Debajyoti Pati

Relationships Between Exterior Views and Nurse Stress: An Exploratory Examination

Objective: Examine the relationships between acute stress and alertness of nurse, and duration and content of exterior views from nurse work areas. Background: Nursing is a stressful job, and the impacts of stress on performance are well documented. Nursing stress, however, has been typically addressed through operational interventions, although the ability of the physical environment to modulate stress in humans is well known. This study explores the outcomes of exposure to exterior views from nurse work areas. Methods: A survey-based method was used to collect data on acute stress, chronic stress, and alertness of nurses before and after 12-hour shifts. Control measures included physical environment stressors (that is, lighting, noise, thermal, and ergonomic), organizational stressors, workload, and personal characteristics (that is, age, experience, and income). Data were collected from 32 nurses on 19 different units at two hospitals (part of Childrens Healthcare of Atlanta) in November 2006. Results: Among the variables considered in the study view duration is the second most influential factor affecting alertness and acute stress. The association between view duration and alertness and stress is conditional on the exterior view content (that is, nature view, non-nature view). Of all the nurses whose alertness level remained the same or improved, almost 60% had exposure to exterior and nature view. In contrast, of all nurses whose alertness levels deteriorated, 67% were exposed to no view or to only non-nature view. Similarly, of all nurses whose acute stress condition remained the same or reduced, 64% had exposure to views (71% of that 64% were exposed to a nature view). Of nurses whose acute stress levels increased, 56% had no view or only a non-nature view. Conclusions: Although long working hours, overtime, and sleep deprivation are problems in healthcare operations, the physical design of units is only now beginning to be considered seriously in evaluating patient outcomes. Access to a nature view and natural light for care-giving staff could bear direct as well as indirect effects on patient outcomes.

A framework for evaluating evidence in evidence-based design.

A major challenge in the evidence-based design (EBD) practice model has been in determining the degree of credibility of specific (or a body of) evidence. This challenge has remained one of the key impediments to the broader adoption of EBD. Borrowing from evidence-based medicine and evidence-based practice literatures, this paper proposes a framework for evaluating evidence in EBD. Key to the proposed framework is the separation of the evaluation of strength and quality of evidence from the evaluation of appropriateness and feasibility in a specific application context.

Influence of Positive Distractions on Children in Two Clinic Waiting Areas

Objective: To examine the influence of positive distraction on the behavior and activity of children in two clinic waiting areas. Background: People spend a considerable proportion of time waiting in hospitals. Studies show that the quality of waiting environments influences the perception of quality of care and caregivers, that perception of waiting time is a better indicator of patient satisfaction than actual waiting time, and that the waiting environment contributes to the perception of wait time. In fact, the attractiveness of the physical environment in waiting areas has been shown to be significantly associated with higher perceived quality of care, less anxiety, and higher reported positive interaction with staff. Can positive distractions in waiting areas improve the waiting experience, as indicated by the behavior and activities of children waiting for treatment? Method: Five distraction conditions were randomly introduced in the waiting area of the dental and cardiac clinics of a major pediatric tertiary care center through a single plasma screen intervention. The attention, behavior, and activities of waiting children were recorded. Data on 158 pediatric patients were collected over 12 days during December 2008 and January 2009. Results: Data analysis shows that the introduction of distraction conditions was associated with more calm behavior and less fine and gross movement, suggesting significant calming effects associated with the distraction conditions. Data also suggest that positive distraction conditions are significant attention grabbers and could be an important contributor to improving the waiting experience for children in hospitals by improving environmental attractiveness.

An empirical examination of the impacts of decentralized nursing unit design

Objective: The objective of the study was to examine the impact of decentralization on operational efficiency, staff well-being, and teamwork on three inpatient units. Background: Decentralized unit operations and the corresponding physical design solution were hypothesized to positively affect several concerns—productive use of nursing time, staff stress, walking distances, and teamwork, among others. With a wide adoption of the concept, empirical evidence on the impact of decentralization was warranted. Methods: A multimethod, before-and-after, quasi-experimental design was adopted for the study, focusing on five issues, namely, (1) how nurses spend their time, (2) walking distance, (3) acute stress, (4) productivity, and (5) teamwork. Data on all five issues were collected on three older units with centralized operational model (before move). The same set of data, with identical tools and measures, were collected on the same units after move in to new physical units with decentralized operational model. Data were collected during spring and fall of 2011. Results: Documentation, nurse station use, medication room use, and supplies room use showed consistent change across the three units. Walking distance increased (statistically significant) on two of the three units. Self-reported level of collaboration decreased, although assessment of the physical facility for collaboration increased. Conclusions: Decentralized nursing and physical design models potentially result in quality of work improvements associated with documentation, medication, and supplies. However, there are unexpected consequences associated with walking, and staff collaboration and teamwork. The solution to the unexpected consequences may lie in operational interventions and greater emphasis on culture change.

An Empirical Examination of Patient Room Handedness in Acute Medical-Surgical Settings

Objective: The study objective was to examine whether standardized same-handed room configurations contribute more to operational performance in comparison to standardized mirror-image room configurations. Based on a framework that physical environment standardization supports process and workflow standardization, thus contributing to safety and efficiency, the study examined the comparative effectiveness of the standardized same-handed configuration and the standardized mirror-image configuration. Background: Patient room handedness has emerged as an important issue in inpatient unit design, with many hospitals adopting the standardized same-handed room concept at all levels of patient acuity. Although it is argued that standardized same-handed rooms offer greater levels of safety and efficiency in comparison to standardized mirror-image rooms, there is little empirical evidence either to support or refute these contentions. Method: An experimental setting was developed where elements of the physical environment and approach to the caregiver zone were systematically manipulated. Twenty registered nurses (10 left-handed and 10 right-handed) provided three types of care to a patient-actor across nine physical design configurations, which were videotaped in 540 separate segments. Structured interviews of the subjects were conducted at the end of each individual set of simulation runs to obtain triangulation data. Video segments were coded by nursing experts. Statistical and content analyses of the data were conducted. Results: Study data show that standardized same-handed configurations may not contribute to process and workflow standardization—hence, to safety and efficiency—any more than standardized mirror-image configurations in acute medical-surgical settings. Data suggest that a global view of the patient care environment upon entry is the most sought-after familiarization factor to reduce cognitive load.

An exploratory examination of medical gas booms versus traditional headwalls in intensive care unit design.

Should power, medical gases, and monitoring and communications systems be located in a headwall or a ceiling-mounted boom in intensive care unit (ICU) rooms? Often, only the financial costs could be determined for the options, whereas data regarding its potential influence on teamwork, safety, and efficiency are lacking. Hence, purchase decisions are more arbitrary than evidence based. This study simulated care delivery in settings with a traditional headwall and a ceiling boom. Observed were the way the following elements were managed and the extent either system affected flexibility, ergonomics, and teamwork: tubing for intravenous fluids, medical gases, and suction drainage; monitoring leads and equipment power cords; and the medical equipment itself. Simulation runs involving 6 scenarios were conducted with the voluntary participation of 2 physicians, 2 nurse practitioners, 2 respiratory therapists, and 4 registered nurses at a childrens tertiary care center in December 2007. Analysis suggests that booms have an advantage over headwalls in case of high-acuity ICU patients and when procedures are performed inside patient rooms. However, in case of lower-acuity ICU patients, as well as when procedures are not typically conducted in the patient room, booms may not provide a proportionate level of advantage when compared with the additional cost involved in its procurement.

Lessons from neuroscience: form follows function, emotions follow form

The argument that the environment impacts human perception and behaviour, and vice versa, is not a new one. What is lacking however is a fine-grained, deep understanding of the neural underpinnings that drive human behaviour as a result of environmental interaction. The challenge of simulating three-dimensional environments while mapping brain behaviour (which is still a rather confined activity) has made this initiative daunting. In this article, we argue that a common unit between architectural environments and functional magnetic resonance imaging (fMRI) experiments is ‘the visual image’. Architecture relies on visual stimuli to conceive, design, present, and even experience environments. fMRI experiments use visual stimuli to induce desired cognitive and emotional states to study the neural underpinnings. Although a wealth of evidence exists in the field of environmental psychology and psychophysiology on how visual images, specifically nature content in visual images, can reduce the negative emotions of fear, pain and anxiety-aiding restoration to a positive state, it is not clear, however, which specific visual properties contribute to this effect. If the specific visual properties could be isolated and correlated to specific emotional response, they could serve as the building blocks for designing not just for functions a design supports, but also the emotions it invokes. In this article we look at the emotional impact of visual stimuli, and bridge the evidence between environmental psychology and neuroscience, within the scope of nature images, to identify specific visual properties that (may) elicit emotional responses. We then investigate a particular visual property ‘contours’ and explore it within the theoretical paradigm of neuro-architecture to generate specific hypotheses for architecture and neuroscience. Finally, we take the discourse to architecture and explore the relevance of the subject of form, especially rapid emotional response to form, elicited by the specific property of contours.

Estimating design impact on waste reduction: examining decentralized nursing.

The objective of this study was to understand the impact that decentralization of nursing support spaces may have on the total distances nurses walk and hence the magnitude of time that can be diverted to productive use. Reducing nurse walking has attracted attention from multiple perspectives—human factor, system performance, lean process, care quality, and safety. A simulation-based experimental study was designed that incorporated task frequency data from a nationwide sample of 700 RNs. The simulation runs were conducted on a 30-bed medical-surgical unit, over 12-hour day shifts, in which physical locations of 8 nursing support spaces were systematically manipulated. Findings suggest that total walking time can be reduced by as much as 67.9%, depending on the level of decentralization. Care quality and efficiency issues can be significantly addressed through appropriate levels of decentralization.

Neuroesthetics and Healthcare Design

While there is a growing consciousness about the importance of visually pleasing environments in healthcare design, little is known about the key underlying mechanisms that enable aesthetics to play an instrumental role in the caregiving process. Hence it is often one of the first items to be value engineered. Aesthetics has (rightfully) been provided preferential consideration in such pleasure settings such as museums and recreational facilities; but in healthcare settings it is often considered expendable. Should it be? In this paper the authors share evidence that visual stimuli undergo an aesthetic evaluation process in the human brain by default, even when not prompted; that responses to visual stimuli may be immediate and emotional; and that aesthetics can be a source of pleasure, a fundamental perceptual reward that can help mitigate the stress of a healthcare environment. The authors also provide examples of studies that address the role of specific visual elements and visual principles in aesthetic evaluations and emotional responses. Finally, they discuss the implications of these findings for the design of art and architecture in healthcare.

Security Implications of Physical Design Attributes in the Emergency Department

Background: Security, a subset of safety, is equally important in the efficient delivery of patient care. The emergency department (ED) is susceptible to violence creating concerns for the safety and security of patients, staff, and visitors and for the safe and efficient delivery of care. Although there is an implicit and growing recognition of the role of the physical environment, interventions typically have been at the microlevel. Objective: The objective of this study was to identify physical design attributes that potentially influence safety and efficiency of ED operations. Method: An exploratory, qualitative research design was adopted to examine the efficiency and safety correlates of ED physical design attributes. The study comprised a multimeasure approach involving multidisciplinary gaming, semistructured interviews, and touring interviews of frontline staff in four EDs at three hospital systems across three states. Results: Five macro physical design attributes (issues that need to be addressed at the design stage and expensive to rectify once built) emerged from the data as factors substantially associated with security issues. They are design issues pertaining to (a) the entry zone, (b) traffic management, (c) patient room clustering, (d) centralization versus decentralization, and (e) provisions for special populations. Conclusion: Data from this study suggest that ED security concerns are generally associated with three sources: (a) gang-related violence, (b) dissatisfied patients, and (c) behavioral health patients. Study data show that physical design has an important role in addressing the above-mentioned concerns. Implications for ED design are outlined in the article.