The Integral Role of Nurses in Ensuring Well‐Designed and Functional New Public Hospitals: A Qualitative Study

ABSTRACT

Aim

To explore the role of nursing in the planning and establishment of a new public hospital, from initial design to full operational capacity.

Background

Building new public hospitals requires comprehensive planning and collaboration to address population growth and aging demographics. Nurses offer invaluable insights into patient care and workflow, which are crucial for effective hospital design.

Methods

A qualitative descriptive study was conducted using focus groups and interviews with 36 participants, including nurses, administrative staff, physicians, and laboratory directors involved in the design and operation of a new public hospital. Data were analyzed using thematic analysis.

Findings

Three themes emerged. The first involved challenges such as recruiting qualified staff, creating standardized regulations, and mismatches between infrastructure and system requirements. The second described coping strategies, including salary adjustments, policy development, and equipment acquisition. The third offered recommendations for future projects, emphasizing comprehensive planning, collaboration, and nursing involvement in decision‐making.

Discussion

Nurses’ knowledge of patient care and workflows bridges the gap between architectural design and clinical function. Their early and sustained involvement supports operational readiness and interdisciplinary collaboration.

Conclusions

Nurses play a vital role in hospital planning and operation, improving teamwork, recruitment, and standardization.

Implications for Nursing

Nursing involvement in hospital planning ensures alignment with patient care and workflow needs. Leaders should advocate for participation and develop competencies in design and construction to enhance collaboration and patient safety.

Implications for Nursing Policy

Evidence‐based nursing input should be integrated into hospital design, and nursing leaders should promote expertise in planning and architectural considerations.

1. Introduction

Hospital systems frequently encounter substantial challenges, including overcrowding and high pressure (Waitzberg et al. 2020; Page et al. 2024), a low curative hospital bed ratio (Haklai and Hallel 2019), and escalating demands on health services due to increased life expectancy (Liu and McKibbin 2022). Consequently, with adequate financial support, building new hospitals can help mitigate some of these issues.

The design of a new hospital necessitates extensive communication with various stakeholders, such as government officials, architects, construction companies, and building engineers, who facilitate the exchange of knowledge and skills among different user groups (Brambilla et al. 2019). These user groups primarily comprise clinicians (physicians and nurses, either individually or in multidisciplinary groups), managers, and patients and their families (Carthey 2020). Successful collaboration between stakeholders and user groups requires agreement on shared goals and assignment of roles, ideally guided by a team leader who is attuned to the complexities of group dynamics.

Architects should learn about the culture, hierarchy, and cross‐departmental ties of the center. This knowledge enables them to design workspaces that support effective healthcare delivery (Brambilla et al. 2019; Carthey 2020; Keys et al. 2017). Accordingly, during the design process, having a diverse team advise on the design is advantageous because it offers access to a broad range of knowledge and information, facilitating problem identification, analysis, and decision‐making. This professional diversity is preferable, given that previous studies have indicated that differing professional subcultures and historical hierarchical power dynamics favoring physicians may lead to group conflicts (Carthey 2020; Hall 2005).

In designing a health system, various environmental categories must be considered concerning their impact on patients, families, staff (including physicians and nurses), and organizational outcomes (Ulrich et al. 2010). These categories encompass audio and visual environments, safety, wayfinding systems, sustainability, patient rooms, and various support spaces for patients’ families, physicians, and other staff members. As all these elements can significantly affect users and organizational outcomes, the objective is to reduce stress, enhance safety and productivity, minimize resource waste, and improve communication among stakeholders (Bernhardt et al. 2022; Tafelmeyer et al. 2017; Ulrich et al. 2010).

The work environment can affect nursing outcomes. It can lead to job injuries, illnesses, and absenteeism. It also affects patient care, job satisfaction, stress, fatigue, job control, social support, teamwork, service quality, patient safety, and hospital commitment (Ulrich et al. 2010).

Nurses represent the largest cohort of healthcare professionals in hospital settings, and their direct interactions with patients and their families enable them to identify factors that can enhance patient outcomes (Tafelmeyer et al. 2017). Furthermore, the extensive hours they dedicate to hospital work and their consequent in‐depth understanding of the work environment can significantly inform the design process to optimize outcomes for patients, families, and clinicians, improve workflows, and facilitate organizational communication (Jouppila 2022; Tafelmeyer et al. 2017).

This study is grounded in the principles of implementation science, specifically utilizing frameworks such as the Consolidated Framework for Implementation Research (CFIR) and the Promoting Action on Research Implementation in Health Services (PARIHS) model. These frameworks highlight the interplay among evidence, context, and facilitation, offering a framework for analyzing nursing leadership and collaboration in hospital design and operational readiness (Nilsen 2015; Harvey and Kitson 2015).

For instance, the design of a patient's room should prioritize safety, such as minimizing fall risks or infection transmission, while also enhancing the overall experience of hospitalization. This may involve incorporating visually soothing elements, such as plants and window views, ensuring comfortable and accessible furniture, reducing noise levels, and improving air quality (Brambilla et al. 2019; Brewer et al. 2018; Waroonkun 2020).

While nurses’ perspectives are crucial to the co‐design process, they often lack expertise in healthcare design, governmental regulations, and budgetary constraints. This gap can hinder effective communication with architects because of the absence of a shared professional language (Carthey 2020; Jouppila 2022). To effectively integrate nurses’ work‐related insights into the healthcare design process, nurses must transition from being mere sources of information to active partners in the design process. A critical aspect is the necessity for administrative support to provide scheduling flexibility, enabling nurses to participate in the design meetings (Jouppila 2022; Keys et al. 2017).

This study aimed to retrospectively examine various aspects of hospital design and construction processes, with a particular focus on nursing. The study analyzed manpower recruitment and retention, working processes and workspace communication patterns, unit design and equipment, and nursing staff education and training. The findings contribute to enhancing future hospital design processes.

The specific study aims were as follows: (1) to explore the role of nursing in the planning and design of a new public hospital; (2) to investigate the processes of staff education and recruitment involved in the design of a new public hospital; and (3) to analyze the workflow interactions among nursing staff, administrators, physicians, and laboratory managers throughout the design process, from initial planning to the opening of the clinical departments and commencement of patient care.

These aims were intended to address the following research questions: (1) What role did nursing play in the design and establishment phases of the new public hospital? (2) What challenges did nurses encounter during this process, and how did the profession address them? (3) What professional insights can be gained from the establishment of a new public hospital project?

2. Materials and Methods

2.1. Design

The present study was conducted at a newly established public hospital in Israel, which spans an area of 70 dunams. The hospital features a nine‐story central accommodation block, a seven‐story building dedicated to scientific institutes and clinical units, and specialized research laboratories within its premises. This facility was developed in response to the increasing regional healthcare demands driven by population growth and an aging demographic profile. It serves as the sole hospital for approximately half a million residents in the surrounding southern Israel region, which is characterized by a diverse population. The hospital includes several departments, such as emergency, internal medicine, and pediatrics departments.

Utilizing a qualitative descriptive methodology, the study explored participants’ perspectives (Bradshaw 2020) on the planning and implementation of the public hospital. The process design facilitated reflection at each stage, resulting in findings that reported changes in practices and interprofessional relationships.

To minimize recall bias, we implemented strategies such as member checking, and participant validation of transcripts to ensure accuracy and credibility.

2.2. Participants

By examining hospital archival documents and consulting with senior nursing and administrative staff, the authors identified 48 potential participants who had been involved in the design, planning, and operation of the new public hospital from its inception to full operation in 2017. These individuals were subsequently contacted for telephone interviews. Of the 48 individuals, 36 agreed to participate, resulting in a 75% response rate. The primary reasons for non‐participation were scheduling conflicts and unavailability during the study period. The interviews were conducted exclusively with the participants and the researchers. In total, 36 participants were involved in the study: 34 were organized into four focus groups (comprising 9 men and 25 women), representing nurses, physicians (medical department managers), and administrative managers (human resources, construction, engineering, etc.) (Table 1), while two additional participants (former medical and nursing directors) were interviewed individually. Most of these participants continue to be employed at the hospital, except for three nurses and two administrative staff. The research team consisted of the first author (PhD, RN, with experience in hospital administration) and a research assistant (MA with expertise in qualitative research). Neither had hierarchical relationships with the participants. Reflexivity was maintained through peer debriefing and audit trails.

TABLE 1.

FGD: Participant characteristics.

Variable	FGD 1 Nursing (N = 12)	FGD 2 Nursing (N = 8)	FGD 3 Administrative workers (N = 8)	FGD 4 Physician/ laboratory (N = 6)
Gender
Male	2	1	4	2
Female	10	7	4	4
Age range (years)
35–40	0	0	3	0
41‐49	7	4	2	2
50–55	3	3	1	3
56–60	1	0	2	1
61–69	1	1	0	0
Education
B.A	0	1	3	0
M.A	11	7	5	0
PhD/MD	1	0	0	6

The intentional distribution of participants, with a predominance of nurses relative to other professional groups, was designed to reflect their pivotal role in hospital planning and operations. Nurses were prioritized due to their direct involvement in patient care and workflow design, both of which are essential to hospital functionality. This distribution ensured that nursing perspectives were adequately represented while also incorporating insights from administrative and medical staff. The inclusion of participants from diverse professional groups allowed us to compare perspectives from different angles, ensuring that the themes reflected both clinical realities and managerial considerations involved in establishing a hospital.

2.3. Procedure and Data Collection

We employed focus group discussions (FGDs), a well‐established qualitative research method for eliciting comprehensive descriptions of experiences through interactive group dialogue (Sim and Waterfield 2019). This methodology facilitates the sharing of ideas and sensitive information among participants, offering advantages over individual interviews (Kruger et al. 2019). Between December 2023 and January 2024, the first and last authors conducted four scheduled Zoom FGDs, each lasting between 60 and 90 minutes, with an average duration of 75 minutes. Individual interviews lasted approximately 60 minutes. The total data corpus comprised approximately 250 pages of transcribed text.

Two FGDs were conducted with the nursing staff, one with the administrative staff, and one combined session with physicians and laboratory directors. The group sizes (12, 8, 8, and 6 participants) facilitated meaningful interactions and productive discussions, while the Zoom format enabled participation from various locations nationwide. Additionally, two individual in‐depth interviews with the hospital's former medical (male) and nursing (female) directors were conducted via Zoom to gain deeper insights into the study. These separate interviews also mitigated the potential hierarchical influence on other participants.

The interview guide was developed based on the existing literature (Buschle et al. 2022) and expert consultation. It was pilot tested with two nursing staff members who were not included in the final sample to ensure clarity and relevance. The feedback from the pilot was used to refine the questions. The interview guide included questions regarding the nurses’ roles and the challenges associated with the new hospital design plan and implementation. Each session commenced with an introduction to the research team and clarification of the study's objectives.

Demographic information was collected before proceeding to the main question. The guide questions included open‐ended prompts such as: “What was your role in the hospital design?”; “What was your part in operating the new hospital?”; “What challenges did you encounter?”; “How did you address these challenges?”; “What insights from your experience would you apply to future projects?”; and “What recommendations would you offer to stakeholders or health policy directors for the planning and design of a new hospital in the future?” The question for non‐nursing participants was: “In your opinion, what was the role of nursing in the planning and operation of the hospital?” Participants were given ample time to share their perspectives, and the researcher employed probing and clarification questions to encourage deeper exploration of their responses.

The researchers took field notes during the FGDs to facilitate the review of the participants’ content. All FGDs and interviews were audio and video‐recorded, and prior to analysis, the verbatim transcripts were shared with a few participants for content validation. None of the participants requested any changes to their transcripts. Participants were approached via telephone using a standardized script to minimize bias. We considered thematic saturation to have been reached when no new codes emerged.

2.4. Data Analysis

The transcriptions were professionally translated from Hebrew to English and then back to Hebrew. Coding was performed on English transcripts to facilitate team collaboration. Translation was completed before the analysis. In addition to back‐translation, bilingual researchers compared the translations with the original Hebrew transcripts and deliberated on ambiguous terms to ensure cultural and linguistic accuracy of the final version.

The thematic analysis was guided by principles of implementation science, with a focus on determinants such as context and facilitation to inform interpretation (Nilsen 2015).

The researchers meticulously reviewed all transcripts and employed thematic analysis to identify, analyze, and report the patterns within the data (Vaismoradi et al. 2016). Thematic analysis is particularly suitable for studies with extensive qualitative data sets because it enables systematic coding, theme identification, and interpretation. It facilitates the comparison of participant perspectives, uncovers similarities and differences, generates unexpected insights, and enhances the study's trustworthiness (Squires 2023; Ahmed et al. 2025).

This analysis adhered to a structured, chronological process encompassing the following phases: (1) preparation and organization of the recorded discussions; (2) verbatim transcription of the discussions; (3) thorough review of the transcripts to enhance familiarity with the data; (4) initial generation of insights through self‐notes; (5) data coding with concise descriptive phrases designed to assign meaning; (6) transformation of codes into categories and subsequently themes (Table 2); and (7) development of a transparent analytic process by organizing findings into a theme and subtheme tree (Lester et al. 2020). Two researchers independently analyzed the data and subsequently convened to discuss and reach a consensus on the results. The authors adhered to the COREQ‐32 reporting items throughout the research process (Tong et al. 2007).

TABLE 2.

Example of thematic analysis process.

Raw data excerpt	Initial code	Category	Theme
“We started recruiting nurses, and after about a month… we didn't have a single nurse.”	Difficulty recruiting nurses	Workforce challenges	Challenges in Hospital Establishment
“Imagine what it's like when a team starts to coalesce, and then the head nurse leaves…”	High turnover in nursing management	Workforce challenges	Challenges in hospital establishment
“Everyone comes from a different hospital, and each thinks that [the hospital] they came from is the best place.”	Lack of unified work processes	Operational integration issues	Challenges in hospital establishment
“We performed both ‘dry [theoretical] and wet’ [with patients] simulations….”	Use of simulations for process testing	Workflow standardization	Managing challenges
“We [nurses and administrators] started to travel to medical centers in Europe to learn….”	Learning from international hospital models	Strategic planning	Managing challenges
“Listen to the nurses. If there's a demand… the support from nursing is essential….”	Valuing nursing input	Nursing contributions	Insights and future recommendations

2.5. Ethical Considerations

Participants were provided with written information detailing the study's objectives and were required to sign a consent form to indicate their willingness to participate and have their responses recorded. Anonymity was guaranteed, and data access was restricted to researchers. The study was approved by the Institutional Review Board of Samson Assuta Ashdod University Hospital and the Tel‐Aviv University Ethics Committee (No. 0006702‐1).

2.6. Rigor and Reflexivity

The rigor and reflexivity of the study data were evaluated using four key criteria: credibility, transferability, dependability, and confirmability, as outlined by Krefting (1991). We implemented several strategies to uphold the quality of the study, including peer review and member checking of the study design to enhance credibility. The participants provided detailed descriptions to facilitate transferability. Furthermore, we ensured the reliability of our data collection, analysis, and interpretation processes by supplying adequate contextual details to support dependability and confirmed the findings through a comprehensive review. Two researchers experienced in qualitative methodology, independently analyzed the data and subsequently compared and discussed their findings in relation to the resulting thematic structure. Finally, the participants were invited to review the findings and confirm their accuracy to bolster confirmability (Ahmed 2024). Trustworthiness was ensured through member checking, peer reviews, and maintaining an audit trail. The researchers acknowledged their professional backgrounds and the potential influence they may have on the interpretation.

3. Findings

The FGDs and interviews with the professional staff involved in establishing a new hospital revealed three main themes and nine subthemes (Figure 1).

FIGURE 1.

Study themes and subthemes.

The first theme highlighted significant challenges, such as difficulties in recruiting and retaining skilled personnel, creating uniform work regulations, and discrepancies between hospital systems and physical infrastructure.

The second theme delved into the coping strategies employed by the staff, including adjusting salary agreements, establishing new regulations, and procuring the necessary equipment.

The third theme offered participants’ recommendations for future hospital establishments, emphasizing the importance of comprehensive pre‐planning, staff collaboration, and integrating nursing staff into planning and decision‐making processes.

3.1. Theme 1: Challenges in Hospital Establishment

The establishment of the hospital under study faced significant challenges, particularly in recruiting and retaining skilled nursing staff members. This situation has resulted in compromises in hiring qualified staff and efficiently managing departments. Integrating teams from various hospitals into a single entity posed difficulties in consolidating work processes, policies, and value sharing. Furthermore, the transition from planning to implementation revealed several discrepancies between the hospital's operational functionality and physical infrastructure.

3.1.1. Subtheme 1: Workforce Building and Training

Significant challenges in recruiting and retaining skilled personnel have led to the hiring of minimally qualified individuals, some of whom have left shortly after being employed, resulting in management instability.

Interviews revealed substantial difficulties, particularly in nursing recruitment, with one interviewee noting the reluctance of nurses in secure positions to transition to a new hospital setting. The emergency department faced specific challenges, managing to secure only four nurses with basic training for its opening (Table 3).

TABLE 3.

Illustrative participant quotes and thematic categorization.

Participant Quote	Participant identifier	Theme	Subtheme
“The process of recruiting nursing staff began; however, no nurses were recruited for about a month. None of the applicants agreed to work in the institution unless a collective [labor] agreement was established. Extensive demographic information was gathered, including how many nurses live within the projected hospital's [geographic] area, which is a proxy measure of the potential workforce. These numbers did not definitively determine the supply of staff available; however, a percentage of qualified nurses were not willing to be employed by our facility, choosing instead to find a job in more remote hospitals, even though they lived within the potential catchment area.”	Participant #21 (Administration)	Challenges in hospital establishment	Workforce building and training
“A team of diverse chief nurses, their deputies, and other personnel must be able to communicate effectively in a common language. All participants follow an identical code of ethics and have completed the basic nursing curriculum, making them qualified for their respective jobs. However, there are differences in their work processes; not all of them use the same frameworks and control systems and their performance capabilities and professional potential are highly variable.”	Participant #18 (Nursing)	Challenges in hospital establishment	Difficulties in joint operational frameworks
“In essence, the current building was modified according to the expected operational needs but the expected operational outlook was incompatible with the available physical composition which was inflexible due to its strong construction. The operational methodologies were of an American and Australian pattern, but the building was of a European medical work pattern, thus creating a disconnect between operations and design.”	Participant #3 (Physicians)	Challenges in hospital establishment	Physical resource issues: planning and operational discrepancies
“We [nurse managers] defined, for example, the size of the pharmacy and storerooms in internal wards, and found out later that they [contractors] built the rooms in a way that does not meet the standard. They were too small. Internal medicine requires large quantities of drugs, but it was no longer possible to change the size of the room; it was impossible to fix the mistake. When we entered the hospital [for its operation], we intended to knock down a wall, and I don't know if it was done. On the other hand, in an operating theater, for example, we saw that there was a problem with the storerooms. So, we changed the functions there.”	Participant #30 (Nursing)	Challenges in hospital establishment	Physical resource issues: planning and operational discrepancies
“The chance to help in the formation of a new hospital inspired many recruits because this was something that had never been repeated in the country during the previous forty years. This opportunity was appealing to the young nurses, as they saw an opportunity to develop their talent within the institution and a clear path to professional growth. Six or seven years after its establishment, it is clear that the institution has achieved its goal, as evidenced by the many nurses interviewed, who were fledgling professionals at the time but are now in top management roles.”	Participant #9 (Nursing)	Managing challenges	Navigating workforce shortages
" In the very beginning, the problem of human resource and constant lack of staff permeated the whole system, thus, a national system was necessary to develop future human resource. To give an example, when a new hospital needs more physicians, it is wise that planning should begin at least 10 years or in practice seven or eight years beforehand.”	Participant #25 (Administration)	Insights and future recommendations	Pre‐project setup
“Earlier contributions by skilled individuals would have alleviated a myriad of structural problems. In the technical case of planning, simulations were carried out before departmental operations began to ensure smooth operation. In addition, the institution emphasizes the need for daily research and constant process innovations, thus, positively influencing the future development of procedures.”	Participant #32 (Physicians)	Insights and future recommendations	Pre‐project setup
“The interdisciplinary processes must be put in place during the pre‐design stage so that the differences that exist between operational performance and final results, including differences between bathroom sink placement or X‐ray counter placement and departmental goals, are reconsidered when the stakeholders realize the need to work together across several disciplines. These disjunctures between the functioning and final outcome can change when an interdisciplinary knowledge among incumbents recognizes that such a co‐operation is essential.”	Participant #16 (Nursing)	Insights and future recommendations	Pre‐project setup
“The collective involvement of all team members, including both managerial and non‐managerial staff, is necessary to create an open channel of communication and listening. This type of collaborative structure helps to adjust to changing demands and the ongoing process of evolution, preventing the stagnation of organizations.”	Participant # 5 (Nursing)	Insights and future recommendations	Employee cohesion cooperation
“At the departmental level, the institute's director was provided with a comprehensive package, but he never participated in any investigations regarding planning, achieving goals, or executing operations. As a result, responsibility was taken up by nursing personnel and this trend has been emulated in most of the departments.”	Participant #24 (Administration)	Insights and future recommendations	Recognizing essential contributions of nursing

Challenges were also evident in forming the nursing management team. For instance, a participant described the difficulty in recruiting personnel for the management team, which experienced a high turnover of head nurses, causing considerable disruption in the department: “Imagine when a team starts to coalesce, and then the head nurse leaves under poor circumstances. A new head nurse with just 6 years' experience fails and leaves a year later” [Participant #6, Nursing].

Another participant further argued that the issue of recruiting experienced staff during the hospital's opening phase was highly problematic: “It's impossible for 80% of nurses to have only two months of experience. You cannot build a department like that. I was assigned to a department where most nurses were recent graduates who had never treated pediatric or children's patients. It wasn't easy” [Participant #12, Nursing].

3.1.2. Subtheme 2: Difficulties in Joint Operational Frameworks

The integration of teams from various hospitals into a single cohesive unit presents challenges across multiple domains, including differing work processes, policies, and administrative systems, as well as a lack of a unified professional language and shared values. For example, one participant described the nursing team as resembling a “kibbutz [cooperative settlement] of exiles because every nurse came from a different place” [Participant #21, Nursing]. This sentiment was echoed by Participant #18, who compared the hospital to the “Tower of Babel” (Table 3). Participant #23 further elaborated on the difficulties faced during the hospital's establishment: “Everyone comes from a different hospital, and each thinks that [the hospital] they came from is the best place. Now, we need to agree on what is right for us here” [Participant #23, Physicians].

3.1.3. Subtheme 3: Physical Resource Issues: Planning and Operational Discrepancies

The establishment of the hospital faced substantial challenges during both the planning and implementation stages, resulting in frequent discrepancies between its operational functionality and its physical structure. The lack of established hospital planning models in the country further intensifies these challenges, underscoring the disconnect between architectural planning and implementation and complicating the identification of effective strategies for facility design.

The interviewees reported experiencing considerable stress and difficulty in the hospital planning process. For instance, Participant #28 noted: “Building a hospital requires multiple consultants for electricity, water, and other utilities. Unclear ideas can lead to significant problems. The ward size discrepancies were concerning: planned at 22 m², approved at 24 m², and built at 25 m². The original three‐bed plan was reduced to two beds, with a third bed reserved for emergencies only” [Participant #28, Administration]. (See Table 3 for further supporting quotations.)

3.2. Theme 2: Managing Challenges

The hospital faced numerous challenges, such as manpower shortages, uncoordinated workflows, equipment deficiencies, inconsistencies in the physical infrastructure, and financial difficulties.

3.2.1. Subtheme 1: Navigating Workforce Shortages

The hospital's personnel shortage has led to extended and stressful working hours for the current staff, ultimately affecting patient care. For example, Participant #5 shared: “I worked 360 hours a month… I was hesitant to leave the team alone, especially since many of the new staff had just obtained their Registered Nurse (RN) licenses and lacked experience in emergency medicine” [Participant #5, Nursing]. To address this issue, the hospital shifted from individual wage agreements to collective agreements and introduced professional training and advancement opportunities to retain employees. Participant #27 noted this transition, explaining that initially, nurses preferred personal agreements, as was common in other private hospitals, but this approach impeded the recruitment efforts. He explained that adopting a collective agreement model that offered clear and stable terms resulted in an increase in nurse applications. He remarked: “People tend to be conservative and want security. The collective wage agreement provided clarity, enabling us to recruit more effectively” [Participant #27, Administration]. A significant additional strategy for recruiting employees involved highlighting opportunities for advancement to key positions (see Participant #9 in Table 3). Participant #5 concluded that addressing the manpower shortage required innovative thinking by the hospital staff, who devised a unique solution: “We'll recruit new people, fund their initial training, and ensure they commit to us in return” [Participant #5, Nursing].

3.2.2. Subtheme 2: Refining Workflows and Process Management Strategies

The lack of standardized management and operational procedures at the hospital presented significant challenges, requiring close collaboration and extensive training. Simulations were instrumental in standardizing management practices and facilitating phased departmental openings to ensure seamless operations and high‐quality service delivery.

To address the need for protocols, Participant #18 described her approach as follows: “I drew on prior experience and adapted nursing protocols from other institutions.” She also discussed a months‐long learning process designed to define work processes, stating, “I worked mornings at the Gastro unit and afternoons until 10 PM at another hospital with my [previous workplace] team, which helped me learn work processes, protocols, and equipment” [Participant #18, Nursing].

External assistance [from other hospital colleagues] proved invaluable, as Participant 16 recalled: “I recruited a talented nurse from another medical center, where she served as deputy nurse. She worked here for four months to train other nurses during the shifts. We implemented protocols and work processes after reaching a consensus through discussions” [Participant #16, Nursing].

Participant #30 (physicians) emphasized the importance of starting with fundamental competencies to establish effective processes, explaining the value of a gradual, well‐planned opening of departments over six months to a year. This strategy allowed for the successful rollout of services through measured steps and careful scheduling [Participant #30, Physician]. Participant #2 noted that before opening each department, simulations were conducted to test equipment and patient flow: “We performed both ‘dry [theoretical] and wet’ [with patients] simulations, identifying and addressing gaps quickly. Only after thorough testing would a department be opened. Today, simulations remain a standard procedure before launching new services, ensuring that all aspects function optimally” [Participant #2, Nursing].

3.2.3. Subtheme 3: Strategic Equipment and Facility Planning

When establishing the hospital, the founders faced significant challenges in procuring equipment and designing buildings. To tackle these issues, the founding team embarked on extensive travels to Europe, studied hospital infrastructure, and leveraged personal connections to find solutions. Participant #36 recounted: “We [nurses and administrators] visited European medical centers to understand the facilities and specialized units. We toured factories producing beds and lighting, learning about clinical room requirements, including design, components, floors, walls, and window placement.” In addition to determining the necessary equipment for each department, she noted that they consulted with professionals in the field, including “experts in various fields and nurses from hospital wards or the Ministry of Health” [Participant #36, former nursing director].

Participants also described the difficulties in acquiring essential equipment and the accompanying frustrations. For instance, Participant #7 detailed her use of personal connections to secure critical equipment for the hospital's opening: “I simply reached out to X [name of people], leveraging my connections… with an agent from my previous role… and requested donated devices even before the hospital was operational, thus acquiring devices from the company's warehouses…. I received them as an initial donation, along with other equipment” [Participant #7, Nursing].

3.3. Theme 3: Insights and Future Recommendations

The FGDs revealed significant insights and recommendations relevant to the development of future hospitals. A common challenge identified was the lack of a shared working language among team members from diverse backgrounds. Therefore, fostering collaboration and prioritizing relationship building and mutual respect are crucial. Additionally, recognizing the vital contributions of nursing staff and incorporating their perspectives and needs into planning and decision‐making processes is of utmost importance.

3.3.1. Subtheme 1: Pre‐Project Setup

The participants highlighted the crucial importance of meticulous preparation and comprehensive planning for successfully inaugurating hospitals. Key elements include understanding construction regulations, developing phased opening strategies, and involving experienced professionals. Interviewees stressed the need for the founding team to dedicate significant time and effort before the opening date. For example, Participant #21 described understanding building regulations as requiring “a lot of advance preparation. Anyone establishing a hospital must do this well in advance” [Participant #21, Administration]. (Additionally, see Participants #25, #32, and #16 in Table 3.)

3.3.2. Subtheme 2: Employee Cohesion Cooperation

Collaboration and effective leadership are essential for establishing and operating hospitals. Participants emphasized the need for interdisciplinary teamwork in decision‐making and the integration of new team members into the team. This collaboration is vital for achieving successful outcomes, with strong leadership as a fundamental prerequisite. Participant #30 highlighted the importance of early alignment of objectives and the development of a shared language among team members, stating: “We train medical professionals but don't emphasize collaboration, leading to gaps” [Participant #30, Physicians]. She advocated for the early introduction of interdisciplinary processes designed to foster understanding and address operational challenges from the hospital's inception. Participant #17 also reflected on a critical moment during the hospital's establishment when the management team engaged in open brainstorming, thereby acquiring a diverse array of insights that informed their subsequent actions [Participant #17, Nursing].

From an administrative perspective, the significance of motivation and commitment is often underestimated. For instance, Participant #22 (Administration) noted that valuable skills can exist beyond formal qualifications and lamented the restrictions placed on hiring medical secretaries, advocating for the creation of a commitment‐driven workplace focused on service. The FGDs revealed that the process of creating a united team with a shared language is ongoing and continues even after the hospital's establishment (Participant #5, Table 3).

3.3.3. Subtheme 3: Recognizing Essential Contributions of Nursing

The importance of nursing in the establishment and operation of hospitals was frequently highlighted in the FGDs and interviews. Participants stressed the need to value the insights and needs of the nursing staff, incorporate their perspectives into planning and decision‐making, and acknowledge their expertise in providing patient care. Additionally, the crucial role of the nursing team in the hospital's construction was highlighted. For instance, Participant #24 (Administration) described it as: “a hospital built by nurses, opened by nurses.” She asserted that nursing played a decisive role in ensuring that any requirements or requests were implemented by the nursing staff [Participant #24, Administration] (see Table 3).

Given the significance of nurses in guiding the hospital's establishment process, Participant #8 advised: “Listen to the nurses. If there is a demand, whether for equipment or other needs, nursing support is essential, straightforward, and uncomplicated. From my perspective, it all comes back to the nursing team.” She further highlighted the consequences of nursing absence, stating, “We observed that when nursing was absent or not engaged, mistakes occurred in understanding the processes. Ultimately, nurses understand these processes better than anyone else.” [Participant #8, Nursing]. These pivotal organizational skills were corroborated by the physicians' FGDs, as Participant #33 stated: “Nurses were very, very good at creating [clinical] teams and establishing functioning departments” [Participant #33, Physicians]. The former medical director, in his interview, also emphasized: “Nursing played a very central role in determining the protocols, and the joint training and instruction. I regarded them with appreciation.”

4. Discussion

4.1. Challenges in Hospital Establishment

Our study confirms that workforce shortages, fragmented operational frameworks, and infrastructure deficiencies are not just theoretical concerns but real challenges faced by the participants. These issues directly impact nurses' ability to provide safe care and influence organizational preparedness (Bahadori et al. 2016; Bhatia et al. 2023).

Our findings are also consistent with implementation science frameworks, demonstrating how nursing leadership and interdisciplinary collaboration serve as facilitators for organizational change, in accordance with CFIR and PARIHS constructs (Harvey and Kitson 2015).

Unlike previous studies that have categorized these as structural issues (Bahadori et al. 2016), our data illustrate how these gaps disrupt workflow and compromise patient safety. In the realm of implementation research, our findings demonstrate how nurses serve as facilitators by bridging design decisions with workflow realities and interdisciplinary collaboration.

This aligns with the principles of implementation science, which emphasize evidence, context, and facilitation for sustainable change (Harvey and Kitson 2015). Furthermore, our empirical results support international evidence that interprofessional collaboration, particularly between nursing and administrative or technical professions, enhances successful implementation and organizational learning (Zhou et al. 2021; Keys et al. 2017).

4.2. Managing Challenges

Participants identified adaptive strategies to tackle workforce shortages, workflow inconsistencies, and resource limitations. These strategies encompass collective wage agreements, phased openings, and simulation approaches that align with best practices in the literature (Tamata and Mohammadnezhad 2023; Bhatia et al. 2023).

Unlike generic recommendations, our findings illustrate the practical application of these strategies in real‐world settings. After pinpointing the key challenges in hospital design and operation, the participants described methods for managing workforce shortages, addressing discrepancies in work processes, and allocating equipment and resources.

Initially, during the operational phase, nurses addressed manpower shortages by increasing the workload of existing staff. However, this approach is known to exacerbate nurse burnout and negatively impact patient safety (Tamata and Mohammadnezhad 2023).

As previously documented (Lowman and Harms 2022), the issue was later resolved by implementing a new wage agreement and presenting the nursing position in the new hospital as a unique opportunity for a challenging career.

Regarding the establishment of unified work processes, the interviewees reported using simulations and exercises that aligned with the literature recommendations (Bhatia et al. 2023; Garg 2023). Strategies for resource planning were informed by practices from medical centers abroad, and nurses employed creativity and interpersonal skills to secure funds and equipment, as previously reported in other contexts (Bhatia et al. 2023; Segev 2023).

4.3. Insights and Future Recommendations

Participants consistently emphasized three key priorities for upcoming hospital projects: comprehensive advance planning, fostering interdisciplinary collaboration, and acknowledging the vital contributions of nurses. These recommendations align directly with the themes of planning, team cohesion, and leadership.

While existing literature underscores the importance of regulatory knowledge and architectural considerations (Bhatia et al. 2023; Garg 2023; Bahadori et al. 2016), our findings expand on this by illustrating how frontline nursing insights bring these principles to life in practice.

Nurses’ involvement ensured that workflow realities and patient safety were integrated into design decisions, thereby addressing the study's original aim of exploring the role of nursing in hospital establishment. Moreover, the enhancement of collaboration between nursing and engineering, as highlighted in previous research (Zhou et al. 2021), was evident in participants’ accounts of joint problem‐solving during construction and equipment planning.

Although these findings are specific to the national context examined, several principles, such as early involvement of nursing professionals, interdisciplinary collaboration, and phased implementation, may be relevant to other health systems.

Nonetheless, the transferability of these principles depends on factors such as organizational culture, regulatory frameworks, and resource availability. Health systems facing similar structural challenges may find these strategies adaptable, whereas systems with differing governance or funding models may necessitate context‐specific modifications. This perspective aligns with Greenhalgh et al. (2017), who argue that successful implementation depends on the dynamic interaction between the intervention and its context.

4.4. Strengths and Limitations of the Study

This study examined the essential role of nursing in the planning, design, and operation of a new public hospital from a multidisciplinary perspective. The involvement of nursing personnel in these processes is crucial due to their systemic vision, organizational skills, competencies, and creativity in addressing complex managerial issues related to clinical workflow and staffing.

This study identifies key challenges based on evidence and experience and proposes strategies to address them, thereby enhancing future projects. As a pioneering effort in this field, it offers a comprehensive analysis of a subject that, to our knowledge, has not been explored in detail.

The strength of this research lies in its examination of the intersection between nursing practices and hospital design, highlighting the invaluable contributions that nursing professionals can make to optimize the healthcare environment.

The limitations of this study primarily arise from its retrospective nature, which relies on the experiences and perceptions of administrative staff, physicians, laboratory managers, and nursing staff. Consequently, the findings depend on participants’ memories, which may introduce biases related to the selectivity of recalled events and examples.

The implementation of FGDs facilitated dynamic interactions among participants, enabling them to stimulate and corroborate one another's recollections. This process effectively mitigated recall bias and enhanced the quality of the data collected for this study's analysis.

Another limitation pertains to the use of Zoom for the interviews. While this format allowed for broader geographical representation and reduced travel costs for interviewers, it hindered our ability to incorporate formal participant observation into our research methodology. Specifically, we encountered challenges in capturing facial expressions and body language, as well as in distinguishing between individual speakers without repeatedly reviewing the recorded interviews.

Another drawback concerns the translation of Hebrew‐origin interviews into English. Although the translations were conducted by a professional translator and a back‐translation procedure was employed to prevent errors, minor linguistic and cultural nuances may have been diluted or distorted during translation. This may have influenced the meaning of some participants' expressions. As a countermeasure to this risk, the research team compared the translations with the original transcripts and discussed ambiguous words until consensus was reached.

Future hospital projects should employ implementation science methodologies to systematically incorporate nursing insights into both design and operational planning (Nilsen 2015).

4.5. Implications for Nursing and Health Policy

The findings of this study are of considerable importance to nursing managers and health policy stakeholders, underscoring the critical role of professional nursing involvement in the planning and establishment of healthcare institutions. Additionally, healthcare stakeholders can utilize these insights to improve manpower and resource planning, optimize team training, and create effective workflows.

Prioritizing nursing involvement is essential and can be achieved by equipping nurses with a thorough understanding of construction, building regulations, and architecture, which facilitates effective communication with team members.

We strongly advocate for investment in this area, as it not only enhances the profession's prominence and prestige but also has the potential to significantly improve the quality of patient care.

5. Conclusions

This study underscores the crucial role nurses play in the planning, design, and operation of a new state‐owned hospital. As key intermediaries, nurses influence clinical, architectural, and managerial domains, ensuring that patient care priorities and efficient work processes are seamlessly integrated at every stage of development. Their involvement promotes interprofessional collaboration, enhances workforce integration, and supports evidence‐based decision‐making.

These findings highlight the importance of fostering leadership in nursing and providing specialized training in design and planning to create effective healthcare environments. Future research should investigate nurses’ roles in facilitating interprofessional collaboration, promoting sustainability, and achieving organizational success in various settings.

Author Contributions

Study design: RS, ILN, and TD. Data collection: All authors. Data analysis: RS. Manuscript writing: All authors. Critical reading and revisions: All authors. Study supervision: RS, ILN, and TD.

Conflicts of Interest

The authors declare no conflicts of interest.

Funding

The authors have nothing to report.

Segev, R. , Leibovich‐Nassi I., Perepech A., Adler I., and Danieli T.. 2026. “The Integral Role of Nurses in Ensuring Well‐Designed and Functional New Public Hospitals: A Qualitative Study.” International Nursing Review 73, no. 1: e70156. 10.1111/inr.70156

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.