PDC_2008_Childrens Atlanta Study

A Caregivers View and its Effect on gPatient 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™

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


DefinitionsDefinitions

Ch i St Al t• Chronic Stress:– is a prolonged stress that

exists for weeks, months,

• Alertness:– a state of readiness to

respondor even years.

• Acute stress:– is usually for short timeis usually for short time

and may be due to work pressure, meeting deadlines pressure or pminor accident, over exertion…


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 LOSunit

• Subjects:Matched patients

• Fewer pain medication• More favorable

comments from nurses– Matched patients recovering from surgery



– 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 durooms (5% more in dull rooms)

– Patients admitted directly to CICU



– 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



– 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



– 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



– 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


program


– 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


Some Conclusions

• Operational design (schedules, shift length) has a major impact on performance

• The physical environment (specifically visual) may alleviate conditions ) y


ContentsContentsWhy the inquiry?

• Objective• Hypothesesyp• Methods• Results• Discussions


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


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)


AHRQ (2001)

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, 20055 ONA, 2005-66 Tabone, 20047 AHRQ, 2001; Page, 2004


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, 19849 Topf, 198810 Carpman, 1984; Nelson-Shulman, 1983-

8411 Ulrich et al, 1991, 2003; Leather et al,


2003

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, 198413 Keep et al, 1980; Wilson, 197214 Verderber, 1987


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?


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 StressAlertness

OrganizationalOrganizational Characteristics

Work Load

Physical EnvironmentPhysical Environment Characteristics

Personal Factors


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


– Alertness

View TypesView Types


Methods StatisticalMethods - Statistical• Paired sample comparison• Multivariate regression• Joint partial F-testJoint partial F test• Multivariate regression with interaction terms


InstrumentsInstrumentsMeasure 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 questionnaireg

Organizational stress Revised Nursing Work Index (NWI-R)

Work load Investigator designed questionnaire

Work experience Investigator designed questionnaire

Age, education, position Investigator designed questionnaire


A. Chronic StressMean chronic stress

– before shiftMean 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


p

B. AlertnessMean alertness –

before shiftMean

alertnessDifference between

t-statistics Significancebefore shift alertness –

after shiftbetween means

7.9714 4.4551 -3.51634 8.052 0.000***

STATISTICALLY


• STATISTICALLY SIGNIFICANT DIFFERENCE BETWEEN MEAN ALERTNESS SCORES

Alertness

N SS SCO S• DIRECTION OF DIFFERENCE

SUPPORTED7:00 am 7:00 pm


p

C. Acute StressMean acute stress –

before shiftMean acute

stress – after Difference between

t-statistics Significance

shift means

-3.925 -1.835 2.0897 4.535 0.000***

• STATISTICALLY


STATISTICALLY SIGNIFICANT DIFFERENCE BETWEEN MEAN ACUTE STRESS SCORES

Acute Stress

• DIRECTION OF DIFFERENCE SUPPORTED

7:00 am 7:00 pm


p

D. Alertness after shiftR R2 R2 adjusted F Significance

0.624 0.389 0.372 22.103 0.000***

Parameters Estimate Beta t SignificanceConstant 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 significantJoint Partial F-Test2


• View significant• + 4.8% explanatory

power

R2 full model 0.372R2 sub model 0.324

R2 change 0.048


E. Acute stress after shiftR 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 SignificanceConstant -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


• View significant• + 6.4% explanatory power

Joint Partial F TestR2 full model 0.431R2 sub model 0.367

R2 change 0.064


F. Alertness and view contentR R2 R2 adjusted F Significance

0.643 0.413 0.39 17.983 0.000***

Parameters Estimate Beta t SignificanceConstant 15.759 8.79 0.000***

Non-nature view 0.286 0.021 0.256 0.798Nature 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 0.237NWI-R -2.862 -0.266 -3.728 0.000***


Nature View

Alertness

7:00 am 7:00 pm

Non-Nature ViewNo View


7:00 am 7:00 pm

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)

ponly 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


Acute stress and view contentR R2 R2 adjusted F Significance

0.506 0.256 0.227 8.801 0.000***

Parameters Estimate Beta t SignificanceConstant -9.252 -4.077 0.000***

Non-nature view -0.657 -0.043 -0.429 0.668Nature 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 0.000AE Index -0.924 -0.31 -4.238 0.000***

Work Load 0.561 0.127 1.466 0.144NWI-R 1.322 0.108 1.356 0.177


Acute StressNature ViewNon-Nature View

No View

7:00 am 7:00 pm


p

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

ponly 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


Impact on patients andImpact on patients and organization

Organizational CharacteristicsWork Load

l

Organizational CharacteristicsWork Load

l

St ff O t

Personal Factors Personal Factors

Physical Environment

Staff Outcome

Patient Outcome Organizational Outcome


Implications

• How does this contribute to a healing environment?


Implications

• Capital planning and budgeting:– Embrace the importance of view and visual p

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


Implications

• Design:– Insist that design of capital projects g 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


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


Questions
