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View From a Far: The Influence ofe o a a e ue ce o
The View Content & Duration on
Nurse Stress LevelsNurse Stress Levels
D...
Questions
• What constitutes “View”?
• Can technology play a role in addressing the
need for view?
• How do we balance the...
Definitions
• Chronic Stress:
is a prolonged stress that
• Arousal:
a state of readiness to– is a prolonged stress that
ex...
What do you think?
• How should chronic stress change between beginning
and end of a shift?and end of a shift?
• How shoul...
Contents
Why the inquiry?
• Objective
• Hypotheses
• Methods
– Definitions
– Instruments
• Results
• Discussion
Limitation...
We want to see
• The impact of view on staff alertness and stress.
• What does that mean to healthcare
organizations?
May ...
Why the inquiry?
• Stressed Nurses
Data S ggest N rse – Fatigue and sleep– Data Suggest Nurse
Fatigue Threatens Patient
Sa...
Why the inquiry?
• Impacts of stress
Cogniti e performance4 – slowed reaction time– Cognitive performance4
– Errors and ne...
Why the inquiry?
• Physical environment as
stressor
– Visual environment:
• Patients : stress painstressor
– The built env...
Why the inquiry?
• Influence of view
Patients– Patients
• LOS, pain drugs, minor
complications 12
• Memory time orientatio...
Questions
• How does the view influence staff stress and
arousal levels?
• How does nature view (as opposed to non-
t i i ...
Study Objective
• To study the association between the view
duration and content on stress and arousalduration and content...
Hypotheses
1. Between the beginning and end of the shift
CHRONIC STRESS levels (as measured byCHRONIC STRESS levels (as me...
Hypotheses - continued
4. At the end of the shift,
R d t d t t l i h ld• Respondents exposed to external view should
demon...
Methods
• Setting
– CHOA at Egleston and
• Predictor:
Vie d rationCHOA at Egleston and
Scottish Rite Hospitals
• Data coll...
Methods - Statistical
• Paired sample comparison
• Multivariate regression
• Joint partial F-test
• Multivariate regressio...
Instruments
Measure Instrument
Ch i P i d S S l (PSS 10) 0 40Chronic stress Perceived Stress Scale (PSS-10); 0 to +40
Acut...
RESULTS
18Health Care Design 2007, Dallas TX
A. Chronic Stress
Mean chronic
stress – before
Mean chronic
stress – after
Difference
between
t-statistics Significance
sh...
B. Arousal
Mean arousal –
before shift
Mean arousal
– after shift
Difference
between
t-statistics Significance
means
7.971...
C. Acute Stress
Mean acute stress
– before shift
Mean acute
stress – after
Difference
between
t-statistics Significance
sh...
D. Arousal after shift
R R
2
R
2
adjusted F Significance
0.624 0.389 0.372 22.103 0.000***
Parameters Estimate Beta t Sign...
E. Acute stress after shift
R R
2
R
2
adjusted F Significance
0.669 0.447 0.431 28.063 0.000***
Parameters Estimate Beta t...
F. Arousal and view content
R R
2
R
2
adjusted F Significance
0.643 0.413 0.39 17.983 0.000***
Parameters Estimate Beta t ...
DISCUSSION: Arousal and view content
• Of all nurses whose response
readiness level remained the
• The presence or absence...
Acute stress and view content
R R
2
R
2
adjusted F Significance
0.506 0.256 0.227 8.801 0.000***
Parameters Estimate Beta ...
Acute stress and view content
• Of all nurses whose acute stress
condition remained the same or
• The presence or absence ...
STUDY LIMITATIONS
• Sample size: nurses
• Sample size: shifts
• Follow-up recommendations:
– Natural experiment design
– O...
CONCLUSIONS
• Summary
Vie has positi e infl ence
• Next step
Slope parameters– View has positive influence
on arousal
– Vi...
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HCD_2007_Childrens Atlanta Study

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HCD_2007_Childrens Atlanta Study

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HCD_2007_Childrens Atlanta Study

  1. 1. View From a Far: The Influence ofe o a a e ue ce o The View Content & Duration on Nurse Stress LevelsNurse Stress Levels Debajyoti Pati, PhD, AIIA, HKS Architects Paul Barach, MD, MPH, University of Utrecht, Netherlands Tom E Harvey, AIA, FACHA, MPH, HKS Architects Health Care Design 2007, Dallas TX 1
  2. 2. Questions • What constitutes “View”? • Can technology play a role in addressing the need for view? • How do we balance the potential benefits of view and the patient’s need for privacy? O ti l d t bilit i i f i• Operational adaptability versus provision of view – can both be accommodated satisfactorily? H d b ildi f t i t (fl i ) l• How does building footprint (floor area size) play into this issue? (European building codes often mandate/limits distance from a window)mandate/limits distance from a window) May 31, 2007 EDRA 38 Sacramento 2
  3. 3. Definitions • Chronic Stress: is a prolonged stress that • Arousal: a state of readiness to– is a prolonged stress that exists for weeks, months, or even years. A t t – a state of readiness to respond • Acute stress: – is usually for short time and may be due to work pressure, meeting deadlines pressure or minor accident, over e ertion increasedexertion, increased physical activity, searching something but you misplaced it 3 misplaced it... Health Care Design 2007, Dallas TX
  4. 4. What do you think? • How should chronic stress change between beginning and end of a shift?and end of a shift? • How should alertness change between beginning and end of a shift? • How should acute stress change between beginning and end of a shift? H h ld t i i t l t ?• How should exposure to view impact alertness? • What role should view content play in modulating alertness?alertness? • How should exposure to view impact acute stress? • What role should view content play in modulating acute stress? May 31, 2007 EDRA 38 Sacramento 4
  5. 5. Contents Why the inquiry? • Objective • Hypotheses • Methods – Definitions – Instruments • Results • Discussion Limitations of St d• Limitations of Study • Recommendations 5Health Care Design 2007, Dallas TX
  6. 6. We want to see • The impact of view on staff alertness and stress. • What does that mean to healthcare organizations? May 31, 2007 EDRA 38 Sacramento 6
  7. 7. Why the inquiry? • Stressed Nurses Data S ggest N rse – Fatigue and sleep– Data Suggest Nurse Fatigue Threatens Patient Safety1 70 5% of nurses surveyed – Fatigue and sleep deprivation common among medical personnel3 – 70.5% of nurses surveyed indicated ‘acute/chronic effects of stress and overwork’ as one of theiroverwork as one of their top three concerns: injury, disease, assault, allergy, accident2acc de t 1 Tabone (2004) 2 Houle (2001) 3 AHRQ (2001) 7Health Care Design 2007, Dallas TX
  8. 8. Why the inquiry? • Impacts of stress Cogniti e performance4 – slowed reaction time– Cognitive performance4 – Errors and near errors 5 – decreased alertness, – slowed reaction time, lapses of attention to detail, errors of omission, compromised problem problems with task completion, problems with concentration, irritability, unsafe actions and unsafe compromised problem solving, reduced motivation, and decreased energy 7 unsafe actions, and unsafe decision making 6 4 Reiling, 2005g 5 ONA, 2005-6 6 Tabone, 2004 7 AHRQ, 2001; Page, 2004 8Health Care Design 2007, Dallas TX
  9. 9. Why the inquiry? • Physical environment as stressor – Visual environment: • Patients : stress painstressor – The built environment – Auditory environment Patients : stress, pain, mood satisfaction 11 • Patients : blood pressure, heart rate, sleep deprivation, pain 8 Staff occ pational stress 9• Staff : occupational stress 9 – Informational environment • Patients : stress, heart rate 10 8 Topf et al, 2001; Baker, 1984 9 T f 19889 Topf, 1988 10 Carpman, 1984; Nelson-Shulman, 1983- 84 11 Ulrich et al, 1991, 2003; Leather et al, 2003 9 2003 Health Care Design 2007, Dallas TX
  10. 10. Why the inquiry? • Influence of view Patients– Patients • LOS, pain drugs, minor complications 12 • Memory time orientation• Memory, time orientation, hallucination, delusion 13 – Staff • Windowless room : lower reported well being 14 12 Ulrich, 1984 13 Keep et al, 1980; Wilson, 1972 14 Verderber, 1987 10Health Care Design 2007, Dallas TX
  11. 11. Questions • How does the view influence staff stress and arousal levels? • How does nature view (as opposed to non- t i i ) i fl th t ffnature view or no view) influence the staff stress and arousal levels? 11Health Care Design 2007, Dallas TX
  12. 12. Study Objective • To study the association between the view duration and content on stress and arousalduration and content on stress and arousal levels Other Factors Other Factors Ph i l Staff Outcome O i i lPhysical Environment Patient Outcome Organizational Outcome 12Health Care Design 2007, Dallas TX
  13. 13. Hypotheses 1. Between the beginning and end of the shift CHRONIC STRESS levels (as measured byCHRONIC STRESS levels (as measured by PSS-10 scale) should not change 2 f2. Between the beginning and the end of the shift AROUSAL levels (as measured by SACL) should generally go downSACL) should generally go down 3. Between the beginning and the end of the shift ACUTE STRESS levels (as measured byshift ACUTE STRESS levels (as measured by SACL) should generally go up 13Health Care Design 2007, Dallas TX
  14. 14. Hypotheses - continued 4. At the end of the shift, R d t d t t l i h ld• Respondents exposed to external view should demonstrate higher arousal state. • Respondents exposed to external view should• Respondents exposed to external view should demonstrate lower acute stress. • Those with a nature view should demonstrate higher arousal state as opposed to a non- nature and no view. Th ith t i h ld d t t• Those with a nature view should demonstrate lower acute stress as compared to a non- nature and no view. 14 nature and no view. Health Care Design 2007, Dallas TX
  15. 15. Methods • Setting – CHOA at Egleston and • Predictor: Vie d rationCHOA at Egleston and Scottish Rite Hospitals • Data collection: Nov 2006 – 12 hours day shift – View duration – View content: nature; non- nature 12 hours day shift – Sample 32 of 55 personnel – Unit types: 19 • Design • Control Group: – Stress from lighting, auditory, thermal andDesign – Observational; single measurement • Outcome measure: y ergonomic environment – Organizational stress – Work load – Chronic stress – Acute stress – Arousal Work load – Work experience – Personal data: age, education position 15 education, position Health Care Design 2007, Dallas TX
  16. 16. Methods - Statistical • Paired sample comparison • Multivariate regression • Joint partial F-test • Multivariate regression with interaction terms 16Health Care Design 2007, Dallas TX
  17. 17. Instruments Measure Instrument Ch i P i d S S l (PSS 10) 0 40Chronic stress Perceived Stress Scale (PSS-10); 0 to +40 Acute stress; arousal Cox’s Stress/Arousal Adjective Checklist (SACL); -12 to +18 View duration; view content Investigator designed questionnaire Lighting, auditory, thermal, ergonomic stress Investigator designed questionnaire ergonomic stress Organizational stress Revised Nursing Work Index (NWI-R) Work load Investigator designed questionnaireg g q Work experience Investigator designed questionnaire Age, education, position Investigator designed questionnaire 17 g p g g q Health Care Design 2007, Dallas TX
  18. 18. RESULTS 18Health Care Design 2007, Dallas TX
  19. 19. A. Chronic Stress Mean chronic stress – before Mean chronic stress – after Difference between t-statistics Significance shift shift means 14.5953 13.6961 -0.89923 1.897 0.062 *** significant at 0.001 ** significant at 0.01 * significant at 0.05 • NO STATISTICALLY Chronic Stress SIGNIFICANT DIFFERENCE BETWEEN MEAN PSS SCORES 19 7:00 am 7:00 pm Health Care Design 2007, Dallas TX
  20. 20. B. Arousal Mean arousal – before shift Mean arousal – after shift Difference between t-statistics Significance means 7.9714 4.4551 -3.51634 8.052 0.000*** *** significant at 0.001 ** significant at 0.01 * significant at 0.05 • STATISTICALLY SIGNIFICANT DIFFERENCE BETWEEN MEAN AROUSAL SCORES Arousal SCORES • DIRECTION OF DIFFERENCE SUPPORTED 20 7:00 am 7:00 pm Health Care Design 2007, Dallas TX
  21. 21. C. Acute Stress Mean acute stress – before shift Mean acute stress – after Difference between t-statistics Significance shift means -3.925 -1.835 2.0897 4.535 0.000*** *** significant at 0.001 ** significant at 0.01 * significant at 0.05 • STATISTICALLY SIGNIFICANT DIFFERENCE BETWEEN MEAN ACUTE STRESS SCORES Acute Stress STRESS SCORES • DIRECTION OF DIFFERENCE SUPPORTED 21 7:00 am 7:00 pm Health Care Design 2007, Dallas TX
  22. 22. D. Arousal after shift R R 2 R 2 adjusted F Significance 0.624 0.389 0.372 22.103 0.000*** Parameters Estimate Beta t Significance Constant 13.28 7.006 0.000*** View duration 0.1 0.273 4.109 0.000*** Arousal- Before Shift 0 511 0 502 7 106 0 000***Arousal- Before Shift 0.511 0.502 7.106 0.000 Env Stress -0.46 -0.236 -3.693 0.000*** AE Index 0.47 0.159 2.464 0.015* Work Load -0.867 -0.191 -3.119 0.002* NWI-R -3.664 -0.307 -4.851 0.000*** *** significant at 0.001 ** significant at 0.01 * significant at 0.05 • View significant Joint Partial F-Test 2 • View significant • + 4.8% explanatory power R2 full model 0.372 R2 sub model 0.324 R 2 change 0.048 22Health Care Design 2007, Dallas TX
  23. 23. E. Acute stress after shift R R 2 R 2 adjusted F Significance 0.669 0.447 0.431 28.063 0.000*** Parameters Estimate Beta t Significance Constant -13.223 -6.348 0.000*** View duration 0.117 0.266 4.956 0.000*** f S f 0 99 0 9 616 0 000***Arousal- Before Shift 0.499 0.5 9.616 0.000*** Env Stress 0.847 0.362 6.453 0.000*** AE Index -0.864 -0.244 -4.174 0.000*** Work Load 0.599 0.11 1.998 0.047* NWI-R 0 902 0 063 1 157 0 249NWI-R 0.902 0.063 1.157 0.249 *** significant at 0.001 ** significant at 0.01 * significant at 0.05 • View significantJoint Partial F-Test • View significant • + 6.4% explanatory power Joint Partial F Test R2 full model 0.431 R2 sub model 0.367 R 2 change 0.064 23Health Care Design 2007, Dallas TX
  24. 24. F. Arousal and view content R R 2 R 2 adjusted F Significance 0.643 0.413 0.39 17.983 0.000*** Parameters Estimate Beta t Significance Constant 15.759 8.79 0.000*** Non-nature view 0.286 0.021 0.256 0.798 Nature view 1.877 0.178 2.51 0.013* A l B f Shift 0 185 0 199 3 067 0 002*Arousal- Before Shift 0.185 0.199 3.067 0.002* Env Stress -0.679 -0.384 -6.283 0.000*** AE Index 1.157 0.44 6.505 0.000*** Work Load -0.357 -0.091 -1.186 0.237 NWI-R -2.862 -0.266 -3.728 0.000*** *** significant at 0.001 ** significant at 0.01 * significant at 0.05 N t Vi Arousal Nature View Non-Nature View No View 24 7:00 am 7:00 pm Health Care Design 2007, Dallas TX
  25. 25. DISCUSSION: Arousal and view content • Of all nurses whose response readiness level remained the • The presence or absence of view in the nurses’ workplace trailed same or improved: 58 percent had exposure to a view (100 percent of the 58 percent were exposed to a nature view) p behind only the organizational stressors as the factor bearing most influence on response readiness in nursesnature view) • Of all nurses whose response readiness levels deteriorated readiness in nurses • Physical environmental stressors (light noise thermal comfort andreadiness levels deteriorated between the beginning and end of the shift 67 percent had no view or only a non-nature view (light, noise, thermal comfort, and ergonomics) ranked third in the order of influence on response readiness in nurses 25Health Care Design 2007, Dallas TX
  26. 26. Acute stress and view content R R 2 R 2 adjusted F Significance 0.506 0.256 0.227 8.801 0.000*** Parameters Estimate Beta t Significance Constant -9.252 -4.077 0.000*** Non-nature view -0.657 -0.043 -0.429 0.668 Nature view -0.724 -0.061 -0.727 0.468 Acute stress- Before Shift 0.316 0.328 4.651 0.000***cute st ess e o e S t 0 3 6 0 3 8 65 0 000 Env Stress 0.513 0.256 3.759 0.000*** AE Index -0.924 -0.31 -4.238 0.000*** Work Load 0.561 0.127 1.466 0.144 NWI-R 1.322 0.108 1.356 0.177 *** significant at 0.001 ** significant at 0.01 * significant at 0.05 Acute Stress N t Vi Non-Nature View No View Nature View 26 7:00 am 7:00 pm Health Care Design 2007, Dallas TX
  27. 27. Acute stress and view content • Of all nurses whose acute stress condition remained the same or • The presence or absence of view in the nurses’ workplace trailed improved between the beginning and end of the shift, 64 percent had exposure to views (71 percent of that 64 percent were exposed p behind only the physical environmental stressors (light, noise, thermal comfort, and ergonomics) as the factor bearingof that 64 percent were exposed to nature view) • Of all nurses whose acute stress ergonomics) as the factor bearing most influence on acute stress in nurses • Demographic factors (age,Of all nurses whose acute stress levels deteriorated between the beginning and end of the shift, 56 percent had no view during the hift h d l t i g p ( g , experience, education, and pay scale) ranked third in the order of influence on acute stress shift or had only a non-nature view May 31, 2007 EDRA 38 Sacramento 27
  28. 28. STUDY LIMITATIONS • Sample size: nurses • Sample size: shifts • Follow-up recommendations: – Natural experiment design – Objective and subjective measures L l– Larger sample – More settings
  29. 29. CONCLUSIONS • Summary Vie has positi e infl ence • Next step Slope parameters– View has positive influence on arousal – View has positive influence on acute stress – Slope parameters – Patient outcomes – Organizational outcomes on acute stress – View explains a considerable proportion of variance in arousal andvariance in arousal and acute stress – Nature view has positive influence on arousalinfluence on arousal – Nature view has positive influence on acute stress 29Health Care Design 2007, Dallas TX

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