The floor plans were classified first into different zones that could be used to analyse and interpret photos of different practice spaces:
Public – unrestricted areas (free access to all). Examples were the patient entry areas, including waiting rooms, and public access toilets.
Public – restricted areas (access restricted to control by staff). Examples included corridors behind consulting rooms.
Staff-only areas. Examples included reception and administration areas, tearooms and storage areas.
Clinical/Patient interaction areas. Examples included consulting and treatment rooms.
It was quickly clear that practices in the study sample fell into two categories: practices that had modified an older existing building (often a house) to accommodate a medical clinic; and practices that had built (or extended) into a purpose designed clinic Figure .
Contrasting the floor plans in Figures and , the differences between the two categories are highlighted. The first (Figure ) is a long established practice, in a converted federation style house, in the inner suburbs of a metropolitan area. This practice has one nurse, and about 12 GPs. The entrance way is determined by the established front door of the house. Extensive internal work has been done to create consulting rooms, and the overall appearance is that of a ‘rabbit warren’. There is little clear delineation of the public unrestricted area, and public restricted areas. The nurse in this clinic has the smallest consulting room, and no specified treatment room. The ability for the nurse to carry out significant functions within the practice is limited by the practice design.
The practice in Figure however, is purpose built. This is manifest in the clear identification of the four zones. Design consideration has been given to the working needs of the staff, and the nurse is given a central position. This structure was not unusual for these type of surgeries: waiting area to the front, consulting rooms around the edge, and a central island that contains administrative and nurse/clinical areas. In this case the nurse has her own administrative area, as well as having access to, and responsibility for, several spaces.
How nurses use space: looking at the built environment
Within the surgery, nurses have a wide-ranging physical workspace, often wider than the doctors or reception staff. These areas reflect their combination of clinical and non-clinical roles. All but one practice had a treatment room as a centre of nurse clinical activity, whilst several also had dedicated consulting or clinical rooms. Many had an arrangement for time-sharing of consulting rooms when not in use by a doctor. While they clearly focused on treatment and consulting rooms, nurses also identified cupboards and stockrooms as key work areas, demonstrating a prioritisation of workplaces which were not “premium space” in the general practice.
The photograph in Figure presents the most common workspace for nurses – the treatment room. It is in a four consulting room practice, and occupies a central or ‘hub’ position. Treatment rooms are often in a position that makes them a hub of activity within the practice, either amongst the consulting rooms or between the rooms and the reception area. The curtain seen in the right of the picture was the only form of visual privacy, and consequently conferred no aural privacy. This nurse works in a public (but controlled) environment. Observations revealed that other staff had little compunction in intruding in this space, quite distinct from their attitude to the consultation room. Examining the elements of the photos reveals much that is ‘intrinsically active’ - or designed to be used. These are occupational objects in the typology proposed by Riggins [21
]. The predominance of clinical equipment and the organisation of the room indicate that this is a place where things are “done” to patients. There is very little personalisation of this workspace with esteem or social objects - objects conveying status or personality. The central object of this, and all treatment room photos, is the trolley or bed – reinforcing the centrality of the bed to nurse activity in this environment. The focus of this clinical workspace is on the patient – and the procedure to be undertaken - the nurse is secondary. This is in contrast to many medical consulting rooms that display personal artifacts important to the individual practitioner.
By contrast, the nurse desk in Figure is not in a primarily clinical area, but in a shared administration area, adjacent to storage rooms. Here, there is much more ‘intrinsically passive’ material, with social objects found in the form of the jellybean jar and the pot plant. A common feature of all these workspaces is the presence of posters/handouts stuck on the wall. You can see here several sheets of information on the wall, information that the nurse feels she needs rapid access to. This is mirrored in the first photo, with the space above the desk covered with information. In the first photo, note also on the other side of the gloves is more generic information that is more available to the patient and may be less frequently referred to.
A third category of nurse workspace identified in this study is storage or utility areas. These may be integrated into existing spaces or occupy separate areas/cupboards, but are typically like the one shown in Figure – containing almost exclusively active, occupational objects. Their frequent presence in the photos is a reflection of their prominence in nurses’ work practices, both in ensuring stock is kept up to date, and in managing patients in a clinical environment. Nurses frequently reference this aspect of their work and see it as an underpinning component of their contribution to the practice team.
The overall impression is that nurses enact their work in three spatial domains: clinical interactions and activity primarily within patient-centred spaces; administrative work in an ‘office’ setting, and equipment, stock management and support activities conducted within the ‘backstage’ areas of a practice. Correlating this information with the observational and interview data reinforces the fluidity of the nurse space, with nurses cycling through multiple tasks in a given time frame, and deploying a series of operating roles as they adapt to the practice environment.
The six primary operating roles of general practice nurses identified in this study have been described elsewhere [18
], but include: patient care; organisation; problem solving; quality control; education and connectivity. Nurses move consistently through practice space as they cycle between these operating roles. The physical characteristics of the practice space influence these roles through the positioning of nurse spaces, their accessibility, and the independence or shared nature of space utilization. In particular, these elements affect the interconnectedness of nurse work with that of others, and the strength and utility of their connectivity role. This role is an important capacity factor in many practices and an enabler of extended relationships with patients and the broader community.
Nurses are frequent sharers of space – either with other nurses or with colleagues from other disciplines including GPs. In this situation they commonly appropriate elements of the space to be used in a certain way and act as monitors of the behaviour of other space users. This is illustrated by the signage in Figure that acts as both a communication and quality control mechanism.
“A free consulting room is like a present”: talking about space
A prominent theme in the interview and observation data was the lack of space available in general practice to perform the tasks required of the practice team.
Nurse: “[We] don’t need more staff. More than anything we need more space. And -”
Interviewer: “So another treatment room ?”
Nurse: “No, we need - well, a bigger treatment room would have been good but we also need more consulting rooms. I think we could have done with at least one or two more consulting rooms” [PN, practice 3]
This space shortage applied to many activities of the practice as a whole, as well as to nurses specifically.
"“Room, space is…that would be the most difficult thing here, lack of space it just makes everything difficult. I don’t know if you noticed this morning I went and asked if there was any free consulting rooms, you know if there is a free consulting room it is sort of like a present” [PN, practice 2]"
The influence that this had on nurse practice was generally acknowledged, and several of the interviewees noted that, in the scheme of practice allocations, doctors (as greater income generating units) would always have priority over nurses. This was particularly evident in practices based on a modified house design, such as in Figure . Nurses in those practices often described them as ‘rabbit warrens” or “cramped and cosy”. Those in surgeries that had been renovated or purpose built had a more positive view of the space allocation. In the following account, a nurse in a rural area describes the section of the clinic where she works, which has been purpose-built with central cubicles and a nursing desk.
Nurse: “[W]e have a designated nurses area where we have a main desk with our computer system where we do all of our own filling and obviously all the encounters and things for every patient is on the computer.…”
Interviewer: “So that’s almost like a front desk, isn’t it?”
Nurse: “It is, yes. So patients come to us to report, which they don’t really need to but they all like to report to certain doctors…And then from there we have the sterilising area which has also got where we keep all of our medications from the drug reps and things like that, and stock in that area, which goes out to the theatre, which joins onto the theatre which also has a lot of our stock in there.” [PN, practice 13]
Nurses were often involved in the designs of renovations and new surgeries, and this was clearly associated with higher satisfaction with the space allocation. In the following account, a nurse in a large multi-doctor and multi-nurse practice describes a process where the nurses limited their accessibility to patients while maximizing the contiguousness of working patterns with other nurses.
"“The initial plan by the architect just wasn’t - wasn’t very good. Well, we didn’t think it was. And we had a nurses meeting one night because we kept saying to them no, it’s not good enough, we’ve got to walk around too much. And in the original planning they actually had the nurses area directly linked to the patient waiting area and so we would have been walking in and out the patient waiting area, you know, like - and you couldn’t get to the tea room without people sitting and watching you going [and] having cuppas, [that] sort of thing. So we had a meeting one night at one of the nurse’s homes and we actually sat down with the plan and redrew our nursing area. And what we’ve got basically is what we drew up.” [PN, practice 6]"
We have already noted the diverse spaces in which general practice nurses work, characterised by a much more mobile, accessible, open work orientation, especially when compared to the closed, consulting room settings favoured by doctors. Such an open environment was a feature of both the older style surgeries, and the purpose built ones. Nurses are clearly comfortable with, and in fact favour, such an open environment. They saw it not just as a task related feature, but as an expression of their accessibility and the candid or relaxed relationship that perceive they have with patients.
"“[W]e don’t put up barriers for people. We don’t make it difficult for them. We don’t make them feel like ooh, I’m overstepping the mark here, I shouldn’t be here or - yeah, make it very warm. It’s like walking into a home, this place, yeah, and I think that makes a big difference.” [PN, Practice 3]"
The example in Figure shows how rapid cycling of tasks is enabled by working in an open environment. The space requirement of this nurse took her from treatment room through shared and administrative spaces, but importantly her availability in a shared space allows the connectivity element to occur. Doctors are locked away in consulting room, requiring a knock and permission before entering, Nurses, by virtue of the combination of their role and accessibility in the practice space, are available for more unstructured staff and patient contact.
Space and the rapid cycling of nurse tasks.