Thomas E. Harvey

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.

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.

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.

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.

Physical design correlates of efficiency and safety in emergency departments: a qualitative examination.

The objective of this study was to explore and identify physical design correlates of safety and efficiency in emergency department (ED) operations. This study adopted an exploratory, multimeasure approach to (1) examine the interactions between ED operations and physical design at 4 sites and (2) identify domains of physical design decision-making that potentially influence efficiency and safety. Multidisciplinary gaming and semistructured interviews were conducted with stakeholders at each site. Study data suggest that 16 domains of physical design decisions influence safety, efficiency, or both. These include (1) entrance and patient waiting, (2) traffic management, (3) subwaiting or internal waiting areas, (4) triage, (5) examination/treatment area configuration, (6) examination/treatment area centralization versus decentralization, (7) examination/treatment room standardization, (8) adequate space, (9) nurse work space, (10) physician work space, (11) adjacencies and access, (12) equipment room, (13) psych room, (14) staff de-stressing room, (15) hallway width, and (16) results waiting area. Safety and efficiency from a physical environment perspective in ED design are mutually reinforcing concepts—enhancing efficiency bears positive implications for safety. Furthermore, safety and security emerged as correlated concepts, with security issues bearing implications for safety, thereby suggesting important associations between safety, security, and efficiency.

Factors impeding flexible inpatient unit design.

Objective: To identify and examine factors extraneous to the design decision-making process that could impede the optimization of flexibility on inpatient units. Background: A 2006 empirical study to identify domains of design decisions that affect flexibility on inpatient units found some indication in the context of the acuity-adaptable operational model that factors extraneous to the design process could have negatively influenced the successful implementation of the model. This raised questions regarding extraneous factors that might influence the successful optimization of flexibility. Method: An exploratory, qualitative method was adopted to examine the question. Stakeholders from five recently built acute care inpatient units participated in the study, which involved three types of data collection: (1) verbal protocol data from a gaming session; (2) in-depth semi-structured interviews; and (3) shadowing frontline personnel. Data collection was conducted between June 2009 and November 2010. Results: The study revealed at least nine factors extraneous to the design process that have the potential to hinder the optimization of flexibility in four domains: (1) systemic; (2) cultural; (3) human; and (4) financial. Conclusions: Flexibility is critical to hospital operations in the new healthcare climate, where cost reduction constitutes a vital target. From this perspective, flexibility and efficiency strategies can be influenced by (1) return on investment, (2) communication, (3) culture change, and (4) problem definition. Extraneous factors identified in this study could also affect flexibility in other care settings; therefore, these findings may be viewed from the overall context of hospital design.

Physical Design Factors Contributing to Patient Falls

OBJECTIVES The aim of this study was to identify physical design elements that contribute to potential falls in patient rooms. METHODS An exploratory, physical simulation-based approach was adopted for the study. Twenty-seven subjects, older than 70 years (11 male and 16 female subjects), conducted scripted tasks in a mockup of a patient bathroom and clinician zone. Activities were captured using motion-capture technology and video recording. After biomechanical data processing, video clips associated with potential fall moments were extracted and then examined and coded by a group of registered nurses and health care designers. Exploratory analyses of the coded data were conducted followed by a series of multivariate analyses using regression models. RESULTS In multivariate models with all personal, environmental, and postural variables, only the postural variables demonstrated statistical significance-turning, grabbing, pushing, and pulling in the bathroom and pushing and pulling in the clinician zone. The physical elements/attributes associated with the offending postures include bathroom configuration, intravenous pole, door, toilet seat height, flush, grab bars, over-bed table, and patient chair. CONCLUSIONS Postural changes, during interactions with the physical environment, constitute the source of most fall events. Physical design must include simultaneous examination of postural changes in day-to-day activities in patient rooms and bathrooms. Among discussed testable recommendations in the article, the followings design strategies should be considered: (a) designing bathrooms to reduce turning as much as possible and (b) designing to avoid motions that involve 2 or more of the offending postures, such as turning and grabbing or grabbing and pulling, and so on.

A Multidimensional Framework for Assessing Patient Room Configurations

Purpose: A framework for multidimensional assessment of patient room configurations is presented. Twenty-three issues are considered and categorized under six domains of assessment: (1) patient safety, (2) staff efficiency, (3) circulation, (4) infection control, (5) patient considerations, and (6) family amenities. Use of the framework to rank issues by importance and assess six alternative patient room configurations by a diverse group of experts in a symposium is described. Background: One of the key questions posed during inpatient room design is the location of the bathroom. What issues are affected by the variations in room configuration that arise from bathroom location? A complete articulation of the issues that potentially are affected by room configuration is not available in the literature. Framework: The list of issues was developed by the authors in preparation for a symposium. The symposium was organized in May 2007 and attended by 14 experts from four institutions. Six alternative room configurations were used. Variations in the configurations included: (1) three same-handed and three mirror-image rooms; (2) three outboard, two inboard, and one nested bathroom; and (3) three rooms with footwall bathrooms and three with headwall bathrooms. In a four-step process, the attendees ranked the issues, discussed them in detail, rated each room configuration against each issue on a seven-point suitability scale, and conducted an overall assessment of the six configurations. Conclusions: Based on the ratings and rankings provided by the symposium participants, outboard bathroom locations were found to be most suitable, followed by nested and inboard configurations. Furthermore, configurations with patient bathrooms located on the footwall were rated as more suitable than headwall locations. The authors recommend, however, that the framework be used to determine a suitable room configuration in a specific context, rather than to identify configurations that will perform well universally.