The Rise of the RN

Marion Fraser and Alison Wesley-James are in remarkably good spirits, considering what they have to accomplish over the next several hours: squeezing 27 surgical beds, six operating rooms, labs, CT scanners, and support areas into 30,000 or so square feet of planned hospital space.

Sitting with healthcare architects in a meeting room at the Omaha, Neb., headquarters of the firm HDR, Fraser and Wesley-James—the CFO and planning manager, respectively, of the Ottawa Heart Institute in Canada—study CAD drawings and stacks of spreadsheets as they weigh all the factors. These include work hours (If the ORs were used more hours per day, wonders Fraser, could they make do with five?) and hospital politics (Where is the best spot to put the CT scanners, so as many doctors as possible can have them close by?).

Most tortuous of all is phasing, the logistics of which can be paradoxical: “You have to build new, to take out the old, to be able to refurbish, to build new,” says Fraser, who wears the sensible clothes of an accountant but a ready smile.

The planned cardiac unit might be new construction or an existing facility that's been renovated—or a combination of both. It's too early to say, since ground won't be broken on the project, a major expansion of the Ottawa Hospital, for another decade. And some of the changes that Fraser and Wesley-James foresee won't take effect until 2031.

2031: That's 24 years from now. To put it in context, 24 years ago, the world's .first “test-tube baby” had just turned .five. Researchers had not yet discovered the cause of AIDS, and balloon angioplasty was a new procedure.

A love of historic buildings fueled the second career of Tammy Felker (left, with colleague Teri Oelrich), a former critical-care nurse who obtained her architecture license in April. The only registered architect at the firm NBBI who also has been a nurse, Felker says her integrated experience is a great asset: "When someone [at a hospital] says, 'We'll get a balloon pump in the elevator,' I know what that equipment is."

Credit: William Anthony

No area of architectural practice today is as fast-moving and complex as healthcare, with its heady (or, depending on your perspective, bone-dry) mix of data crunching, value engineering, and crystal-ball gazing. But the crucial ingredient in healthcare architecture, say its practitioners, is really empathy: for patients who are unsteady after an operation; for doctors and nurses who can treat cancer but can't think in square feet.

Which is why the person running the meeting in Omaha is not a hospital administrator or even an architect. She's the one with frosted hair and stylish glasses at the back of the room, who listens more than talks, asking occasional, to-the-point questions. The one who keeps the discussion on track. The one who makes sure that everyone eats a decent lunch.

That last part figures: Debra Sanders, the director of healthcare consulting at HDR, is a registered nurse.

“I often think back and scratch my head about how I ended up on this career path,” Sanders told me by phone prior to my trip to Omaha. Fourteen years ago, Sanders, a Nebraska native, was working as nurse executive at Clarkson Hospital in Omaha as the hospital underwent a redesign. “Organizations from around the world wanted to come and visit Clarkson and see what we had done,” she remembers, and she spent a lot of time leading them on tours.

But it was a chance meeting that crystallized her interest in healthcare architecture. “I happened to be at a social event where I met the healthcare leadership from HDR, and they said, ‘Will you come talk to us?' They were contemplating developing a consulting practice.” Now Sanders leads a 45-person team at HDR that handles master planning, space programming, signage and way finding, and technology and medical equipment on projects across North America.

Sanders' story—part logic, part luck—is echoed by RNs at architecture firms around the country. Some arrived there with a lifelong interest in building design, but others— probably most—got involved in a renovation or expansion at the hospital where they worked, and realized, Hey, I like this, and I'm good at it. Some have pursued architectural licensure, but the majority have not. Most concentrate on “front-end” planning and space programming, although a few do design work. And a number, like Sanders, are vice presidents or principals, proof that solid nursing and managerial experience can trump years of detailing hospital bathrooms.

Three or four times during her 30-year nursing career, recalls Lynne Shira of Seattle, she was asked to participate in the planning of hospital projects with architects. “I found it very exhilarating, very challenging,” she says. Then her father was diagnosed with Alzheimer's, and she decided that the stress of being a hospital administrator and supervising hundreds of employees was too much. She knew that a leading healthcare-focused firm, NBBJ, was headquartered in Seattle, so she gave them a call. Seven years later, she's a principal in the firm's healthcare consulting practice.

Likewise, Joyce Durham, a licensed architect in the Detroit-area office of HKS, discovered her latent interest in architecture by chance. As a surgical nurse at Duke University Hospital in North Carolina, she volunteered to lead staff members on orientation tours of Duke's new hospital building. “I would ask why things [in the building] were done a certain way: ‘Why is this like this? It doesn't make sense,' ” she says. “I knew at that point I wanted to study architecture.” Durham went on to get a B.Arch. and then an M.Arch. from the University of Michigan, nursing part time through five years of school.

Four of NBBI's seven nurses, from left to right: Tammy Felker, Teri Oelrich, Lynne Shira, and Jane Loura. Says Shira, a principal at the firm: "My role is operations lead-- I'm making sure what we design is operationally efficient. That's my passion, making sure that form follows function."

Credit: William Anthony

The route from floor nurse to floor plan may take different twists, but one thing is clear: It's increasingly well-traveled. Nurses have long parlayed their clinical experience into second careers in healthcare consulting, working either independently or for consulting companies. But in the past decade or so, more and more have signed on as full-fledged employees at architecture firms. (This is in large part due to poaching: Firms realize that although a smart consultant can help them, she might help their competitors, too, unless she's on staff.) These nurses now work as, or alongside, architects on most big healthcare projects in the United States, and their ranks seem destined to keep growing.

“The number of nurses who do this [i.e., start a second career in architecture] is increasing significantly,” says George Tingwald, until this fall the director of healthcare design at Skidmore, Owings & Merrill (he has since become director of medical planning for Stanford University Medical Center). Tingwald himself earned a medical degree before getting his M.Arch. He used to keep a list of nurses and others with clinical experience (like doctors and radiation therapists) who were working in architecture, but when the number passed 50 several years ago, he started to lose track.

Barbara Anderson Zimmer Gunsul Frasca "In the late '80s, I didn't meet another nurse doing what I was doing."

Credit: William Anthony

“We're talking in the low 100s right now,” he guesses, quipping, “If we had a convention of healthcare architects who are clinical architects, we could go to a very small resort.” (The AIA and other national architecture organizations do not tally how many architects have transitioned from a previous career, and the American Nurses Association did not respond to requests for comment.)

Driving the influx of nurses into architecture is the fact that healthcare is big business for U.S. firms. According to the AIA's 2006 firm survey, conducted every three years, healthcare projects accounted for 14 percent of all billings in 2005, making healthcare the top sector served by architects that year (trailed by the office sector at 12 percent). As the demographic bulge of baby boomers nears old age, analysts predict that America's over-65 population will triple by 2030, with chronic ailments and hospital admissions increasing steadily—spurring yet more healthcare construction.

With more construction comes more competition. Ten or 15 years ago, savvy firms discovered that bringing an experienced nurse with them to client meetings could help land a big project and lay the groundwork for a long, profitable relationship. The trend seems to have started in Seattle. As early as 1981, Barbara Anderson, now an associate partner at Zimmer Gunsul Frasca, was scanning the newspaper want ads in that city and spotted one that intrigued her: Architect looking for registered nurse. “It wasn't any longer than three lines,” Anderson says. She got the job and spent the next four years helping a local architect with marketing. In the process, she learned all about architecture and construction.

Joyce Durham HKS "Research and evidence-based design are changing the way things are done."

Credit: William Anthony

Anderson then began to freelance for NBBJ. In 1989, that firm hired Teri Oelrich, a registered nurse with an MBA and a passion for statistics. Now a principal, Oelrich has seen NBBJ's healthcare consulting practice grow into a nurses' powerhouse—there are currently seven nurses employed firmwide and five in the Seattle office, one of whom, Tammy Felker, is a licensed architect. “Every healthcare studio at NBBJ has a nurse,” says Oelrich.

Today it's de rigueur for firms that do healthcare work to have an RN on staff or even a number of RNs in a dedicated healthcare-consulting arm. “I think the past couple of years, it's really become kind of the norm,” says RN and registered architect Kerrie Cardon, a former NBBJ employee who is currently a healthcare consultant for Herman Miller. “If you work on healthcare projects, you need to have a nurse be part of your healthcare team. It's almost expected now.” Merle Bachman, president of HDR Architecture, agrees. When the company recruited Sanders and other RNs, he says, “We did it for selfish reasons, obviously: We wanted a differentiator. Being [one of the] first out there to do it, it helped a great deal. It's not quite as unique as it once was.”

Which means that not having a nurse on the team can be a major liability. “If you're marketing a project, going to a healthcare facility to talk about programming and how you interact with physicians and nurses—if two of the firms have clinicians there, the other two firms are sunk,” Tingwald says.

What nurse–architects and –facility planners bring to the table, above all, is the ability to translate between two professions with very different skill sets—to “fill in the Grand Canyon,” in the words of Rebecca Hathaway, an RN who is vice president of healthcare services at California firm HMC. “Architects can be intimidating [to clinicians],” contends Oelrich. “They use great words, but sometimes no one wants to say, ‘How far do I have to walk? I can't tell from the plan.' We never ask architects to read an EKG.” Bachman says that “97 percent of the time,” bringing a nurse to client interviews has been a “very positive” step. Still, he points out, nurse-consultants can't act as if they have all the answers—hospital staff don't want their own expertise challenged. “It's a little bit of a tightrope,” he concedes.

When Teri Oelrich was studying for her MBA, she thought she'd work for a big management consulting firm like McKinsey or Bain. But an internship at Kaiser Permanente prompted Oelrich, a registered nurse, to consider staying in healthcare, just in a different capacity. "The first day I walked in [to NBBI], I thought, "I want to do this--to help plan hospitals.'"

Credit: William Anthony

By acting as interpreters, nurses in design firms feel they can make hospitals safer, more comfortable places for both patients and the clinicians treating them. Improving work environments for nurses who are run off their feet is cited as a motivation by most of the subjects of this article. “I've worked in facilities that are dark, that don't provide respite spaces for staff to recharge,” recalls Shira. A colleague at NBBJ Seattle, registered architect and former critical-care nurse Felker, argues that patient-centered design—a current buzz phrase in healthcare architecture—should not come at the expense of hospital staff. “They're there 24/7, 365 days a year,” Felker says. “Anything we can do to make a better environment, so they provide effective healthcare, is critical.”

When seen through a nurse's eyes, seemingly insignificant design decisions take on new, surprising weight. Hathaway cites the example of electrical outlets. As the nursing workforce grows older, “Why do we put electrical outlets next to the floor, with nurses bending over constantly?” she asks. Or, as Oelrich puts it, “Have you ever hauled laundry 500 feet? Look where you put the utility room!”

“Burnout” is a term that crops up frequently when speaking to RNs. Oelrich stresses that she tries not to worsen an already severe nursing shortage by hiring straight off the hospital floor: The RNs she recruits need to have administrative experience first. Ultimately, Oelrich hopes, “by having nurses design [nursing] units, we can make them more efficient, which will off set the shortage.”

Kerrie Cardon Herman Miller for Healthcare "Having walked in white shoes, I could see how staff would use those spaces."

Credit: William Anthony

For others, the focus of their design and planning efforts is firmly on the patient. Sharon Woodworth, an architect and former nurse (though not an RN) who is an associate principal at Anshen + Allen in San Francisco, spent much of her childhood as a patient in Texas Children's Hospital. After graduating from nursing school, she went to work for the medical team that had cared for her and “had some illusions shattered.” An aptitude test pointed her towards law or architecture, and she went on to get an M.Arch. from the University of Texas, Austin.

Even after 15 years in nursing and 12 in architecture, Woodworth stresses that her perspective is still that of a patient. She laughs as she describes the first hospital project she worked on as an architect, when a naïve younger team member tried to cram two unisex patient showers into a small space under a stair. “I said, ‘That's not going to work. You [the patient] have got a tube coming out of your body and no room to maneuver!'”

“For me,” she continues, “hospitals are our most powerful buildings. They are a metaphor for life. I don't think nurses necessarily bring that to the table—but those who experience hospitals fully [as patients] do.”

Today, as state-of-the-art robotic devices revolutionize the operating room, hospital architects must learn how to design around new equipment and procedures. Evidence-based design—an approach that draws on quantitative research to reduce the rate of medical errors and improve patient outcomes—continues to gain ground, but the definition of “evidence” remains slippery. There is a more urgent need for specialist healthcare architects and planners than ever before.

Rebecca Hathaway HMC "People [at client meetings] have come up and said, `I'm really glad they have someone like you.' "

Credit: William Anthony

And yet only two architecture schools in the United States offer specialized healthcare programs. “One of the biggest mysteries of my life is that there aren't 20 programs like ours,” says George Mann, who helped to create Texas A&M's Certificate in Health Systems & Design. (The other program is at Clemson University.) Mann has seen an uptick in interest from students, but not enough to meet demand: He estimates that graduates of his program receive an average of eight job offers.

With national shortages, then, of healthcare architects and nurses, and given the fact that many nurses are nearing retirement, who will provide the expertise to navigate medicine's next wave of change? It's a question that's bound to tax architecture firms (not to mention the hospitals that hire them) as they look to the future.

But for now, the dedication of the nurses in their ranks remains unabated. Anderson of Zimmer Gunsul Frasca, who was perhaps the first nurse to go to work for an architecture firm back in 1981, had a total hip replacement at Seattle's Swedish Hospital over the summer. “Boy, did I get to see the other side of what nurses do again,” she says. “They are running so hard. We need to really listen to them and act as their advocate.”