HERD Health Environments Research & Design Journal

Published by SAGE Publications
Online ISSN: 2167-5112
Publications
Mean approximate gross area per bed by construction type.
Mean approximate gross area per bed by unit specialty type.
Allocation of space by unit specialty type. A) Mean total patient room area as percentage of unit gross area. B) Mean total area for support and service functions as percentage of unit gross area. C) Mean total circulation area as percentage of unit gross area. 
Different types of unit layout by decade.
Mean approximate gross area per bed by unit layout type.
Article
Objective: This exploratory study describes space allocation among different generic categories of functions in adult intensive care units (ICUs) showing how the amount of space of any one functional category is related to that of another functional category, and how different strategic choices, such as size, construction type, specialty type, and layout type, affect space allocation in these ICUs. Background: Even though critical care practice has already undergone significant changes in the last few decades, it is still an evolving domain of medical practice. As a result, ICU design is also evolving as new regulatory standards, new technologies, and new clinical models are being introduced. A good understanding of the above issues regarding space allocation may help us better guide the evolution of ICU design. Methods: The study includes a set of 25 adult ICUs that were recognized between 1993 and 2012 by the Society of Critical Care Medicine (SCCM), the American Association of Critical Care Nurses (AACCN), and the American Institute of Architects Academy of Architecture for Health (AIA AAH) for their efforts to promote healing of the critically ill and injured patients through the design of the critical care unit environment. Results: The study finds notable differences in space allocation among different generic categories of functions between the ICUs of the first decade (1993-2002) and the second decade (2003-2012). The study also finds notable differences in space allocation among different generic categories of functions in relation to size, construction type, specialty type, and layout type. Conclusions: Despite several limitations, the study should help design better adult ICUs based on an evidence-based understanding of the relationships between space allocation and strategic choices. Keywords: Construction, critical care/intensive care, evidence-based design, planning, project management.
 
Article
In July, 2013, the International Academy for Design & Health held the 9th World Congress in Brisbane, Australia. Australia's proposal to host the Congress evolved into the book, Australian Healthcare Design 2000-2015, which was then published to coincide with the event. Alan Dilani, Founder and CEO of the International Academy for Design & Health, states in the book's preface, "Australia's successful bid to host the event reflects the huge amount of new healthcare building that is taking place across the region, and the body of research and knowledge that has developed there as a result...this book aims to communicate to the rest of the world that the region has some of the most advanced healthcare buildings of our time" (p. 12).This richly illustrated book appeals to visually-oriented designers, but offers valuable information for scholars and healthcare administrators as well. Many compelling contemporary international healthcare projects are featured in journals and books, but rarely do we get to see so many projects collected together focused on a specific geographic region, as is done in Australian Healthcare Design 2000-2015. The book serves as both a compendium and snapshot of the latest research, practice, and design in a large and diverse country. While Australia faces some unique challenges such as the vast distances between cities and the large number of rural community facilities, most issues are those facing every country and society: rising healthcare costs, patient and worker safety, an aging population, and rapidly advancing technology.The World Health Organization defines health as "... a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (1948). Most medical care, and healthcare design, in the second half of the twentieth century followed the "pathogenic" and "biomedical" model, in which mind and body were viewed as separate rather than inextricably linked, and diseases were addressed primarily with pharmaceutical drugs and/or surgery. Healthcare practice and design is now moving in the direction of care that does not just treat the sick after the fact, but instead uses a more holistic preventive care model, encouraging health and wellness in all aspects and through all stages of life. The term "salutogenesis," first coined by Aaron Antonovski in 1979, has begun to be adopted by members of the healthcare design community as an expression of this belief. This approach promotes health and well being-not just for buildings, but for all scales of design (cities, communities, landscapes). Salutogenic design and biophilic design are closely linked to concepts associated with evidence-based design.The book is organized into two sections: Essays and Projects. Following the Introduction, which includes a preface by Alan Dilani, and Forewords by the editor and the sponsors, are 15 essays by a mix of researchers and professionals, all of whom have practiced in Australia. …
 
Article
This article aims to define the major trends currently affecting space needs for academic medical center (AMC) cancer centers. It will distinguish between the trends that promote the concentration of services with those that promote decentralization as well as identify opportunities for achieving greater effectiveness in cancer care space planning. Changes in cancer care-higher survival rates, increased clinical trials, new technology, and changing practice models-increasingly fill hospitals' and clinicians' schedules and strain clinical space resources. Conflicts among these trends are concentrating some services and dispersing others. As a result, AMCs must expand and renovate intelligently to continue providing state-of-the-art, compassionate care. Although the typical AMC cancer center can expect to utilize more space than it would have 10 years ago, a deeper understanding of the cancer center enterprise can lead to opportunities for more effectively using available facility resources. Each AMC must determine for itself the appropriate balance of patient volume, clinical activity, and services between its main hospital campus and satellite branches. As well, space allocation should be flexible, as care trends, medical technology, and the provider's own priorities shift over time. The goal isn't necessarily more space-it's better space. © The Author(s) 2015.
 
Article
Objective: To investigate the role of a dedicated service corridor in intensive care unit (ICU) noise control and staff stress and satisfaction. Background: Shared corridors immediately adjacent to patient rooms are generally noisy due to a variety of activities, including service deliveries and pickups. The strategy of providing a dedicated service corridor is thought to reduce noise for patient care, but the extent to which it actually contributes to noise reduction in the patient care environment and in turn improves staff performance has not been previously documented. Methods: A before-and-after comparison was conducted in an adult cardiac ICU. The ICU was relocated from a traditional hospital environment to a new addition with a dedicated service corridor. A total of 118 nursing staff participated in the surveys regarding pre-move and post-move environmental comfort, stress, and satisfaction in the previous and new units. Acoustical measures of noise within the new ICU and a control environment of the previous unit were collected during four work days, along with on-site observations of corridor traffic. Results: Independent and paired sample t-tests of survey data showed that the perceived noise level was lower and staff reported less stress and more satisfaction in the new ICU (p < 0.01). Analyses of acoustical data confirmed that the new ICU was significantly quieter (p < 0.02). Observations revealed how the service corridor impacted patient care services and traffic. Conclusions: The addition of a dedicated service corridor works in the new unit for improving noise control and staff stress and satisfaction. Keywords: Critical care/intensive care, noise, satisfaction, staff, work environment.
 
Survival of MRSA on Copper Alloys Employing EPA Testing Criteria. 
Article
Hospitals clean environmental surfaces to lower microbial contamination and reduce the likelihood of transmitting infections. Despite current cleaning and hand hygiene protocols, hospital-acquired infections (HAIs) continue to result in a significant loss of life and cost the U.S. healthcare system an estimated $45 billion annually. Stainless steel and chrome are often selected for hospital touch surfaces for their “clean appearance,” comparatively smooth finish, resistance to standard cleaners, and relative effectiveness for removing visible dirt during normal cleaning. Designers use wood surfaces for aesthetics; plastic surfaces have become increasingly endemic for their relative lower initial cost; and “antimicrobial agents” are being incorporated into a variety of surface finishes. This paper concentrates on environmental surface materials with a history of bactericidal control of infectious agents and focuses on the methods necessary to validate their effectiveness in healthcare situations. Research shows copper-based metals to have innate abilities to kill bacteria in laboratory settings, but their effectiveness in patient care environments has not been adequately investigated. This article presents a research methodology to expand the evidence base from the laboratory to the built environment. For such research to have a meaningful impact on the design/specifying community, it should assess typical levels of environmental pathogens (i.e., surface “cleanliness”) as measured by microbial burden (MB); evaluate the extent to which an intervention with copper-based materials in a randomized clinical trial affects the level of contamination; and correlate how the levels of MB affect the incidence of infections acquired during hospital stays.
 
Article
The construction trend in healthcare remains strong compared to other construction markets due to the stability of the forces driving the growth. Constructing new healthcare facilities is challenging because of the need to collaborate continuously with the operational components of the organization. Successful planning and activation greatly enhance the outcome of any project. Working with an operational point of view throughout the building activation process, beginning with design, benefits both the construction and operational teams. The result is a more positive outcome for the institution, fewer changes during the project for the construction team, and the ability to minimize costly renovations and/or change orders. Focused and intentional communication throughout the design and construction phase is vital to the activation and success of any project. Developing a communication plan early in the project supports the development of trust and organizational participation. Activation planning must link design and operations to improve project outcomes.
 
Article
The healthcare construction boom requires evidence for effective design of nurse stations, including evidence supporting workflow processes, computerization, integration of technology, communication of caregivers, and optimal patient outcomes. This article describes the examination of a traditional centralized nursing station using a total patient care delivery model and minimal computerization and a highly computerized, decentralized nursing station using a team nursing model. Results specific to communication activities, time with patients, number of patient visits per registered nurse, and patient satisfaction with response time are reported.Key WordsPatient care unit design, ergonomics, healthcare workflow, medical-surgical unit, registered nurse work activities.
 
Article
To substantiate the anticipated benefits of the original acuity-adaptable care delivery model as defined by innovator Ann Hendrich. In today's conveyor belt approach to healthcare, upon admission and through discharge, patients are commonly transferred based on changing acuity needs. Wasted time and money and inefficiencies in hospital operations often result-in addition to jeopardizing patient safety. In the last decade, a handful of hospitals pioneered the implementation of the acuity-adaptable care delivery model. Built on the concept of eliminating patient transfers, the projected outcomes of acuity-adaptable units-decreased average lengths of stay, increased patient safety and satisfaction, and increased nurses' satisfaction from reduced walking distances-make a good case for a model patient room. Although some hospitals experienced the projected benefits of the acuity-adaptable care delivery model, sustaining the outcomes proved to be difficult; hence, the original definition of acuity-adaptable units has not fared well. Variations on the original concept demonstrate that eliminating patient transfers has not been completely abandoned in healthcare redesign and construction initiatives. Terms such as flex-up, flex-down, universal room, and single-stay unit have since emerged. These variations convolute the search for empirical evidence to support the anticipated benefits of the original concept. To determine the future of this concept and its variants, a significant amount of outcome data must be generated by piloting the concept in different hospital settings. As further refinements and adjustments to the concept emerge, the acuity-adaptable room may find a place in future hospitals.
 
Article
To describe the degree to which Environmental Congruence (EC) is present in sampled units and considered important/desirable by staff RNs; staff RNs' reported level of work-related stress (WRS); the perceived contribution of the physical environment to WRS; and the relationship between existing levels of EC and WRS. Few studies have focused on how the physical environment might contribute to nurses' WRS and chronic nursing shortages. The construct of EC can be used, within a Person Environment (PE)-Fit framework, to assess the fit among nurses, nursing work, the physical work environment, and WRS. EC was measured using investigator-developed, literature/criterion-based survey instruments. Staff RNs reported WRS variables by using two single-item self-report measures. The final convenience sample consisted of 471 staff RNs from 39 medical/surgical units from 12 hospitals in the upper Midwest. Data were collected over a 7-month period. The mean level of existing EC in the sample was roughly 70% percent of highest capacity and that of important/desired EC in the sample was 93%. Staff RNs' mean level of WRS was 6.7; the mean contribution of the physical environment to WRS was 5.8. Moderate negative correlations were found between EC and WRS (r = -.41, p < .05), and between physical environment contribution to WRS and EC (r = -.55, p <.001). Staff RNs in the sampled units wanted a significantly higher level of EC. They rated their WRS moderately high and the contribution of the physical environment to it as moderate. A moderately negative relationship was found between EC and WRS. EC may be a useful construct in research that attempts to improve hospital nursing work environments.
 
Article
Determining the number of patient rooms for an acute care (medical-surgical) patient unit is a challenge for both healthcare architects and hospital administrators when renovating or designing a new patient tower or wing. Discussions on unit bed size and its impact on hospital operations in healthcare design literature are isolated, and clearly there is opportunity for more extensive research. Finding the optimal solution for unit bed size involves many factors, including the dynamics of the site and existing structures. This opinion paper was developed using a "balanced scorecard" concept to provide decision makers a framework for assessing and choosing a customized solution during the early planning and conceptual design phases. The context of a healthcare balanced scorecard with the quadrants of quality, finance, provider outcomes, and patient outcomes is used to compare the impact of these variables on unit bed size.
 
Article
To describe the current state of design characteristics of acute care units in China's public hospitals and compare these with characteristics with acute care units in the United States. The healthcare construction industry in China is one of the fastest growing sectors in China and, arguably, in the world. Understanding the physical design of acute care units in China is of great importance because it will influence a large population. Descriptive study was performed of unit configuration, size, patient visibility, distance to nursing station and supplies, and lighting conditions in 25 units in 19 public hospitals built after 2003. Data and information were collected based on spatial and visibility analysis. The study identified major design characteristics of the recently built (from 2003 onward) acute care units in China, comparing them, where appropriate, with those in U.S. It found there are three dominant types of unit layout: single-corridor (52%), triangular (36%), and double-corridor (12%). The number of private rooms is very low (11%), compared with two- or three-bed rooms. Centralized nursing stations are the only type of nurses' working area. China also has a large unit size in terms of number of patient beds. The average number of patient beds in a unit is 40.6 in China (versus 32.9 in U.S.). The care units in China have longer walking distance from nursing station to patient bedside. The percentage of beds visible from a nursing station is lower in China than in the U.S. The access to natural light and direct sunlight in patient rooms is greater in China compared with those in U.S.-100% of patient rooms in China have natural lighting. A majority of them face south or southeast and thus receiving direct sunlight (91.4%). Because of the differences in economies and building codes, there are dramatic differences between the spatial characteristics of acute care units in China and the United States. © 2014 Vendome Group, LLC.
 
Article
Objective: The purpose of this case study was to examine environmental variables that lead to staff error in acute care settings: noise; lighting; ergonomics, furniture, and equipment; and patient room design and unit layout. Background: Chaudhury, Mahmood, & Valente (2009) reviewed a number of design considerations related to reducing errors by nursing staff in acute care settings. The Neurological Rehabilitation Unit (NRU) at one hospital served to further examine the design recommendations outlined by Chaudhury et al. (2009). Methods: Based on photographs, a site tour, interviews with the NRU manager and with the son of a patient of 5 months, comparisons were made between the NRU and the acute care setting design considerations reviewed by Chaudhury et al. (2009). Results: The NRU appeared to comply with many recommendations: enforced noise reduction was facilitated through limiting both the number of patients per room and the number of patients admitted to the unit. Distinct rooms were used for various tasks that helped to contain activity-based noise. A combination of daylighting and artificial lighting was in place, but efforts to control glare and thermal comfort were not integrated into the design. The ergonomic needs of employees were incorporated in the design of the NRU, and the layouts of patient rooms and the layout of the NRU in general also were compatible with the design recommendations reviewed by Chaudhury et al. (2009). Conclusions: Many of the design attributes advocated by Chaudhury et al. (2009) were included in the NRU. Supplemental research should be undertaken, however, to objectively measure nursing error, efficiency, and staff satisfaction with respect to the comparisons and assumptions presented in this study. Keywords: Case study, design, hospital, satisfaction, staff.
 
Article
Objective: This paper introduces a new design tool to increase efficiency in acute care settings. This visual tool facilitates matching spatial flow with caregivers' workflow to reduce waste and redundancies, as recommended by Lean thinking. Providing work environments that protect caregivers from fatigue, interruptions, and redundancies can contribute to quality patient care. Methods: By studying the Guidelines for Design and Construction of Health Care Facilities and reviewing the literature, the authors identified the main clinical spaces supporting nursing care and their important linkages. Space syntax, a diagrammatic analysis of relationships, was used to decode spatial relationships among the clinical spaces in five case studies. The movement distributions were measured and possible conflicts with focus-demanding tasks, such as noise and interruptions, were identified. The information was summarized in a visual diagram providing the "syntactic anatomy" of the most important work spaces. Results: The main clinical spaces were the following: (1) patient corridor; (2) nurses' station; (3) medication area; (4) clean room; (5) soiled room; (6) physicians' dictation area; (7) report room; (8) restricted nourishment area; (9) equipment storage; and (10) unrestricted nourishment area. The report room, nourishment area, and physician workspace showed strong linkages to the patient corridor and nurses' station, although such spaces were not clearly discussed in the design guidelines. The most caregiver movement occurs in the patient corridor and nurses' station. These areas pose the greatest possibility of interruptions by persons. The results were translated into a visual design efficiency checklist. Conclusion: Illustrating the spatial order of the support spaces-and comparing that to use patterns-enables designers to reduce the movement sequences nurses undertake when accessing resources and identify where the flow is disrupted by "displaced" functions.
 
Article
The study objective was to examine whether standardized same-handed room configurations contribute more to operational performance in comparison to standardized mirror-image room configurations. Based on a framework that physical environment standardization supports process and workflow standardization, thus contributing to safety and efficiency, the study examined the comparative effectiveness of the standardized same-handed configuration and the standardized mirror-image configuration. Patient room handedness has emerged as an important issue in inpatient unit design, with many hospitals adopting the standardized same-handed room concept at all levels of patient acuity. Although it is argued that standardized same-handed rooms offer greater levels of safety and efficiency in comparison to standardized mirror-image rooms, there is little empirical evidence either to support or refute these contentions. An experimental setting was developed where elements of the physical environment and approach to the caregiver zone were systematically manipulated. Twenty registered nurses (10 left-handed and 10 right-handed) provided three types of care to a patient-actor across nine physical design configurations, which were videotaped in 540 separate segments. Structured interviews of the subjects were conducted at the end of each individual set of simulation runs to obtain triangulation data. Video segments were coded by nursing experts. Statistical and content analyses of the data were conducted. Study data show that standardized same-handed configurations may not contribute to process and workflow standardization--hence, to safety and efficiency--any more than standardized mirror-image configurations in acute medical-surgical settings. Data suggest that a global view of the patient care environment upon entry is the most sought-after familiarization factor to reduce cognitive load.
 
Article
Objective: The United States is currently in the midst of a hospital construction boom. An increasing number of hospitals are being designed using the principles of evidence-based design to improve patient safety and patient satisfaction. Few studies have examined the impact of new hospital design models on providers' attitudes or work performance. The goal of this study was to determine how providers' attitudes at one children's hospital changed over a 2-year period. It was hypothesized that clinicians' attitudes about their work environment would be significantly more positive 2 years after opening. Background: In 2004 a children's hospital within a hospital was replaced with a free-standing facility, which was designed on the theme of family-centered care. The hospital quality improvement team developed and administered the Environment of Work survey to measure providers' initial impressions of the hospital design on job function, patient safety, and personal well-being. The survey was readministered approximately 2 years later to measure changes in providers' perceptions about the same issues. Methods: A 25-item survey was administered to a convenience sample of clinical staff to measure their attitudes about the effects of family-centered hospital design on providers and patients. Chi-square tests were used to compare subjective ratings collected from the two surveys on pooled samples and on samples stratified by clinical unit. Results: Surveys were collected from 270 clinicians (a 25% response rate) in 2004 and 544 clinicians (a 51% response rate) in 2006. Nurses accounted for a higher percentage of total respondents (78% versus 57%). Most domain areas garnered improved and overall positive ratings from clinicians in 2006. Providers' ratings of elevated mental fatigue, physical fatigue, and walking burden remained high in 2006 despite improvements. Ratings of noise levels increased on all units except the neonatal intensive care unit. Fewer respondents rated the new hospital "somewhat to much better" than the former hospital. Conclusions: Moving into a new healthcare facility is a stressful event for healthcare providers and adapting to a new work environment requires a lengthy period of transition. Providers' initial ratings of a new workspace are likely to change over time as they adjust their work practices to the physical environment.
 
Article
Objective: The purpose of this study is to evaluate staff perceptions of environmental quality before and after the renovation of an existing open-bay neonatal intensive care unit (NICU) and the addition of 23 single-family NICU rooms in the Wasie Neonatal ICU at Joe DiMaggio Children's Hospital. Background: In recent years there has been an increase in the design and construction of single-family rooms (SFRs) because they provide more privacy for families, offer better control over environmental stimuli such as lighting and noise, and possibly reduce infections. On the other hand, this model can cause staff members to feel isolated from one another, reduce their ability to respond quickly in a crisis situation, or impose additional demands on them. Few studies document the advantages and disadvantages of the SFR NICU model. Methods: This study utilized pre- and post-move surveys to investigate staff perceptions of the NICU. Results: Overall, staff members perceive the quality of the work environment, and the safety and quality of the environment provided to patients and their families, as better in the renovated, combination NICU design (SFR and open bay) when compared to the open-bay, pre-move design. Conclusion: In spite of the potential drawbacks of having SFRs in the NICU, the study demonstrates that nurses may perceive associated benefits, such as a reduction of job stress and improvements in parental privacy, along with other positive outcomes.
 
Article
Objective: Our objectives were to (1) develop an in-depth understanding of the workflow and information flow in medication reconciliation, and (2) design medication reconciliation support technology using a combination of rapid-cycle prototyping and human-centered design. Background: Although medication reconciliation is a national patient safety goal, limitations both of physical environment and in workflow can make it challenging to implement durable systems. We used several human factors techniques to gather requirements and develop a new process to collect a medication history at hospital admission. Methods: We completed an ethnography and time and motion analysis of pharmacists in order to illustrate the processes used to reconcile medications. We then used the requirements to design prototype multimedia software for collecting a bedside medication history. We observed how pharmacists incorporated the technology into their physical environment and documented usability issues. Results: Admissions occurred in three phases: (1) list compilation, (2) order processing, and (3) team coordination. Current medication reconciliation processes at the hospital average 19 minutes to complete and do not include a bedside interview. Use of our technology during a bedside interview required an average of 29 minutes. The software represents a viable proof-of-concept to automate parts of history collection and enhance patient communication. However, we discovered several usability issues that require attention. Conclusions: We designed a patient-centered technology to enhance how clinicians collect a patient's medication history. By using multiple human factors methods, our research team identified system themes and design constraints that influence the quality of the medication reconciliation process and implementation effectiveness of new technology. Keywords: Evidence-based design, human factors, patient-centered care, safety, technology.
 
Article
Objective: A discussion of the challenges to completing participatory social research with children and adolescents in a hospital setting. Background: Beginning with the dominant medical culture of hospitals, coupled with a persistent skepticism of social and in particular, qualitative research and its contribution to knowledge in medical circles, restrictive contextual challenges also include attitudinal, methodological, and logistical considerations. Together, these challenges hamper good participatory research practice and the capacity to maintain quality data, as well as impede children's participation in research, which has the capacity to contribute to healthcare design, policy, and planning processes. Methods: Two studies in pediatric settings in Australia, one of which was completed in 2008 and the other which was discontinued in 2011, provide the basis for this research discussion. The discussion addresses the issues that persist in inhibiting the completion of participatory social research and the resulting impacts on research, children's right to participate, and the volume of evidence that is ultimately available from children's perspectives to support and inform healthcare design, planning, and policy in pediatric settings. Conclusions: Recommendations for changes that could strengthen and improve this research experience include building awareness of the potential value of this research; increasing its influence; building the capacity and knowledge of gatekeepers, ethics committees, and researchers working in this context; and recognizing and valuing children's competence and participation. Keywords: Evidence-based design, hospital, methodology, patients, pediatric.
 
Article
To determine differences in the rate of falls, healthcare-acquired infections (HAIs), and the degree of social isolation in hospitalized older adults admitted to private versus semi-private rooms. The American Institute of Architects recommends that private rooms become the industry standard for all new construction of acute care hospitals. Healthcare design researchers contend that private rooms decrease infection, facilitate healthcare workers' efficiency, provide space for families, and afford greater access to privacy. Although links between room type and health outcomes have been described in the literature, the actual relationship between these two variables has not been determined, nor is it clear whether a one-size-fits-all approach to hospital design is appropriate for all patient populations, particularly older adults. This retrospective case comparative design utilized a sample of patients admitted to the University Medical Center of Princeton in 2006 and received full internal review board approval. Patient records were randomly selected through the admission/discharge/transfer system of the hospital and then divided into two groups based on room type. Data collected included demographics, incidence of falls, HAIs, and risk of social isolation. All patients were more than 65 years old and had been admitted to the hospital for a variety of diagnoses. Length of stay was between 3 and 10 days. There was no significant difference between the type of room and the likelihood of falling (p = .37), however the relative risk of falling in a private room was 4.01. There was no significant difference in the occurrence of HAIs based on room type (p = 1.0). The risk-of-social-isolation variable was unable to significantly affect which hospitalized older adults would suffer a negative outcome, fall, or HAI (p = .52). Room type may play a role in the occurrence of falls in hospitalized older adults, but room type alone does not increase the chance of acquiring an infection in the hospital. Nor does the risk of social isolation affect the likelihood of an adverse outcome.
 
Article
Objective: To examine personal, social, and perceived environmental factors related to leisure-time walking behavior among Korean adults using the framework of the Theory of Planned Behavior (TPB). Background: Sedentary lifestyle and physical inactivity contribute to rising obesity rates and chronic diseases among Korean adults. Understanding correlates of walking is necessary to develop effective interventions to promote regular walking. Methods: A cross-sectional survey was conducted in 2008 among 424 Korean adults. Participants completed a questionnaire on perceived neighborhood environment, the TPB constructs, and leisure-time walking behavior. Results: Those who participated in leisure-time walking had more positive perceptions of aesthetics and expressed greater perceived behavioral control (PBC) and intention of walking than nonwalkers. Also, walking correlated with intention and PBC, and perceived crime safety. Intentions were moderately to strongly associated with attitude, PBC, and subjective norm. Integrating TPB constructs and the perceived environment variable (crime safety) resulted in a moderate fit of the data [χ(2)= 2.372, df = 5; p = 0.796; NFI = 0.99; RMSEA = 0.00] with approximately 45.6% variance of intention and 19.4% of the response variance of walking explained. The model showed that perceived safety from crime was not directly related to leisure-time walking, but indirectly predicted walking through the TPB model. Conclusions: Perceived safety was identified as an important environmental variable among Korean adults, and the TPB offered a good prediction of walking behavior. Identifying individual, social, and neighborhood environmental correlates of walking can help develop policies to promote public health for a more active and healthier community.
 
Article
Objective: The objective of this study is to trace short-term changes in mood and heart function in elderly individuals in response to exposure to different landscaped spaces. Background: Nineteen elderly but cognitively intact residents of an assisted living facility participated in the study. They were exposed to three landscaped spaces: a Japanese style garden, an herb garden, and a simple landscaped area planted with a single tree. Methods: To assess the effect of different landscaped spaces on older adults, individuals were monitored for mood and cardiac function in response to short exposures to spaces. Mood state was assessed using Profile of Mood States (POMS) before and after viewing the spaces. Cardiac output was assessed using a portable electrocardiograph monitor before and during the viewing. Results: We found that the structured gardens evoked greater responses in all outcome measures. Scores on the POMS improved after observation of the two organized gardens compared to responses to the simple landscaped space with a single tree. During the observation period, heart rate was significantly lower in the Japanese garden than in the other environments, and sympathetic function was significantly lower as well. Conclusions: We conclude that exposure to organized gardens can affect both the mood and cardiac physiology of elderly individuals. Our data further suggest that these effects can differ depending on the types of landscape to which an individual is exposed. Keywords: Elderly, Japanese garden, herb garden, heart rate, mood, healing environmentPreferred Citation: Goto, S., Park, B-J., Tsunetsugu, Y., Herrup, K., & Miyazaki, Y. (2013). The effect of garden designs on mood and heart output in older adults residing in an assisted living facility. Health Environments Research & Design Journal 6(2), pp 27-42.
 
Article
Objective: This article aims to explore the future of translational research and its physical design implications for community hospitals and hospitals not attached to large centralized research platforms. Background: With a shift in medical services delivery focus to community wellness, continuum of care, and comparative effectiveness research, healthcare research will witness increasing pressure to include community-based practitioners. Methods: The roundtable discussion group, comprising 14 invited experts from 10 institutions representing the fields of biomedical research, research administration, facility planning and design, facility management, finance, and environmental design research, examined the issue in a structured manner. The discussion was conducted at the Washington Hospital Center, MedStar Health, Washington, D.C. Conclusions: Institutions outside the AMCs will be increasingly targeted for future research. Three factors are crucial for successful research in non-AMC hospitals: operational culture, financial culture, and information culture. An operating culture geared towards creation, preservation, and protection of spaces needed for research; creative management of spaces for financial accountability; and a flexible information infrastructure at the system level that enables complete link of key programmatic areas to academic IT research infrastructure are critical to success of research endeavors. Keywords: Hospital, interdisciplinary, leadership, planning, work environment.
 
Article
The primary goal of this study was to test the hypothesis that nurses adopt distinct movement strategies based on features of unit topology and nurse assignments. The secondary goal was to identify aspects of unit layout or organization that influence the amount of time nurses spend in the patient room. Previous research has demonstrated a link between nursing hours and patient outcomes. Unit layout may affect direct patient care time by determining aspects of nurse behavior, such as the amount of time nurses spend walking. The recent nurses' Time and Motion study employed multiple technologies to track the movements and activities of 767 medical-surgical nurses. With regard to unit layout, initial analysis of the data set did not detect differences between types of units and time spent in the patient room. The analysis reported here applies novel techniques to this data set to examine the relationship between unit layout and nurse behavior. Techniques of spatial analysis, borrowed from the architectural theory of spatial syntax, were applied to the Time and Motion data set. Motion data from radio-frequency identification tracking of nurses was combined with architectural drawings of the study units and clinical information such as nurse-patient assignment. Spatial analytic techniques were used to determine the average integration or centrality of nurse assignments for each shift. Nurse assignments with greater average centrality to all assigned rooms were associated with a higher number of entries to patient rooms, as well as to the nurse station. Number of entries to patient rooms was negatively correlated with average time per visit, but positively correlated with total time spent in patient rooms. The data describe two overall strategies of nurse mobility patterns: fewer, longer visits versus more frequent, shorter visits. Results suggest that the spatial qualities of nurse assignments and unit layout affect nurse strategies for moving through units and affect how frequently nurses enter patient rooms and the nurse station.
 
Article
Objective: The objective of this study was to review, identify, and synthesize the literature on patient and healthcare worker safety related to flooring. The topic of flooring in the design of healthcare facilities is complex: healthcare associated infections, push/pull limitations, falls and fall injuries, and noise as a contributing factor to quality of care. Background: Most hospitals have not been explicitly designed to enhance patient safety. Recommendations from the Agency for Healthcare Research and Quality (AHRQ) include preventing patient falls, reducing infections, and preventing medication errors as the areas of emphasis of evidence-based design to improve patient safety and quality of care. Methods: A review of the literature was conducted through search engines using a predefined list of keywords to identify studies about flooring and the safety of patients and healthcare workers. Inclusion criteria included peer-reviewed theoretical and empirical studies published in English from 1982 to 2012. Final inclusion was obtained based on an analysis of research design. Results: Of those 27 articles that met inclusion, 7 focused on healthcare associated infections; 9 focused on slips, trips and falls; 7 articles focused on noise; and 4 focused on fatigue. The studies are profiled in tables and organized by environmental variable. Conclusions: Though a limited number of studies met the criteria for this review, the evidence base is emerging to design for safety. Recommendations for future research and practical application of design are provided. Keywords: Evidence-based design, literature review, patients, safety, staff.
 
Article
This paper analyzes the dynamics relating to flexibility in a hospital project context. Three research questions are addressed: (1) When is flexibility used in the life cycle of a project? (2) What are the stakeholders' perspectives on project flexibility? And (3) What is the nature of the interaction between flexibility in the process of a project and flexibility in terms of the characteristics of a building? Flexibility is discussed from both a project management point of view and from a hospital architecture perspective. Flexibility in project life cycle and from a stakeholder perspective is examined, and the interaction between flexibility in scope lock-in and building flexibility is investigated. The results are based on case studies of four Norwegian hospital projects. Information relating to the projects has been obtained from evaluation reports, other relevant documents, and interviews. Observations were codified and analyzed based on selected parameters that represent different aspects of flexibility. One of the cases illustrates how late changes can have a significant negative impact on the project itself, contributing to delays and cost overruns. Another case illustrates that late scope lock-in on a limited part of the project, in this case related to medical equipment, can be done in a controlled manner. Project owners and users appear to have given flexibility high priority. Project management teams are less likely to embrace changes and late scope lock-in. Architects and consultants are important for translating program requirements into physical design. A highly flexible building did not stop some stakeholders from pushing for significant changes and extensions during construction.
 
Article
Objective: This comparative study in two ICUs examines the impact of the patient-centered unit design on family involvement, operationalized as percentages of family presence and family-patient/family-staff interaction in patient rooms. Background: As hospitals have become more patient-centered, there has been a trend toward including a family area inside the patient area to promote family presence, support, and involvement in patient care. There is growing evidence that family members play an important role in supporting patient care, and that the physical environment affects family involvement. However, few empirical studies have attempted to show the effectiveness of the patient-centered design on family members' presence and their behavior. Methods: This study compared the degree of family presence and family-patient and family-staff interactions in two intensive care units (ICUs) with different physical environmental conditions, but housing patients of similar acuity and disease type. Results: The analysis identified a significant difference in family presence in patient rooms (t = -2.176; df = 79.0; p = 0.03) between the traditional and the patient-centered units. Patients in the family-centered care unit (M = 37.77; SD = 34.02) spent significantly more time with their family members in patient rooms than did patients in the traditional unit (M = 23.89; SD = 21.90). Patient-related variables other than unit design had no significant impact on family presence and interactions. Conclusions: Findings demonstrated that the patient-centered unit (5K) was associated with increased family presence in the patient rooms and increased family interaction with patients, when compared with the traditionally designed unit. Keywords: Critical care/intensive care, evidence-based design, patient-centered care, quality care, social support.
 
Article
Background: Evidence on the importance of the physical environment for the well-being of people with dementia has been growing steadily. Objective: This article aims to (1) introduce an assessment tool for evaluating the physical care environment for people with dementia; (2) describe the method's initial results and the subsequent feedback provided to the 10 care units; and (3) describe the follow-up results 1 year later. The goal has been to provide care workers and managers with information that affects the well-being of people with dementia and to provide this information on the care environment in the context of their own work environment. Methods: The assessment was part of a randomized controlled intervention using nonpharmaceutical methods to decrease behavioral and psychological symptoms of people with dementia. During the half-day visits, photographs and field notes were taken, and a final assessment was carried out via the Residential Care Environment Assessment (RCEA) tool developed at the beginning of the study and based on affordance theory. Follow-up data were gathered after 12 months. Results: There were several possibilities for improvements in the provision of residential care in a person-centered environment. Improvements were needed mostly in comfort and in providing opportunities for engagement, activity, and expression of identity. However, in practice, it was difficult to achieve the improvements even with an intensive intervention study. Conclusions: The authors conclude that the physical care environment involves a complex set of issues and stakeholders in which the impetus to fulfill responsibilities to carry out improvements can easily fall away.
 
Article
The quality of the built environment and the public health and well-being of its inhabitants are profoundly interwoven. Among all age groups, the aged are particularly susceptible to disengagement or avoidance of the built environment and the physical exercise options it affords; this can have a deleterious influence on personal health. In this discussion, concepts drawn from the fields of architecture, landscape research, urban and regional planning, and environmental gerontology are drawn together in the context of a hybrid conceptual and operative model. This model is put forth to assist in the acquisition of knowledge in the field to further understanding of how chronic diseases among the aged can be reduced through the provision and utilization of sufficiently supportive outdoor physical activity options in the everyday environment. This hybrid model, the Prospect-Refuge Competency Index (PRCI), combines key elements of prospect-refuge theory and environmental press-competency theory. It can be applied to diverse settings and user constituencies. The discussion concludes with the presentation of a set of hypotheses for the neighborhood/community level and the residential/exterior environs level of inquiry.
 
Article
The purpose of this study was to gain insight into the use and storage of supplies in the neonatal intensive care and women's health units of Parkland Hospital in Dallas, Texas. Construction of a new Parkland Hospital is underway, with completion of the 862-bed, 2.5-million square feet hospital in 2014. Leaders from the hospital and representatives from one of its major vendors collaborated on a research study to evaluate the hospital's current supply management system and develop criteria to create an improved system to be implemented at the new hospital. Approach includes qualitative and quantitative methods, that is, written survey, researcher observations, focus groups, and evaluation of hospital supply reports. Approaching the ideal location of supplies can be best approached by defining a nurse's activity at the point of care. Determining an optimal supply management system must be approached by understanding the "what" of caregivers' activities and then determining the "where" of the supplies that support those activities. An ideal supply management system locates supplies as close as possible to the point of use, is organized by activity, and is standardized within and across units. © The Author(s) 2015.
 
Article
A medical-surgical unit in a southwestern United States hospital examined the results of adding wireless communication technology to assist nurses in identifying patient bed status changes and enhancing team communication. Following the addition of wireless communication, response time to patient calls and the number of nurse-initiated communications were compared to pre-wireless calls and response time sampling period. In the baseline study, nurse-initiated communications and response time to patient calls were investigated for a team nursing model (Guarascio-Howard & Malloch, 2007). At this time, technology consisted of a nurse call system and telephones located at each decentralized nurse station and health unit coordinator (HUC) station. For this follow-up study, a wireless device was given to nurses and their team members following training on device use and privacy issues. Four registered nurses (RNs) were shadowed for 8 hours (32 hours total) before and after the introduction of the wireless devices. Data were collected regarding patient room visits, number of patient calls, bed status calls, response time to calls, and the initiator of the communication episodes. Follow-up study response time to calls significantly decreased (t-test p = .03). RNs and licensed practical nurses responded to bed status calls in less than 1 minute-62% of the 37 calls. Communication results indicated a significant shift (One Proportion Z Test) in RN-initiated communications, suggesting an enhanced ability to communicate with team members and to assist in monitoring patient status. Patient falls trended downward, although not significantly (p > .05), for a 6-month period of wireless technology use compared to the same period the previous year. The addition of a wireless device has advantages in team nursing, namely increasing communication with staff members and decreasing response time to patient and bed status calls. Limitations of the study included a change in caregiver team members and issues regarding wireless device and locator badge compliance. Administrative issues that arose during this field study included bed and cable maintenance, device battery charging, and the training of new and floating team members.
 
Article
Objective: This study investigates the influence of ambient scent and music, and their combination, on patients' anxiety in a waiting room of a plastic surgeon. Background: Waiting for an appointment with a plastic surgeon can increase a patient's anxiety. It is important to make the waiting time before an appointment with the surgeon more pleasant and to reduce the patient's anxiety. Ambient environmental stimuli can influence people's mood, cognition, and behavior. This experimental study was performed to test whether ambient scent and music can help to reduce patients' anxiety. Methods: Two pre-studies (n = 21) were conducted to measure the subjective pleasantness and arousal of various scents and music styles. Scent and music that scored high on pleasantness and low on arousal were selected for the main study. The field experiment (n = 117) was conducted in the waiting room of a German plastic surgeon. The patients' levels of anxiety were measured in four conditions: (1) without scent and music, (2) with lavender scent; (3) with instrumental music; (4) with both scent and music. Results: When used separately, each of the environmental factors, music and scent, significantly reduced the level of patient's anxiety compared to the control condition. However, the combination of scent and music was not effective in reducing anxiety. Conclusions: Our results suggest that ambient scent and music can help to reduce patients' anxiety, but they should be used with caution. Adding more ambient elements to environment could raise patients' level of arousal and thus increase their anxiety. Keywords: Healing environments, patient, patient-centered care, quality care, satisfaction.
 
Article
We sought to examine the effect of exposure to an ambient environment in a pediatric emergency department. We hypothesized that passive distraction from ambient lighting in an emergency department would lead to reduction in patient pain and anxiety and increased caregiver satisfaction with services. Passive distraction has been associated with lower anxiety and pain in patients and affects perception of wait time. A pediatric ED was designed that optimized passive distraction techniques using colorful ambient lighting. Participants were nonrandomly assigned to either an ambient ED environment or a traditional ED environment. Entry and exit questionnaires assessed caregiver expectations and experiences. Pain ratings were obtained with age-appropriate scales, and wait times were recorded. A total of 70 participants were assessed across conditions, that is, 40 in the ambient ED group and 30 in the traditional ED group. Caregivers in the traditional ED group expected a longer wait, had higher anxiety pretreatment, and felt more scared than those in the ambient ED group. Caregivers in the ambient ED group felt more included in the care of their child and rated quality of care higher than caregivers in the traditional ED group. Pain ratings and administrations of pain medication were lower in the ambient ED group. Mean scores for the ambient ED group were in the expected direction on several items measuring satisfaction with ED experiences. Results were suggestive of less stress in caregivers, less pain in patients, and higher satisfaction levels in the ambient ED group. © The Author(s) 2015.
 
Article
This research examines whether the physical attractiveness of an outpatient practice influences patients' perceptions of healthcare quality, including patient and staff perceptions of the quality of staff-patient interaction. Despite the high and increasing percentage of healthcare dollars for care delivered on an outpatient basis, relatively little research has examined the relationship between the design of ambulatory facilities and patient outcomes. Few studies have examined how patients' perceptions of healthcare quality differ in the same outpatient practice before and after a move to a new facility designed to be patient-centered. This study is the second phase of a study comparing patients' perceived quality of care in ambulatory facilities that differ markedly in physical attractiveness. Using both a patient and staff survey, and structured interviews, this study compared staff and patient perceptions of healthcare quality (including staff-patient interactions) before and after a move to a new facility designed to be patient-centered. Patients' perceived quality of care, and their perceptions of the quality of interaction with staff, was significantly better in the patient-centered facility. Few differences were found in actual patient-staff interaction behaviors. This study is consistent with other studies that examined the relationship among the physical attractiveness of healthcare settings, patient satisfaction, and perceived quality of care. For this reason, the results are more credible than they would be were they inconsistent with other research or were this the only study examining these issues. These results support the value of investing in the physical attractiveness of patient areas in the ambulatory care setting. Further research is needed to identify specific physical elements that contribute to positive attributions related to quality of care, as well as where the "tipping point" is in investments to improve physical attractiveness.
 
Article
This report of empirical literature on ambulatory care centers (ACCs) addresses a gap in the healthcare field by exploring physical features of ACC settings that have been associated with favorable patient outcomes. Growing numbers of ACCs correspond with an increasing shift from inpatient to outpatient services. As the focus of ACCs shifts from treating episodes of illnesses to comprehensive, longitudinal, patient-centered care, different types of ACC settings seek to accommodate a variety of patient groups from different demographics. Given the range of ACC settings and population types and the paucity of literature focused on any one of these settings, the literature search process was broad based to include not only peer-reviewed literature, but also "gray literature" on ACC design. The primary focus was on research studies and reports that centered on some aspect of the physical environment in ACCs and their relationship to outcomes in these settings. The following patient outcomes were identified in different phases of ACC patient experience: improved access and wayfinding, enhanced waiting experience, enhanced privacy, enhanced physician/staff-patient communication, reduced patient anxiety, and reduced risk of infection. This article identifies physical design features of ACCs that can promote favorable patient outcomes. However, most literature reviewed adheres to a physician-centered model of episodic illness in which care ends with the experience in the exam room of the ACC. A more patient-centered approach has not been explored fully in the literature. The results indicate that there are many opportunities for future inquiry.
 
Article
Objective Considering hospital medical directors' work stress, this study aims to examine how interior amenities might moderate the effect of work stress on their health. Background Previous studies have revealed that hospital medical directors—senior physicians in the management positions with high-demand jobs in clinical practices and management—had a lower self-rated health. Methods This was a cross-sectional survey study and 737 hospital medical directors in Taiwan were included. A developed and structured questionnaire covered the dimensions of patient-related work stress (i.e., physician-patient relationship stress and patient condition stress), hospital interior amenities (i.e., indoor plants, aquarium, music, art and exhibitions, and private or personalized spaces that are common or surround the workplace of healthcare professionals), and self-rated health status and health complaints. Hierarchical regressions were performed. Results Hospital medical directors' physician-patient relationship stresses were found to have more negative effects on their self-reported health status and complaints than do their patient condition stresses; however, only indoor plants were found to have moderating effects on their short-term health complaints ( p < 0.05). On the other hand, the hospital medical directors' patient condition stresses were negatively related to their short-term health complaints; however, music, art and exhibitions, and private or personalized spaces in the workplaces had moderating effects ( p < 0.05). Conclusions Considering the unavoidable patient-related work stresses imposed on hospital medical directors, some proposed interior amenities can produce buffering effects on work stress to some extent. Future studies could focus on finding alternatives to relieve hospital medical directors' physician-patient relationship work stresses.
 
Top-cited authors
Kevin Real
  • University of Kentucky
Lindsey Fay
  • University of Kentucky
Kiley Vander Wyst
  • Midwestern University
Erin Peavey
  • Center for Advdanced Design Research & Evaluation
Anke Jakob
  • Kingston University London