PDC_2008_Childrens Atlanta Study

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™

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
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…

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

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

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

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

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

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
program

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

Some Conclusions
• Operational design (schedules, shift
length) has a major impact on performance
• The physical environment (specifically
visual) may alleviate conditions) y

ContentsContents
Why 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)

• 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

• 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,
2003

• 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

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 Stress
Alertness
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

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

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
BETWEEN MEAN PSS
SCORES
7:00 am 7:00 pm
p

B. Alertness
Mean alertness –
before shift
Mean
alertness
Difference
between
before shift alertness –
after shift
between
means
7.9714 4.4551 -3.51634 8.052 0.000***
STATISTICALLY
• STATISTICALLY
BETWEEN MEAN
ALERTNESS SCORES
Alertness
N SS SCO S
• DIRECTION OF DIFFERENCE
SUPPORTED
7:00 am 7:00 pm
p

C. Acute Stress
Mean acute stress –
before shift
Mean acute
stress – after
Difference
between
shift means
-3.925 -1.835 2.0897 4.535 0.000***
• STATISTICALLY
STATISTICALLY
BETWEEN MEAN ACUTE
STRESS SCORES
Acute Stress
• DIRECTION OF DIFFERENCE
SUPPORTED
7:00 am 7:00 pm
p

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
• + 4.8% explanatory
power
R2
full model 0.372
R2
sub model 0.324
R
2
change 0.048

E. Acute stress after shift
R R2
R2
0 669 0 447 0 431 28 063 0 000***0.669 0.447 0.431 28.063 0.000
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
• + 6.4% explanatory power
Joint Partial F Test
R2
full model 0.431
R2
sub model 0.367
R
2
change 0.064

F. Alertness and view content
R R2
R2
0.643 0.413 0.39 17.983 0.000***
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***
Nature View
Alertness
7:00 am 7:00 pm
Non-Nature View
No 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)
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

Acute stress and view content
R R2
R2
0.506 0.256 0.227 8.801 0.000***
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
Acute Stress
Nature View
Non-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
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

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

Implications
• How does this contribute to a healing
environment?

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

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

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

PDC_2008_Childrens Atlanta Study

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