Development and initial validation of a hospital stress questionnaire

Background

Hospitalisation can be a traumatic experience, where inpatients are exposed to an abundance of physical and psychological stressors. Evidence suggests that these hospital-related stressors negatively impact health: a phenomenon known as post-hospital syndrome. The current study aimed to identify hospital-related stressors, and to develop and provide initial validation for a new measure of in-hospital stress.

Methods

Measure development occurred in three stages: (i) semi-structured interviews, (ii) item generation, and (iii) pilot testing. Twenty-one patients were interviewed regarding their recent hospital experiences, and a list of hospital-related stressors was produced. These stressors were compiled into a questionnaire and piloted on 200 recent inpatients to provide initial evidence of internal consistency and construct validity.

Results

Stressors identified from the interviews captured all relevant questions from three previous hospital stress measures, plus 12 more. The most reported stressor was 'poor sleep'. These hospital-related stressors were developed into 67 questions, forming the Hospital Stress Questionnaire (HSQ). The HSQ showed excellent internal consistency and construct validity, and correlated with feelings of vulnerability and being unprepared to go home.

Conclusion

The HSQ is a promising self-report tool for measuring in-hospital stress. Future research ought to investigate its psychometric properties further in larger and more diverse samples. The measure has potential to be used to monitor patient risk of post-hospital syndrome.

The Influence of Exposure to Nature on Inpatient Hospital Stays: A Scoping Review

AIM

To summarize the existing literature surrounding the influence of natural elements on course in hospital and to introduce clinicians to the concept of biophilic design and the potential for incorporation of nature into the hospital environment as a component of a therapeutic hospitalization.

BACKGROUND

For decades, architects and designers have espoused the benefits of incorporating natural elements into the healthcare environment for therapeutic purposes. The benefits of this "biophilic" design philosophy has been investigated predominantly in long-term care or rehabilitation settings; however, some of the most appealing opportunities lie in the acute care setting.

METHODS

This scoping review surveyed the literature surrounding the influence of exposure to nature on course in acute hospitalizations. After screening 12,979 citations, 41 articles were included. Exposures were divided into seven categories, the most common of which were the presence of a window/natural light, a natural scene through a window, and nature soundscapes. These articles were reviewed in a narrative fashion and thematic analysis was conducted.

RESULTS

Studies were extremely heterogeneous in their design, research questions, and reported outcomes. Types of exposure to nature studied were exposure to a real natural scene through a window, presence of a window/nature light, nature in the healthcare environment, art depicting nature, direct contact with nature, nature soundscapes, and nature experienced through virtual reality (VR).

CONCLUSIONS

Exposure to nature during an acute hospital admission appears to have a real but small therapeutic effect, predominantly on psychological metrics like anxiety/depression, pain, and patient satisfaction. Greater beneficial effects are seen with greater durations of exposure to nature and greater degrees of immersion into nature (e.g., creating multisensory experiences using emerging technology like VR).

Design of Pediatric Outpatient Procedure Environments: A Pilot Study to Understand the Perceptions of Patients and Their Parents

OBJECTIVE

To understand parent and child perception of spaces experienced during outpatient procedures and to measure their anxiety in these spaces.

BACKGROUND

Same-day procedures are becoming prevalent among children in the United States. While studies conducted in different types of healthcare settings show that the physical environment influences healthcare experiences of patients, there is a lack of research on patient and family perceptions of the physical environment of the outpatient centers where such procedures are conducted.

METHODS

This study used ecological momentary assessment to collect patient experience and anxiety data at different points during the patient's journey through an ambulatory surgical center where pediatric gastrointestinal (GI) procedures were performed. Objective and subjective measures of anxiety were collected. A Qualtrics survey asked participants' perceptions about four spaces-waiting, preprocedure, procedure, and recovery.

RESULTS

Child participants reported liking murals, double chairs, patient beds, wall color, and access to a television. They disliked medical equipment and lack of child-friendly furniture. Most parents liked the murals, access to a television, and nature photos, while disliking the lack of privacy, lack of toys in waiting areas, and lack of child-friendly furniture. On average, both children and parents experienced the highest anxiety levels before and during the procedure and the lowest during recovery. Between the four spaces, no significant differences were observed in the heart rate variability and skin conductance responses for both groups.

CONCLUSIONS

Despite the outpatient nature of the procedures, participants experienced anxiety before the GI procedure. Comfortable design features that provide distractions are preferred by children and their parents.

Non-pharmacological interventions to improve sleep quality and quantity for hospitalized adult patients-co-produced study with surgical patient partners: systematic review

BACKGROUND

Hospitalized patients experience sleep disruption with consequential physiological and psychological effects. Surgical patients are particularly at risk due to surgical stress and postoperative pain. This systematic review aimed to identify non-pharmacological interventions for improving sleep and exploring their effects on sleep-related and clinical outcomes.

METHODS

A systematic literature search was performed in accordance with PRISMA guidelines and was preregistered on the Open Science Framework (doi: 10.17605/OSF.IO/EA6BN) and last updated in November 2023. Studies that evaluated non-pharmacological interventions for hospitalized, adult patients were included. Thematic content analysis was performed to identify hypothesized mechanisms of action and modes of administration, in collaboration with a patient partner. Risk of bias assessment was performed using the Cochrane Risk Of Bias (ROB) or Risk Of Bias In Non-Randomized Studies - of Interventions (ROBINS-I) tools.

RESULTS

A total of 59 eligible studies and data from 14 035 patients were included; 28 (47.5%) were randomized trials and 26 included surgical patients (10 trials). Thirteen unique non-pharmacological interventions were identified, 17 sleep measures and 7 linked health-related outcomes. Thematic analysis revealed two major themes for improving sleep in hospital inpatients: enhancing the sleep environment and utilizing relaxation and mindfulness techniques. Two methods of administration, self-administered and carer-administered, were identified. Environmental interventions, such as physical aids, and relaxation interventions, including aromatherapy, showed benefits to sleep measures. There was a lack of standardized sleep measurement and an overall moderate to high risk of bias across all studies.

CONCLUSIONS

This systematic review has identified several sleep interventions that are likely to benefit adult surgical patients, but there remains a lack of high-quality evidence to support their routine implementation.

Nature-themed video intervention may improve cardiovascular safety of psilocybin-assisted therapy for alcohol use disorder

Introduction

Psychedelic-assisted therapy with psilocybin has shown promise in Phase 2 trials for alcohol use disorder (AUD). Set and setting, particularly factors facilitating a connection with nature, may positively influence the psychedelic experience and therapeutic outcomes. But to date, randomized controlled trials of interventions to enhance set and setting for psychedelic-assisted therapy are lacking.

Methods

This was a pilot randomized, controlled trial of Visual Healing, a nature-themed video intervention to optimize set and setting, versus Standard set and setting procedures with two open-label psilocybin 25 mg dosing sessions among 20 participants with AUD. For the first session, participants randomized to Visual Healing viewed nature-themed videos during the preparation session and the "ascent" and "descent" phases of the psilocybin dosing session while participants randomized to the Standard condition completed a meditation during the preparatory session and wore eyeshades and listened to a music playlist throughout the dosing session. For the second session 4 weeks later, participants chose either Visual Healing or Standard procedures. Primary outcomes were feasibility, safety, and tolerability of Visual Healing. Secondary and exploratory outcomes were changes in alcohol use, psychedelic effects, anxiety and stress.

Results

Nineteen of 20 (95%) randomized participants (mean age 49 ± 11 years, 60% female) completed the 14-week study. During the first psilocybin session, participants viewed an average of 37.9 min of the 42-min video and there were no video-related adverse events. Peak increase in post-psilocybin blood pressure was significantly less for participants randomly assigned to Visual Healing compared to Standard procedures. Alcohol use decreased significantly in both Visual Healing and Standard groups and psychedelic effects, stress, and anxiety were similar between groups.

Discussion

In this open-label pilot study, viewing Visual Healing videos during preparation and psilocybin dosing sessions was feasible, safe, and well-tolerated among participants with AUD. Preliminary findings suggest that Visual Healing has potential to reduce the cardiovascular risks of psychedelic therapy, without interfering with the psychedelic experience or alcohol-related treatment outcomes. Studies to replicate our findings as well as studies of different set and setting interventions with other psychedelic medications and indications are warranted.

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.

In-hospital stress and patient outcomes: A systematic review and meta-analysis

BACKGROUND

Hospital inpatients are exposed to high levels of stress during hospitalisation that may increase susceptibility to major adverse health events post-hospitalisation (known as post-hospital syndrome). However, the existing evidence base has not been reviewed and the magnitude of this relationship remains unknown. Therefore, the aim of the current systematic review and meta-analysis was to: 1) synthesise existing evidence and to determine the strength of the relationship between in-hospital stress and patient outcomes, and 2) determine if this relationship differs between (i) in-hospital vs post-hospital outcomes, and (ii) subjective vs objective outcome measures.

METHODS

A systematic search of MEDLINE, EMBASE, PsychINFO, CINAHL, and Web of Science from inception to February 2023 was conducted. Included studies reported a measure of perceived and appraised stress while in hospital, and at least one patient outcome. A random-effects model was generated to pool correlations (Pearson's r), followed by sub-group and sensitivity analyses. The study protocol was preregistered on PROSPERO (CRD42021237017).

RESULTS

A total of 10 studies, comprising 16 effects and 1,832 patients, satisfied the eligibility criteria and were included. A small-to-medium association was found: as in-hospital stress increased, patient outcomes deteriorated (r = 0.19; 95% CI: 0.12-0.26; I2 = 63.6; p < 0.001). This association was significantly stronger for (i) in-hospital versus post-hospital outcomes, and (ii) subjective versus objective outcome measures. Sensitivity analyses indicated that our findings were robust.

CONCLUSIONS

Higher levels of psychological stress experienced by hospital inpatients are associated with poorer patient outcomes. However, more high-quality, larger scale studies are required to better understand the association between in-hospital stressors and adverse outcomes.

Pilot Study of a Digital Screen-Based Calming Device for Managing Resistance During Morning and Evening Care of Persons With Dementia

Resistance to care is among the most common behaviors exhibited by persons with dementia (PwD). Resistance to care is a barrier to safety and comfort of PwD and caregivers. Nonpharmacological interventions are recommended as first-line management. In the current study, 13 long-term care (LTC) residents aged 74 to 100 years with a history of behavioral and psychological symptoms of dementia (BPSD) were randomized to intervention (n = 7) and control (n = 6) groups. On Days 1 to 3, the intervention group received usual care plus exposure to MindfulGarden (MG), a novel digital calming device during morning and evening care, activities widely recognized as problematic for PwD and staff; the control group received usual care only. On Day 4, both groups were exposed to MG with verbal prompting. Trends in the data suggest that MG reduced BPSD and duration of care in the morning and may be a useful tool in management of resistance to routine care in PwD in LTC settings. [Journal of Gerontological Nursing, 47(11), 15-21.].

Mapping the impact of ICU design on patients, families and the ICU team: A scoping review

PURPOSE

Scoping review to map outcomes and describe effects of intensive care unit (ICU) design features on patients, family, and healthcare professionals (HCPs).

MATERIALS AND METHODS

Iteratively developed search strategy executed across seven databases. We included studies (January 2007 to May 2020) exploring ICU design features using any study design. We grouped studies into 12 design features and categorized outcomes into four domains.

RESULTS

Of 18,577 citations screened, 44 studies met inclusion criteria. Newly built or renovated ICUs/ICU rooms were evaluated in 27 (61%) studies; 17 (39%) evaluated existing designs/features. Most commonly evaluated design features were lighting (24, 55%), single vs multi-occupancy rooms/pods (17, 39%), and family-centered design (13, 30%). We identified 63 distinct outcomes in four domains; HCP-related (20, 45%); patient-related (20, 45%); family-related (11, 25%); and environment-related (7, 16%). Eleven (25%) studies measured patient/family-reported outcomes. In studies evaluating single occupancy rooms, three reported increased family satisfaction, two reported decreased delirium burden, while six reported negative consequences on HCP wellbeing and working.

CONCLUSION

Studies evaluating ICU design measure disparate outcomes. Few studies included patient/ family-reported outcomes; fewer measured objective environment characteristics. Single room layouts may benefit patients and family but contribute to adverse HCP-related outcomes.

Interventions to reduce benzodiazepine and sedative-hypnotic drug use in acute care hospitals: A scoping review

BACKGROUND

Benzodiazepines and sedative-hypnotic drugs (BZD/SHD) are commonly utilized in the acute care setting for insomnia and anxiety and are associated with cognitive impairment, falls, and fractures. Interventions to reduce use of BZD/SHD in hospitals are not well characterized.

OBJECTIVE

The objective was to conduct a scoping review to identify and characterize interventions to reduce the use of BZD/SHD by adults in the acute care setting.

METHODS

English language studies and abstracts that described an intervention to reduce BZD/SHD in adult hospital patients were included. Six databases (PubMed, EMBASE, CINAHL, PsycINFO, Scopus, and Web of Science) were searched up to July 2018 and updated to February 3, 2021. The grey literature (Opengrey, Grey Matters, Google Advanced) was searched up to July 2018. Titles and abstracts were screened and full-text articles were reviewed and charted by three independent reviewers. Stakeholders were consulted to inform the scoping review and collect perspectives on the findings.

RESULTS

There were 13,046 records identified and 43 studies included. The most common study designs were uncontrolled before and after (23/43, 53.5%) and randomized controlled trials (7/43, 16.3%). The majority of studies tested a single intervention (32/43, 74.4%) such as education, deprescribing, relaxation training and sleep protocols. Patients were frequently the target of relaxation training and behavior change interventions; while sleep protocols, multifaceted interventions, education and deprescribing were usually directed at healthcare providers, either alone or in combination with patients. Most studies reported positive results in decreasing BZD/SHD use (27/43, 62.8%).

CONCLUSIONS

The scoping review found a variety of interventions to decrease the utilization of BZD/SHD in hospitals. Multifaceted interventions aimed at patients and healthcare providers that include a combination of education, sleep protocols, and deprescribing may support reductions in BZD/SHD use. Stakeholders also recommended policy and system changes such as computer alerts due to feasibility and workload.

Do Simulated Hospital Admissions Reflect Reality? A Qualitative Study of Volunteer Well-Being During a 24-Hr Simulated Hospitalization

OBJECTIVES

This study aims to delineate if and how healthy volunteers admitted to simulated care can aid in understanding real well-being experiences of in-hospital surgical patients.

BACKGROUND

Scientific research is necessary to understand the mediating effect of healthcare design on patient outcomes. Studies with patients are, however, difficult to conduct as they require substantial funding, time, and research capacity, and recovering patients are often not willing or able to participate. If studies conducted with volunteers provide similar findings, such studies might serve as fruitful alternatives for future research.

METHOD

A multimethod study was conducted between July 2017 and December 2017 with 17 volunteers who underwent a 24-hr simulated inpatient postsurgical care protocol. Data on value experiences, norms, and design requirements for an optimal healing environment were collected via diaries and semi-structured value-oriented interviews, focused on the values of spatial comfort, privacy, autonomy, sensory comfort, safety and security, and social comfort. Volunteers' outcomes were compared to prior literature on similar patients' outcomes.

RESULTS

Volunteers seem to experience their healing environment similarly to patients with regard to the values of spatial comfort, privacy, autonomy, sensory comfort, and social comfort related to contact with personnel and relatives. Less valuable insights were gained on the values of safety and security, and social comfort related to interaction with other patients, most probably due to the study design and because the participants did not truly experience a diseased bodily state.

CONCLUSION

Simulated hospital admissions with volunteers provide a satisfactory alternative for studying real patient outcomes.

In the Moment: Fostering Mindfulness and Reducing Stressors in the Healthcare Workplace

While healthcare design research has primarily focused on patient outcomes, there is a growing recognition that environmental interventions could do more by promoting the overall quality of care, and this requires expanding the focus to the health and well-being of those who deliver care to patients. Healthcare professionals are under high levels of stress, leading to burnout, job dissatisfaction, and poor patient care. Among other tools, mindfulness is recommended as a way of decreasing stress and helping workers function at higher levels. This article aims to identify potential environmental strategies for reducing work-related stressors and facilitating mindfulness in healthcare settings. By examining existing evidence on workplace mindfulness and stress-reducing design strategies, we highlight the power of the physical environment in not only alleviating stressful conditions but intentionally encouraging a mindful perspective. Strategies like minimizing distractions or avoiding overstimulation in the healthcare environment can be more effective if implemented along with the provision of designated spaces for mindfulness-based programs. Future research may explore optimal methods and hospital workers' preferences for environments that support mindfulness and stress management. The long-term goal of all these efforts is to enhance healthcare professionals' well-being, reignite their professional enthusiasm, and help them be resilient in times of stress.

A Framework of Smart-Home Service for Elderly’s Biophilic Experience

Smart-home technology and related services can reinforce a person’s experiential nature, promoting sustainable living among the elderly. It is crucial in the housing industry that support “Aging in Place”, contributing to the contact, control, and simulation of nature at home as well as the creation of a high-quality living space instead of mechanical achievement. Further, biophilic experience, the strengthening of inherent human propensity to nature for optimal health and well-being, supports the elderly’s physical, mental, and sociological health. However, despite the continuing emphasis on the benefits of residential nature experiences for the elderly, the application of smart-home technology and services is insufficient. This study presents a theoretical basis for combining biophilia and smart-home technology, providing a framework for smart-home services to ensure elderly residents can have biophilic experiences. In this study, smart-home components and related studies that can support the biophilic experience and the corresponding technology are analyzed. The results suggest the type and content of smart-home service for ensuring a biophilic experience, while also indicating the configuration of supportive input and output devices according to the service framework. Moreover, we recommend the interaction characteristics of smart-home devices from the perspective of residents, space, efficient service provision, and physical application. This paper broadens our understanding of the sustainable, residential-environment nature experience and informs the expansion of the aged-friendly smart-home industry, contributing to smart-home services trends and development.

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 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.

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.