Optimizing Nurse Workflow Efficiency: An Examination of Nurse Walking Behavior and Space Accessibility in Medical Surgical Units

OBJECTIVE

This study aimed to investigate the effect of spatial adjacencies on nurses' walking patterns and the subsequent impact on staff satisfaction with perceived accessibility and adjacency-related issues.

BACKGROUND

Recognizing the crucial importance of spatial adjacencies in healthcare facilities is essential, as they significantly affect staff morale, fatigue management, operational efficiency, error reduction, and overall patient care excellence, highlighting the need for objective assessments to evaluate the impact of facility layout and space configuration on workflow patterns and staff satisfaction in patient care units.

METHODS

Integrating on-site observations with survey data, we explored how spatial adjacencies affect staff walking behavior and satisfaction in two med-surgical unit floors.

RESULTS

The findings highlighted a significant frequency of movements between nurse stations, patient rooms, and medication areas. Regression analysis identified several contributing factors to staff satisfaction, including the proximity of supplies, team visibility, ease of access across departments, and the location of equipment rooms. Specifically, satisfaction with the proximity of supplies was positively associated with increased provider satisfaction with workflow, quality of care, and workplace. Additionally, valuable feedback from staff revealed concerns regarding break room placement, medication area functionality, and disparities in the availability of supplies.

CONCLUSION

This study highlighted the critical need for carefully planned spatial adjacency strategies to enhance workflow efficiency and raise clinical staff satisfaction within healthcare facilities. The actionable insights gleaned from this research offer valuable direction to architects, healthcare administrators, and design professionals, enabling the creation of environments that positively resonate with healthcare providers and improve healthcare operations.

Pioneering the Use of Tracker Data to Evaluate Lean-Led Hospital Design

OBJECTIVE

This study aims to examine how we can effectively and affordably evaluate the impact of design concepts such as Lean-Led Hospital Design (LLHD) on the allocation of nurses' time spent at different locations. Particularly in patient rooms, as this can be seen as value-adding time.

BACKGROUND

LLHD aims to create a hospital environment that supports value creation for patients and reduces waste. However, only a few studies measure its' effects. One of the reasons for this absence is the lack of an adequate and affordable way to evaluate.

METHOD

Nurses' time spent in patient rooms was used as a proxy for value-adding time. Through studying a pioneering case of LLHD, and drawing on a pre-/postoccupancy evaluation approach, this study used an innovative methodology utilizing mobile tracking devices to adequately provide reliable data about the time nurses spend at specific locations.

RESULTS

Our analysis reveals that the answer to the question concerning the impact of LLHD, as advocated by its proponents, on nurses' allocation of time for value-adding activities versus waste time remains inconclusive. Our findings indicate no discernible difference in the amount of value-adding time nurses spent in the old facility compared to the new one.

CONCLUSION

Our experience suggests that mobile tracking devices offer an affordable, efficient means of collecting data that produces objective measurements. Nevertheless, the interpretation of this time-based data necessitates the inclusion of supplementary qualitative information.

Analyzing the Layout of Long-Term Care Facilities: A Psycho-Spatial Approach

When planning long-term care facilities (LTCFs), architects strive to design buildings that support high well-being (WB) levels for those who live and work in them. To achieve this goal, architects must understand what defines WB in old age and how these qualities can be achieved through the designed physical layout. This task must be achieved while tackling additional challenges, such as considering the official planning guidelines, codes, and additional requests given by the client. During the planning process, architects use their subjective impressions by visiting similar institutions, their personal experience as architects, and their subjective assumptions on what residents and caregivers may consider desirable. Once built, there are a lack of methodological ways to evaluate an existing LTCF unit's plan as a supportive tool for higher levels of WB. The current study aims to create a methodological tool to analyze LTCF units' layout, giving scores to each plan based on five aspects of WB that they support. In our article, we demonstrate this methodology's application on 40 plans of LTCFs, demonstrating its effectiveness. We believe that the approach presented in this article will contribute to furthering the quality of planning of LTCFs benefiting residents and caregivers alike.

The Continuous Learning Cycle: A Multi-phase Post-occupancy Evaluation (POE) of Decentralized Nursing Unit Design

PURPOSE

This study aims to demonstrate how multiphase postoccupancy evaluation (POE) research was integrated into multiple projects to develop a continuous learning cycle.

BACKGROUND

Despite the well-recognized importance of POE, few studies have reported how knowledge from POE is applied in new designs.

METHOD

This study is developed as a multiphase POE that spanned 3 years and across three units. Phase I POE compared an existing unit (Unit A) in Hospital A and a new Unit B in Hospital B that has implemented innovative design features such as decentralized nurse stations. The idea was to understand the challenges of the existing facility in Hospital A and gather lessons learned from the new design in Unit B to inform the design of the Hospital A expansion (Unit C). After the new expansion was occupied, the Phase II POE was conducted using the same set of POE tools in both Unit C and Unit A. The POE applied the following methods: (1) patient room evaluations using the Center for Health Design standardized POE tools, (2) space syntax analysis of visibility, and (3) a pre- and postmove analysis of Press Ganey data.

RESULTS

The results demonstrated that by incorporating lessons learned from the Phase I POE, Unit C has further improvement on patient room design ratings, improved patient satisfaction, and better visibility among nurse work areas compared to Unit A and Unit B.

CONCLUSIONS

The multiphase, multisite POE with standardized tools has demonstrated its value as an important tool for continuous design quality improvement.

Assess, Prevent, and Manage Pain; Both Spontaneous Awakening and Breathing Trials; Choice of Analgesia/Sedation; Delirium: Assess, Prevent, and Manage; Early Mobility; Family Engagement and Empowerment Bundle Implementation: Quantifying the Association of Access to Bundle-Enhancing Supplies and Equipment

Describe the physical environment factors (i.e., availability, accessibility) of bundle-enhancing items and the association of physical environment with bundle adherence.

DESIGN

This multicenter, exploratory, cross-sectional study used data from two ICU-based randomized controlled trials that measured daily bundle adherence. Unit- and patient-level data collection occurred between 2011 and 2016. We developed hierarchical logistic regression models using Frequentist and Bayesian frameworks.

SETTING

The study included 10 medical and surgical ICUs in six academic medical centers in the United States.

PATIENTS

Adults with qualifying respiratory failure and/or septic shock (e.g., mechanical ventilation, vasopressor use) were included in the randomized controlled trials.

INTERVENTIONS

The Awakening and Breathing trial Coordination, Delirium assessment/management, Early mobility bundle was recommended standard of care for randomized controlled trial patients and adherence tracked daily.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was adherence to the full bundle and the early mobility bundle component as identified from daily adherence documentation (n = 751 patient observations). Models included unit-level measures such as minimum and maximum distances to bundle-enhancing items and patient-level age, body mass index, and daily mechanical ventilation status. Some models suggested the following variables were influential: unit size (larger associated with decreased adherence), a standard walker (presence associated with increased adherence), and age (older associated with decreased adherence). In all cases, mechanical ventilation was associated with decreased bundle adherence.

CONCLUSIONS

Both unit- and patient-level factors were associated with full bundle and early mobility adherence. There is potential benefit of physical proximity to essential items for Awakening and Breathing trial Coordination, Delirium assessment/management, Early mobility bundle and early mobility adherence. Future studies with larger sample sizes should explore how equipment location and availability influence practice.

Impact of Inpatient Unit Design Features on Overall Patient Experience and Perceived Room-Level Call Button Response

This study explores the relationship between inpatient unit design and patient experience and how spatial features and visibility impact patients' perception of staff responsiveness. The first part of this study is a retrospective pre-post and cross-sectional study evaluating the impacts of unit design on patient experience at the unit level. This study compares patient experiences based on Press Ganey and HCAHPS surveys in two orthopedic units (existing unit in Atrium building and new unit in Tower) with differing design features at Rush University Medical Center. The chi-square test results show that when moving from the old orthopedic unit to the new unit, almost all patient survey items related to patient experience showed statistically significant improvements. The second part of this study is a room level on the new unit. The ANOVA and Pearson correlation tests revealed that the visibility measure of metric step depth had significant impacts on patients' perception of staff's "promptness in responding to call button" and "help with toileting". This study confirms that inpatient unit design plays a direct role in improvement for patient experience and should be considered as an important area of focus for future development.

Efficiency and Teamwork in Emergency Departments: Perception of Staff on Design Interventions

OBJECTIVES

The goal of this study is twofold: (1) identifying design strategies that enhance efficiency and support teamwork in emergency departments (EDs) and (2) identifying design features that contribute to the spread of COVID-19, based on staff perception.

BACKGROUND

Due to increasing ED visits annually, an efficient work environment has become one of the main concerns in designing EDs. According to the literature, an efficient work environment and teamwork improve healthcare outcomes and positively impact staff satisfaction. During the COVID-19 pandemic, EDs faced various changes such as workflow and space usage. Few studies explored staff perceptions about the influence of design features on efficiency, teamwork, and the COVID-19 spread.

METHOD

An online survey with 14 open- and closed-ended questions was distributed among ED staff members to collect data about unit design features that impact efficiency, teamwork, and the COVID-19 spread.

RESULTS

The central nursing station was one of the preferred configurations that increased efficiency and teamwork in EDs. Decentralizing disposal rooms in small-size EDs and decentralizing the medication room in large-size EDs with more than 65 exam rooms can decrease staff walking steps. Flexibility to expand treatment spaces on demand, one-way track circulation path, and changing the air pressure in COVID-19 treatment areas were some of the staff suggestions for future EDs.

CONCLUSION

The findings of this study contribute to the body of knowledge that EDs' physical environments can impact efficiency and teamwork among staff and, consequently, healthcare outcomes. Compartmentalization of the ED layout can reduce the spread of COVID-19.

Balancing Support for Staff and Patient Centeredness Through the Design of Immediate and Relational Space: A Case Study of Ambulatory Care Center Layouts

PURPOSE

This descriptive case study of ambulatory care center typologies builds a layout-based approach to patient-centered care and care team work using theory and methods from space syntax and a recently developed approach to floorplan analysis focused on visibility.

BACKGROUND

Calibrating support for care team work and patient centeredness is a persistent dilemma in ambulatory care settings.

METHOD

A review of literature and floorplan layout analysis are used.

RESULTS

The center-stage layout more strongly integrates staff and patients, while the onstage-offstage layout provides greater privacy to the care team. The integration values for exam rooms in each layout were roughly equivalent. Analysis of variations on each floor plan demonstrates ways relatively small variations can modulate visibility conditions without altering integration patterns.

CONCLUSION

Decoupling design of immediate visual properties and relational layout properties can act as a strategy to address competing demands.

Improving the Efficiency of an Emergency Department Based on Activity-Relationship Diagram and Radio Frequency Identification Technology

Emergency department crowding has been one of the main issues in the health system in Taiwan. Previous studies have usually targeted the process improvement of patient treatment flow due to the difficulty of collecting Emergency Department (ED) staff data. In this study, we have proposed a hybrid model with Discrete Event Simulation, radio frequency identification applications, and activity-relationship diagrams to simulate the nurse movement flows and identify the relationship between different treatment sections. We used the results to formulate four facility layouts. Through comparing four scenarios, the simulation results indicated that 2.2 km of traveling distance or 140 min of traveling time reduction per nurse could be achieved from the best scenario.

What do hospital doctors and nurses think wastes their time?

Objective

With regard to limitation in national budget, the relevant authorities of healthcare and treatment throughout the globe are seeking the use of available resources in a way that no wastage of money or time-which is, of course, convertible to money-is acceptable. This study sought the opinions of hospital doctors and nurses on those activities at work that wasted their time.

Methods

A questionnaire designed to identify activities that waste time during hospital care was completed based on the review of previous studies and including hospital wastes items. The authors designed a questionnaire, which was filled out by 209 nurses and 30 doctors in the surgery wards in hospitals affiliated to Shiraz University of Medical Sciences (SUMS). The items for time wasting activities were extracted from previous studies, and the reliability of the questionnaire was more than 0.785 using Cronbach's alpha. The response rate was more than 60%.

Results

The mean age of the participating nurses and doctors was 30.24 ± 6.85 and 32.77 ± 7.05 years. In all aspects, more time was wasted during the morning and evening shifts in comparison with the night shifts. The activity that was thought to waste time in hospital care the most was paper-based documentation. Preventable wasted time during the shift was 16%-30% in the nurses' view and 18%-34% in the doctors' view. For both nurses and doctors, the highest-rated preventable wasted time was related to time spent waiting in ward for lab data responses, transfer of patients, or delivery of care.

Conclusion

Hospital working environment is complex, and opportunities for improvement of the efficiency of the nurses' and doctors' workload should be analyzed, case by case, in each hospital and work group. Process change (for the decrease in the wasted time for waiting in wards), simple innovative ways (for the decrease in the wasted time for searching the needed equipment), using hospital information system technology for documentation, communication, and the better design of the wards (to decrease the wasted time due to transfer between the ward and restroom) could be helpful for improving efficiency and for a safer and acceptable delivery of care.

Safer health care environments by design

Health care environments can and are being designed to prevent injury, minimize human error, and actually promote improved health and safety. This article shows risk managers how evidence-based design is reducing medication error, staff injury, infection rates, patient falls, and more. Research knowledge can contribute to effective design solutions by simply clarifying a safety problem so solutions can be sought; it can inform the design process with potential solutions; or it can be part of a structured process where new research knowledge is created. This article shares specific examples of the types of research that can inform designing for a safer physical environment. A case study shows how one project in two phases benefited from engaging initially in a general way and later, in a highly structured process, to integrate the evidence to improve design for safety.

Decentralized Nurse Stations: A Methodology for Using Research to Guide Design Decisions

PURPOSE

The purpose of this methodology is to define a process for facility planning teams to use to ensure research findings are used to guide decision making in the design process.

BACKGROUND

Over the past decade and a half, research in health facility design has developed and the body of knowledge has grown significantly, but at the same time, the process for incorporating these findings into the design process has been less defined. This methodology evolved out of the desire to develop a structured process to integrate recent research findings into the planning and programming process at the user group and planning team level.

METHOD

This two-phase methodology consists of, first, reviewing recent, relevant research on the topic, classifying the findings into positive and negative attributes and, then, summarizing the attributes by category on a summary table and in a brief narrative. The second phase consists of reviewing the research to identify operational and facility strategies that can be used to mitigate the inconsistent and negative attributes identified.

RESULTS

In the case study, as a result of this process, one inconsistent attribute and three negative attributes were identified. In the second phase, potential research-based operational and facility strategies were identified to mitigate the inconsistent and negative attributes identified. This information served as the basis for making design decisions.

CONCLUSIONS

This methodology presents an organized, efficient process for organizing and providing relevant research findings to a facility planning team to use in evaluating a new healthcare design concept and making research-based design decisions.

A time–motion observation study to measure and analyse clinical nursing workload in an acute care hospital in Singapore

Internationally, there are concerns about rising nursing workforce shortages, which could be attributed to both recruitment and retention issues. As the population rapidly ages in Singapore, there is an increase in demand for more trained nurses to staff new facilities. Given the problem that Singapore is facing, there is a need for other solutions besides increasing recruitment rate. A time-motion study of nurses’ workload can assist us in determining how and what nurses spend their time on during their working shift. Work processes can then be studied to allow for improvements and implementation of strategies to ease nurses’ workload. Results of the current study demonstrated four main processes (preparing and clearing requisites, documentation, care coordination, transportation) that can be improved upon. Some of these processes do not require dedicated nursing skills; and can potentially be performed for other staff members. Results also demonstrated that nurses spent significantly less time on patient care activities as compared to nurses in United States; with as much as 31% of the nurses’ time being spent on documentation. Future studies can target on the effectiveness of strategies to improve the efficiency and quality of nursing care.

An Empirical Examination of Nursing Units in China Based on Nurse Experience

OBJECTIVES:

To create opportunities to increase nursing staff's satisfaction and operational efficiency and eventually improve nurses' experiences through better design in unit layout.

BACKGROUND:

The majority of research performed on nursing units in China only focused on the spatial design itself, and few studies examined the nursing unit empirically based on nurses' experience. Nursing units need to be designed with understanding nurses' behavior and experience in China.

METHOD:

A mixed-method approach was conducted in four double-corridor nursing units in China. Observation and interview data were collected to explore how physical environments for managing administrative duties, medications, and caring patient were used in nursing units.

RESULTS:

The most frequent activities were communication, medication, and patient-care activities. The places in which nurses spent the most of theirs working times were the nurse station (NS), patient room, workstation on wheels (WoW), and medication room. The important clinical work spaces were the patient room, NS, WoW, medication room, doctor's office, disposal room, examining room, and back corridor. The important traffic linkages were between NS and medication room, patient room and WoW, and medication room and patient room.

CONCLUSIONS:

This article revealed the frequency of nurse activities; how they spent their time; how they use the clinical spaces; identified important clinical spaces, linkages, and driver of inefficiency in nursing work and nursing unit design; and finally generated recommendations for double-corridor nursing unit design in China which can be used by medical planner, hospital administrator.

Emergency Department Crowding and Time at the Bedside: A Wearable Technology Feasibility Study

INTRODUCTION

ED crowding is a public health crisis, limiting quality and access to lifesaving care. The purpose of this study was to (1) evaluate the feasibility of radio-frequency identification tags to measure clinician-patient contact and (2) to test the relationship between ED occupancy and clinician-patient contact time.

METHODS

In this 4-week observational study, radio-frequency identification tags were worn by emergency clinicians in a 21-bay urban teaching hospital emergency department. The time-motion data were merged with electronic medical repository patient information (N = 3,237) to adjust for occupancy, age, gender, and acuity. Qualitative themes were generated from focus group (N = 39) debriefings of the quantitative results.

RESULTS

Data were collected on 56,342 total clinician events. Adjusting for patient age, increasing ED occupancy increased the number of times the attending physician entered and left the patient room (b = 0 .008, 95% confidence interval [CI] = [0.001-0.016], P = 0.03). There was no relationship for patient gender, triage acuity, shift at arrival, disposition to home, or discharge diagnosis category with either total minutes or number of encounters per patient visit. No time-motion and occupancy associations were observed for nurses, residents, or nurse practitioners/physician assistants. Debriefings indicated occupancy influenced the quality of care, despite maintaining the same quantity of contact time.

DISCUSSION

The physical environment and clinician privacy concerns limit the feasibility of wearable tracking technology in the emergency setting. Attending physician care becomes more fragmented with increasing ED occupancy. Other clinicians report changes in the quality of care, whereas the quantity of time and encounters were unchanged with occupancy rates.

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.

Emergency Nurses' Perceptions of Efficiency and Design: Examining ED Structure, Process, and Outcomes

INTRODUCTION

Due to increasing demands, it is imperative for emergency departments to improve efficiency, while providing safe and effective care. Efficient and quality healthcare delivery are impacted by interactions among the emergency department's physical structure, processes, and outcomes. Examining the interrelationship between these three components is essential for assessing quality of care in the ED setting. Studies simultaneously investigating all three aspects of this model are rare.

OBJECTIVES

To study examined emergency nurses' perceptions of efficiency and satisfaction with the design of a newly constructed academic emergency department through analysis of these three assessment factors.

METHODS

Data were collected using observational techniques, physical measurements of walking, and staff questionnaires. Correlation analysis was employed to investigate the relationships among specific structure, process, and outcome factors. Hierarchical linear regression was conducted to understand which structure and process variables in particular were related to the dependent variable, perceptions of efficiency and staff satisfaction with design.

RESULTS

Outcomes revealed that all of the structure and process factors examined in this emergency department including unit configuration, technology, lighting, visibility, patient room layout, storage, walkability, staff stress, data access, and teamwork were significantly associated with perceptions of efficiency and staff satisfaction with design.

DISCUSSION

The findings suggest that the structure of the built environment can shape healthcare processes occurring within it and ultimately improve the delivery of efficient care, thus increasing both patient and staff satisfaction. As such, the designed environment has a critical impact on enhancing performance, productivity, and staff satisfaction.

The content and meaning of administrative work: a qualitative study of nursing practices

AIM

To investigate the content and meaning of nurses' administrative work.

BACKGROUND

Nurses often report that administrative work keeps them away from bedside care. The content and meaning of this work remains insufficiently explored.

DESIGN

Comparative case studies.

METHOD

The investigation took place in 2014. It was based on 254 hours of observations and 27 interviews with nurses and staff in two contrasting units: intensive care and long-term care. A time and motion study was also performed over a period of 96 hours.

RESULTS

Documentation and Organizational Activities is composed of six categories; documenting the patient record, coordination, management of patient flow, transmission of information, reporting quality indicators, ordering supplies- stock management Equal amounts of time were spent on these activities in each case. Nurses did not express complaints about documentation in intensive care, whereas they reported feeling frustrated by it in long-term care. These differences reflected the extent to which these activities could be integrated into nurses' clinical work and this is in turn was related to several factors: staff ratios, informatics, and relevance to nursing work.

CONCLUSION

Documentation and Organizational Activities are a main component of care. The meaning nurses attribute to them is dependent on organizational context. These activities are often perceived as competing with bedside care, but this does not have to be the case. The challenge for managers is to fully integrate them into nursing practice. Results also suggest that nurses' Documentation and Organizational Activities should be incorporated into informatics strategies.

Shifting Landscapes: The Impact of Centralized and Decentralized Nursing Station Models on the Efficiency of Care

Objective:

The focus of this research was to analyze the impact of decentralized and centralized hospital design layouts on the delivery of efficient care and the resultant level of caregiver satisfaction.

Background:

An interdisciplinary team conducted a multiphased pre- and postoccupancy evaluation of a cardiovascular service line in an academic hospital that moved from a centralized to decentralized model. This study examined the impact of walkability, room usage, allocation of time, and visibility to better understand efficiency in the care environment.

Method:

A mixed-methods data collection approach was utilized, which included pedometer measurements of staff walking distances, room usage data, time studies in patient rooms and nurses’ stations, visibility counts, and staff questionnaires yielding qualitative and quantitative results.

Results:

Overall, the data comparing the centralized and decentralized models yielded mixed results. This study’s centralized design was rated significantly higher in its ability to support teamwork and efficient patient care with decreased staff walking distances. The decentralized unit design was found to positively influence proximity to patients in a larger design footprint and contribute to increased visits to and time spent in patient rooms.

Conclusion:

Among the factors contributing to caregiver efficiency and satisfaction are nursing station design, an integrated team approach, and the overall physical layout of the space on walkability, allocation of caregiver time, and visibility. However, unit design alone does not solely impact efficiency, suggesting that designers must consider the broader implications of a culture of care and processes.

Transition from an open-plan to a two-cot neonatal intensive care unit: a participatory action research approach

AIMS AND OBJECTIVES

To facilitate staff transition from an open-plan to a two-cot neonatal intensive care unit design.

BACKGROUND

In 2012, an Australian regional neonatal intensive care unit transitioned from an open-plan to a two-cot neonatal intensive care unit design. Research has reported single- and small-room neonatal intensive care unit design may negatively impact on the distances nurses walk, reducing the time they spend providing direct neonatal care. Studies have also reported nurses feel isolated and need additional support and education in such neonatal intensive care units. Staff highlighted their concerns regarding the impact of the new design on workflow and clinical practice.

DESIGN

A participatory action research approach.

METHODS

A participatory action group titled the Change and Networking Group collaborated with staff over a four-year period (2009-2013) to facilitate the transition. The Change and Networking Group used a collaborative, cyclical process of planning, gathering data, taking action and reviewing the results to plan the next action. Data sources included meeting and workshop minutes, newsletters, feedback boards, subgroup reports and a staff satisfaction survey.

RESULTS

The study findings include a description of (1) how the participatory action research cycles were used by the Change and Networking Group: providing examples of projects and strategies undertaken; and (2) evaluations of participatory action research methodology and Group by neonatal intensive care unit staff and Change and Networking members.

CONCLUSION

This study has described the benefits of using participatory action research to facilitate staff transition from an open-plan to a two-cot neonatal intensive care unit design. Participatory action research methodology enabled the inclusion of staff to find solutions to design and clinical practice questions. Future research is required to assess the long-term effect of neonatal intensive care unit design on staff workload, maintaining and supporting a skilled workforce as well as the impact of a new neonatal intensive care unit design on the neonatal intensive care unit culture.

RELEVANCE TO CLINICAL PRACTICE

A supportive work environment for staff is critical in providing high-quality health care.

Geographical thinking in nursing inquiry, part two: performance, possibility, and non-representational theory

Part one in this two paper series reviewed the nature of geographical thinking in nursing research thus far. The current paper builds on it by looking forwards and providing a particular vision for future research. It argues that it is time to once again look to the parent discipline of human geography for inspiration, specifically to its turn towards non-representational theory, involving an emphasis on life that onflows prior to meaning, significance, and full cognition; on life's 'taking-place'. The paper introduces this way of viewing and animating the world. Some potential connections to nursing research and practice are suggested, as are some specific avenues for future inquiry. Explained is how, through non-representational theory, nursing might be re-imagined as something that reveals space-time.

Space Syntax Analysis

Aim:

This article reviews and addresses various spatial measures that provide and facilitate accurate descriptions of different layout typologies with particular focus on healthcare facilities.

Background:

Evidence-based design is a field of study that emphasizes the importance of using credible data in order to influence the design process. It addresses whether/how the design and operation of buildings support positive health outcomes through a growing collection of solutions informed by research and practical knowledge. In order to acquire this knowledge, we must consider the environment in a very precise and measurable way, which can then be investigated quantitatively with regard to various human behaviors and cognitive processes.

Topical Headings:

Space Syntax theory and methods are concerned with understanding how spaces are arranged and connected to one another. It provides quantitative measures of individual spaces and of the entire layout, thereby achieving great accuracy. Space Syntax researchers have used graph theory to define spatial measures and have produced computer tools to quantify the relational properties of spaces and to provide numerical and display values for each. Moreover, they have developed more precise tools that can be embedded within basic Space Syntax concepts in order to augment the credibility of the acquired data.

Conclusion:

The study elaborates on the effectiveness of Space Syntax and its newly developed measures for the field of healthcare facility design and research. We present a comprehensive model that brings together these measures with their correlated behavioral and perceptual consequences, thereby providing a point of departure for further investigation and exploration.

Effects of nursing unit spatial layout on nursing team communication patterns, quality of care, and patient safety

Studies investigating factors contributing to improved quality of care have found that effective team member communication is among the most critical and influential aspects in the delivery of quality care. Relatively little research has examined the role of the physical design of nursing units on communication patterns among care providers. Although the concept of decentralized unit design is intended to increase patient safety, reduce nurse fatigue, and control the noisy, chaotic, and crowded space associated with centralized nursing stations, until recently little attention has been paid to how such nursing unit designs affected communication patterns or other medical and organizational outcomes. Using a pre/post research design comparing more centralized or decentralized unit designs with a new multi-hub design, the aim of this study was to describe the relationship between the clinical spatial environment and its effect on communication patterns, nurse satisfaction, distance walked, organizational outcomes, patient safety, and patient satisfaction. Hospital institutional data indicated that patient satisfaction increased substantially. Few significant changes were found in communication patterns; no significant changes were found in nurse job satisfaction, patient falls, pressure ulcers, or organizational outcomes such as average length of stay or patient census.

Research on nursing unit layouts: an integrative review

Purpose

– This paper aims to present an integrative review of the research studies on nursing unit layouts.

Design/methodology/approach

– Studies selected for review were published between 1956 and 2014. For the purpose of this review, a framework for integrative review was developed using research orientations. The three primary dimensions – technical, psychological and social – of the designed environment and various combinations of these dimensions were used to define the research orientations of these studies.

Findings

– Of all the publications reviewed for the paper, 21 presented technical orientations, 16 psychological orientations, 3 social orientations, 20 psychotechnical orientations, 10 sociotechnical orientations, 2 psychosocial orientations and 13 presented psychosociotechnical orientations. With only a few exceptions, several issues related to nursing unit layouts were investigated no more than one time in any one category of research orientations. Several other seemingly important issues including patient and family behavior and perception, health outcomes and social and psychosocial factors in relation to unit layouts have not been studied adequately.

Research limitations/implications

– Future studies on nursing unit layouts will need to focus on patient and family behavior and perception, health outcomes and social and psychosocial factors in different units. They will also need to focus on developing theories concerning the effects of layouts on the technical, psychological and social dimensions of nursing units.

Originality/value

– Despite a long history of research on nursing unit layouts, an integrative review of these studies is still missing in the literature. This review fills in the gap using a novel framework for integrative review developed based on research orientations.

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.

The oncology acuity tool: a reliable, valid method for measuring patient acuity for nurse assignment decisions

BACKGROUND AND PURPOSE

Matching nurse assignments with patient acuity has critical implications for providing safe, effective, and efficient care. Despite this, we lack well-established methods for accurate assessment of acuity. This study aimed to evaluate the reliability and validity of the Oncology Acuity Tool (OAT), which is used for determining nurse assignments.

METHODS

Inter-rater reliability and concurrent validity were assessed via surveys of current users of the tool. Content validity data were collected from expert oncology nurses. Predictive validity was assessed by tracking patients who sustained either of two acute events.

RESULTS

Findings included high inter-rater reliability, moderately strong concurrent validity, and moderate content validity. Acuity significantly predicted rapid response team consults but not falls.

CONCLUSIONS

The OAT demonstrated sufficient reliability and validity for measuring acuity prospectively in this population.

Space Syntax in Healthcare Facilities Research: A Review

Space Syntax is a theory and method that has been developing for the last 40 years. Originally conceived as a theory of “society and space,” it has expanded to other areas. An important aspect of this is technical; it allows the quantification of layouts, and unit spaces within a layout, so that the environment itself can produce independent variables in quantitative research. Increasingly, it is being used to study healthcare facilities. Space Syntax has thereby become relevant to healthcare facilities researchers and designers. This paper attempts to explain Space Syntax to a new audience of healthcare designers, administrators, and researchers; it provides a literature review on the use of Space Syntax in healthcare facility research and suggests some possibilities for future application.

Application of Space Syntax Theory in the Study of Medical-Surgical Nursing Units in Urban Hospitals

Additional research is needed to explore how the design of urban, medical-surgical nursing units influences communication patterns, perceptions of social support, and overall job satisfaction for nurses. Space syntax theory has typically been used to study communication in office environments; more recently, it has been applied to the study of healthcare environments. The purpose of this study was to explore the applicability of space syntax theory as a theoretical framework for studying nurses' communication in medical-surgical nursing units in urban hospitals.

Background:

The nursing profession is rapidly changing, and nurses' work is psychologically and physically intense. At the same time, nurses are responsible for patient safety, optimal care delivery, and patient outcomes ( Bureau of Labor Statistics, 2009 ; Clarke, 2007 ; Clarke & Donaldson, 2008 ; Institute of Medicine, 2000 ; Institute of Medicine, 2004 ). Nurses are central to the delivery of care and act as a conduit for communication among members of the patient care team. Some of the design characteristics that create a more appealing environment for patients, such as views of nature and single-patient rooms, may not be fully understood as they relate to nurses' tasks and responsibilities, and they could be detrimental to nursing communication.

Methods:

This study analyzed three medical-surgical nursing unit floor plans using two constructs of space syntax theory, and it verified analysis through three semi-structured interviews with end users.

Results:

The use of space syntax theory for analyzing medical-surgical nursing unit floor plans is complex. Findings indicated that nurses' perceptions of two constructs of space syntax theory, visibility and accessibility, did not consistently match the anticipated benefits of the floor plan designs.

Conclusions:

Understanding how and when nurses communicate with each other could help designers of healthcare spaces create more effective environments that support nurses' work and personal health and welfare. The findings of this study suggest that further exploration is needed to confirm this theory's application to healthcare environments.