Research on nursing unit layouts: an integrative review

Hospital responses to COVID-19: evidence from case studies to support future healthcare design research

Purpose

The Covid-19 pandemic has placed health-care systems and their facilities throughout the world under immense pressure. The pandemic has highlighted the crucial role of health-care facilities design in looking beyond the ongoing crisis and considering how hospitals can better prepare for unexpected future health situations. This study aims to investigate how hospitals reacted to the crisis in terms of their physical spaces, which architectural features permitted the necessary transformations, and how this data can inform hospital design research in the future.

Design/methodology/approach

The research adopted a qualitative and multi-method approach to case studies. Data was collected directly (field survey and interviews) and indirectly (literature, periodicals, specialised websites, webinars, conferences and forums), and a strengths, weaknesses, opportunities, threats analysis supported the data evaluation.

Findings

Hospitals’ responses to the crisis were guided by a host of variables depending on the specific intervention context and risk scenario. Some key issues emerged as particularly meaningful to drive future research in hospital design, namely, architectural typology, layout and spatial proximities, technological systems, the quality of care spaces, the role of public spaces, facility management tools to drive the transformation, territorial health care networks and new technologies.

Originality/value

The paper suggests that the current crisis can be transformed into an opportunity, in terms of research and innovation, to rethink and improve the quality and efficiency of health-care spaces, restoring their crucial role of promoting health by design.

The experience of patients in an outpatient infusion facility: a qualitative study

Purpose

As hospitals are now being designed with an increasing number of single rooms or cubicles, the individual preference of patients with respect to social contact is of great interest. The purpose of this study is to gain a better understanding of the experience of patients in an outpatient infusion center.

Design/methodology/approach

A total of 29 semi-structured interviews were conducted, transcribed and analyzed by using direct content analysis.

Findings

Findings showed that patients perceived a lack of acoustic privacy and therefore tried to emotionally isolate themselves or withheld information from staff. In addition, patients complained about the sounds of infusion pumps, but they were neutral about the interior features. Patients who preferred non-talking desired enclosed private rooms and perceived negative distraction because of spatial crowding. In contrast, patients who preferred talking, or had no preference, desired shared rooms and perceived positive distraction because of spatial crowding.

Research limitations/implications

In conclusion, results showed a relation between physical aspects (i.e. physical enclosure) and the social environment.

Practical implications

The findings allow facility managers to better understand the patients’ experiences in an outpatient infusion facility and to make better-informed decisions. Patients with different preferences desired different physical aspects. Therefore, nursing staff of outpatient infusion centers should assess the preferences of patients. Moreover, architects should integrate different types of treatment places (i.e. enclosed private rooms and shared rooms) in new outpatient infusion centers to fulfill different preferences and patients should have the opportunity to discuss issues in private with nursing staff.

Originality/value

This study emphasizes the importance of a mix of treatment rooms, while new hospital designs mainly include single rooms or cubicles.

Integrated modelling of built environment and functional requirements: Implications for resilience

The built environment is a core part of most healthcare systems, involving a number of requirements such as those related to space and patients' well-being. However, these are usually addressed separately from other functional requirements, resulting in designs that do not support resilient performance. This study proposes a framework for the integrated modelling of built environment and other functional requirements, relying on two approaches: Functional Resonance Analysis Method (FRAM), and Building Information Modelling (BIM). Requirements are defined as equivalent to the precondition aspect of FRAM functions. BIM allows the creation of a database of requirements and functions, linked to an object-oriented model of the built environment. The proposed framework was devised and tested in an intensive care unit. Findings shed light on the necessary resilience to cope with the gap between built environment-as-imagined in design and built environment-as-done due to performance adjustments. This type of resilience may have a long-lasting nature, as many built environment attributes cannot be easily changed.

Simulating the impact of facility design on operations: a study in an internal medicine ward

Purpose

This study aims to use a narrative-based simulation approach to explore potential implications of including or excluding a dayroom in the design of an internal medicine ward.

Design/methodology/approach

The approach involved: collecting data in facilities using field observations and experts’ interviews; modeling representative behavior patterns in the form of rule-based narratives that direct collaborative behaviors of virtual occupants; simulating the behavior patterns in two alternative design options, one of which includes a dayroom; and analyzing the simulation results with respect to selected key performance indicators of day-to-day operations and spatial occupancy, including occupant density in corridors, number and locations of staff-visitor interactions and duration of a doctors’ round procedure.

Findings

Simulation results suggest that the presence of a dayroom reduces visitors’ density in corridors and diminishes the number of staff–visitor interactions that can delay the performing of scheduled medical procedures.

Research limitations/implications

A high level of uncertainty is intrinsic to the simulation of future human behavior. Additional work is required to systematically collect large volumes of occupancy data in existing facilities, model additional narratives and develop validation protocols to assess the degree of uncertainty of the proposed model.

Originality/value

A limited number of studies explore how simulation can be used to study the impact of building design on operations. This study uses a narrative-based approach to address some of the limitations of existing methods, including discrete-event simulations. Preliminary results suggest that the lack of appropriate spaces for patients and visitors to socialize may cause potential disruptions to hospital operations.

The Impact of Infusion Center Layout on Workflow and Satisfactions in Two Cancer Infusion Centers: A Case Study on Staff and Patients

OBJECTIVE

The objective of this empirical research is to compare nurses' operational workflow and nurses' and patients' satisfactions of two different infusion center designs. One center has a traditional open bay design and the other has semi-private bays. This study also intends to gather baseline data to compare to a future post-occupancy evaluation of a new infusion center where the two existing centers will be combined.

BACKGROUND

The increasing number of patients with cancer diagnosis who refer to infusion centers highlights the importance of design of these centers.

METHOD

The mixed-method approach of this study involves shadowing nurses and surveying nurses and patients. Data collection captured nurses' activities, activity durations, and nurses' and patients' satisfaction with the design of clinics.

RESULTS

Comparison of shadowing data indicated that although the infusion centers have different layouts, there are no significant differences in the activities or time spent by nurses in different areas among the centers. Staff, however, have different satisfaction levels with visual and speech privacy, ability to concentrate without distraction, collaboration with other staff, and the process of medication delivery. Patients also had slightly different satisfaction levels with their ability to communicate with staff and design of bays.

CONCLUSION

This research sheds light on operational workflows and satisfaction of staff and patients in two different infusion center design. Considering the limited studies on these settings, this study serves as baseline data to compare to other studies on cancer infusion centers and addresses issues of benchmarking and staff and patient satisfaction.

Systematic Layout Planning of a Radiology Reporting Area to Optimize Radiologists' Performance

Optimizing radiologists' performance is a major priority for managers of health services/systems, since the radiologists' reporting activity imposes a severe constraint on radiology productivity. Despite that, methods to optimize radiologists' reporting workplace layout are scarce in the literature. This study was performed in the Radiology Division (RD) of an 850-bed University-based general hospital. The analysis of the reporting workplace layout was carried out using the systematic layout planning (SLP) method, in association with cluster analysis as a complementary tool in early stages of SLP. Radiologists, architects, and hospital managers were the stakeholders consulted for the completion of different stages of the layout planning process. A step-by-step description of the proposed methodology to plan an RD reporting layout is presented. Clusters of radiologists were defined using types of exams reported and their frequency of occurrence as clustering variables. Sectors with high degree of interaction were placed in proximity in the new RD layout, with separation of noisy and quiet areas. Four reporting cells were positioned in the quiet area, grouping radiologists by subspecialty, as follows: cluster 1-abdomen; cluster 2-musculoskeletal; cluster 3-neurological, vascular and head & neck; cluster 4-thoracic and cardiac. The creation of reporting cells has the potential to limit unplanned interruptions and enhance the exchange of knowledge and information within cells, joining radiologists with the same expertise. That should lead to improvements in productivity, allowing managers to more easily monitor radiologists' performance.

Layout Planning in Healthcare Facilities: A Systematic Review

This study presents a systematic review of the literature on layout planning in healthcare facilities. The review includes 81 articles from journals, conferences, books, and other documents. Articles were classified in two groups according to their main contents including (i) concepts and guidelines and (ii) techniques and tools to assist in layout planning in healthcare facilities. Results indicate that a great variety of concepts and tools have been used to solve layout problems in healthcare. However, healthcare environments such as hospitals can be complex, limiting the ability to obtain optimal layout solutions. Influential factors may include the flows of patients, staff, materials, and information; layout planning and implementation costs; staff and patients safety and well-being; and environmental contamination, among others. The articles reviewed discussed and often proposed solutions covering one or more factors. Results helped us to propose future research directions on the subject.

The Impact of the Physical Environment on Intrapartum Maternity Care: Identification of Eight Crucial Building Spaces

Objectives, Purpose, or Aim:

This article investigates whether the physical environment in which childbirth occurs impacts the intrapartum intervention rates and how this might happen. The study explores the spatial physical characteristics that can support the design of spaces to promote the health and well-being of women, their supporters, and maternity care professionals.

Background:

Medical interventions during childbirth have consequences for the health of women and babies in the immediate and long term. The increase in interventions is multifactorial and may be influenced by the model of care adopted, the relationships between caregivers and the organizational culture, which is made up of many factors, including the built environment. In the field of birth architecture research, there is a gap in the description of the physical characteristics of birth environments that impact users’ health.

Method:

A scoping review on the topic was performed to understand the direct and indirect impacts of the physical environment on birth intervention rates.

Results and Discussion:

The findings are organized into three tables reporting the influence that the physical characteristics of a space might have on people’s behaviors, experiences, practices and birth health outcomes. Eight building spaces that require further investigation and research were highlighted: unit layout configuration, midwives’ hub/desk, social room, birth philosophy vectors, configuration of the birth room, size and shape of the birth room, filter, and sensory elements.

Conclusions:

The findings show the importance of considering the physical environment in maternity care and that further interdisciplinary studies focused on architectural design are needed to enrich the knowledge and evidence on this topic and to develop accurate recommendations for designers.

Nursing Unit Design, Nursing Staff Communication Networks, and Patient Falls: Are They Related?

Purpose:

The purpose of this research is to (1) investigate the impact of nursing unit design on nursing staff communication patterns and, ultimately, on patient falls in acute care nursing units; and (2) evaluate whether differences in fall rates, if found, were associated with the nursing unit physical structure (shape) or size.

Background:

Nursing staff communication and nursing unit design are frequently linked to patient safety outcomes, yet little is known about the impact of specific nursing unit designs on nursing communication patterns that might affect patient falls.

Method:

An exploratory longitudinal correlational design was used to measure nursing unit communication structures using social network analysis techniques. Data were collected 4 times over a 7-month period. Floor plans were used to determine nursing unit design. Fall rates were provided by hospital coordinators.

Results:

An analysis of covariance controlling for hospitals resulted in a statistically significant interaction of unit shape and size (number of beds). The interaction occurred when medium- and large-sized racetrack-shaped units intersected with medium- and large-sized cross-shaped units.

Conclusion:

The results suggest that nursing unit design shape impacts nursing communication patterns, and the interaction of shape and size may impact patient falls. How those communication patterns affect patient falls should be considered when planning hospital construction of nursing care units.

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.

Macrocognition in the Healthcare Built Environment (mHCBE): A Focused Ethnographic Study of “Neighborhoods” in a Pediatric Intensive Care Unit

Objectives:

The objectives of this research were to describe the interactions (formal and informal), in which macrocognitive functions occur and their location on a pediatric intensive care unit, to describe challenges and facilitators of macrocognition using space syntax constructs (openness, connectivity, and visibility), and to analyze the healthcare built environment (HCBE) using those constructs to explicate influences on macrocognition.

Background:

In high reliability, complex industries, macrocognition is an approach to develop new knowledge among interprofessional team members. Although macrocognitive functions have been analyzed in multiple healthcare settings, the effect of the HCBE on those functions has not been directly studied. The theoretical framework, “macrocognition in the healthcare built environment” (mHCBE) addresses this relationship.

Method:

A focused ethnographic study was conducted including observation and focus groups. Architectural drawing files used to create distance matrices and isovist field view analyses were compared to panoramic photographs and ethnographic data.

Results:

Neighborhoods comprised of corner configurations with maximized visibility enhanced team interactions as well as observation of patients, offering the greatest opportunity for informal situated macrocognitive interactions (SMIs).

Conclusions:

Results from this study support the intricate link between macrocognitive interactions and space syntax constructs within the HCBE. These findings help increase understanding of how use of the framework of Macrocognition in the HCBE can improve design and support adaptation of interprofessional team practices, maximizing macrocognitive interaction opportunities for patient, family, and team safety and quality.

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.