payroll, and total payroll design r
constitutes more than 50 percent of all hospital operating costs. Nursing ments f
merits active involvement throughout the planning process in order to por:ated
produce management and operating efficiencies. The very nature of The fi
nursing's role as nursing service's representative and patient advocate sultant:
makes it a source of invaluable experience and insight about nursing
practice, the flow of materials and people, functional requirements of 1. Coor,
space, and environmental issues important to nursing staff, patients, decis
families, and other health care providers. All of these elements can be 2. Gathr
enhanced or hindered by the design of the environment (2). 3. Exan
The planning and design of building programs require a decision- ganiz
making process that involves several levels within an organization. For to pli
major building programs, there is usually a director of planning who 4. Revie
functions as the representative of hospital administration, a planning requi
committee, special committees with broad and diverse user represen-
5. Act al
tation, and the governing board, which retains ultimate authority and
tweer
responsibility for the entire building program. Smaller building pro-
apprc
grams and renovation projects may compress these decision-making
levels. Nursing has an opportunity to provide input into the organization 6. Monit
at the levels where strategic program management and operational plann
planning occur throughout the planning and design process.
The task of strategically planning health facilities is generally accom- Since 1
plished by a planning committee typically composed of representatives a numbe.
from various departments or disciplines. Nursing administration must in facilit
be represented at this level, where needs and future programs of the that reco
organization will be determined. At the same time, nursing can develop needs of
its own internal organizational structure to designate the appropriate nursing's
staff who need to be involved on any special committees to influence the healti
the management of the program design and provide educated direction ily needs
on nursing practice and function. Such organization is important care facil

16. FACILITIES PLANNING I87
gn for a whether the facility planning project is large or small, for the design
portion of the process itself demands significant time commitments to
, identi-
Leduling the development, review, and approval of final design schemes.
rlly con- For a large replacement project spanning a number of years, consid-
ent will eration should be given to establishing and assigning a full-time nursing
mmit to representative to serve as a consultant and a link between the nursing
are sub- staff and the architect, providing knowledge about the impacts of the
physical environment on nursing practice.
Additionally, the facility planning arena introduces nursing to the
world of planners, architects, engineers, and health consultants and
brings with it techniques and terminology that are relatively new and
unfamiliar. The nurse consultant must learn such techniques and ter-
,lanning minology through daily interaction with these planning professionals
Lical and in order to be able to communicate in planning jargon, anticipate in-
rsing ac- formation needed by the architect in each design phase, and evaluate
I payroll design schemes. Well-prepared and relevant functional spatial require-
Nursing ments for nursing have a good chance of successfully becoming incor-
order to porated into the final design.
.ature of The following responsibilities are essential to the role of nurse con-
rdvocate sultant:
nursing
ments of 1. Coordinate the involvement of nursing in the planning and design
patients, decision-making processes.
-s can be 2. Gather data and prepare documentation to facilitate decision making.
3. Examine and evaluate innovative design concepts, care delivery or-
lecision- ganization, and new technology, and make recommendations related
tion. For to planning objectives.
ring who 4. Review program plans and assist in the definition of nursing practice
planning requirements.
represen-
5. Act as liaison to interpret terminology and professional concerns be-
rrity and tween the staff, consultants, and external planning and regulatory
ling pro- approval agencies.
L-making
anization 6. Monitor the design and construction for consistency with the original
:rational planning concepts. (3)
y accom- Since the profession of nursing serves as a patient advocate, there are
entatives a number of patient and family needs that can be coordinated by nursing
ion must in facility planning. Nursing care is approached from a holistic view
ns of the that recognizes the physical, spiritual, psychosocial, and developmental
r develop needs of patients, with the patient, family, and community central to
propriate nursing's concern and program implementation. The design or plan of
influence the health care environment, therefore, should support patient and fam-
direction ily needs for a therapeutic milieu. However, more often than not, health
nportant care facilities are designed primarily to meet health professional's needs

17. 188 FACILITATING PROFESSIONAL NURSING PRACTICE
for efficiency of practice and often fail to provide an environment that
supports recovery (4).
While there is currently a dearth of information in the literature di-
rectly pertaining to hospital design and human behavior, nursing can,
through experience, sensitize planners and architects to environmental
design and behavior as it affects not only staff, but patients and their
families as well. The needs of patients and their families basically relate
to the degree of control they have over an otherwise stressful environ-
ment. Six such needs have been identified:
l. The ability to find one's way between destinations.
2. The ability to control what is likely to be seen and heard as a result
of space relationships.
3. The ability to regulate the amount of interaction with others visually
and acoustically.
4. The security and safety of the environment.
5. The convenience with which various amenities and destinations can
be reached.
6. Special needs due to age or to physical or mental limitations.
Incorporating these needs into design enhances the delivery of quality
patient care (5).
THE FACILITY PLANNING AND DESIGN PROCESS
Whether in building a new health care facility or accomplishing major
additions or alterations to an existing facility, optimal long-term out-
comes are achieved when those involved have a basic understanding of
the planning process and a concept of design objectives (6). This section
describes the process phases and discusses ways in which nursing can
positively influence the phases (see Figure 14.1).
Mission and Role Study
The first phase of the planning process defines the facilities mission and
role for at least l0 years in terms of programs, physical facilities, and
general space requirements for departments of all types. Recently, health
facilities have employed independent, professional consultants to de-
FIGURE 14.1 The planning and design process continuum. (From the Office of
Planning, Research and Development. The University of Michigan Hospitals,
Ann Arbor, MI.)

18. r9d
;PS
nent that
6o
'ature di-
sing can,
rnmental
rnd their
lly relate
environ-
sa result
s visually
tions can
)ns.
rf quality
ng maJor
-erm out-
anding of
is section
rsing can
;sion and
ities, and
ly, health
rts to de-
e Office of
Hospitals,
s-
; li 'i
9i
189

19. 190 FACILITATING PROFESSIONAL NURSING PRACTICE
velop long-range role and program plans. The mission and role study 6. The
has the dimensions of a community-wide survey and includes such ele- 7. Sepa
ments as patient origin studies, population projections, utilization 8. Privz
trends, length of stay, patient days, average daily census, and bed re- 9. Buil<
quirements. The study includes the examination of plans of other health
care providers in the area, community characteristics, the effects of leg- The fun
islation, and its primary, secondary, and tertiary care roles on a defined health c
area-wide basis. niques o
At the same time, required health care resources, the role of the health rhose ch
care facility in education and research, and long-range personnel re- Ifam
quirements are evaluated. Upon completion and acceptance by the fa- and funr
cility of this survey of health care needs and the services to be provided, process i
capital costs and the ability to finance the project must be determined the decir
by a financial feasibility study. Effective nursing involvement later in out proc
the design process as it relates to types of patients and services to be l'olveme.
provided requires that nursing be part of the prior development of long- not unre
range goals for the facility and be aware of the impetus for the building be assigr
project (6). project. I
The mission and role study is also necessitated by the high degree of :e desigr
regulation of the health care environment. Nursing may be involved in :he proje
collecting and analyzing data to convince review agencies of the need The im
for and economics of the project. quality o
Jepends ,
erchitect
Physical and Functional Evaluation
:lex relal
The basic purpose of the physical evaluation is to determine the degree rents, ar
of physical obsolescence of the existing facility, identify major code vi- .eries of
olations, and project the facility's usability in the future. The functional :reate a F
evaluation assesses the facility's ability to serve as an efficient work -s of reas<
place for personnel and to provide a supportive environment for patients llLlOYeS fit
and their families. The methodology used to functionally evaluate a fa- ,nd assis.
cility compares functional attributes to adopted criteria. Minimum Re' : romises
quirements of Construction and Equipment for Hospitals and Medical Fa-
cilities, HEW Publication (HRA) 79-1'4500, and pertinent state rules and
regulations serve as the basis for criteria' laster P
In addition to the codes and regulations, a number of functional con- fhe mastr
cepts provide standards for evaluating functional features' The more :-rual des
common concepts include: :rich a fe
:ires, reql
1. Viewing the whole facility as a single, efficient system. - re projec
2. Physical relationships required between departments. .lmissionr
-
3. Room size and shape needed to accommodate function. - le study.
4. The ability of the facility to expand. faster p
_
_ .-r- maste
5. Space and equipment flexibility.

20. FACILITIES PLANNING 191
6. The degree of automation.
le study
uch ele- 7. Separation of cleaned and soiled zones.
lization 8. Privacy accommodations for patients.
bed re- 9. Building circulation patterns. (6)
,rhealth
ls of leg- The functional concept of flexibility deserves much emphasis. For a
defined health care facility, flexibility is critical in allowing for changing tech-
niques of professional practice, alteration of department layouts to meet
Le health those changes, and addition of new departments in the future.
nnel re- If a major design effort is to be undertaken as a result of the physical
y the fa- and functional evaluation, then usually at this phase of the planning
rovided, process a project team is formed, roles of the members are defined, and
ermined the decision-making process is clarified. This is when a well thought-
later in out process of designating staff or nursing committees for ongoing in-
:es to be volvement in the remainder of the process can also be developed. It is
. of long- not unreasonable to request that a nurse consultant or several nurses
building be assigned to the project team on a major renovation or replacement
project. For minor projects, a consistent point of contact in nursing can
legree of be designated to coordinate and provide input at each major phase in
'olved in the project.
lhe need The importance of this involvement cannot be overemphasized. The
quality of a facility planning and design effort in the remaining phases
depends on those assigned to plan the building in detail and upon the
architect who will design it. Health care facilities are composed of com-
plex relationships, flows of people and supplies, technological require-
e degree ments, and operational procedures. These relationships necessitate a
code vi- series of planning and design decisions and compromises in order to
.nctional create a project that balances user needs, is aesthetically pleasing, and
:nt work is of reasonable cost and optimal utility. To achieve these goals, it be-
patients hooves nursing to be an integral part of the decision-making process
rate a fa- and assist in determining which program planning and design com-
mum Re- promises minimally affect the functions required to care for patients.
dical Fa-
'ules and
Master Program
rnal con- The master program phase of planning health care facilities precedes
'he more
actual design efforts. The master program describes the concepts upon
which a facility will operate and specifies functions in terms of proce-
dures, required equipment, and numbers and categories of space users.
The projected number of procedures or tests is based on the number of
admissions, patient days, and clinic visits projected in the mission and
role study.
Master programming is one of the most important planning activities.
The master program is reviewed by external regulatory agencies and

21. t92 EAqluIAIINe rQIESQIONAL NU RsrNG pRACrrcE
becomes the major approved policy document. It serves as a guide for
the architect, the manager responsible for constructing the facility, thest
administration, and the people who will use the space. This program- pers(
ming effort, once the province of the design architect, is now frequently in ot
conducted by planners familiar with health care functions. Titled func- throt
tional planners, such professionals usually have a background in hospital views
management, and many are trained by consulting firms that specialize to pr,
in both health care programs and facility planning. quire
A number of nursing-related operational concepts require decisions perfo.
at this stage (6): tain s
1. Types and mix of patient rooms (single, double, four-bed)
2. Centralized versus decentralized supply processing and material dis- Spac
tribution systems
A spa,
3. Size of nursing units is assi
4, Presence or absence of a nursing station the m
5. Type of care delivery (team, primary, functional) needs
6. Degree of automation for processing data The tr
7. Degree of centralization for laboratories and pharmacies. unit ot
of eacl
It is in this part of the planning process that the nurse administrator unders
can make a significant contribution by utilizing designated nursing but thr
planning resources to describe and document for the planners the plan- dition
ning objectives and design concepts that are not only required but de- follows
sired in order to implement nursing practice in a new setting. depart.
The planning objectives and design concepts can begin with a de- Seve
scription of the patient population and the philosophy of delivering sions a
nursing care within the overall mission and role of the health care fa- ner for
cility. Such objectives include but are not limited to the operational architr
concepts previously described. gramII
Once the philosophy of care and the patient population are identified, equate
it is useful to identify the program goals and assumptions for nursing, :he arc
including definition of terms. An example of a program goal is to main- ,or the
tain a system of decentralized nursing administration. Once all the goals ,ne im
have been listed, with objectives stated for each, the operational and .pens,
physical space requirements to implement each goal can be identified. Anot
Examples of operational and physical space requirements for the goal :Qu3I€
of decentralized nursing administration are to locate units with similar siate al
patient populations in close geographical proximity and to require office :rinimr
space for each head nurse on the unit for which he or she is responsible ., be la
(7). .r -.,spita
As part of the master program, it is valuable if the documentation o:
,.:ructi<
planning objectives and design concepts for nursing itself are stated i; :'Strict,
a format that all parties can understand. To assist in the description o-
.. hen t
ni:rrsinl

22. FACILITIES PLANNING 193
uide for
these objectives and concepts, the nurse consultant, designated nursing
facility, personnel, or both should review layouts of nursing areas and systems
rogram- in other health care facilities. Such a review can be accomplished
:quently
through carefully documented visits to other health care facilities; re-
ed func-
views of hospital, medical, and design journals; and operational analyses
hospital
to prepare adequate documentation to support the proposed space re-
lecialize quirements. An example of an operational analysis that may need to be
performed is to describe and document the rationale for desiring a cer-
lecisions
tain size nursing unit.
erial dis- Space Program
A space program is a listing of every room or area to which a function
is assigned in a proposed construction project. As a direct derivative of
the master program, a space program is used to communicate facility
needs to the architect and is frequently prepared by a functional planner.
The traditional space program lists the type of room required within a
unit or department and the quantity, size, and functional requirements
of each. The space program should provide the architect with a clear
understanding of not only what function is to be performed in the space,
nistrator but the quantity and type of personnel required for the function, in ad-
I nursing dition to the equipment and environmental needs. The listing of rooms
the plan- follows the order of the master program, and rooms are grouped by
d but de- department, functional entity, or both (see Table 14.1).
Several factors influence the space program phase. Different conclu-
rith a de- sions about the dimensions and space identified by the functional plan-
elivering ner for a room can be arrived at during the actual design by different
h care fa- architects. For example, an intensive care patient care room pro-
rerational grammed for a certain size might need a generous width to allow ad-
equate clearance at the foot of the bed during a cardiac arrest. However,
dentified, the architect might believe that the length dimension is more important
r nursing, for the medical gas outlets and equipment required at the bedside. Thus,
s to main-
one important requirement might be needlessly compromised at the
L the goals
expense of another equally important functional requirement.
ional and Another factor influencing the space program includes minimum
identified. square footage assignments or the amount of space stipulated by most
,r the goal
state and federal regulatory agencies for certain functions. While these
th similar minimum requirements must be met for licensure, certain spaces need
luire office to be larger to accommodate specific functions; for example, a teaching
:sponsible hospital would require spaces to accommodate students. Finally, con-
struction budgets influence space assignment size. When budgets are
:ntation of restricted, space sizes for rooms are usually at their functional minimum;
e stated in when budgets are unrestricted, optimal space sizing can be achieved.
cription of Nursing can provide assistance in monitoring those essential spaces that

23. s
may t
*lL O 9 O (6).
@ oo Oo <)
Ac:
^
Ll O^ o- O
Fi:l N gram
d5t care f
I
desigr
S
.! ^.
qiJ
(il often r
o
xtl O @ O+
c.l
o
ca
.x{l Block
>,t
Block
o co$
which
c.l simple
o faciliti
r-.u partm(
.5;.€
tE- 9'< i!
E! p TiF intensi
ill pati,
'6ii *,; Fi :.iEE
I
E;+; Ev9
lit:
?€E iiSa ;=s: -O
d I
it relat
and ele
iF'igc ,r
' x I oq i f. ) q
^qr'ej o :',oto
a d tr- O'
l
El=tr I .iGqO .:o-oco grd up the
;u5: -=t
c3? ; _.O63
,-{!;s !r= !g;; €;e# E< -Cg:3 fit on t
I
Gn -o v;
I
At th
a,2
i6tl oEE c,T#t ii'==i 5
)'i CJ .! ;'j
brr
;!q." ci";! 9.6;E 'EEU,9 (dE I
alterna
r:FG HfE EsE€ FEaE a>
l'52 tr o,'F! .'-a5
i
tionshil
1=;S.i; t*E iiar =' 2a .9 o. termini
-l '-E.:Hoe;u
co s 3 b o .! i o Fgi.s
,^tt:7JLt::-LJ--;P
o f 6; " : o 5 cdl I
rvrthin
oh
criteria
p
uoi g;EI
,F€3.i*iEE
i:+E
'ua
Ari
Et
I
rional r
: A;5:E;;E :Ei;
I
6
E€E; ^,J
UC ieria of
lil
*lnri::Ee.9i'T :: L-.r9 6rlo -cJ l
:he locr
zl !ti
ol
E';E:;iii;;Eii H;t; <E
$ P;iiE:3e je s.t'P !E[-E
tr,o
O=
cdP I
As bl<
This pr
tr d .:;i'J' z==?, }J= E > i ia " Jevelop
i€E c.,.93F- tt:
cli sl
!i rii'E 6i6'o a g:16;?l*c
L'v
LI
'll part
n, g
bo
o
h ';i=:.1=6 L'- E1 rCCOmn
O(!
ol :eriod f
o
ol
(g
A
al
S
I
;;!€r E;:i 5 s; -*e
F+€t .Bl .raffic f
.rd lan
d
=l _3re, pr,
LI o XYl. .. an irr
cdl
A] b0
=A The b
+ 01
a).-* ,e bui
a- d^^
^ -- ho .:uippe
HG.l F-'l r!P
-.alth c
'l trl o li
<x
FEl
OL
tr tu a :(e
a0< z -ree di
194

24. FACILITIES PLANNING 195
may be in danger of becoming dysfunctional under budget constraints
(6).
A carefully prepared master program and a well-defined space pro-
gram can assist in achieving functional rooms and spaces for a health
care facility, which enables administration to make many important
design-related decisions without repeating the trial-and-error process
often encountered in design.
Block Plan Drawings
Block plan drawings represent the beginning of design, the point at
which the architect translates the program and space descriptions into
simple drawings of blocks of space. Block plans graphically depict a
facilities evaluation of necessary functional adjacencies between de-
partments; for example, the emergency room should be located near the
intensive care units in order to minimize travel distance for critically
ill patients. The block of space for each department and the departments
it relates to are shown by building level, along with major corridors
and elevators. Alternative ways in which these blocks of space that make
up the building can be designed are then evaluated as to how well they
fit on the site designated for the facility.
At this phase, three-dimensional models are useful in demonstrating
alternative building forms to assist in the selection of optimum rela-
tionships and configurations. Since the nursing unit is the major de-
terminant of the building's shape, the architect focuses on its location
within the building first. Nursing can assist the architect by providing
criteria on departmental adjacencies important.to nursing and on func-
tional requirements that will influence the shape of a nursing area. Cri-
teria of importance include nursing travel distances between spaces and
the location of supplies for those spaces.
As block plan drawings are developed, a master site plan is formulated.
This process encompasses selection of a site, analysis of the site, and
development of drawings to visually portray the buildings and uses of
all parts of the site. A site plan is the rational selection of a location to
accommodate all construction envisioned during a l5-to-2}-year future
period for a health care facility. The plan reflects vehicle and pedestrian
traffic flows, parking, building configuration, placement, organization,
and landscape details. With the advancement of technology in health
care, provisions for flexibility of site use and expandability of structures
is an important part of the facility planning process (6).
The block plan phase is also the stage in the design process at which
the building and evaluation of full-size mock-ups of various fully
equipped rooms are of extreme importance. In planning and designing
health care facilities, no other adequate substitute for seeing spaces in
three dimensions exists. Users of the space can be involved at this point

25. W FACrLlrArrNG pReIEqQloNAL_Nu&sI_c pB4erllE
to evaluate function and predict the operational quality of certain spaces,
building materials, equipment, and furnishings. Mock-ups can also be
of significant value to administration in introducing the new facility to
the community. In fact, mock-ups should be installed permanently in
the new facility as an in-service education tool for everyone from health
q$
"i;;"%,
care personnel to maintenance and housekeeping. t^' 'fii
As part of the initial design phase, a mock-up program can be un-
:a,,-...
dertaken in several steps:
I
l. The project team and architect can evaluate two-dimensional draw-
ings (sketches or floor plans).
2. Visits can be made to mock-up displays prepared by manufacturers
o[ specilic health care equipment.
3. The team can study three-dimensional scale models of specific spaces
and participate in evaluating full-scale mock-ups with actual or sim-
ulated equipment and furnishings. Full-scale mock-ups can be built
in the existing facility or in a nearby building and can be constructed
for a small percentage of the overall project budget, particularly if
planned from the onset.
A space can be considered a prime candidate for mocking up if:
1. The space recurs frequently in the design.
2. The space is complex and needs to be visualized in order to under-
stand its functional relationships with people, equipment, and other
spaces.
3. A mock-up is the best way to acquire, evaluate, and transmit mean-
ingful user input about the space.
4. The capital and operating costs of the space are great.
5. The space is expensive to renovate after occupancy. s
u
.?E
>c
Spaces that might be mocked up include a general and an intensive care o
<
og
ufo
,. o
patient bedroom, a nursing station, an exam room, and an operating
room. If full-scale room mock-ups are not financially feasible for a proj- ; ss
a
ect, three-dimensional models should be used as a fallback predesign
evaluation tool (8).
The first step in evaluating full-scale mock-up rooms is to develop
performance criteria for how the space is expected to function; for ex-
ample, there should be adequate space in a two-patient room at the foot
of the bed to allow the second bed to be removed during a cardiac arrest
without unduly disrupting the arrest procedure. The next step is to de-
termine what tools will be used to evaluate the spaces, for example,
questionnaires, interviews, and checklists. Activities that will routinely
occur in the space can be role-played or simulated and can be photo-

26. spaces,
also be
:ility to
:ntly in
health
be un-
I draw-
.cturers
) spaces
or sim-
re built
tructed :-H=€-3 E*6
rlarly if E: y.o'; tr 6 i
q cd -:'c cd<o
!: ! P dZ U-
*'ll Q
i "-oF- -v) dN
s : ;: c ;
, if: E e'"
9
5E,!; H=tg
aJtVh- (g.:
H 9E{ - c.9E
EiAt656.9a
..t#'_i-- F' L
,under-
rd other
; I3E l? 8.sS
qI a,'"--:-XJ
"'.:-q= p..x|{ =;
.::-*C,^@<!tr ! -
t mean- H! E; S ;U :,
O /' Y H
i#5
* 8 3 cr o :: o
'eOPX'--.!-=
Lril.oyrg(J(rl.!
^
Bz EE
vo
I nr ! v ,
? 6 ii o F H Xa ?
N+ *
:: tE -s !8
--
- E i. b-. >b
d 9
:3'E-f; re:i
A.= 6 Y ()* s h
t 6 5T: it..: G
! s3 Pa -EE r$ trC.Y!o66Xdr F
rve care
rerating
:
U
oO
6E
-* $g €g sE
o
;s
<:
6-
cE
O!
1Yl
sE
;: *
E
er! P
'ETo.,trF!X.:<1l
O
s: i is€
ql<
r a proj- AaN-€
'edesign E.H€EEAgTb
d=- O-art!V'i>
v._
l3Q!ltr
! ---{!
develop H'i
> Y D A.--
_ Y
: o = 9 F:".
u o =
; for ex- 2a9!-=o:-!
O! reili.r4 C (s,J
the foot N -= >: c) 6 E ! S ",
rc arrest +E b !; H;!i
F tr e
is to de-
xample,
EE
J
/i **
E
Aa .) !* L:
s:3!t; d E;
rutinely : i 6F ?.: , s- o
S or -e,
Er i OE s 6-
: photo-
197

27. l0
qualitl' assurance can be especialnl. iruitlul io nunsing if more research should
efforts are channeled inro eramining the relationships among structure, in the
process, and outcome. and ar
Nurses experience that all patients do not respond the same to the
same nursing inter-vention; for example, some patients relax when given
a back rub, while others feel no change or become more tense. This Qualir
example could be used as an argument for why evaluating outcome is in be_s
more accuraie than evaluating process. Indeed, if the desired outcome framer
is decreased tension in a patient, then the focus of a review of care quality structu
should be the measure of tension experienced by the patient, not the suranc(
nursing intervention to achieve that outcome. On the aggregate level of develol
patient care, the specific interventions are perhaps less important than for sucl
the patient's health status-as indicated by outcomes-but if the out- egates
comes are not achieved, the process may be at fault. gram.
However, nursing does not have tested nursing interventions that re- The s
Iate to patients'achieving specific outcomes. In a quality assurance audit, but ma.
such interventions ccluld be reviewed, and a determination could be nursing
made as to which interventions are most successful and thus which of resou
to use with particular kinds of patients. Although this type of review is respons
not research, it is a use of the collective experience of a specific nursing ity assu
service and thus can have validity for a specific nursing care environ- Iosophy
ment. In addition, nurses can assist in formulating research questions an inte6
related to audit results. The data from audits can provide a rich source nursing
of information for clinical research. few adrr
An additional complicating factor in the structure-process-outcome In an
relationship is that patients may achieve the desired outcomes without may be
any nursing interventions. For example, some patients Iearn self-care gical, pt
through the teaching of relatives or a physician. Although the nurse as- structurr
sumes the primary responsibility for teaching patients, the outcome of are illus
successful learning cannot be assumed to be the result of nurse teaching. committ
Because patient outcomes are products of many processes, nursing would br
cannot be ccrtain that outcomes as measured result from nursing in- committ
terventions. One must also consider the level at which the nursing in-
tervention was directed. That is, how conccntrated, intense, skillcd, or
Iong was the intervcntion? For example , implemcnting a formal teaching
plan for a newly diagnosed diabetic should result in more patient learn-
ing than a singlc talk with the patient aboul diabetes. Similarly, a be-
havior change is more likely in an adolescent mothcr who has a series
of home visits from a public health nurse, rather than just one visit.
Not achieving specific outcomes is not always due to a lack of proper,
adequate, or sufficient process from professional health care providers.
Unless process is aimed at achieving the specific outcomes, they will
I
I
r
Medical nurs
quality assura
not consistently be achieved unless by chance or other influences. Docs I subcommitt
this mean that we should abandon the measurement of palient outcomes FIGURE I]
in favor of measures more demonslrable of nursing care? The question setting.