Perceptual Effects of Physical and Visual Accessibilities in Intensive Care Units: A Quasi-experimental Study.

This article reports the findings of a 2-phase quasi-experimental study looking at the perceptual effects of physical and visual accessibilities on clinical staff in intensive care units (ICUs). In a previous CCNQ article by Rashid et al, the first phase of the study was reported comparing, among other things, physical and visual accessibilities and their associations with staff perception in 2 ICUs with the open-plan and racetrack-type layouts. The data for that phase of the study were collected in December 2014, which included the data on physical and visual accessibilities collected using the spatial analysis techniques of Space Syntax, and the data on staff perception collected using a questionnaire survey. Since then, the open-plan ICU has been completely redesigned using a layout composed of 4-bed pods (each dubbed as a HYPERPOD by the designer). However, the racetrack ICU has remained unchanged. In August 2016, more than years after the data for the first phase of this study were collected, the authors went back to the study sites to collect similar data using the methods of the previous study by Rashid et al. The purpose of the 2-phase study was 2-fold: (1) to see whether staff perception and their associations with physical and visual accessibilities observed in the racetrack ICU during the first phase would remain unchanged during the second phase of the study; and (2) to see whether staff perception and their associations with physical and visual accessibilities observed in the open-plan ICU during the first phase would change in the new ICU during the second phase of the study. The findings of the study comparing the racetrack ICU of the first and second phases show that while staff perception in this unit changed, its associations with the physical and visual accessibilities of the unit did not change during the period between the first and second phases of the study. In contrast, the findings of the study comparing the open-plan ICU of the first phase and the new ICU with 4-bed pods of the second phase show that staff perception as well as its associations with the physical and visual accessibilities of the unit changed in a positive direction from the open-plan ICU to the new ICU. It is concluded that staff perception is likely to change over time even in the absence of environmental changes, but any change in staff perception can be made more effective when it is associated with thoughtful environmental design changes.

Evaluating Nurses' Perception of Patient Safety Design Features in Intensive Care Units.

A methodological study was conducted to test the validity and reliability of the patient safety (PS) scale developed by Rashid (2007) for evaluating nurses' perception of adult intensive care unit (ICU) design features related to patient safety. Data for the study were collected using a Web-based survey instrument. A link to the survey instrument was posted on the Web site of American Association of Critical-Care Nurses (AACN) for ICU nurses in different US states to participate. A sample of 587 valid responses was divided into 2 halves for cross-validation. The first half of the sample was used for exploratory factor analysis and the second half for confirmatory factor analysis. This method was applied to identify any latent factor structure in the PS scale. Based on the factor analyses, 4 relevant PS subscales-Efficient Work Process, Patient Room, Accessibility and Visibility, and Maintain Sterility-were identified. These PS subscales were used to investigate whether ICU unit characteristics, nurse characteristics, and hospital type affected nurses' perception of ICU design features in relation to patient safety. The study shows that nurses' perception of ICU design features related to patient safety can be influenced by such factors as nurse characteristics and unit characteristics. When using the scales, therefore, the designers can be aware of the influence of these external factors on nurses' perception. It is hoped that the PS subscales evaluating nurses' perception of ICU physical environmental features related to patient safety would help designers and health care personnel make better ICU design choices.

Physical and Visual Accessibilities in Intensive Care Units: A Comparative Study of Open-Plan and Racetrack Units.

This study compared physical and visual accessibilities and their associations with staff perception and interaction behaviors in 2 intensive care units (ICUs) with open-plan and racetrack layouts. For the study, physical and visual accessibilities were measured using the spatial analysis techniques of Space Syntax. Data on staff perception were collected from 81 clinicians using a questionnaire survey. The locations of 2233 interactions, and the location and length of another 339 interactions in these units were collected using systematic field observation techniques. According to the study, physical and visual accessibilities were different in the 2 ICUs, and clinicians' primary workspaces were physically and visually more accessible in the open-plan ICU. Physical and visual accessibilities affected how well clinicians' knew their peers and where their peers were located in these units. Physical and visual accessibilities also affected clinicians' perception of interaction and communication and of teamwork and collaboration in these units. Additionally, physical and visual accessibilities showed significant positive associations with interaction behaviors in these units, with the open-plan ICU showing stronger associations. However, physical accessibilities were less important than visual accessibilities in relation to interaction behaviors in these ICUs. The implications of these findings for ICU design are discussed.

Network of spaces and interaction-related behaviors in adult intensive care units.

Using three spatial network measures of "space syntax", this correlational study describes four interaction-related behaviors among three groups of users in relation to visibility and accessibility of spaces in four adult intensive care units (ICUs) of different size, geometry, and specialty. Systematic field observations of interaction-related behaviors show significant differences in spatial distribution of interaction-related behaviors in the ICUs. Despite differences in unit characteristics and interaction-related behaviors, the study finds that when nurses and physicians "interact while sitting" they prefer spaces that help maintain a high level of environmental awareness; that when nurses "walk" and "interact while walking" they avoid spaces with better global access and visibility; and that everyone in ICUs "walk" more in spaces with higher control over neighboring spaces. It is argued that such consistent behavioral patterns occur due to the structural similarities of spatial networks over and above the more general functional similarities of ICUs.

Developing nurse and physician questionnaires to assess primary work areas in intensive care units.

The objective of the study was to develop instruments for describing and assessing some aspects of design of the primary work areas of nurses and physicians in intensive care units (ICUs). Separate questionnaires for ICU physicians and nurses were developed. Items related to individual- and unit-level design features of the primary work areas of nurses and physicians were organized using constructs found in the literature. Items related to staff satisfaction and staff use of time in relation to primary work area design were also included. All items and constructs were reviewed by experts for content validity and were modified as needed before use. The final questionnaires were administered to a convenience sample of 4 ICUs in 2 large urban hospitals. A total of 55 nurses and 29 physicians completed the survey. The Cronbach α was used to measure internal consistency, and factor analysis was used to provide construct-related validity. Convergent and discriminant validity were assessed through examining bivariate correlations between relevant scales/items. Analysis of variance was used to identify whether the between-group member responses were significant among the 4 units. The Cronbach α values for all except 3 preliminary scales indicated acceptable reliability. Factor analysis indicated that some preliminary scales could be partitioned into subscales for finer descriptions of the primary work areas. Correlational analysis provided strong evidence of convergent and discriminant validity of all the scales and subscales. The significance level of F-statistics showed that the units were significantly different from each other, providing evidence of more between-unit variance than within-unit variance. Therefore, the questionnaires developed in the study offer a promising departure point for rigorous description and evaluation of the primary work areas in relation to staff satisfaction and use of time in ICUs at a time when the importance of such studies is growing.

Space Allocation in the Award-Winning Adult ICUs of the Last Two Decades (1993-2012): An Exploratory Study.

OBJECTIVE: This exploratory study describes space allocation among different generic categories of functions in adult intensive care units (ICUs) showing how the amount of space of any one functional category is related to that of another functional category, and how different strategic choices, such as size, construction type, specialty type, and layout type, affect space allocation in these ICUs. BACKGROUND: Even though critical care practice has already undergone significant changes in the last few decades, it is still an evolving domain of medical practice. As a result, ICU design is also evolving as new regulatory standards, new technologies, and new clinical models are being introduced. A good understanding of the above issues regarding space allocation may help us better guide the evolution of ICU design. METHODS: The study includes a set of 25 adult ICUs that were recognized between 1993 and 2012 by the Society of Critical Care Medicine (SCCM), the American Association of Critical Care Nurses (AACCN), and the American Institute of Architects Academy of Architecture for Health (AIA AAH) for their efforts to promote healing of the critically ill and injured patients through the design of the critical care unit environment. RESULTS: The study finds notable differences in space allocation among different generic categories of functions between the ICUs of the first decade (1993-2002) and the second decade (2003-2012). The study also finds notable differences in space allocation among different generic categories of functions in relation to size, construction type, specialty type, and layout type. CONCLUSIONS: Despite several limitations, the study should help design better adult ICUs based on an evidence-based understanding of the relationships between space allocation and strategic choices. KEYWORDS: Construction, critical care/intensive care, evidence-based design, planning, project management.

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.

The question of knowledge in evidence-based design for healthcare facilities: limitations and suggestions.

OBJECTIVE: To help designers and researchers and other proponents of evidence-based design (EBD) overcome limitations concerning knowledge categorization and acquisition of evidence-based design (EBD). BACKGROUND: The evidence-based design (EBD) approach for healthcare facilities has been widely embraced by both designers and researchers in recent years; however, there are some limitations concerning knowledge categorization and acquisition of EBD. These limitations include an overemphasis on empirical knowledge gained by experimental research, a narrow focus that excludes design knowledge generated outside healthcare and allied fields, and a lack of interest in empirical knowledge gained by qualitative studies. In order to overcome these limitations, the proponents of EBD must acknowledge that design knowledge relevant to healthcare design can be found in disciplines unrelated to healthcare; that design knowledge does not always need empirical validation; and that design knowledge of the semantic kind can be more easily accessed and understood through qualitative studies. CONCLUSIONS: To reassess the foundations of knowledge of EBD with moderated skepticism is necessary because there are philosophical and analytical problems yet to be overcome in delivering on the promises of EBD. To question and reassess the foundations of knowledge base of EBD is not necessarily to deny its value, but rather to stimulate a judicious and balanced appraisal of its limitations so that, in future, we are able to take necessary steps to overcome these limitations. KEYWORDS: Design process, evidence-based design, methodology, theory, interdisciplinary.

Development and reliability testing of a self-report instrument to measure the office layout as a correlate of occupational sitting.

BACKGROUND: Spatial configurations of office environments assessed by Space Syntax methodologies are related to employee movement patterns. These methods require analysis of floors plans which are not readily available in large population-based studies or otherwise unavailable. Therefore a self-report instrument to assess spatial configurations of office environments using four scales was developed. METHODS: The scales are: local connectivity (16 items), overall connectivity (11 items), visibility of co-workers (10 items), and proximity of co-workers (5 items). A panel cohort (N = 1154) completed an online survey, only data from individuals employed in office-based occupations (n = 307) were used to assess scale measurement properties. To assess test-retest reliability a separate sample of 37 office-based workers completed the survey on two occasions 7.7 (±3.2) days apart. Redundant scale items were eliminated using factor analysis; Chronbach's α was used to evaluate internal consistency and test re-test reliability (retest-ICC). ANOVA was employed to examine differences between office types (Private, Shared, Open) as a measure of construct validity. Generalized Linear Models were used to examine relationships between spatial configuration scales and the duration of and frequency of breaks in occupational sitting. RESULTS: The number of items on all scales were reduced, Chronbach's α and ICCs indicated good scale internal consistency and test re-test reliability: local connectivity (5 items; α = 0.70; retest-ICC = 0.84), overall connectivity (6 items; α = 0.86; retest-ICC = 0.87), visibility of co-workers (4 items; α = 0.78; retest-ICC = 0.86), and proximity of co-workers (3 items; α = 0.85; retest-ICC = 0.70). Significant (p ≤ 0.001) differences, in theoretically expected directions, were observed for all scales between office types, except overall connectivity. Significant associations were observed between all scales and occupational sitting behaviour (p ≤ 0.05). CONCLUSION: All scales have good measurement properties indicating the instrument may be a useful alternative to Space Syntax to examine environmental correlates of occupational sitting in population surveys.

Technology and the future of intensive care unit design.

Changing market demand, aging population, severity of illnesses, hospital acquired infection, clinical staff shortage, technological innovations, and environmental concerns-all are shaping the critical care practice in the United States today. However, how these will shape intensive care unit (ICU) design in the coming decade is anybody's guess. In a graduate architecture studio of a research university, students were asked to envision the ICU of the future while responding to the changing needs of the critical care practice through innovative technological means. This article reports the ICU design solutions proposed by these students.

Hospital design and face-to-face interaction among clinicians: a theoretical model.

A growing body of literature suggests that face-to-face interaction among clinicians in hospitals affects patient outcomes. How can face-to-face interaction among clinicians be influenced positively to improve patient outcomes in hospitals? So far, most strategies for improving face-to-face interaction in hospitals have focused on changing organizational culture. In contrast, this paper proposes a theoretical model that shows how spatial program and structure can help face-to-face interaction fulfill its purposes in hospitals by controlling the interfaces among different communities of clinicians.

The architecture of safety: hospital design.

PURPOSE OF REVIEW: This paper reviews recent research literature reporting the effects of hospital design on patient safety. RECENT FINDINGS: Features of hospital design that are linked to patient safety in the literature include noise, air quality, lighting conditions, patient room design, unit layout, and several other interior design features. Some of these features act as latent conditions for adverse events, and impact safety outcomes directly and indirectly by impacting staff working conditions. Others act as barriers to adverse events by providing hospital staff with opportunities for preventing accidents before they occur. SUMMARY: Although the evidence linking hospital design to patient safety is growing, much is left to be done in this area of research. Nevertheless, the evidence reported in the literature may already be sufficient to have a positive impact on hospital design.

Developing scales to evaluate staff perception of the effects of the physical environment on patient comfort, patient safety, patient privacy, family integration with patient care, and staff working conditions in adult intensive care units: a pilot study.

Studies suggest that the physical environment can be important for patient comfort, patient safety, patient privacy, family integration with patient care, and staff working condition in adult intensive care units (ICUs). In the absence of any measuring scales, however, evaluations of the physical environment of ICUs in terms of any of these dimensions have remained vague. For rigorous evaluations of ICU designs from the viewpoint of clinical staff, a self-report instrument with several multiple-item scales was created. These scales were tested in a pilot survey that was administered among a small group of nurse managers and ICU directors at several best practice example sites. Reliability analysis of the survey data showed some scales to be internally consistent. For the other scales, factor analysis revealed multiple components, which were then combined to create additional subscales. Using these scales and subscales, the underlying effects of design on staff perception were studied at the best practice example sites that participated in the pilot survey. The results, limitations, and the future directions of the study are discussed.

A decade of adult intensive care unit design: a study of the physical design features of the best-practice examples.

This article reports a study of the physical design characteristics of a set of adult intensive care units (ICUs), built between 1993 and 2003. These ICUs were recognized as the best-practice examples by the Society of Critical Care Medicine, the American Association of Critical Care Nurses, and the American Institute of Architects. This study is based on a systematic analysis of the materials found on these ICUs in the booklet and videos jointly published by the above organizations in 2005. The study finds that most of these examples of best-practice adult ICUs have the following negative characteristics: (1) they are built as renovation projects with more health and safety hazards during construction; (2) most of them are mixed-service units with more safety and staffing problems; (3) the overall layout and the layout of staff work areas in these ICUs do not have any common design solutions for improved patient and staff outcomes; and (4) in these ICUs, family space is often located outside the unit, and family access to the patient room is restricted, even though family presence at the bedside may be important for improved patient outcomes. Some of these negative characteristics are offset by the following positive characteristics in most ICUs: (1) they have only private patient rooms for improved patient care, safety, privacy, and comfort; (2) most patient beds are freestanding for easy access to patients from all sides; (3) they have handwashing sinks and waste disposal facilities in the patient room for improved safety; and (4) most patient rooms have natural light to help patients with circadian rhythms. The article discusses, in detail, the implications of its findings, and the role of the ICU design community in a very complicated design context.