Influence of Evidence-Based Design Strategies on Nurse Wellness.

OBJECTIVES: The purpose of this study was to understand how specific evidence-based design strategies are related to aspects of nurse wellness. BACKGROUND: Addressing burnout among the healthcare workforce is a system-level imperative. Nurses face continuous and dynamic physical and emotional demands in their role. Greater insight into the role of the physical environment can support efforts to promote nurse wellness. METHODS: This exploratory qualitative study was conducted at new Parkland Hospital in Dallas, TX. We conducted five focus groups with nursing staff in July 2018. These sessions covered five topics related to nursing work in the facility which had been redesigned nearly 3 years earlier: (1) professional and social communication, (2) workflow and efficiency, (3) nurses' tasks and documentation, (4) ability to care for patients, and (5) nurses' overall health. We conducted a thematic analysis and first identified different aspects of wellness discussed by participants. Then, we examined how nurses related different design elements to different aspects of their wellness. RESULTS: Participants included 63 nurses and nurse managers. They related environmental factors including facility size, break rooms, and decentralized workstations to social, emotional/spiritual, physical, intellectual, and occupational aspects of wellness. CONCLUSIONS: It is critical to inform and integrate nurses at all levels into planning, design, and activation of new healthcare environments in order to ensure the well-being of nurses and, therefore, their ability to effectively support patients.

The HDR CARE Scale, Inpatient Version: A validated survey instrument to measure environmental affordance for nursing tasks in inpatient healthcare settings.

Rigorous healthcare design research is critical to inform design decisions that improve human experience. Current limitations in the field include a lack of consistent and valid measures that provide feedback about the role of the built environment in producing desirable outcomes. Research findings about nurses' efficiency, quality of care, and satisfaction related to inpatient unit designs have been mixed, and there was previously no validated instrument available to quantitatively measure nurses' ability to work efficiently and effectively in their environment. The objective of this study was to develop, refine, and validate a survey instrument to measure affordance of the care environment to nurse practice, based on various aspects of their work in inpatient units. The HDR Clinical Activities Related to the Environment (CARE) Scale Inpatient Version was developed using item design, refinement, and reliability and validity testing. Psychometric methods from classical test theory and item response theory, along with statistical analyses involving correlations and factor analysis, and thematic summaries of qualitative data were conducted. The four-phase process included (1) an initial pilot study, (2) a content validation survey, (3) cognitive interviews, and (4) a final pilot study. Results from the first three phases of analysis were combined to inform survey scale revisions before the second pilot survey, such as a reduction in the number and rewording of response options, and refinement of scale items. The updated 9-item scale showed excellent internal consistency and improved response distribution and discrimination. The factor analysis revealed a unidimensional measure of nurse practice, as well as potential subscales related to integration, efficiency, and patient care. Within the healthcare design industry, this scale is much needed to generate quantitative and standardized data and will facilitate greater understanding about the aspects of an inpatient healthcare facility that best support nurses' ability to provide quality patient care.

Effects of a Decentralized Nursing Model on Patient Outcomes in Two Rural Community Hospitals.

AIM: To assess hypothesized effects of decentralized nursing models on adult inpatient outcomes, patient medical records and satisfaction surveys were analyzed from two rural community hospitals that transitioned from centralized to decentralized nursing unit designs in 2015. BACKGROUND: The objective to place nurses closer to patients precipitates broad use of decentralized nursing unit designs over models with centralized nurse stations. Decentralized models have been hypothesized to improve patient outcomes, but few studies have empirically measured effects. METHODS: A cross-sectional, pre-post study used regression and interrupted time series models of adult inpatient data. Encounter-level patient records and survey responses across both sites were analyzed for a change in length of stay (LOS) and patient satisfaction from the preperiod (centralized) to the postperiod (decentralized). RESULTS: LOS decreased in the postperiod compared to the preperiod at one site, and there was no change in LOS at the other. Patient satisfaction mostly improved at both hospitals in the decentralized model; however, most upward trends started prior to the move, with no change postmove. Patient satisfaction significantly improved regarding quietness at night and overall hospital rating at one hospital and decreased regarding receiving help as soon as wanted at the other hospital. These changes occurred at the time of the move but may not be solely attributable to the decentralized nursing model. CONCLUSIONS: Overall, the results were mixed. One hospital experienced positive changes while the other did not, suggesting factors apart from nursing unit design are important to assess.

From Fable to Reality at Parkland Hospital: The Impact of Evidence-Based Design Strategies on Patient Safety, Healing, and Satisfaction in an Adult Inpatient Environment.

OBJECTIVE: This research aimed to evaluate the quantitative effects of new hospital design on adult inpatient outcomes. BACKGROUND: Tenets of evidence-based healthcare design, notably single-patient acuity-adaptable and same-handed rooms, decentralized nursing stations, onstage offstage layout, and access to nature were expected to promote patient healing and increase patient satisfaction, while decreasing adverse events. METHODS: Patient healing was operationalized through length of stay (LOS) and patient safety through three adverse events: falls, hospital-acquired infections (HAI), and medication-related events. Standard patient surveys captured patient satisfaction. Patient records from 2013 through 2017 allowed for equivalent time periods surrounding the move to the new hospital in August 2015. Stratified by hospital division where significant, pre/post comparisons utilized proportional hazards or logistic regression models as appropriate; interrupted time series analyses afforded longitudinal interpretations. RESULTS: Observed higher postmove LOS was due to previously increasing trends, not increases after the move. In surgical and trauma units, a constant increase in falls was unaffected by the move. Medication events decreased consistently over time; medication events with harm dropped significantly after the move. No change in HAI was found. Significant improvement on most relevant patient satisfaction items occurred after the move. Call button response decreased immediately after the move but subsequently improved. CONCLUSION: Results did not clearly indicate a net change in adult inpatient outcomes of healing and safety due to the hospital design. There was evidence that the new hospital improved patient satisfaction outcomes related to the environment, including comfort, noise, temperature, and aesthetics.

Single-family room neonatal intensive care unit design: do patient outcomes actually change?

OBJECTIVE: This study examined outcomes in a single-family room neonatal intensive care unit (NICU) compared to an open bay within a public safety net hospital. STUDY DESIGN: We included 9995 NICU encounters over 5 years pre and post move for a predominantly low SES population. Outcomes were length of stay (LOS), growth, time to first oral feeding, and incidence of sepsis. Analysis included regression models, interrupted time series, and growth models. RESULTS: LOS decreased over time in preterm infants both pre and post move, but increased post move for term/post-term infants (p < 0.001). First oral feeding decreased over time in both periods. A higher incidence of sepsis was found in the post period for term/post-term infants (p = 0.01). CONCLUSION: Our analysis appropriately accounted for time trends. Few differences were observed. Changes in LOS for term/post-term infants should be further explored as well as the impact of NICU care patterns.

From Competition to Collaboration: How a Multi-Firm Research Coalition Is Realizing Rigorous Facility Evaluation at Parkland Hospital.

This case study presents the process of developing a multi-entity Research Coalition to evaluate the new Parkland Hospital. The field of evidence-based design has made progress in systematically investigating relationships between healthcare facility design and a range of human outcomes. Yet healthcare facility evaluation is not typically included in the scope of building contracts. Lack of clear responsibility for evaluation and limited funding have been long-term barriers that the industry has yet to overcome. Firms engaged in design research at Parkland Hospital agreed with hospital representatives to collaborate on an integrated facility evaluation. Each participating entity contributed resources toward the effort. To formalize shared goals and priorities, the group developed a Research Coalition Charter. Goals included streamlining evaluation efforts to minimize burden on the hospital, leveraging multiple expertise areas to vet research aims and approaches, contributing knowledge to inform healthcare design, and innovating a model for multi-firm collaboration. The Coalition also developed guidelines for sharing data and disseminating research findings. To date, the Research Coalition has achieved key milestones including institutional review board exemption, data use and research collaboration agreements, and data collection. The research aims encompass patient and staff outcomes hypothesized to improve in the new facility. Both primary and secondary data are being analyzed to test the hypotheses. Publications of findings are forthcoming. Collaborative research among competitors may be a viable approach to realizing evaluation that is critical to learning for healthcare facility decision makers and design practitioners.

Associations of Patient and Staff Outcomes With Inpatient Unit Designs Incorporating Decentralized Caregiver Workstations: A Systematic Review of Empirical Evidence.

OBJECTIVES:: This systematic literature review synthesizes and assesses quality of research addressing associations of patient and staff outcomes with inpatient unit designs incorporating decentralized caregiver workstations. BACKGROUND:: A current hospital design trend is to include decentralized caregiver workstations on inpatient units. A review of literature addressing decentralized unit design is needed. METHODS:: The systematic review methodology was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Database searches were conducted for studies published in peer-reviewed journals through October 2017. Included were empirical studies associating patient and/or staff outcomes and unit design with decentralized caregiver workstations. Individual studies were evaluated for quality using established methods, and Grading of Recommendations Assessment, Development and Evaluation (GRADE) and GRADE-Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) guided rigorous inspection of evidence quality and strength for quantitative outcomes and qualitative findings, respectively. RESULTS:: The search yielded 1,096 records with 36 full-text articles examined and 12 articles included in the final review. This work was dominated by studies with limited analyses. Staff outcomes have been most widely studied, especially collaboration/communication and walking. Overall, studies exploring decentralized nursing as a design intervention have produced limited results for both staff and patient outcomes. Strength of evidence of the current literature with quantitative methods as a whole was rated very low quality. CONCLUSIONS:: Although varying degrees of caregiver workstation decentralization in inpatient units are now common, the literature addressing the impacts of such designs is of very low quality and shows inconsistency in associated outcomes. Rigorous, well-designed studies with consistently defined design and outcome measures are needed for greater confidence in determining any effects of decentralized unit design.

Impacts of active school design on school-time sedentary behavior and physical activity: A pilot natural experiment.

BACKGROUND: Children spend a significant portion of their days in sedentary behavior (SB) and on average fail to engage in adequate physical activity (PA). The school built environment may influence SB and PA, but research is limited. This natural experiment evaluated whether an elementary school designed to promote movement impacted students' school-time SB and PA. METHODS: Accelerometers measured SB and PA at pre and post time-points in an intervention group who moved to the new school (n = 21) and in a comparison group experiencing no school environmental change (n = 20). Difference-in-difference (DD) analysis examined SB and PA outcomes in these groups. Measures were also collected post-intervention from an independent, grade-matched group of students in the new school (n = 21). RESULTS: As expected, maturational increases in SB were observed. However, DD analysis estimated that the intervention attenuated increase in SB by 81.2 ± 11.4 minutes/day (p<0.001), controlling for time in moderate to vigorous physical activity (MVPA). The intervention was also estimated to increase daily number of breaks from SB by 23.4 ± 2.6 (p < .001) and to increase light physical activity (LPA) by 67.7 ± 10.7 minutes/day (p<0.001). However, the intervention decreased MVPA by 10.3 ± 2.3 minutes/day (p<0.001). Results of grade-matched independent samples analysis were similar, with students in the new vs. old school spending 90.5 ± 16.1 fewer minutes/day in SB, taking 21.1 ± 2.7 more breaks from SB (p<0.001), and spending 64.5 ± 14.8 more minutes in LPA (p<0.001), controlling for time in MVPA. Students in the new school spent 13.1 ± 2.7 fewer minutes in MVPA (p<0.001) than their counterparts in the old school. CONCLUSIONS: This pilot study found that active school design had beneficial effects on SB and LPA, but not on MVPA. Mixed results point to a need for active classroom design strategies to mitigate SB, and quick access from classrooms to areas permissive of high-intensity activities to promote MVPA. Integrating active design with programs/policies to promote PA may yield greatest impact on PA of all intensities.

Children's Discourse of Liked, Healthy, and Unhealthy Foods.

BACKGROUND: Food literacy and nutrition education from kindergarten to 12th grade is a recommended strategy to address obesity prevention. However, limited research has explored children's understanding and conceptualization of food and healthy eating to inform the development of curricula and messaging strategies. OBJECTIVE: To explore and identify patterns and themes regarding how children discuss and describe food and healthy eating. DESIGN: Focus groups were conducted during which children were asked to identify and describe foods they liked and perceived as healthy and unhealthy. To triangulate findings, children also completed written worksheets on which they identified and described foods. Discourse analysis was used to code and interpret data by focusing on the language children used in relation to different types of food. PARTICIPANTS/SETTING: Seven focus groups were held with children in grades 3 through 7 (n=38) from one rural community. RESULTS: Analysis indicated four main themes. Children used a heuristic based on major food groups to determine healthfulness, did not strongly connect health values with liked foods and foods perceived as unhealthy, expressed that taste, texture, and visual appeal primarily shaped likeability, and associated liked foods with positive home and family experiences. CONCLUSIONS: Children's descriptions of liked and unhealthy foods were largely disconnected from health values and connected to taste and familiarity. Nutrition education should expand strategies beyond promotion of health benefits to include taste and sociocultural familiarity.

The Role of School Design in Shaping Healthy Eating-Related Attitudes, Practices, and Behaviors Among School Staff.

BACKGROUND: Schools have increasing responsibility to address healthy eating, but physical barriers influence their ability to adopt and sustain recommended strategies. We took advantage of a natural experiment to investigate the role of the physical environment in shaping healthy eating attitudes and practices among school staff members. METHODS: A school district consolidated its elementary schools and incorporated architectural features to support healthy eating into a building renovation. Surveys along with structured, in-depth interviews were administered prior to and at 12 months postoccupancy. Paired t-tests and McNemar's tests were used to analyze changes in survey indices and interview data were coded for themes. RESULTS: The school implemented new policies and programs, including staff wellness activities. There was a significant decrease in the percent of teachers with a high-fat diet (from 73.68% to 57.14%, p < .05). Many physical barriers were removed but new challenges emerged, and staff varied in their awareness and comfort with using the new healthy eating features. CONCLUSIONS: We found promising evidence that school architecture can support a school to address healthy eating. To enhance influence of the physical environment, more research is merited to test complementary strategies such as improving ownership of space and increasing self-efficacy to manage space.

Consumer Opinions of Health Information Exchange, e-Prescribing, and Personal Health Records.

BACKGROUND: Consumer satisfaction is a crucial component of health information technology (HIT) utilization, as high satisfaction is expected to increase HIT utilization among providers and to allow consumers to become full participants in their own healthcare management. OBJECTIVE: The primary objective of this pilot study was to identify consumer perspectives on health information technologies including health information exchange (HIE), e-prescribing (e-Rx), and personal health records (PHRs). METHODS: Eight focus groups were conducted in seven towns and cities across Nebraska in 2013. Each group consisted of 10-12 participants. Discussions were organized topically in the following categories: HIE, e-Rx, and PHR. The qualitative analysis consisted of immersion and crystallization to develop a coding scheme that included both preconceived and emergent themes. Common themes across focus groups were identified and compiled for each discussion category. RESULTS: The study had 67 participants, of which 18 (27 percent) were male. Focus group findings revealed both perceived barriers and benefits to the adoption of HIT. Common HIT concerns expressed across focus groups included privacy and security of medical information, decreases in quality of care, inconsistent provider participation, and the potential cost of implementation. Positive expectations regarding HIT included better accuracy and completeness of information, and improved communication and coordination between healthcare providers. Improvements in patient care were expected as a result of easy physician access to consolidated information across providers as well as the speed of sharing and availability of information in an emergency. In addition, participants were optimistic about patient empowerment and convenient access to and control of personal health data. CONCLUSION: Consumer concerns focused on privacy and security of the health information, as well as the cost of implementing the technologies and the possibility of an unintended negative impact on the quality of care. While negative perceptions present barriers for potential patient acceptance, benefits such as speed and convenience, patient oversight of health data, and safety improvements may counterbalance these concerns.

Physical Activity Design Guidelines for School Architecture.

Increasing children's physical activity at school is a national focus in the U.S. to address childhood obesity. While research has demonstrated associations between aspects of school environments and students' physical activity, the literature currently lacks a synthesis of evidence to serve as a practical, spatially-organized resource for school designers and decision-makers, as well as to point to pertinent research opportunities. This paper describes the development of a new practical tool: Physical Activity Design Guidelines for School Architecture. Its aims are to provide architects and designers, as well as school planners, educators, and public health professionals, with strategies for making K-12 school environments conducive to healthy physical activity, and to engage scientists in transdisciplinary perspectives toward improved knowledge of the school environment's impact. We used a qualitative review process to develop evidence-based and theory-driven school design guidelines that promote increased physical activity among students. The design guidelines include specific strategies in 10 school design domains. Implementation of the guidelines is expected to enable students to adopt healthier physical activity behaviors. The tool bridges a translational gap between research and environmental design practice, and may contribute to setting new industry and education standards.

Community-Engaged Public Health Research to Inform Hospital Campus Planning in a Low Socioeconomic Status Urban Neighborhood.

OBJECTIVE: To compare sociodemographic and motivational factors for healthcare use and identify desirable health-promoting resources among groups in a low socioeconomic status (SES) community in Chicago, IL. BACKGROUND: Disparities in health services and outcomes are well established in low SES urban neighborhoods in the United States and many factors beyond service availability and quality impact community health. Yet there is no clear process for engaging communities in building resources to improve population-level health in such locales. METHODS: A hospital building project led to a partnership of public health researchers, architects, and planners who conducted community-engaged research. We collected resident data and compared factors for healthcare use and choice and likelihood of engaging new health-promoting services. RESULTS: Neighborhood areas were strongly associated with ethnic groupings, and there were differences between groups in healthcare choice and service needs, such as, proximity to home was more important to Latinos than African Americans in choice of healthcare facility ( p adj = .001). Latinos expressed higher likelihood to use a fitness facility ( p adj = .001). Despite differences in vehicle ownership, >75% of all respondents indicated that nearby public transportation was important in choosing healthcare. CONCLUSION: Knowledge of community needs and heterogeneity is essential to decision makers of facility and community development plans. Partnerships between public health, urban planning, architecture, and local constituents should be cultivated toward focus on reducing health disparities. Further work to integrate community perspectives through the planning and design process and to evaluate the long-term impact of such efforts is needed.

SaludABLEOmaha: improving readiness to address obesity through healthy lifestyle in a Midwestern Latino community, 2011-2013.

BACKGROUND: A community's readiness for change is a precursor to the effective application of evidence-based practices for health promotion. Research is lacking regarding potential strategies to improve readiness to address obesity-related health issues in underserved communities. COMMUNITY CONTEXT: This case study describes SaludABLEOmaha, an initiative to increase readiness of residents in a Midwestern Latino community to address obesity and adopt healthy lifestyles. METHODS: SaludABLEOmaha emphasized 2 core approaches, youth activism and collaboration among public and private institutions, which we applied to planning and implementing tactics in support of 3 interconnected strategies: 1) social marketing and social media, 2) service learning in schools (ie, curricula that integrate hands-on community service with instruction and reflection), and 3) community and business engagement. Following the Community Readiness Model protocol (http://triethniccenter.colostate.edu/communityReadiness.htm), structured interviews were conducted with community leaders and analyzed before and 2.5 years after launch of the program. OUTCOME: The community increased in readiness from stage 3 of the Community Readiness Model, "vague awareness," at baseline to stage 5, "preparation," at follow-up. INTERPRETATION: SaludABLEOmaha improved community readiness (eg, community knowledge, community climate), which probably contributed to the observed increase in readiness to address obesity through healthy lifestyle. Community mobilization approaches such as youth activism integrated with social marketing and social media tactics can improve community responsiveness to obesity prevention and diminish health disparities.

Influence of school architecture and design on healthy eating: a review of the evidence.

We examined evidence regarding the influence of school physical environment on healthy-eating outcomes. We applied a systems perspective to examine multiple disciplines' theoretical frameworks and used a mixed-methods systematic narrative review method, considering both qualitative and quantitative sources (published through March 2014) for inclusion. We developed a causal loop diagram from 102 sources identified. We found evidence of the influence of many aspects of a school's physical environment on healthy-eating outcomes. The causal loop diagram highlights multilevel and interrelated factors and elucidates the specific roles of design and architecture in encouraging healthy eating within schools. Our review highlighted the gaps in current evidence and identified areas of research needed to refine and expand school architecture and design strategies for addressing healthy eating.

Healthy eating design guidelines for school architecture.

We developed a new tool, Healthy Eating Design Guidelines for School Architecture, to provide practitioners in architecture and public health with a practical set of spatially organized and theory-based strategies for making school environments more conducive to learning about and practicing healthy eating by optimizing physical resources and learning spaces. The design guidelines, developed through multidisciplinary collaboration, cover 10 domains of the school food environment (eg, cafeteria, kitchen, garden) and 5 core healthy eating design principles. A school redesign project in Dillwyn, Virginia, used the tool to improve the schools' ability to adopt a healthy nutrition curriculum and promote healthy eating. The new tool, now in a pilot version, is expected to evolve as its components are tested and evaluated through public health and design research.

SaludableOmaha: development of a youth advocacy initiative to increase community readiness for obesity prevention, 2011-2012.

BACKGROUND: Childhood obesity rates in minority populations continue to rise despite leveling national trends. Although interventions that address social and environmental factors exist, processes that create demand for policy and environmental change within communities have not been identified. COMMUNITY CONTEXT: We developed a pilot program in South Omaha, a Nebraska Latino community, based on the community readiness model (CRM), called SaludableOmaha. We used CRM to explore the potential of youth advocacy to shift individual and community norms regarding obesity prevention in South Omaha and to advocate for health-promoting community environments. METHODS: We used CRM to assess supply and demand for health programs, engage the community, determine the community's baseline readiness to address childhood obesity, and guide youth advocacy program development. We conducted our project in 2 phases. In the first, we trained a cohort of youth. In the second, the youth cohort created and launched a Latino health movement, branded as SaludableOmaha. A third phase, which is currently under way, is directed at institutionalizing youth advocacy in communities. OUTCOME: At baseline, the community studied was at a low stage of readiness for change. Our program generated infrastructure and materials to support the growth and institutionalization of youth advocacy as a means of increasing community readiness for addressing obesity prevention. INTERPRETATION: CRM is an important tool for addressing issues such as childhood obesity in underserved communities because it provides a framework for matching interventions to the community. Community partnerships such as SaludableOmaha can aid the adoption of obesity prevention programs.