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PDC_2008_Childrens Atlanta Study

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PDC_2008_Childrens Atlanta Study

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PDC_2008_Childrens Atlanta Study

  1. 1. A Caregivers View and its Effect ong Patient Well Being Debajyoti Pati, PhD, AIIA, Director of Research, HKS Architects Paul Barach, MD, MPH, Professor, University of Utrecht, Netherlands 2008 International Conference and Exhibition on Planning, Design and Construction™
  2. 2. Session ObjectivesSession Objectives Id tif h i l l t th t t t• Identify physical elements that act as stressors to patients and staff • State the impact of nature views on staff in relation to stress and alertness • Discuss the importance of view in relation to other stressors 2008 International Conference and Exhibition on Planning, Design and Construction™
  3. 3. DefinitionsDefinitions Ch i St Al t• Chronic Stress: – is a prolonged stress that exists for weeks, months, • Alertness: – a state of readiness to respond or even years. • Acute stress: – is usually for short timeis usually for short time and may be due to work pressure, meeting deadlines pressure orp minor accident, over exertion… 2008 International Conference and Exhibition on Planning, Design and Construction™
  4. 4. Some Studies • Investigator/s: – Ulrich, 1984 • Findings: – Patients with nature i ( d t• Setting: – Post-surgical recovery it view (compared to brick wall) had: • Shorter LOS unit • Subjects: Matched patients • Fewer pain medication • More favorable comments from nurses– Matched patients recovering from surgery 2008 International Conference and Exhibition on Planning, Design and Construction™
  5. 5. Some Studies • Investigator/s: – Beauchemin & Hays, 1998 • Findings: – Shorter LOS in sunny (1 d l )1998 • Setting: C di ICU rooms (1 day less) – Significantly higher mortality in dull– Cardiac ICU • Subjects: Patients admitted o ta ty du rooms (5% more in dull rooms) – Patients admitted directly to CICU 2008 International Conference and Exhibition on Planning, Design and Construction™
  6. 6. Some Studies • Investigator/s: – Grantcharov et al • Findings: – Impaired speed and i i l t d• Setting: – Gastroenterological i l it i accuracy in simulated laparoscopic performance after a surgical unit in a teaching hospital • Subjects: night on-call • Time taken • ErrorsSubjects: – 14 surgeons in training • Errors • Unnecessary movements 2008 International Conference and Exhibition on Planning, Design and Construction™
  7. 7. Some Studies • Investigator/s: – Fahrenkopf et al, 2007 • Findings: – Depressed residents d i ifi tl• Setting: – 3 urban children’s h it l made significantly more medication errors than non- hospitals • Subjects: Residents in pediatric depressed residents • 6.2x more medication errors– Residents in pediatric residency program 2008 International Conference and Exhibition on Planning, Design and Construction™
  8. 8. Some Studies • Investigator/s: – Landrigan et al, 2004 • Findings: – Interns in a traditional h d l (• Setting: – MICU and CCU, B i h d schedule (versus an intervention schedule) made substantially Brigham and Women’s Hospital, Boston more serious medical errors • 35 9% more serious • Subjects: – Interns • 35.9% more serious medical errors in traditional schedule 2008 International Conference and Exhibition on Planning, Design and Construction™
  9. 9. Some Studies • Investigator/s: – Lockley et al, 2004 • Findings: – Subjects on an i t ti k• Setting: – Brigham and W ’ H it l intervention work schedule (versus traditional schedule) Women’s Hospital, Boston • Subjects: had decreased attentional failures • Rate of attentionalSubjects: – Internal medicine recidency training • Rate of attentional failure less than half in intervention schedule 2008 International Conference and Exhibition on Planning, Design and Construction™ program
  10. 10. Some Studies • Investigator/s: – Lockley et al 2006 • Findings: – Light quality (certain l th ) i t• Setting: – Brigham and W ’ H it l wavelengths) impact alertness, vigilance and performance Women’s Hospital, Boston • Subjects:Subjects: – Healthy adults 2008 International Conference and Exhibition on Planning, Design and Construction™
  11. 11. Some Conclusions • Operational design (schedules, shift length) has a major impact on performance • The physical environment (specifically visual) may alleviate conditions) y 2008 International Conference and Exhibition on Planning, Design and Construction™
  12. 12. ContentsContents Why the inquiry? • Objective • Hypothesesyp • Methods • Results • Discussions 2008 International Conference and Exhibition on Planning, Design and Construction™
  13. 13. We want to examineWe want to examine • The influence of view on staff alertness and stress. • What does that mean to patient healing and healthcare organizations?g 2008 International Conference and Exhibition on Planning, Design and Construction™
  14. 14. Why the inquiry?Why the inquiry? • Stressed Nurses• Stressed Nurses – Data Suggest Nurse Fatigue Threatens Patient Safety1 – Fatigue and sleep deprivation common among medical personnel3 Safety1 – 70.5% of nurses surveyed indicated ‘acute/chronic effects of stress and among medical personnel effects of stress and overwork’ as one of their top three concerns: injury, disease assault allergydisease, assault, allergy, accident2 1 Tabone (2004) 2 Houle (2001) 3 AHRQ (2001) 2008 International Conference and Exhibition on Planning, Design and Construction™ AHRQ (2001)
  15. 15. Why the inquiry?Why the inquiry? • Impacts of stress• Impacts of stress – Cognitive performance4 – Errors and near errors 5 – slowed reaction time, lapses of attention to detail, errors of omission, – decreased alertness, problems with task completion, problems with i i i bili detail, errors of omission, compromised problem solving, reduced motivation, and decreased concentration, irritability, unsafe actions, and unsafe decision making 6 energy 7 4 Reiling, 2005 5 ONA, 2005-6 6 Tabone, 2004 7 AHRQ, 2001; Page, 2004 2008 International Conference and Exhibition on Planning, Design and Construction™
  16. 16. Why the inquiry?Why the inquiry? • Physical environment as t – Visual environment: P ti t t istressor – The built environment – Auditory environment • Patients : stress, pain, mood satisfaction 11 • Patients : blood pressure, heart rate, sleep deprivation, pain 8 • Staff : occupational stress 9 – Informational environment • Patients : stress, heart rate 10 8 Topf et al, 2001; Baker, 1984 9 Topf, 1988 10 Carpman, 1984; Nelson-Shulman, 1983- 84 11 Ulrich et al, 1991, 2003; Leather et al, 2008 International Conference and Exhibition on Planning, Design and Construction™ 2003
  17. 17. Why the inquiry?Why the inquiry? • Influence of viewInfluence of view – Patients • LOS, pain drugs, minor complications 12complications • Memory, time orientation, hallucination, delusion 13 – Staff • Windowless room : lower reported well being 14reported well being 12 Ulrich, 1984 13 Keep et al, 1980; Wilson, 1972 14 Verderber, 1987 2008 International Conference and Exhibition on Planning, Design and Construction™
  18. 18. QuestionsQuestions • How does the view influence staff stress and alertness levels? • How does nature view (as opposed to non• How does nature view (as opposed to non- nature view or no view) influence the staff stress and alertness levels?stress and alertness levels? 2008 International Conference and Exhibition on Planning, Design and Construction™
  19. 19. Study ObjectiveStudy Objective • To examine the association between the view duration d t t t d l t l land content on stress and alertness levels View Content View Duration Stress Alertness OrganizationalOrganizational  Characteristics Work Load Physical EnvironmentPhysical Environment  Characteristics Personal Factors 2008 International Conference and Exhibition on Planning, Design and Construction™
  20. 20. MethodsMethods • Setting: Children’s Healthcare of • Predictor: Vi d ti– Children s Healthcare of Atlanta • Data collection: 12 hours day shift – View duration – View content: nature; non- nature C l– 12 hours day shift – Sample 32 of 55 personnel – Unit types: 19 • Design: • Controls: – Stress from lighting, auditory, thermal and ergonomic i t• Design: – Observational; single measurement • Outcome measure: environment – Organizational stress – Work load W k i• Outcome measure: – Chronic stress – Acute stress Alertness – Work experience – Personal data: age, education, position 2008 International Conference and Exhibition on Planning, Design and Construction™ – Alertness
  21. 21. View TypesView Types 2008 International Conference and Exhibition on Planning, Design and Construction™
  22. 22. Methods StatisticalMethods - Statistical • Paired sample comparison • Multivariate regression • Joint partial F-testJoint partial F test • Multivariate regression with interaction terms 2008 International Conference and Exhibition on Planning, Design and Construction™
  23. 23. InstrumentsInstruments Measure Instrument Ch i t P i d St S l (PSS 10)Chronic stress Perceived Stress Scale (PSS-10) Acute stress; Alertness Cox’s Stress/Arousal Adjective Checklist (SACL) View duration; view content Investigator designed questionnaire Lighting, auditory, thermal, ergonomic stress Investigator designed questionnaire g Organizational stress Revised Nursing Work Index (NWI-R) Work load Investigator designed questionnaire Work experience Investigator designed questionnaire Age, education, position Investigator designed questionnaire 2008 International Conference and Exhibition on Planning, Design and Construction™
  24. 24. A. Chronic Stress Mean chronic stress – before shift Mean chronic stress – after Difference between t-statistics Significance 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 SIGNIFICANT DIFFERENCE Chronic Stress SIGNIFICANT DIFFERENCE BETWEEN MEAN PSS SCORES 7:00 am 7:00 pm 2008 International Conference and Exhibition on Planning, Design and Construction™ p
  25. 25. B. Alertness Mean alertness – before shift Mean alertness Difference between t-statistics Significance before shift alertness – after shift between means 7.9714 4.4551 -3.51634 8.052 0.000*** STATISTICALLY *** significant at 0.001 ** significant at 0.01 * significant at 0.05 • STATISTICALLY SIGNIFICANT DIFFERENCE BETWEEN MEAN ALERTNESS SCORES Alertness N SS SCO S • DIRECTION OF DIFFERENCE SUPPORTED 7:00 am 7:00 pm 2008 International Conference and Exhibition on Planning, Design and Construction™ p
  26. 26. 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*** • STATISTICALLY *** significant at 0.001 ** significant at 0.01 * significant at 0.05 STATISTICALLY SIGNIFICANT DIFFERENCE BETWEEN MEAN ACUTE STRESS SCORES Acute Stress • DIRECTION OF DIFFERENCE SUPPORTED 7:00 am 7:00 pm 2008 International Conference and Exhibition on Planning, Design and Construction™ p
  27. 27. D. Alertness after shift R R2 R2 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*** Alertness Before Shift 0 511 0 502 7 106 0 000***Alertness- 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*** • View significant Joint Partial F-Test 2 *** significant at 0.001 ** significant at 0.01 * significant at 0.05 • View significant • + 4.8% explanatory power R2 full model 0.372 R2 sub model 0.324 R 2 change 0.048 2008 International Conference and Exhibition on Planning, Design and Construction™
  28. 28. E. Acute stress after shift R R2 R2 adjusted F Significance 0 669 0 447 0 431 28 063 0 000***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*** Acute Stress- 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 0.249 • View significantJoint Partial F-Test *** significant at 0.001 ** significant at 0.01 * significant at 0.05 • 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 2008 International Conference and Exhibition on Planning, Design and Construction™
  29. 29. F. Alertness and view content R R2 R2 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* Alertness- Before Shift 0.185 0.199 3.067 0.002* E St 0 679 0 384 6 283 0 000***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 Nature View Alertness 7:00 am 7:00 pm Non-Nature View No View 2008 International Conference and Exhibition on Planning, Design and Construction™ 7:00 am 7:00 pm
  30. 30. DISCUSSION: Alertness and view content • Of all nurses whose response readiness level remained the same or • The presence or absence of view in the nurses’ workplace trailed behind improved: 58 percent had exposure to a view (100 percent of the 58 percent were exposed to a nature view) p only the organizational stressors as the factor bearing most influence on response readiness in nurses • Of all nurses whose response readiness levels deteriorated between the beginning and end of the shift 67 • Physical environmental stressors (light, noise, thermal comfort, and ergonomics) ranked third in the orderthe beginning and end of the shift 67 percent had no view or only a non- nature view ergonomics) ranked third in the order of influence on response readiness in nurses 2008 International Conference and Exhibition on Planning, Design and Construction™
  31. 31. Acute stress and view content R R2 R2 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*** Env Stress 0.513 0.256 3.759 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 Nature View Non-Nature View No View 7:00 am 7:00 pm 2008 International Conference and Exhibition on Planning, Design and Construction™ p
  32. 32. 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 behind improved between the beginning and end of the shift, 64 percent had exposure to views (71 percent of that 64 percent were exposed to nature p only the physical environmental stressors (light, noise, thermal comfort, and ergonomics) as the factor bearing most influence on acute64 percent were exposed to nature view) • Of all nurses whose acute stress levels factor bearing most influence on acute stress in nurses • Demographic factors (age, experience, education, and pay scale)Of all nurses whose acute stress levels deteriorated between the beginning and end of the shift, 56 percent had no view during the shift or had only a i p , , p y ) ranked third in the order of influence on acute stress non-nature view 2008 International Conference and Exhibition on Planning, Design and Construction™
  33. 33. Impact on patients andImpact on patients and organization Organizational  Characteristics Work Load l Organizational  Characteristics Work Load l St ff O t Personal Factors Personal Factors Physical Environment Staff Outcome Patient Outcome Organizational Outcome 2008 International Conference and Exhibition on Planning, Design and Construction™
  34. 34. Implications • How does this contribute to a healing environment? 2008 International Conference and Exhibition on Planning, Design and Construction™
  35. 35. Implications • Capital planning and budgeting: – Embrace the importance of view and visualp relief for staff work areas • Programming:g g – Require space requirements include specific description of design intent for generous views along with allocation of spaces 2008 International Conference and Exhibition on Planning, Design and Construction™
  36. 36. Implications • Design: – Insist that design of capital projectsg p p j demonstrate attention t the provision of view in all staff work areas • Policy: – Mandate restorative breaks as an integral aspect of operational policies 2008 International Conference and Exhibition on Planning, Design and Construction™
  37. 37. STUDY LIMITATIONSSTUDY LIMITATIONS • Sample size: nurses • Sample size: shiftsp • Follow-up recommendations: Natural experiment design– Natural experiment design – Objective and subjective measures L l– Larger sample – More settings 2008 International Conference and Exhibition on Planning, Design and Construction™
  38. 38. Questions 2008 International Conference and Exhibition on Planning, Design and Construction™

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