NICU redesign from open ward to private room: a longitudinal study of parent and staff perceptions

Clinical, humanistic and economic outcomes, including experiencing of patient safety events, associated with admitting patients to single rooms compared with shared accommodation for acute hospital admissions: a systematic review and narrative synthesis

OBJECTIVES

Assess the impact of single rooms versus multioccupancy accommodation on inpatient healthcare outcomes and processes.

DESIGN

Systematic review and narrative synthesis.

DATA SOURCES

Medline, Embase, Google Scholar and the National Institute for Health and Care Excellence website up to 17 February 2022.

ELIGIBILITY CRITERIA

Eligible papers assessed the effect on inpatients staying in hospital of being assigned to a either a single room or shared accommodation, except where that assignment was for a direct clinical reason like preventing infection spread.

DATA EXTRACTION AND SYNTHESIS

Data were extracted and synthesised narratively, according to the methods of Campbell et al. RESULTS: Of 4861 citations initially identified, 145 were judged to be relevant to this review. Five main method types were reported. All studies had methodological issues that potentially biased the results by not adjusting for confounding factors that are likely to have contributed to the outcomes. Ninety-two papers compared clinical outcomes for patients in single rooms versus shared accommodation. No clearly consistent conclusions could be drawn about overall benefits of single rooms. Single rooms were most likely to be associated with a small overall clinical benefit for the most severely ill patients, especially neonates in intensive care. Patients who preferred single rooms tended to do so for privacy and for reduced disturbances. By contrast, some groups were more likely to prefer shared accommodation to avoid loneliness. Greater costs associated with building single rooms were small and likely to be recouped over time by other efficiencies.

CONCLUSIONS

The lack of difference between inpatient accommodation types in a large number of studies suggests that there would be little effect on clinical outcomes, particularly in routine care. Patients in intensive care areas are most likely to benefit from single rooms. Most patients preferred single rooms for privacy and some preferred shared accommodation for avoiding loneliness.

PROSPERO REGISTRATION NUMBER

CRD42022311689.

Comparison of neonatal morbidity and mortality between single-room and open-bay care: a retrospective cohort study

OBJECTIVE

In response to the increasing focus on family-centred care, neonatal intensive care unit (NICU) environments have gradually shifted towards the single-room design. However, the assumed benefits of this emerging design remain a subject of debate. Our goal was to evaluate the impact of single-room versus open-bay care on the risk of neonatal morbidity and mortality in preterm neonates.

DESIGN

Retrospective cohort study.

SETTING

Level III NICU.

PATIENTS

Neonates born <32 weeks' gestation between 15 May 2015 and 15 May 2019.

MAIN OUTCOME MEASURES

Mortality and morbidities of a cohort of neonates admitted to a new, single-room unit (SRU) were compared with a historical cohort of neonates admitted to an open-bay unit (OBU). Group differences were evaluated and multivariable logistic regression analyses were performed.

RESULTS

Three-hundred and fifty-six and 343 neonates were admitted to the SRU and OBU, respectively. No difference in neonatal morbidities and mortality were observed between cohorts (bronchopulmonary dysplasia: OR 1.08, 95% CI 0.73 to 1.58, p=0.44; retinopathy of the prematurity stage ≥2: OR 1.36, 95% CI 0.84 to 2.22, p=0.10; intraventricular haemorrhage: OR 0.89, 95% CI 0.59 to 1.34, p=0.86; mortality: OR 1.55, 95% CI 0.75 to 3.20, p=0.28). In adjusted regression models, single-room care was independently associated with a decreased risk of symptomatic patent ductus arteriosus (adjusted OR 0.54, 95% CI 0.31 to 0.95). No independent association between single-room care and any of the other investigated outcomes was observed.

CONCLUSIONS

Implementation of single-rooms in our NICU did not lead to a significant reduction in neonatal morbidity and mortality outcomes.

Unintended Consequences of the Neonatal Intensive Care Unit Environment: Integrative Review of Single-Family Room Unit Design

BACKGROUND

Recent trends in neonatal intensive care unit design have been directed toward reducing negative stimuli and creating a more developmentally appropriate environment for infants who require intensive care. These efforts have included reconfiguring units to provide private rooms for infants.

PURPOSE

The purpose of this integrative review was to synthesize and critically analyze negative outcomes for patients, families, and staff who have been identified in the literature related to single-family room (SFR) care in the neonatal intensive care unit.

METHODS/SEARCH STRATEGY

The electronic databases of CINAHL, ProQuest Nursing & Allied Health, and PubMed databases were utilized. Inclusion criteria were research studies in English, conducted from 2011 to 2021, in which the focus of the study was related to unit design (SFRs). Based on the inclusion criteria, our search yielded 202 articles, with an additional 2 articles found through reference list searches. After screening, 44 articles met our full inclusion/exclusion criteria. These studies were examined for outcomes related to SFR unit design.

FINDINGS/RESULTS

Our findings revealed both positive and negative outcomes related to SFR unit design when compared with traditional open bay units. These outcomes were grouped into 4 domains: Environmental Outcomes, Infant Outcomes, Parent Outcomes, and Staff Outcomes.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Although SFR neonatal intensive care unit design improves some outcomes for infants, families, and staff, some unexpected outcomes have been identified. Although these do not negate the positive outcomes, they should be recognized so that steps can be taken to address potential issues and prevent undesired outcomes.

Intensive Care Unit Built Environments: A Comprehensive Literature Review (2005-2020)

BACKGROUND

The intensive care environment in hospitals has been the subject of significant empirical and qualitative research in the 2005-2020 period. Particular attention has been devoted to the role of infection control, family engagement, staff performance, and the built environment ramifications of the recent COVID-19 global pandemic. A comprehensive review of this literature is reported summarizing recent advancements in this rapidly expanding body of knowledge.

PURPOSE AND AIM

This comprehensive review conceptually structures the recent medical intensive care literature to provide conceptual clarity and identify current priorities and future evidence-based research and design priorities.

METHOD AND RESULT

Each source reviewed was classified as one of the five types-opinion pieces/essays, cross-sectional empirical investigations, nonrandomized comparative investigations, randomized studies, and policy review essays-and into nine content categories: nature engagement and outdoor views; family accommodations; intensive care unit (ICU), neonatal ICU, and pediatric ICU spatial configuration and amenity; noise considerations; artificial and natural lighting; patient safety and infection control; portable critical care field hospitals and disaster mitigation facilities including COVID-19; ecological sustainability; and recent planning and design trends and prognostications.

CONCLUSIONS

Among the findings embodied in the 135 literature sources reviewed, single-bed ICU rooms have increasingly become the norm; family engagement in the ICU experience has increased; acknowledgment of the therapeutic role of staff amenities; exposure to nature, view, and natural daylight has increased; the importance of ecological sustainability; and pandemic concerns have increased significantly in the wake of the coronavirus pandemic. Discussion of the results of this comprehensive review includes topics noticeably overlooked or underinvestigated in the 2005-2020 period and priorities for future research.

NICU Nurses' Stress and Work Environment in an Open Ward Compared to a Combined Pod and Single-Family Room Design

BACKGROUND

The architectural design of a neonatal intensive care unit may affect the quality of the work environment for nurses, yet few studies have been conducted using reliable and valid measures. Recent studies have suggested some drawbacks of single-family rooms (SFRs) for both infants and parents. Research is needed to explore nurses' work environment in units combining pods and SFRs.

PURPOSE

To compare neonatal intensive care unit nurses' work stress, satisfaction, obstacles, support, team effectiveness, ability to provide family-centered care, and satisfaction with noise, light, and sightlines in an open ward with a new unit of pods and SFRs.

METHODS

A pre-post occupancy study was conducted in a level 3 unit before and after transitioning to a new unit of 6-bed pods and SFRs.

RESULTS

There were no significant differences in nurse stress, satisfaction, support from colleagues, perceptions of team effectiveness, and ability to provide family-centered care between the open ward and the pod/SFR unit. Organizational obstacles, such as difficulties obtaining information from colleagues, were significantly lower in the pod/SFR. In contrast, environmental and technology obstacles were greater in the new pod/SFR unit.

IMPLICATIONS FOR PRACTICE

Some specific aspects of the pod/SFR unit are optimal for neonatal intensive care unit nurses, while other aspects of the open ward are perceived more favorably.

IMPLICATIONS FOR RESEARCH

Studies are needed to examine the isolation the nurses may experience in SFR units, as well as strategies to reduce isolation.

Evidence-based design for neonatal units: a systematic review

Evidence-based design (EBD) of hospitals could significantly improve patient safety and make patient, staff and family environments healthier. This systematic review aims to determine which neonatal intensive care unit design features lead to improved neonatal, parental and staff outcomes. Medline, CINAHL, Web of Science Citation Index and Cochrane Central Register of Controlled Trials Registry, were searched in January 2017. Using combinations of the relevant key words, review was performed following the recommended guidelines for reporting systematic reviews. English language limitation was applied and term limited to 2006–2016. Included studies were assigned a grade based upon their level of evidence and critically appraised using defined tools. Data were not synthesized for meta-analysis due to nature of literature reviewed and heterogeneity. Three thousand five hundred ninety-two titles were screened with 43 full-texts assessed for eligibility. Twenty nine studies were deemed eligible for inclusion. These included 19 cohort studies, two qualitative studies, seven cross-sectional studies, and one randomised control trial. Grey literature search from guidelines, and repositories yielded an additional 10 guidelines. ‘Single family room’ (SFR) design for neonatal units is recommended. An optimally designed neonatal unit has many possible health implications, including improved breastfeeding, infection and noise control, reduced length of stay, hospitalisation rates and potentially improved neonatal morbidity and mortality. High quality, family centred care (FCC) in neonatology could be assisted through well grounded, future proofed and technology enabled design concepts that have the potential to impact upon early life development.

Parents' Experiences of Support in NICU Single-Family Rooms

PURPOSE

This study aimed to explore support for mothers and fathers in single-family rooms (SFRs) of a NICU.

DESIGN

A qualitative descriptive design was employed.

SAMPLE

A convenience sample of 15 parents (nine mothers, six fathers) were recruited from a Level III NICU.

METHOD

During their infants' hospitalization, each parent recorded their thoughts and feelings regarding support whenever appropriate over a period of 48 hours using Handy Application to Promote Preterm infant happY-life (HAPPY), an android recording application.

RESULTS

Parents felt supported when staff facilitated their learning in a collaborative manner, fostered their optimism, and provided situational assistance. Continuity and consistency of care and presence were important characteristics of supportive nursing care. Though SFRs offered privacy for parents to learn and to be with their infants, the design limited parental access to nursing and medical staff, which sometimes prevented parents from receiving adequate support and partaking in decision making concerning their infants' care.

Does the architectural layout of a NICU affect alarm pressure? A comparative clinical audit of a single-family room and an open bay area NICU using a retrospective study design

OBJECTIVES

To determine differences in alarm pressure between two otherwise comparable neonatal intensive care units (NICUs) differing in architectural layout-one of a single-family room (SFR) design and the other of an open bay area (OBA) design.

DESIGN

Retrospective audit of more than 2000 patient days from each NICU cataloguing the differences in the number and duration of alarms for critical and alerting alarms, as well as the interaction of clinicians with the patient monitor.

SETTING

Two level 3 NICUs.

RESULTS

A total of more than 150 000 critical and 1.2 million alerting alarms were acquired from the two NICUs. The number of audible alarms and the associated noise pollution varied considerably with the OBA NICU generating 44% more alarms per infant per day even though the SFR NICU generated 2.5 as many critical desaturation alarms per infant per day.

CONCLUSION

Differences in the architectural layout of NICUs and the consequent differences in delays, thresholds and distribution systems for alarms are associated with differences in alarm pressure.

Exploring the Impact of a Dual Occupancy Neonatal Intensive Care Unit on Staff Workflow, Activity, and Their Perceptions

In 2012, a tertiary neonatal intensive care unit (NICU) transitioned from an open plan (OP) to a dual occupancy (DO) NICU. The DO design aimed to provide a developmental appropriate, family-centered environment for neonates and their families. During planning, staff questioned the impact DO would have on staff workflow and activity. To explore the impact of changing from an OP to a DO NICU, a prospective longitudinal study was undertaken from 2011 to 2014, using observational, time and motion, and surveys methods. Main outcome measures included distance walked by staff, minutes of staff activity, and staff perceptions of the DO design. Results highlighted no significant difference in the distances clinical nurses walked nor time spent providing direct clinical care, whereas technical support staff walked further than other staff in both designs. Staff perceived the DO design created a developmentally appropriate, family-centered environment that facilitated communication and collaboration between staff and families. Staff described the main challenges of the DO design such as effective staff communication, gaining educational opportunities, and the isolation of staff and families compared to the OP design. Our study provides new evidence that DO provides an improved developmentally environment and has similar positive benefits to single-family room for neonates and families. Such design may reduce the larger floor plan's impact on staff walking distance and work practices. Challenges of staff transition can be minimized by planning and leadership throughout the development and move to a new design.

Staff Nurse Perceptions of Open-Pod and Single Family Room NICU Designs on Work Environment and Patient Care

BACKGROUND

Neonatal intensive care units have historically been constructed as open units or multiple-bed bays, but since the 1990s, the trend has been toward single family room (SFR) units. The SFR design has been found to promote family-centered care and to improve patient outcomes and safety. The impact of the SFR design NICU on staff, however, has been mixed.

PURPOSE

The purposes of this study were to compare staff nurse perceptions of their work environments in an open-pod versus an SFR NICU and to compare staff nurse perceptions of the impact of 2 NICU designs on the care they provide for patients/families.

METHODS/SEARCH STRATEGY

A prospective cohort study was conducted. Questionnaires were completed at 6 months premove and again at 3, 9, and 15 months postmove. A series of 1-way analyses of variance were conducted to compare each group in each of the 8 domains. Open-ended questions were evaluated using thematic analysis.

FINDINGS/RESULTS

The SFR design is favorable in relation to environmental quality and control of primary workspace, privacy and interruption, unit features supporting individual work, and unit features supporting teamwork; the open-pod design is preferable in relation to walking.

IMPLICATIONS FOR PRACTICE

Incorporating design features that decrease staff isolation and walking and ensuring both patient and staff safety and security are important considerations.

IMPLICATIONS FOR RESEARCH

Further study is needed on unit design at a microlevel including headwall design and human milk mixing areas, as well as on workflow processes.

Through the Eyes of the User: Evaluating Neonatal Intensive Care Unit Design

Objective:

This article presents a pilot study that employed a user-centered methodology for evaluating and quantifying neonatal intensive care unit (NICU) designs based on the needs of the primary users.

Background:

The design of NICUs has begun to shift from open-bay to single-family rooms. Both designs present unique advantages and challenges that impact babies, families, and caregivers.

Methods:

One NICU design was analyzed using the functional scenario (FS) analysis method. For the FS, users’ needs were determined through literature review, interviews with NICU providers and parents, and a review of published design guidelines. Quantitative metrics were developed for each FS, so that characteristics of the NICU design could be analyzed to determine how successful they were in meeting the users’ needs. The results were graphically represented to visualize the success and considerations of the design.

Results:

A total of 23 FSs and 61 spatial metrics were developed. FSs for babies focused on infection prevention, minimizing exposure to environmental stimuli, and supporting enriching care activities. FSs for family members focused on direct access to the baby, and privacy and adequate space for daily activities. FSs for providers and caregivers focused on infection prevention, care activities, care zones, and visibility.

Conclusion:

Using an FS approach highlights design characteristics in the NICU that need to be addressed during the design process to more successfully meet the needs of the different users. Additionally, using this approach can inform design professionals’ decision-making by presenting them with the design characteristics that impact the needs of the user groups.

The NICU Environment: Infusing Single-Family Room Benefits into the Open-Bay Setting

Two distinct architectural designs are found in today's NICUs-the open-bay (OPBY) and the single-family room (SFR) designs. When neonatology was recognized as a medical subspecialty in the 1970s, the OPBY design was the only platform offered to neonates and families. The OPBY design facilitated communication between staff, collegiality, and interprofessional collaboration among members of the neonatal team. Over time, pitfalls to the design were recognized, including increased transmission of sound and light. As a result, the SFR design emerged offering a family-centered, customizable environment. Through recognition and adoption of best practices, the neurodevelopmental benefits to SFRs can be infused within the OPBY unit. This article aims to identify best practices to infuse the benefits of SFR design (such as low light, low sound, and less overstimulation) into the OPBY NICU to reduce negative stimulation and optimize developmental outcomes for vulnerable neonates.

Neonatal Intensive Care Unit Layout and Nurses’ Work

Neonatal intensive care units (NICUs) remain one of the few areas in hospitals that still use an open bay (OPBY) design for patient stays greater than 24 hr, housing multiple infants, staff, and families in one large room. This creates high noise levels, contributes to the spread of infection, and affords families little privacy. These problems have given rise to the single-family room NICU. This represents a significant change in the care environment for nurses. This literature review answers the question: When compared to OPBY layout, how does a single family room layout impact neonatal nurses’ work? Thirteen studies published between 2006 and 2015 were located. Many studies reported both positive and negative effects on nurses’ work and were therefore sorted by their cited advantages and disadvantages. Advantages included improved quality of the physical environment; improved quality of patient care; improved parent interaction; and improvements in nurse job satisfaction, stress, and burnout. Disadvantages included decreased interaction among the NICU patient care team, increased nurse workload, decreased visibility on the unit, and difficult interactions with family. This review suggests that single-family room NICUs introduce a complex situation in which trade-offs occur for nurses, most prominently the trade-off between visibility and privacy. Additionally, the literature is clear on what elements of nurses’ work are impacted, but how the built environment influences these elements, and how these elements interact during nurses’ work, is not as well understood. The current level of research and directions for future research are also discussed.

Neonatal Intensive Care Unit Nurses Working in an Open Ward: Stress and Work Satisfaction

There is some research on the impact of open-ward unit design on the health of babies and the stress experienced by parents and nurses in neonatal intensive care units. However, few studies have explored the factors associated with nurse stress and work satisfaction among nurses practicing in open-ward neonatal intensive care units. The purpose of this study was to examine what factors are associated with nurse stress and work satisfaction among nurses practicing in an open-ward neonatal intensive care unit. A cross-sectional correlational design was used in this study. Participants were nurses employed in a 34-bed open-ward neonatal intensive care unit in a major university-affiliated hospital in Montréal, Quebec, Canada. A total of 94 nurses were eligible, and 86 completed questionnaires (91% response rate). Descriptive statistics were computed to describe the participants' characteristics. To identify factors associated with nurse stress and work satisfaction, correlational analysis and multiple regression analyses were performed with the Nurse Stress Scale and the Global Work Satisfaction scores as the dependent variables. Different factors predict neonatal intensive care unit nurses' stress and job satisfaction, including support, family-centered care, performance obstacles, work schedule, education, and employment status. In order to provide neonatal intensive care units nurses with a supportive environment, managers can provide direct social support to nurses and influence the culture around teamwork.

Transition from an open-plan to a two-cot neonatal intensive care unit: a participatory action research approach

AIMS AND OBJECTIVES

To facilitate staff transition from an open-plan to a two-cot neonatal intensive care unit design.

BACKGROUND

In 2012, an Australian regional neonatal intensive care unit transitioned from an open-plan to a two-cot neonatal intensive care unit design. Research has reported single- and small-room neonatal intensive care unit design may negatively impact on the distances nurses walk, reducing the time they spend providing direct neonatal care. Studies have also reported nurses feel isolated and need additional support and education in such neonatal intensive care units. Staff highlighted their concerns regarding the impact of the new design on workflow and clinical practice.

DESIGN

A participatory action research approach.

METHODS

A participatory action group titled the Change and Networking Group collaborated with staff over a four-year period (2009-2013) to facilitate the transition. The Change and Networking Group used a collaborative, cyclical process of planning, gathering data, taking action and reviewing the results to plan the next action. Data sources included meeting and workshop minutes, newsletters, feedback boards, subgroup reports and a staff satisfaction survey.

RESULTS

The study findings include a description of (1) how the participatory action research cycles were used by the Change and Networking Group: providing examples of projects and strategies undertaken; and (2) evaluations of participatory action research methodology and Group by neonatal intensive care unit staff and Change and Networking members.

CONCLUSION

This study has described the benefits of using participatory action research to facilitate staff transition from an open-plan to a two-cot neonatal intensive care unit design. Participatory action research methodology enabled the inclusion of staff to find solutions to design and clinical practice questions. Future research is required to assess the long-term effect of neonatal intensive care unit design on staff workload, maintaining and supporting a skilled workforce as well as the impact of a new neonatal intensive care unit design on the neonatal intensive care unit culture.

RELEVANCE TO CLINICAL PRACTICE

A supportive work environment for staff is critical in providing high-quality health care.

Perceptions of Palliative Care in the NICU

BACKGROUND AND PURPOSE

The American Academy of Pediatrics supports palliative care (PC) for all children with life-threatening illnesses. Thus, many neonatal intensive care unit (NICU) patients and their families could benefit from PC. Our study objective was to examine provision of PC as experienced by mothers and healthcare providers (HCPs) of NICU patients with life-threatening illnesses. Palliative care components explored included communication, choices, comfort, psychosocial and spiritual needs, and coordination of care.

METHODS

In this qualitative, descriptive study, we conducted semistructured interviews with mothers of infants with life-threatening illnesses and NICU HCPs who cared for these infants. Mothers selected HCPs who were key figures during their infant's NICU stay to participate. Interviews were transcribed and manually coded until themes emerged and theoretical saturation was achieved. Researchers reviewed charts for demographics and notes pertaining to PC. Triangulation of maternal interviews, HCP interviews, and chart notes was performed.

RESULTS

Theoretical saturation was achieved after 12 interviews. Mothers identified 5 nurses and 1 physician to be interviewed. Five themes were identified following data analysis and triangulation: (1) communication, (2) privacy, (3) continuity of care and relationship building, (4) maternal knowledge seeking, and (5) emotional turmoil.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Of domains of pediatric PC explored, participants emphasized transparent communication, family meetings as a venue for collaboration and shared decision making, the significance of psychosocial support for maternal emotional distress, and the importance of continuity of care across an often long and stressful hospitalization. Although mothers desired privacy, participants valued the security of the open-room NICU design. Future research should address components of PC that predominate in this specialized population.