How Visibility May Reduce Security Issues in Community Hospitals' Emergency Departments.

This research explored the relationship between visibility and the level of security risks as perceived by nurses and physicians in emergency departments (EDs). Security in EDs has been reported as a major global concern, and visibility has been identified as a design factor impacting behavior. However, few previous studies have rigorously investigated the role of visibility in reduction of ED security risks with evidence-based design approach. There is a lot of significant questions about how visibility impacts the reduction of security issues in EDs. METHODS: How visibility may influence ED security was explored via qualitative methods in five EDs using semi-structured one-on-one interviews with 17 clinical staff and 48 hr of field observations. The coding process for both interviews and observational notes followed the principles of naturalistic inquiry. RESULTS: The findings suggest security risks can be decreased by improving visibility. Medical staff (registered nurses and physicians) felt more secure in the EDs with higher visibility. DISCUSSION: This study provides a framework to identify preferable levels of visibility in EDs and proposes design strategies to minimize security issues. Registered nurses and physicians can improve their team's sense of security by considering visibility throughout their daily practices.

Could Spatial Awareness Affect Situation Awareness: A Conceptual Examination.

PURPOSE: The purpose of this study was to explore the relationship between situation awareness (SA) and the physical environment in patient rooms through building a conceptual model. BACKGROUND: Nurses work in very complicated and dynamic environments where having high levels of SA could be critical for their performance. Studies have also shown that nurses' awareness of the physical environment and patient room is a part of their awareness of dynamic situations in which nurses' spatial awareness may play a role in SA. Despite literature outlining the importance of SA, there is a lack of studies exploring the relationship between the two. METHOD: A literature review was conducted for the study from nursing and psychology databases. Thirty-three articles, books, and dissertations from a scoping review were included for in-depth review. RESULTS: An in-depth review of the harvested literature indicated that there is in fact a relationship between these two phenomena. Founded on Endsley's model of SA, the literature review in this study offers a conceptual model that articulates a plausible causal pathway between the physical environment and SA. CONCLUSIONS: There are a lot of studies focusing on SA and various aspects of it related to nursing, but almost none mention the physical environment and its impact on SA. The current inquiry suggests that spatial awareness plays a prominent role in SA.

Reimagining America's Rural Health: Challenges and Opportunities.

OBJECTIVES: The objective of this inquiry was to identify (a) rural health challenges in the United States, especially in the context of the COVID-19 pandemic and (b) to identify opportunities within the disruptions caused by the pandemic. BACKGROUND: Rural healthcare challenges in the United States are not the same as those faced in urban and suburban communities. Nor are rural hospitals a miniature version of larger urban hospitals. Urban healthcare and hospital-centric policies and solutions, hence, do not help address or optimize the unique health challenges of rural communities. Furthermore, the challenges previously faced by rural hospitals were further exacerbated by COVID-19. METHODS: Key points from public deliberations among experts in a 1-day symposium on rural health, attended by 65 professionals representing 18 west Texas institutions, were captured by the authors. The data were subsequently analyzed to identify common areas of information. FINDINGS: Four clusters of challenges and opportunities were identified: healthcare delivery, healthcare infrastructure/building, community health, and public administration. CONCLUSIONS: Symposium data suggest that rural health faced numerous unique challenges, which were further compounded by the COVID-19 pandemic. However, the pandemic also helped discover the resiliency of clinicians working in rural areas. For rural health optimization, rural health buildings also need to be flexible. While funds are not easily available, some innovative community collaborations with healthcare institutions may generate novel solutions. In the meantime, telemedicine promises a radical change in rural community health services in the future.

Exploring Hospital Physical Environment Influencing Users First Impressions of the Healthcare Organizations: A Conceptual Framework Based on Literature Review.

PURPOSE: The aim of the study was to examine literature on first impressions and how physical design factors influence users' first impressions. BACKGROUND: Engineering a first impression through physical design has been successfully used in the context of US federal buildings and retail. A patient's first impression is important as it affects their downstream behaviors and experiences. However, little is known about it in the context of healthcare design. METHOD: This study is part of a broader literature review that searched for studies on the first impression phenomenon, which were examined in a cross-disciplinary literature review, along with trade/professional journals/magazines. Three databases were in-depth searched-Scopus, Web of Science, and HaPI along with Google Scholar search and hand searching. A total of 187 satisfied articles and three books were reviewed through three phases to obtain an understanding of the first impressions and the factors affecting it. RESULTS: After the in-depth review of the theories behind the first impression, the authors proposed a conceptual framework explaining the concept of the first impression and engineering it through physical design. The findings from published articles suggest five conceptual steps between early information pickup and early impression formation: (1) exposure time, (2) information pickup, (3) cognition, (4) emotion, and (5) judgment. CONCLUSIONS: The findings show a causal association between one's initial information pickup during the first 5 min of exposure to a target and the formation of a first impression. It suggests a crucial role of physical design of the environment, including in healthcare facilities.

Hierarchy of Evidence: An Appraisal Tool for Weighting the Evidence in Healthcare Design Research Based on Internal Validity.

PURPOSE: This inquiry aims to develop an appraisal tool to offer greater granularity in weighing evidence in the field of healthcare design research. BACKGROUND: In evidence-based design (EBD), the goal is to implement interventions that result in a meaningful and optimal effect based on current best evidence. Although multiple appraisal tools (many adopted from medical disciplines) have been instrumental in evaluating studies in the field of healthcare design research to identify the best evidence, they do not necessarily consider the unique contexts of healthcare design research, and methodologies appropriate to the field. METHODS: Five basic types of studies are ranked based on the level of confidence that they offer regarding the estimate of an effect: (1) meta-analysis studies, (2) causal studies, (3) correlational studies, (4) descriptive studies, and (5) anecdotal evidence. Causal studies are further divided into four levels based on the interaction of two factors: (1) type of intervention and (2) groups' equivalency and extraneous variable control. RESULTS: An eight-level hierarchy of evidence for healthcare design research is proposed that is expected to improve upon previous hierarchies in three major ways: (a) including research methods that are more relevant to healthcare design research, (b) enhancing evaluation accuracy and reliability by providing a clearer definition of studies based on their key components rather than using study labels alone, and (c) distinguishing different levels of evidence, particularly in causal studies. CONCLUSIONS: The proposed appraisal tool is developed specifically for EBD by reflecting on the unique context of healthcare design research and practice.

Exploring the Relationship Between Perceived Visual Access to Nature and Nurse Burnout.

OBJECTIVE: This study aims to investigate the relationship between perceived visual access to nature views in nurse work and break environments and scores for subscales of Maslach Burnout Inventory among nurses. BACKGROUND: Burnout is a severe problem among nurses. Literature shows a relationship between stress and burnout and between nature exposure and stress. However, the possible consequent relationship between connection to nature and nurse burnout needs further study. METHODS: This cross-sectional study explored the relationship between the subscales (Emotional Exhaustion, Depersonalization, and Personal Accomplishment [EE, DP, and PA]) of the Maslach Burnout Inventory as "outcome variables" and perception of view duration, frequency of exposure to views, view content and artwork content as "explanatory variables" in a subset regression model. The study model also included organizational stressors, environmental design factors, unit type, workload, and personal factors as control variables. Fifty-one nurses working in six units in a large tertiary care hospital participated in the study. RESULTS: Percentage of perceived nature views and organizational stressors were the top two best predictors correlating with EE (37% of the EE variance; p < .05). Percentage of perceived nature views, organizational stressors, and environmental design were the top three predictors correlating with DP (43% of variance for DP; p < .05). No significant relationship was found between study variables and PA. CONCLUSIONS: The results of this study recommend perceiving nature views as an independent or integrated intervention to meditation and relaxation techniques. From a design standpoint, this study suggests that a unit and breakroom design with access to nature views could work as a consistent preventive intervention for burnout.

Lessons Learned From Decentralization of an Elective Surgery Medical-Surgical Unit.

OBJECTIVE: The objective of this study was to examine changes in healthcare practitioners' perception of supportiveness of their physical work environment, and trend in patient fall, when moving from a centralized to a decentralized unit configuration. BACKGROUND: Previous studies on decentralization have not uniformly provided findings consistent with desired outcome. METHOD: A pretest-posttest study was conducted in an elective surgery medical-surgical unit in the mid-Atlantic region of the United States. The independent variable was the physical design supporting centralized versus decentralized nursing models. Data were collected from healthcare staff with a self-report survey "before" (September 2017; n = 42) and "after" (June 2019; n = 22), and interviews. Before-after data were analyzed using both parametric and nonparametric tests to identify significant differences. Qualitative responses were analyzed to identify triangulating evidences. Monthly patient fall data were collected for a 3-year period and analyzed using log-linear Poisson Regression model. RESULTS: Results show favorable assessments in the areas of overall supportiveness of design, equipment and soiled utility location, peer support, process flow visualization, and overall satisfaction. A reduction in patient falls was observed. Unfavorable outcomes were found in the contexts of walking distance, multidisciplinary collaboration, alarm audibility, nurse station size, and PPE location. CONCLUSIONS: This study underscores that the success of a unit cannot be achieved without coordinated and successful interventions in the areas of operations, processes, policies, culture, and the physical design.

A Narrative Review of Theories of Wayfinding Within the Interior Environment.

PURPOSE: The aim of this article is to provide a narrative overview of theories that are available in the published literature on wayfinding in interior environments. BACKGROUND: Wayfinding is an issue in healthcare facilities, and it has been documented that wayfinding problems have negative impacts on patients, visitors, caregivers' time, and the organization's bottom line. This issue can be more challenging for people with illness, low vision, cognitive disorders, and limited physical mobility. Wayfinding is a complex phenomenon depending on a variety of cognitive processes and behaviors. METHODS: This article is a part of a broader literature review that searched for empirical studies on interior wayfinding. Four databases were systematically searched-PsychINFO, JSTOR, ProQuest, and EBSCO. A total of 81 articles satisfied all inclusion criteria for the broader study. Each article included in the broader study was reviewed to identify theory or theories, if any, that a study was founded on. RESULTS: After an in-depth review of the theories, the authors proposed four categories of theories relating to human wayfinding. The four classes and the specific theories in those are articulated in this article, including major changes during their evolution. The four classes of theories explain four facets of wayfinding: (1) theories of perception, (2) theories of spatial knowledge development, (3) theories of mental representation of spatial knowledge, and (4) theories of spatial cognition. CONCLUSION: Since wayfinding is essentially a cognitive/problem-solving phenomenon, understanding the theoretical underpinnings of wayfinding may result in more meaningful and impactful design decisions.

Physical Design Factors Contributing to Patient Falls.

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

The Impact of the Built Environment on Patient Falls in Hospital Rooms: An Integrative Review.

OBJECTIVES: The aims of this study were to identify and evaluate scientific evidence examining the impact of the built environment on patient falls in hospital rooms. METHODS: An integrative review (IR) with a systematic literature search was performed using the patient, intervention, comparison, outcome framework. We searched CINAHL, PsychINFO, PubMED, and Web of Science databases. The search included peer-reviewed studies from 1990 to 2017 written in English. An additional hand search was also conducted. Selected articles were reviewed and rated based on a hierarchical categorization, comprising six evidence levels, developed by the American Association of Critical-Care Nurses and adapted for evidence-based design systematic literature reviews. RESULTS: After a multitiered process, 30 articles met the selection criteria. Thematic areas were created based on the examined elements of the physical environment including patient room configuration and available space, bathroom configuration, bathtub and shower, door, bed height and bed rail, flooring, floor mats, patient chair, lighting, toilet, handrail, grab bars, intravenous pole, sink, ceiling lift, and wheelchair and walking aids. Findings of studies on each element are discussed in detail. CONCLUSIONS: Some environmental elements have not been examined in past relational or causal studies, and the level of evidence for the examined attributes is not high enough to gain robust confidence in healthcare design decision-making. Because of the low level of evidence for several environmental elements, conclusions must be taken with caution. More studies using quantitative, relational, or causal designs are recommended to develop actionable interventions on patient falls in hospital rooms.

Can Physical Design Help Reduce Loneliness in the Elderly? A Theoretical Exploration.

BACKGROUND: Over the past several years, a new problem affecting the elderly population has been increasingly reported in popular press-the elderly population is dying as a result of loneliness and related factors at a rate greater than that of lack of medical care. The problem is so pervasive that loneliness is being described as an epidemic. OBJECTIVE: The objective of this inquiry was to examine whether the physical design of the lived environments could contribute to reducing loneliness in the elderly population. METHOD: A combination of scoping and conceptual review of published literature was adopted for the study. The process involved multiple phases of searching, and a review was conducted at each stage. Databases targeted include PsycINFO, Academic Search Complete, PsycArticles, Psychology and Behavioral Sciences Collection, and SocINDEX. In all, 44 articles and books were subjected to in-depth analyses of underlying concepts, constructs, relationships, and empirical findings. RESULTS: Several theories including meaning in life theory, lifespan ego-development theory, symbolic interaction theory, proxemics, and affordance theory suggest that the design of the physical environment may have a role in addressing loneliness in the elderly. A potential explanatory model articulating the causal pathway is presented in this article. CONCLUSIONS: Between theoretical propositions and empirical literature, there exist grounds to assert that a plausible causal pathway exists between the physical environment and loneliness in the elderly population. The explanatory pathway suggests that the physical design could play both a direct and moderating role in influencing loneliness.

Wayfinding in Interior Environments: An Integrative Review.

Wayfinding is an issue in complex facilities-including hospitals, airports, and office buildings-and wayfinding difficulties are associated with negative psychological and physiological consequences. In addition, since finding one's way in a building is a prerequisite for successfully using that building, wayfinding has attracted the attention of scholars and decision makers. The goal of this article is to review and synthesize the published literature on wayfinding in interior environments. A systematic search was conducted of four databases: PsychINFO, JSTOR, ProQuest, and EBSCO. A hand search was also conducted. From the initial harvest of 804 records, a total of 84 records met the inclusion criteria for full review. After several rounds of review, four broad domains were identified: (1) wayfinding cognition, (2) wayfinding behavior, (3) individual and group differences, and (4) environmental factors. These domains are used as a framework to organize the findings, and the review shows that the sub-domains most thoroughly addressed in the literature are spatial memories, floor plan configuration, landmarks, signs, and maps. This review can deepen the field's understanding of factors that contribute to interior wayfinding and can serve as a resource for decision makers and designers.

The Correlation Between Visibility and Medical Staff Collaborative Communication in Emergency Departments.

OBJECTIVES: This study empirically investigates the correlation between visibility and nurses and physicians' collaborative communication in emergency departments (EDs). The researchers hypothesized that higher visibility levels in EDs are associated with higher collaborative communication among nurses and physicians. BACKGROUND: The review of related literature addresses the role of communication in EDs, and more specifically, how visibility has been found to affect nurse and physician behavior in healthcare facilities. METHOD: The visibility levels in four EDs within the same hospital system were quantitatively measured in this study. Also, the communication levels among medical staff were explored by two methods. Data collection included computerized floor plan analyses, observations, and surveys. RESULTS: The researchers found statistically significant relationships between several underlying dimensions of ED visibility and collaborative communication among the medical staff members. CONCLUSION: Understanding the role of visibility provides a critical design principle for future EDs. The enhancement of ED design helps nurses and physicians to benefit from supportive environments.

Improving Precision and Confidence of Research Application Through Mediator and Moderator Models.

PURPOSE: The purpose of this article is to conceptually discuss moderator and mediator models in healthcare design studies. BACKGROUND: Healthcare outcomes are many times the result of meaningful interactions between multiple factors from different domains such as physical design, operations, culture, psychology, physiology, and social, among others. Simple multivariate models may not (a) capture these intricate relationships, (b) provide predictive precision, and (c) optimize arguments behind design decisions. METHODS: A review of text books and publications on research methods was conducted, along with a review of completed research studies to identify appropriate examples for articulation. RESULTS: An analysis of a nonrandom sample of completed healthcare design studies demonstrates the potential benefits of developing and testing moderator and mediator models in healthcare design studies. CONCLUSIONS: Moderator and mediator models may help optimize multifaceted solutions that include simultaneous and parallel interventions in the physical, operational, cultural, psychological, physiological, social, and/or other environments hypothesized to play a role in the outcome of interest.

The Influence of Visibility on Medical Teamwork in Emergency Departments: A Mixed-Methods Study.

AIM: This mixed-methods study delivers empirical evidence on the influence of visibility on healthcare teamwork in Emergency Departments (EDs). This study researchers hypothesized that with changes of visibility in EDs, teamwork among medical staff members will be impacted. BACKGROUND: Prior research results suggest that visibility can influence health-setting efficacy. Teamwork is one of the components of each healthcare system that can be supported by environmental design. METHOD: Visibility in four subject sites from the same healthcare system was objectively measured by morphology plan analyses. Teamwork among medical staff members was the behavioral variable of interest and explored through field observations, interviews, and surveys. RESULTS: The qualitative outcomes demonstrated that teamwork can be enhanced by improved visibility, while the quantitative findings supported the idea that some specific measures of visibility were correlated with teamwork. CONCLUSION: This study provides a model for future research on the association between healthcare staff behavior and ED plan configuration. The enhancement of ED design, considering the significance of visibility, enhances the perceptions of nurses and physicians in terms of teamwork.

Designing efficient emergency departments: Discrete event simulation of internal-waiting areas and split flow sorting.

OBJECTIVE: Evaluate nine different models, the interaction of three flow models (ESI, intake attending physician, and no split flow) and three physical design typologies (zero, one, and two internal-waiting areas), on Emergency Department (ED) flow and patient-centered metrics. METHODS: Discrete Event Simulation (DES) was used to systematically manipulate flow and physical design. Three base models were developed and validated using ED and patient specific data. Subsequently, systematic manipulations of flow and internal-waiting areas were performed on other models. Five outcomes of interest were tracked - length of stay (LOS), bed utilization rate, door to provider time, left without being seen rate, and number of movements per patient. Models were compared for statistical significance and effect size using ANOVA, and linear and non-linear regression. RESULTS: The shortest LOS (mean 175.2 min) and highest bed utilization rate (5.02 patients/bed/day) were obtained with flow split by an intake attending physician with two internal-waiting areas. These represented improvements of 54 min and 1.48 patients/bed/day over the control model. Two-way ANOVA demonstrated that both physical design and flow type were statistically significant predictors of all outcomes of interest (p < .0001). Depending on flow type, adding one additional internal-waiting area resulted in decreased LOS (range 10.6-21.8 min), increased bed utilization (range 0.23-0.40 patients/bed/day), decreased D2P (range 1.3-4.8 min), and decreased LWBS (0.66%-2.0%). CONCLUSION: Based on a DES model with empirical data from a single institution, combining flow split by an intake attending physician and multiple internal-waiting areas resulted in improved ED operational and patient-centered metrics.

The Physiological Impact of Window Murals on Pediatric Patients.

OBJECTIVES: To examine the magnitude of impact of two nature-themed window murals on physiological processes, as measured by heart rate and blood pressure, of pediatric patients. BACKGROUND: Many children and adolescents find at least one aspect of the hospitalization process frightening or anxiety provoking. One physical feature linked to stress reduction is access to positive distractions. Views of nature are one of the most common forms of positive distractions in healthcare environments. Patient room windows are the most common way patients are exposed to natural elements. Exposure to views of nature is linked to a number of positive impacts on physiological outcomes. Unfortunately, not every patient room will be able to provide a nature-filled window view. In situations where nature scenes do not occur, enhanced nature views may be utilized to replicate many of the same benefits as actual nature views. METHODS: Pediatric patients were randomly assigned to one of the three room conditions: aquatic window mural, tree window mural, or control condition. The medical data of participants ( n = 90) who stayed in the rooms were gathered and evaluated for differences. RESULTS: Data analysis supports the notion that patient stress is heightened at the time of admission. Patients in the rooms with murals were found to have improvements in heart rate and systolic blood pressure in comparison to patients in control rooms, suggesting that the murals had an impact on physiological processes. Data also suggest that subject matter played a role, as patients in tree murals rooms had the most health-related outcomes.

Top Five Physical Design Factors Contributing to Fall Initiation.

PURPOSE:: To develop a prioritized list of physical design questions/interventions to reduce patient falls by conducting expanded analysis (Phase II) of data generated from a completed study phase. BACKGROUND:: Patient falls continue to be a critical concern for healthcare providers, patients, and families. While substantial literature exist on intrinsic factors, scientific evidence on the role of the physical environment is scarce. METHOD:: Expanded analysis of data from 180 videos of trials conducted in a physical mock-up of a medical-surgical inpatient room in a previously completed study phase. The odds of subject's exhibited postures (predictors) on fall initiation (outcome) were examined in a series of generalized linear mixed effects models. Physical design elements and attributes associated with postures exhibiting statistical significance were examined. RESULTS:: Turning, pulling, pushing, and bending forward exhibited the highest odds of contributing to fall initiation in the bathroom. Grabbing, pushing, and sitting exhibited the highest odds of contributing to fall initiation around the patient bed. Physical design elements/attributes associated with the above postures are the (1) bathroom door; (2) bathroom spatial configuration-relative locations of door, toilet bowl, and the sink; (3) door, toilet, and sink hardware; (4) space availability/tightness inside the clinician zone; and (5) spatial configuration around patient bed-relative locations of bed, patient chair, and overbed table, in relation to bathroom door, and resulting obstructions originating from the configuration. CONCLUSIONS:: Patient falls during unassisted ambulation may be reduced through appropriate examination of these five physical elements/attributes.

Safer chairs for elderly patients: design evaluation using electromyography and force measurement.

A vast majority of patient fall events in hospitals involve the elderly. In inpatient care settings, despite the risk of fall, patients are encouraged to leave their bed, move around their room, and sit on their chair to progress in their healing. Despite the vital role of patient chair design in improving recovery, few studies have examined the ergonomic requirements of safe patient chairs. This study examined the impact of manipulating horizontal and vertical positions of armrests in a test chair on required physical effort during Stand-to-Sit-to-Stand (St-Si-St) transitions among 15 elderly women. Physical effort was measured using: (1) surface electromyography (sEMG); (2) force measurement by load cells; (3) video recording. Findings showed non-linear patterns of change in required physical effort due to changes in armrests' height and distance. It was also found that minimum effort is associated with armrests higher and farther apart than those in typical patient chairs. Practitioner Summary: Safe chairs are essential for inpatient recovery, yet their ergonomic features are not investigated. Impact of changes in chair armrests on required physical effort was examined using electromyography, force measurement and video recording. Armrests higher and farther apart than those in typical patient chairs may be safer for elderly patients.