The impact of single family room design on patients and caregivers: executive summary

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.

The Role of Healthcare Facility Design on the Mental Health of Healthcare Professionals: A Literature Review

OBJECTIVE

This study aims to review and synthesize the empirical evidence about the connection between healthcare facility design and the mental health of healthcare professionals by reviewing the relevant literature.

BACKGROUND

Mental exhaustion of healthcare professionals is becoming a critical issue in healthcare, especially during the pandemic. The physical design of healthcare facilities has significant potential to reduce and prevent the mental exhaustion of healthcare professionals by removing environmental stressors and providing restorative experiences. However, the built environment is not fully utilized as an intervention to support healthcare professionals.

METHODS

Relevant articles were identified from the Medline, PsycINFO, PubMed, and Web of Science databases using a combination of search terms representing environmental design factors and health outcomes. Identified articles were reviewed by their titles, abstracts, and full texts using the inclusion and exclusion criteria.

RESULTS

The search yielded 27 empirical articles investigating the relationships between environmental design factors and staff mental health outcomes, including stress, fatigue, job satisfaction, burnout, and well-being. Healthcare design aspects that were investigated in the identified articles include overall facility and perception (e.g., aesthetic appeal and impression, belonging to the surroundings, safety), specific spaces (e.g., patient area, staff workspace), intangible elements (e.g., exterior view, light, sound), and interior space and ergonomics (e.g., material finishes, furniture).

CONCLUSIONS

Through the synthesis of the current literature regarding the relationships between healthcare facility design and the mental health of healthcare professionals, this study provides implications for supporting healthcare professionals through the design of the healthcare facility.

The Environmental Factors Associated With Fatigue of Frontline Nurses in the Infection Disease Nursing Unit

The workload in the Infection Disease Nursing Unit (IDNU) is increasing dramatically due to COVID-19, and leads to the prevalence of fatigue among the frontline nurses, threatening their health, and safety. The built environment and design could fundamentally affect the fatigue of nurses for a long-term perspective. This article aims to extract the environmental factors of IDNU and explore nurses' perceptions of these factors on the work-related fatigue. It would produce evidences for mitigating the fatigue by environmental interferons. A cross-sectional design was employed by combination of focus group interview and written survey. Environmental factors of IDNU were collected from healthcare design experts (n = 8). Nurses (n = 64) with frontline COVID-19 experiences in IDNU were recruited to assess these factors individually. Four environmental factors were identified as: Nursing Distance (ND), Spatial Crowdness (SC), Natural Ventilation, and Light (NVL), and Spatial Privacy (SP). Among them, ND was considered as the most influential factor on the physical fatigue, while SP was on the psychological fatigue. Generally, these environmental factors were found to be more influential on the physical fatigue than the psychological fatigue. Technical titles were found to be associated with the nurses' perceptions of fatigue by these environmental factors. Nurse assistant and practical nurse were more likely to suffer from the physical fatigue by these factors than senior nurse. The result indicated that environmental factors of IDNU were associated with the nurses' fatigue, particularly on the physical aspect. Environmental interventions of design could be adopted to alleviate the fatigue by these factors such as reducing the ND and improving the spatial privacy. The accurate interventional measures should be applied to fit nurses' conditions due to their technical titles. More attention should be given to the low-ranking nurses, who account for the majority and are much vulnerable to the physical fatigue by environmental factors.

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.

Effects of single family room architecture on parent-infant closeness and family centered care in neonatal environments-a single-center pre-post study

OBJECTIVE

The aim of this study was to evaluate the effects of a single family room architecture in a neonatal intensive care unit (SFR-NICU) on parents' presence, parent-infant skin-to-skin contact (SSC) and the quality of family centered care.

STUDY DESIGN

Two cohorts of parents of preterm infants were compared: those in the unit before and after the move to SFR-NICU. The parents used daily diaries to report their presence and SSC, and they responded to daily text message questions about the quality of family centered care.

RESULTS

Parents spent more time in the SFR-NICU, but no significant change was found in SSC. Parents rated the quality of family centered care highly in both unit architectures, without a change in rating after the move.

CONCLUSION

The SFR-NICU increased parents' presence but not SSC. The change in architecture did not affect parents' evaluations of the quality of family centered care, which was already highly rated before the move.

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.

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.

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.

Can the physical environment itself influence neurological patient activity?

PURPOSE

To evaluate if a changed physical environment following redesign of a hospital ward influenced neurological patient physical and social activity.

METHODS

A "before and after" observational design was used that included 17 acute neurological patients pre-move (median age 77 (IQR 69-85) years Ward A and 20 post-move (median age 70 (IQR 57-81) years Ward B. Observations occurred for 1 day from 08.00-17.00 using Behavioral Mapping of patient physical and social activity, and location of that activity. Staff and ward policies remained unchanged throughout. An Environmental Description Checklist of each ward was also completed.

RESULTS

Behavioral Mapping was conducted pre-/post-move with a total of 801 Ward A and 918 Ward B observations. Environmental Description Checklists showed similarities in design features in both neurological wards with similar numbers of de-centralized nursing stations, however there were more single rooms and varied locations to congregate in Ward B (30% more single-patient rooms and separate allied health therapy room). Patients were alone >60% of time in both wards, although there was more in bed social activity in Ward A and more out of bed social activity in Ward B. There were low amounts of physical activity outside of patient rooms in both wards. Significantly more physical activity occurred in Ward B patient rooms (median = 47%, IQR 14-74%) compared to Ward A (median = 2% IQR 0-14%), Wilcoxon Rank Sum test z = -3.28, p = 0.001.

CONCLUSIONS

Overall, patient social and physical activity was low, with little to no use of communal spaces. However we found more physical activity in patient rooms in the Ward B environment. Given the potential for patient activity to drive brain reorganization and repair, the physical environment should be considered an active factor in neurological rehabilitation and recovery. Implications for Rehabilitation Clinicians should include consideration of the impact of physical environment on physical and social activity of neurological patients when designing therapeutic rehabilitation environments. Despite architectural design intentions patient and social activity opportunities can be limited. Optimal neurological patient neuroplasticity and recovery requires sufficient environmental challenge, however current hospital environments for rehabilitation do not provide this.

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.

Occupancy and patient care quality benefits of private room relative to multi-bed patient room designs for five different children's hospital intensive and intermediate care units

BACKGROUND

Prior research documents occupancy and patient care quality (OPCQ) benefits for private room (PR) relative to multi-bed (MB) designs in neonatal intensive care units (NICUs).

OBJECTIVE

To extend this research design to four additional types of children's hospital units: a cardiovascular care center (CVCC), an infant care center (ICC), a medical/surgical unit (Med/Surg), and a pediatric intensive care unit (PICU).

METHODS

Staff comments, task activities, patient care demands, and perceptual survey rankings for twelve major indicators of OPCQ were assessed with nursing staff on these units plus an NICU.

RESULTS

With the PR designs, for 38 of 48 pairwise comparisons for the twelve major OPCQ indicators, CVCC staff rankings are significantly lower than those by staff on the other four units. For 47 of 48 pairwise comparisons for the twelve major OPCQ indicators, NICU, ICC, Med/Surg, and PICU staff rankings for PR designs do not differ significantly from those for MB designs. Comments by staff on all five units target numerous PR OPCQ defects.

CONCLUSION

Design, operation and management of the patient care environments on the five different PR units evaluated in this research confront a challenge in realizing OPCQ benefits that match experience with PR NICU designs in other contexts.

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.

The Influence of Neonatal Nursery Design on Mothers' Interactions in the Nursery

This study examined the influence of neonatal nursery design on interactions between nurses and mothers of infants in the nursery.

DESIGN AND METHODS

We used a natural quasi-experimental design, using semi-structured interviews and a structured measure of mothers' and nurses' perceptions of nursing care, to compare mothers (n=26 and n=40) and nurses (n=22 and n=29) in an open-bay (OB) nursery and a single family room (SFR) nursery. Thematic analysis was used to generate key themes from the interviews.

RESULTS

Mothers and nurses in both nursery designs talked about Valuing interactions; the importance of interactions between mothers and nurses. Mothers and nurses described SFRs as providing a space, My/their room, which enhanced mothers' sense of control and connection with the infant. SFRs were also associated with Changing the norms of interactions with nurses and other mothers, which created challenges in the desired quantity and quality of interactions for mothers and nurses. Nurses in the SFR nursery also reported Enhanced interactions, including improved confidentiality and personalized communication. Mothers in the OB nursery reported more supportive mothering actions from nurses than mothers in the SFR nursery. Both mothers and nurses in the OB nursery also talked about Our nursery community, which captured the value of having other nurses and mothers in the rooms.

CONCLUSION

Mothers and nurses perceived that the SFR nursery enhanced privacy and maternal closeness for mothers compared to the OB nursery. However, the SFR nursery design presented challenges to some interactions of value to nurses and mothers.

Staff Perceptions Before and After Adding Single-Family Rooms in the NICU

OBJECTIVE

The purpose of this study is to evaluate staff perceptions of environmental quality before and after the renovation of an existing open-bay neonatal intensive care unit (NICU) and the addition of 23 single-family NICU rooms in the Wasie Neonatal ICU at Joe DiMaggio Children's Hospital.

BACKGROUND

In recent years there has been an increase in the design and construction of single-family rooms (SFRs) because they provide more privacy for families, offer better control over environmental stimuli such as lighting and noise, and possibly reduce infections. On the other hand, this model can cause staff members to feel isolated from one another, reduce their ability to respond quickly in a crisis situation, or impose additional demands on them. Few studies document the advantages and disadvantages of the SFR NICU model.

METHODS

This study utilized pre- and post-move surveys to investigate staff perceptions of the NICU.

RESULTS

Overall, staff members perceive the quality of the work environment, and the safety and quality of the environment provided to patients and their families, as better in the renovated, combination NICU design (SFR and open bay) when compared to the open-bay, pre-move design.

CONCLUSION

In spite of the potential drawbacks of having SFRs in the NICU, the study demonstrates that nurses may perceive associated benefits, such as a reduction of job stress and improvements in parental privacy, along with other positive outcomes.

Environmental affordances: designing for family presence and involvement in patient care

OBJECTIVE

This comparative study in two ICUs examines the impact of the patient-centered unit design on family involvement, operationalized as percentages of family presence and family-patient/family-staff interaction in patient rooms.

BACKGROUND

As hospitals have become more patient-centered, there has been a trend toward including a family area inside the patient area to promote family presence, support, and involvement in patient care. There is growing evidence that family members play an important role in supporting patient care, and that the physical environment affects family involvement. However, few empirical studies have attempted to show the effectiveness of the patient-centered design on family members' presence and their behavior.

METHODS

This study compared the degree of family presence and family-patient and family-staff interactions in two intensive care units (ICUs) with different physical environmental conditions, but housing patients of similar acuity and disease type.

RESULTS

The analysis identified a significant difference in family presence in patient rooms (t = -2.176; df = 79.0; p = 0.03) between the traditional and the patient-centered units. Patients in the family-centered care unit (M = 37.77; SD = 34.02) spent significantly more time with their family members in patient rooms than did patients in the traditional unit (M = 23.89; SD = 21.90). Patient-related variables other than unit design had no significant impact on family presence and interactions.

CONCLUSIONS

Findings demonstrated that the patient-centered unit (5K) was associated with increased family presence in the patient rooms and increased family interaction with patients, when compared with the traditionally designed unit.

KEYWORDS

Critical care/intensive care, evidence-based design, patient-centered care, quality care, social support.

Recommendations for enhancing psychosocial support of NICU parents through staff education and support

Providing psychosocial support to parents whose infants are hospitalized in the neonatal intensive care unit (NICU) can improve parents' functioning as well as their relationships with their babies. Yet, few NICUs offer staff education that teaches optimal methods of communication with parents in distress. Limited staff education in how to best provide psychosocial support to families is one factor that may render those who work in the NICU at risk for burnout, compassion fatigue and secondary traumatic stress syndrome. Staff who develop burnout may have further reduced ability to provide effective support to parents and babies. Recommendations for providing NICU staff with education and support are discussed. The goal is to deliver care that exemplifies the belief that providing psychosocial care and support to the family is equal in importance to providing medical care and developmental support to the baby.

Psychosocial program standards for NICU parents

This article provides a rationale for and brief description of the process of developing recommendations for program standards for psychosocial support of parents with babies in the neonatal intensive care unit (NICU). A multidisciplinary workgroup of professional organizations and NICU parents was convened by the National Perinatal Association. Six interdisciplinary committees (family-centered developmental care, peer-to-peer support, mental health professionals in the NICU, palliative and bereavement care, follow-up support and staff education and support) worked to produce the recommendations found in this supplemental issue. NICU parents contributed to the work of each committee.

Restorative Design Features for Hospital Staff Break Areas

Objectives:

The study investigated the main restorative components of staff break areas in healthcare facilities, by assessing usage patterns, verbal/visual preferences, and perceived restorative qualities of specific design features found in break areas for hospital staff.

Background:

Nurses are extremely important to the healthcare industry, and maintaining the quality of nursing care is a central concern for healthcare administrators. While healthcare leaders are concerned about improving nurses’ satisfaction, performance, and job retention, they may overlook the importance of respite for nurses and underestimate the value of designing staff break areas to maximize their restorative potential.

Methods:

A multi-method approach combined qualitative explorations (focused interviews and narrative survey questions) with quantitative measurements (discrete survey questions and a visual ranking of break-room spaces), and the results were compared and triangulated.

Results:

It was found that staff break areas are more likely to be used if they are in close proximity to nurses’ work areas, if they have complete privacy from patients and families, and if they provide opportunities for individual privacy as well as socialization with coworkers. Having physical access to private outdoor spaces (e.g., balconies or porches) was shown to have significantly greater perceived restorative potential, in comparison with window views, artwork, or indoor plants.

Conclusions:

The results of this empirical study support the conclusion that improvements in the restorative quality of break areas may significantly improve nurses’ satisfaction and stress reduction, potentially leading to improved care for the patients they serve.

The Influence of Flooring on Environmental Stressors

Objective:

Three flooring materials, terrazzo, rubber, and carpet tile, in patient unit corridors were compared for absorption of sound, comfort, light reflectance, employee perceptions and preferences, and patient satisfaction.

Background:

Environmental stressors, such as noise and ergonomic factors, effect healthcare workers and patients, contributing to increased fatigue, anxiety and stress, decreased productivity, and patient safety and satisfaction.

Methods:

A longitudinal comparative cohort study comparing three types of flooring assessed sound levels, healthcare worker responses, and patient Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) ratings over 42 weeks. A linear mixed model analysis was conducted to determine significant differences between the means for participant responses and objective sound meter data during all three phases of the study.

Results:

A significant difference was found for sound levels between flooring type for equivalent continuous sound levels. Carpet tile performed better for sound attenuation by absorption, reducing sound levels 3.14 dBA. Preferences for flooring materials changed over the course of the study. The HCAHPS ratings aligned with the sound meter data showing that patients perceived the noise levels to be lower with carpet tiles, improving patient satisfaction ratings.

Conclusions:

Perceptions for healthcare staff and patients were aligned with the sound meter data. Carpet tile provides sound absorption that affects sound levels and influences occupant’s perceptions of environmental factors that contribute to the quality of the indoor environment. Flooring that provides comfort underfoot, easy cleanability, and sound absorption influence healthcare worker job satisfaction and patient satisfaction with their patient experience.

Two decades (1993-2012) of adult intensive care unit design: a comparative study of the physical design features of the best practice examples

In 2006, Critical Care Nursing Quarterly published a study of the physical design features of a set of best practice example adult intensive care units (ICUs). These adult ICUs were awarded between 1993 and 2003 by the Society of Critical Care Medicine (SCCM), the American Association of Critical-Care Nurses, and the American Institute of Architects/Academy of Architecture for Health for their efforts to promote the critical care unit environment through design. Since 2003, several more adult ICUs were awarded by the same organizations for similar efforts. This study includes these newer ICUs along with those of the previous study to cover a period of 2 decades from 1993 to 2012. Like the 2006 study, this study conducts a systematic content analysis of the materials submitted by the award-winning adult ICUs. On the basis of the analysis, the study compares the 1993-2002 and 2003-2012 adult ICUs in relation to construction type, unit specialty, unit layout, unit size, patient room size and design, support and service area layout, and family space design. The study also compares its findings with the 2010 Guidelines for Design and Construction of Health Care Facilities of the Facility Guidelines Institute and the 2012 Guidelines for Intensive Care Unit Design of the SCCM. The study indicates that the award-winning ICUs of both decades used several design features that were associated with positive outcomes in research studies. The study also indicates that the award-winning ICUs of the second decade used more evidence-based design features than those of the first decades. In most cases, these ICUs exceeded the requirements of the Facility Guidelines Institute Guidelines to meet those of the SCCM Guidelines. Yet, the award-winning ICUs of both decades also used several features that had very little or no supporting research evidence. Since they all were able to create an optimal critical care environment for which they were awarded, having knowledge of the physical design of these award-winning ICUs may help design better ICUs.

Evaluating a major innovation in hospital design: workforce implications and impact on patient and staff experiences of all single room hospital accommodation

Background

New hospital design includes more single room accommodation but there is scant and ambiguous evidence relating to the impact on patient safety and staff and patient experiences.

Objectives

To explore the impact of the move to a newly built acute hospital with all single rooms on care delivery, working practices, staff and patient experience, safety outcomes and costs.

Design

(1) Mixed-methods study to inform a pre-/post-‘move’ comparison within a single hospital, (2) quasi-experimental study in two control hospitals and (3) analysis of capital and operational costs associated with single rooms.

Setting

Four nested case study wards [postnatal, acute admissions unit (AAU), general surgery and older people’s] within a new hospital with all single rooms. Matched wards in two control hospitals formed the comparator group.

Data sources

Twenty-one stakeholder interviews; 250 hours of observation, 24 staff interviews, 32 patient interviews, staff survey (n = 55) and staff pedometer data (n = 56) in the four case study wards; routinely collected data at ward level in the control hospitals (e.g. infection rates) and costs associated with hospital design (e.g. cleaning and staffing) in the new hospital.

Results

(1) There was no significant change to the proportion of time spent by nursing staff on different activities. Staff perceived improvements (patient comfort and confidentiality), but thought the new accommodation worse for visibility and surveillance, teamwork, monitoring, safeguarding and remaining close to patients. Giving sufficient time and attention to each patient, locating other staff and discussing care with colleagues proved difficult. Two-thirds of patients expressed a clear preference for single rooms, with the benefits of comfort and control outweighing any disadvantages. Some patients experienced care as task-driven and functional, and interaction with other patients was absent, leading to a sense of isolation. Staff walking distances increased significantly after the move. (2) A temporary increase in falls and medication errors within the AAU was likely to be associated with the need to adjust work patterns rather than associated with single rooms, although staff perceived the loss of panoptic surveillance as the key to increases in falls. Because of the fall in infection rates nationally and the low incidence at our study site and comparator hospitals, it is difficult to conclude from our data that it is the ‘single room’ factor that prevents infection. (3) Building an all single room hospital can cost 5% more but the difference is marginal over time. Housekeeping and cleaning costs are higher.

Conclusions

The nature of tasks undertaken by nurses did not change, but staff needed to adapt their working practices significantly and felt ill prepared for the new ways of working, with potentially significant implications for the nature of teamwork in the longer term. Staff preference remained for a mix of single rooms and bays. Patients preferred single rooms. There was no strong evidence that single rooms had any impact on patient safety but housekeeping and cleaning costs are higher. In terms of future work, patient experience and preferences in hospitals with different proportions of single rooms/designs need to be explored with a larger patient sample. The long-term impact of single room working on the nature of teamwork and informal learning and on clinical/care outcomes should also be explored.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

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

OBJECTIVE

Assess the attitudes and perceptions of parents and healthcare providers regarding the neonatal intensive care unit (NICU) environment while transitioning from an open ward (OW) to private-room (PR) NICU.

STUDY DESIGN

Parents and staff were surveyed 6 months before and 1 and 8 months after moving from OW to PR in a Level III NICU in 2009. Questions were scored on a 0 to 10 scale in areas of teamwork, communication, development, facility, safety and privacy.

RESULTS

In OW, parents and medical staff were satisfied with the teamwork. After 1 month in the PR, advanced practitioners reported higher scores whereas nurses reported declines in teamwork and safety but gains in other areas. Advanced practitioners' scores did not vary between surveys in the PR. Nurses were initially satisfied with the PR, but by 8 months, the scores declined. Parental satisfaction scores were consistently higher than medical staff in both settings.

CONCLUSIONS

Parental satisfaction is likely due to focus on their infant rather than facilities. In the PR, lower nursing scores are likely due to decreased interaction with peers. Research is needed to ensure that improvements gained from a PR NICU are meaningfully consistent.

Mothers' experiences expressing breast milk for their preterm infants: does NICU design make a difference?

PURPOSE

This study examined differences in outcomes of provision of mothers' milk before and after implementation of a single-family room (SFR) neonatal intensive care unit (NICU) and described issues related to long-term milk expression.

SAMPLE

The sample included 40 mothers (15 in the original NICU and 25 in the SFR NICU).

DESIGN

Descriptive comparative.

METHODS

Mothers were recruited 2 months before and 3 months after opening an SFR NICU. Nutritional data were collected throughout hospitalization. Mothers used a milk expression diary during hospitalization and completed a survey, "My Experiences With Milk Expression" immediately before infant discharge.

RESULTS

Seventy-five percent of mothers planned to express breast milk or breastfeed before delivery. The majority of the mothers (55%) were most comfortable pumping in their own homes because of the increased privacy. There were no statistically significant differences between the 2 groups regarding the place where they were most comfortable pumping or where they usually pumped, although more mothers pumped in their babies' rooms in the SFR NICU. The majority of the mothers reported concern about their milk supply at some time during hospitalization and 47.5% reported having breast problems. At discharge, 71.8% of the total group was providing some breast milk and 44.7% of the total group was providing breast milk exclusively. There were no significant differences between the groups in outcomes concerning the provision of breast milk.

CONCLUSIONS

Individual mother's needs for privacy need to be determined and interventions to support mothers' feeding plans throughout hospitalization and at discharge need to be developed.

The Environment of Inpatient Healthcare Delivery and Its Influence on the Outcome of Care

Aim:

This paper addresses issues arising in the literature regarding the environmental design of inpatient healthcare settings and their impact on care.

Background:

Environmental design in healthcare settings is an important feature of the holistic delivery of healthcare. The environmental influence of the delivery of care is manifested by such things as lighting, proximity to bedside, technology, family involvement, and space. The need to respond rapidly in places such as emergency and intensive care can override space needs for family support. In some settings with aging buildings, the available space is no longer appropriate to the needs—for example, the need for privacy in emergency departments. Many aspects of care have changed over the last three decades and the environment of care appears not to have been adapted to contemporary healthcare requirements nor involved consumers in ascertaining environmental requirements. The issues found in the literature are addressed under five themes: the design of physical space, family needs, privacy considerations, the impact of technology, and patient safety.

Conclusion:

There is a need for greater input into the design of healthcare spaces from those who use them, to incorporate dignified and expedient care delivery in the care of the person and to meet the needs of family.

Target Value Design: Applications to Newborn Intensive Care Units

There is a need for greater understanding of the health impact of various design elements in neonatal intensive care units (NICUs) as well as cost-benefit information to make informed decisions about the long-term value of design decisions. This is particularly evident when design teams are considering the transition from open-bay NICUs to single-family-room (SFR) units. This paper introduces the guiding principles behind target value design (TVD)—a price-led design methodology that is gaining acceptance in healthcare facility design within the Lean construction methodology. The paper also discusses the role that set-based design plays in TVD and its application to NICUs.

Guidelines for intensive care unit design

OBJECTIVE

To develop a guideline to help guide healthcare professionals participate effectively in the design, construction, and occupancy of a new or renovated intensive care unit.

PARTICIPANTS

A group of multidisciplinary professionals, designers, and architects with expertise in critical care, under the direction of the American College of Critical Care Medicine, met over several years, reviewed the available literature, and collated their expert opinions on recommendations for the optimal design of an intensive care unit.

SCOPE

The design of a new or renovated intensive care unit is frequently a once- or twice-in-a-lifetime occurrence for most critical care professionals. Healthcare architects have experience in this process that most healthcare professionals do not. While there are regulatory documents, such as the Guidelines for the Design and Construction of Health Care Facilities, these represent minimal guidelines. The intent was to develop recommendations for a more optimal approach for a healing environment.

DATA SOURCES AND SYNTHESIS

Relevant literature was accessed and reviewed, and expert opinion was sought from the committee members and outside experts. Evidence-based architecture is just in its beginning, which made the grading of literature difficult, and so it was not attempted. The previous designs of the winners of the American Institute of Architects, American Association of Critical Care Nurses, and Society of Critical Care Medicine Intensive Care Unit Design Award were used as a reference. Collaboratively and meeting repeatedly, both in person and by teleconference, the task force met to construct these recommendations.

CONCLUSIONS

Recommendations for the design of intensive care units, expanding on regulatory guidelines and providing the best possible healing environment, and an efficient and cost-effective workplace.

Comparing sound measurements in the single-family room with open-unit design neonatal intensive care unit: the impact of equipment noise

OBJECTIVE

To determine if measured sound levels in the occupied level 3 single-family room (SFR) neonatal intensive care unit (NICU) will be significantly and perceptibly different from the occupied level 3 open-unit (OU) NICU.

STUDY DESIGN

Case-control. Comparison of sound measurements obtained with varying types of respiratory support in SFR unit with measurements obtained from OU level 3 bedside NICU.

RESULT

SFR sound measurements were quieter and less loud compared with the open unit, except when high-frequency ventilation (HFV) was used.

CONCLUSION

The SFR level 3 NICU is a quieter, less loud environment compared with the open unit level 3 Bedside NICU when the patient is supported on room air, high flow nasal cannula, bubble continuous positive airway pressure and conventional ventilation. High HFV will result in similar measurements to the open unit level 3 bedside NICU.

Patients and Their Families Weigh in on Evidence-Based Hospital Design

Background

In 2 landmark publications, the Institute of Medicine reported on significant deficiencies in our current health care system. In response, an area of research examining the role of the physical environment in influencing outcomes for patients and staff gained momentum. The concept of evidence-based design has evolved, and the development of structural guidelines for new hospital construction was instituted by the American Institute of Architects in 2006.

Objective

To determine perceptions of patients and their families of evidence-based design features in a new heart center.

Methods

Hospitalized patients and their families, most of whom were in intensive care and step-down units, were surveyed and data from the Hospital Consumer Assessment of Healthcare Providers and Systems were reviewed to determine perceptions of evidence-based design features incorporated into a new heart center and to assess patients’ satisfaction with the environment.

Results

Responses were reviewed and categorized descriptively. Five general environment topics of focus emerged: privacy, space, noise, light, and overall atmosphere. Characteristics perceived as being dissatisfying and satisfying are discussed.

Conclusions

Critical care nurses must be aware of the current need to recognize how much the physical environment influences care delivery and take steps to maximize patients’ safety, satisfaction, and quality of care.

Evaluation of the Built Environment: Staff and Family Satisfaction Pre- and Post-Occupancy of the Children's Hospital

Objective:

To evaluate and compare the impact of an existing and newly built hospital environment on family and staff satisfaction related to light, noise, temperature, aesthetics, and amenities, as well as safety, security, and privacy.

Background:

The United States is engaged in an unprecedented healthcare building boom driven by the need to replace aging facilities, understand the impact of the built environment on quality and safety, incorporate rapidly emerging technologies, and enhance patient- and family-centered care. More importantly, there is heightened attention to creating optimal physical environments to achieve the best possible outcomes for patients, families, and staff.

Methods:

Using a pre-post descriptive survey design, all nursing, social work, therapy staff, and families on selected inpatient units were invited to participate. A demographic form and Family and Staff Satisfaction Surveys were developed and administered pre- and post-occupancy of the new facility.

Results:

Pre/post mean scores for staff satisfaction improved on all survey subscales with statistically significant improvement ( p < .05) in most areas. The most improvement was seen with layout of the patient room, natural light, storage and writing surfaces, and comfort and appeal. Family satisfaction demonstrated statistically significant improvement on all subscales (p ≤ .01), especially for natural light, quiet space, parking, and the child's room as a healing environment.

Conclusions:

Families and staff reported greater satisfaction with the newly built hospital environment compared to the old facility. Study results will help guide future architectural design decisions, attract and retain staff at a world-class facility, and create the most effective healing environments.

A Comparison of Parent Satisfaction in an Open-Bay and Single-Family Room Neonatal Intensive Care Unit

Objective:

The purpose of this research was to test the hypothesis that parental satisfaction with neonatal intensive care is greater in a single-family room facility as compared with a conventional open-bay neonatal intensive care unit (NICU).

Methods:

This investigation was a prospective cohort study comparing satisfaction survey results for parents who responded to a commercially available parent NICU satisfaction survey following the provision of NICU care in open-bay and single-family room facilities. A subset of 16 items indicative of family-centered care was also computed and compared for these two NICU facilities.

Results:

Parents whose babies received care in the single-family room facility expressed significantly improved survey responses in regard to the NICU environment, overall assessment of care, and total survey score than did parents of neonates in the open-bay facility. With the exception of the section on nursing in which scores in both facilities were high, nonsignificant improvement in median scores for the sections on delivery, physicians, discharge planning, and personal issues were noted. The total median item score for family-centered care was significantly greater in the single-family room than the open-bay facility.

Conclusions:

Parental satisfaction with care in the single-family room NICU was improved in comparison with the traditional open-bay NICU. The single-family room environment appears more conducive to the provision of family-centered care. Improved parental satisfaction with care and the potential for enhanced family-centered care need to be considered in decisions made regarding the configuration of NICU facilities in the future.

Infant neurobehavioral development

The trend toward single-room neonatal intensive care units (NICUs) is increasing; however scientific evidence is, at this point, mostly anecdotal. This is a critical time to assess the impact of the single-room NICU on improving medical and neurobehavioral outcomes of the preterm infant. We have developed a theoretical model that may be useful in studying how the change from an open-bay NICU to a single-room NICU could affect infant medical and neurobehavioral outcome. The model identifies mediating factors that are likely to accompany the change to a single-room NICU. These mediating factors include family centered care, developmental care, parenting and family factors, staff behavior and attitudes, and medical practices. Medical outcomes that plan to be measured are sepsis, length of stay, gestational age at discharge, weight gain, illness severity, gestational age at enteral feeding, and necrotizing enterocolitis (NEC). Neurobehavioral outcomes include the NICU Network Neurobehavioral Scale (NNNS) scores, sleep state organization and sleep physiology, infant mother feeding interaction scores, and pain scores. Preliminary findings on the sample of 150 patients in the open-bay NICU showed a "baseline" of effects of family centered care, developmental care, parent satisfaction, maternal depression, and parenting stress on the neurobehavioral outcomes of the newborn. The single-room NICU has the potential to improve the neurobehavioral status of the infant at discharge. Neurobehavioral assessment can assist with early detection and therefore preventative intervention to maximize developmental outcome. We also present an epigenetic model of the potential effects of maternal care on improving infant neurobehavioral status.

The ability of environmental healthcare design strategies To impact event related anxiety in paediatric patients: A comprehensive systematic review

EXECUTIVE SUMMARY

Background Children's' hospitals are by definition hospitals specialized in all aspects of children's care, but are they and if so, how is that achieved? Are healthcare facilities more than a 'space' in which to ask medical questions, seek answers and obtain treatment? Some suggest that the very design of a space can positively or negatively impact healing, hence the term referred to by those in the architectural community as 'healing spaces'. To date empirical studies to provide evidence to this effect, although growing in number, are still few. What is known is that hospitals, doctor's offices and dental offices alike unintentionally create an atmosphere, particularly for children, that add to an already heightened level of anxiety and fear. Designing a children's hospital, unlike a generalist facility, presents a unique and significant challenge. Those involved in designing such hospitals are faced with the opportunity and responsibility to care for and respond to the needs of children across the age spectrum; infants to toddlers, school aged children to adolescents. As healthcare professionals and architects, it is our responsibility to create healthcare facilities that are of purposeful design; anticipating and alleviating children's anxiety and fear wherever possible.Objectives The objective of this systematic review is to evaluate the effects of environmental design strategies in healthcare institutions such as hospitals and dental offices on event-related anxiety in the paediatric population.Inclusion Criteria This comprehensive systematic review involved children from the age of 1 to 18 years of age admitted to a healthcare facility with the primary outcomes of interest being four key design strategies: positive distraction; elimination of environmental stressors; access to social support and choice (control); and connection to nature.Search Strategy Using the Joanna Briggs defined three step search strategy, both published and unpublished studies were sought from the period of 1980 to 2010.Methods of the Review Data for each study was extracted and assessed by two independent reviewers for methodological validity prior to inclusion in the review using the Joanna Briggs Institute standardised critical appraisal instruments for Qualitative data (JBI-QARI) and for the Meta Analysis of Statistics Assessment (JBI-MAStARI).Results Twenty studies were reviewed, seven of a descriptive experimental design, three of mixed methodologies and thirteen of various qualitative research design methodologies inclusive of Observational, Grounded Theory, Ethnography and Phenomenology.Conclusions The design of the built environment does have the ability to impact either positively or negatively the level of anxiety and fear that children experience when exposed to a healthcare setting. The coping strategies engaged by and unique to each paediatric age group need to not only be understood but supported and reflected in the built environment.Implications for research Architects and healthcare researchers need to collaborate to establish a solid base of evidence related to this important area of interest. Irrespective of the challenges that researchers face in attempting to randomise, manipulate and control the numerous environmental variables that impact a question such as this, such challenges need not, nor should not, prevent or discourage future research. An innovative solution to the challenges faced by researchers in this field is the use of computer modelling and/ or simulation of the hospital environment. Through the use of simulated environments researchers can directly observe user preferences and/ physiological responses.Implication for practice This review highlights an insightful look into the preferences of children as consumers. Although sample sizes were small and results were not quantified in measurable outcomes, the ability for such studies to inform design should not be underestimated. Design strategies both from a practical perspective of minimal cost to construction projects warranting extensive resources are discussed.

Documenting the NICU design dilemma: parent and staff perceptions of open ward versus single family room units

OBJECTIVE

With neonatal intensive care units (NICUs) evolving from multipatient wards toward family-friendly, single-family room units, the study objective was to compare satisfaction levels of families and health-care staff across these differing NICU facility designs.

STUDY DESIGN

This prospective study documented, by means of institutional review board-approved questionnaire survey protocols, the perceptions of parents and staff from two contrasting NICU environments.

RESULT

Findings showed that demographic subgroups of parents and staff perceived the advantages and disadvantages of the two facility designs differently. Staff perceptions varied with previous experience, acclimation time and employment position, whereas parental perceptions revealed a naiveté bias through surveys of transitional parents with experience in both NICU facilities.

CONCLUSION

Use of transitional parent surveys showed a subject naiveté bias inherent in perceptions of inexperienced parents. Grouping all survey participants demographically provided more informative interpretations of data, and revealed staff perceptions to vary with position, previous training and hospital experience.

Neonatal intensive care nursery staff perceive enhanced workplace quality with the single-family room design

OBJECTIVE

To compare perceived workplace quality in an open-bay neonatal intensive care unit (NICU) and a single-family room (SFR) NICU.

STUDY DESIGN

Prospective non-randomized, non-controlled cohort study.

RESULT

Staff workplace quality perceptions assessed included the following: the quality of being a Sanford Health System employee (NS-not significant), the quality of the NICU physical work environment, the quality of NICU patient care, the job quality in the NICU, the quality of health and safety in the NICU (NS), the quality of safety and security in the NICU, the quality of interaction with other members of the NICU health-care team (NS; in subanalysis nurse scores significantly declined), the quality of interaction with NICU technology and the off-job quality of life (NS). Scores for each category and the total scores were statistically greater in the SFR, except as noted (NS).

CONCLUSION

Staff perceptions of workplace quality were significantly greater in the SFR than the open-bay NICU.