Beruflich Dokumente
Kultur Dokumente
Abstract
Objective: This comparative study of two adult neuro critical care units examined the impact of patientand family-centered design on nursefamily interactions in a unit designed to increase family involvement.
Background: A growing evidence base suggests that the built environment can facilitate the delivery of
patient- and family-centered care (PFCC). However, few studies examine how the PFCC model impacts
the delivery of care, specifically the role of design in nursefamily interactions in the adult intensive care
unit (ICU) from the perspective of the bedside nurse. Methods: Two neuro ICUs with the same patient
population and staff, but with different layouts, were compared. Structured observations were conducted to assess changes in the frequency, location, and content of interactions between the two units.
Discussions with staff provided additional insights into nurse attitudes, perceptions, and experiences
caring for families. Results: Nurses reported challenges balancing the needs of many stakeholders in a
complex clinical environment, regardless of unit layout. However, differences in communication patterns
between the clinician- and family-centered units were observed. More interactions were observed in
nurse workstations in the PFCC unit, with most initiated by family. While the new unit was seen as more
conducive to the delivery of PFCC, some nurses reported a loss of workspace control. Conclusions:
Patient- and family-centered design created new spatial and temporal opportunities for nursefamily
interactions in the adult ICU, thus supporting PFCC goals. However, greater exposure to unplanned family
encounters may increase nurse stress without adequate spatial and organizational support.
Keywords
critical care, patient- and family-centered care, evidence-based design, nursefamily interactions, stress
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Rippin et al.
Introduction
Critical care stands at an important moment of
transition. The trend toward patient- and familycentered care (PFCC) is steadily transforming
attitudes and behaviors toward family members
with a loved one in the adult intensive care unit
(ICU). For many years, restrictions have been
placed on family presence in these highly charged
environments in an effort to protect the critical
patient and staff privacy. However, an emerging
body of evidence confirms what has long been
intuited: Families play a vital role in patient and
family healing, particularly during an acute medical crisis (Davidson et al., 2007). In response,
ICUs across the United States are increasingly
opening their doors to families (to varying
degrees), with policies and processes that recognize family as valuable partnersnot just visitorsin the care and recovery of their loved one.
While the traditional, clinician-centered approach to critical care has limited family involvement,
PFCC invites families to take a more active role.
The intent is to bring wholeness to the patient
through collaboration and personalized care that
respects the values, beliefs, and experiences of the
individual. This collaborative approach, catalyzed
by an increasingly consumer-driven marketplace,
is bringing policy and departmental changes. Physical spaces, too, are being redesigned to better
support the multifaceted needs of families. Comfortable waiting areas, designated family zones inside
the patient room, thoughtful amenities, and flexible
visiting hours encourage longer stays and ongoing
communication with the care team.
While family presence benefits patients, families, and providers, PFCC requires substantial
cultural and procedural change for ICU staff.
Organizational and consumer expectations of
timely, well-coordinated care are high, and transitioning to this new care environment can create
stress for staff. This is particularly cogent in the
ICU workplace where rates of nurse burnout are
high (France et al., 2008; Poncet et al., 2007).
While much of the conversation in healthcare
has focused on improving the patient and family
experience, less is known about the impact of this
new care environment and culture on frontline caregivers, particularly the bedside nurse who works in
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Background
Literature Review
Family members of an adult patient in the ICU
have traditionally been restricted when visiting
their loved one during hospitalization. Concerns
for patient safety and staff privacy prevailed
despite growing awareness of the need for family presence in the care of patients. This began
to change in 1988 when The Picker Institute recommended the inclusion of patient and family in
care delivery (Ciufo, Hader, & Holly, 2011).
Since then, advocacy groups and professional
organizations continue to define the standards
of PFCC and set forth guidelines that encourage
family partnership (Conway et al., 2006; Davidson et al., 2007; Kohn, Corrigan, & Donaldson,
2001). These guidelines reflect a wealth of
research demonstrating the needs of family,
including proximity to loved ones, assurance of
good care, and honest, timely information (Lam
Rippin et al.
Introduction
Critical care stands at an important moment of
transition. The trend toward patient- and familycentered care (PFCC) is steadily transforming
attitudes and behaviors toward family members
with a loved one in the adult intensive care unit
(ICU). For many years, restrictions have been
placed on family presence in these highly charged
environments in an effort to protect the critical
patient and staff privacy. However, an emerging
body of evidence confirms what has long been
intuited: Families play a vital role in patient and
family healing, particularly during an acute medical crisis (Davidson et al., 2007). In response,
ICUs across the United States are increasingly
opening their doors to families (to varying
degrees), with policies and processes that recognize family as valuable partnersnot just visitorsin the care and recovery of their loved one.
While the traditional, clinician-centered approach to critical care has limited family involvement,
PFCC invites families to take a more active role.
The intent is to bring wholeness to the patient
through collaboration and personalized care that
respects the values, beliefs, and experiences of the
individual. This collaborative approach, catalyzed
by an increasingly consumer-driven marketplace,
is bringing policy and departmental changes. Physical spaces, too, are being redesigned to better
support the multifaceted needs of families. Comfortable waiting areas, designated family zones inside
the patient room, thoughtful amenities, and flexible
visiting hours encourage longer stays and ongoing
communication with the care team.
While family presence benefits patients, families, and providers, PFCC requires substantial
cultural and procedural change for ICU staff.
Organizational and consumer expectations of
timely, well-coordinated care are high, and transitioning to this new care environment can create
stress for staff. This is particularly cogent in the
ICU workplace where rates of nurse burnout are
high (France et al., 2008; Poncet et al., 2007).
While much of the conversation in healthcare
has focused on improving the patient and family
experience, less is known about the impact of this
new care environment and culture on frontline caregivers, particularly the bedside nurse who works in
81
Background
Literature Review
Family members of an adult patient in the ICU
have traditionally been restricted when visiting
their loved one during hospitalization. Concerns
for patient safety and staff privacy prevailed
despite growing awareness of the need for family presence in the care of patients. This began
to change in 1988 when The Picker Institute recommended the inclusion of patient and family in
care delivery (Ciufo, Hader, & Holly, 2011).
Since then, advocacy groups and professional
organizations continue to define the standards
of PFCC and set forth guidelines that encourage
family partnership (Conway et al., 2006; Davidson et al., 2007; Kohn, Corrigan, & Donaldson,
2001). These guidelines reflect a wealth of
research demonstrating the needs of family,
including proximity to loved ones, assurance of
good care, and honest, timely information (Lam
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Perceived concerns of PFCC. Despite its many benefits, family presence brings its share of concerns.
Much of the available literature focuses on family
presence (FP) during episodes of care (e.g., CPR)
rather than day-to-day family presence on the unit.
One common concern among staff is that family
can disrupt patient care (Egging et al., 2011). In
one study, nurses perceived family as taking focus
away from patient duties, which could result in
medication errors (Farrell, Joseph, & SchwartzBarcott, 2005). Other concerns include patient privacy, prolonged futile resuscitation, and litigation
(Pankop, Chang, Thorlton, & Spitzer, 2013).
According to the American Association of
Critical-Care Nurses (AACN, 2010) recommendations, however, there is little concrete evidence
that family presence negatively impacts safety or
interferes with patient care or staff performance.
In fact, a comparison of data between 2004 and
2010 shows that concerns about family interruptions during CPR/IP have decreased, with no
reports of litigation (Pankop et al., 2013). Moreover, when staff gains clinical confidence and
experience working alongside families, attitudes
appear to change (Mian, Warchal, Whitney, Fitzmaurice, & Tancredi, 2007; Robinson et al., 1998).
There is a robust body of literature and wellfounded concern, however, for the psychological
health of families. Davidson, Daly, Agan, Brady,
and Higgins (2010) report that up to 80% of family members may experience long-lasting anxiety, depression, and symptoms of post-traumatic
stress disorder (PTSD) following a stay in the
ICUa condition known as post-intensive care
syndrome-family. Exposure to an unfamiliar,
frightening environment, coupled with pressures
to make life and death decisions on behalf of
loved ones, can significantly heighten stress
(Azoulay et al., 2001; Engstrom, Uusitalo, &
Engstrom, 2011). Consequently, nurses may be
reluctant to include family in potentially disturbing events such as CRP (Robinson et al., 1998),
although recent studies suggest nurses have more
favorable views of FP than other health professionals (Duran et al., 2007; Meyers et al., 2000).
In a prospective, cluster-randomized control trial,
Rippin et al.
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Research Setting
Two neuroscience ICUs at a leading U.S. university teaching hospital served as the research settings for this study. In the neuro ICU, patients
have suffered a traumatic brain injury or illness
and often require life-sustaining intervention.
Mortality is high (1:5), which means family presence is important to coordinate care and make
difficult end-of-life decisions. In 2007, one of
the two units underwent renovations that incorporated EBD and principles of PFCC with the
intent to increase family involvement and improve
outcomes. This study was completed as a postoccupancy evaluation 3 years after opening the
new unit. Data were collected from both the renovated 20-bed patient- and family-centered unit
(FCU) and the older 7-bed clinician-centered unit
(CCU). The setting posed a unique opportunity
to compare two ICUs that share many of the same
workplace characteristics yet differ significantly in
terms of layout. Both units are located on the same
floor of the hospital and share the same patient
population and staff. Nurses work in one unit per
shift but may alternate units during the week. The
units also share the same patient- and familycentered culture and policies, which were enacted
at the same time the FCU opened. Visiting hours
are 24/7, and family members are invited to stay
overnight and be present during shift changes.
While both units support PFCC, their layouts
reflect the dramatic shift toward family involvement in the ICU. In the smaller CCUthe
control group of this studystaff work in a
Study Rationale
Three years after the unit reopened, nurses
reported high levels of workplace stress. An
in-house survey found that 42% of registered
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Figure 2. Images of clinician-centered unit (CCU). (a) Clinician hallway with centralized nursing station.
(b) Semiprivate family hallway, facing patient room. Reprinted with permission from WHR Architects.
Figure 3. Patient- and family-centered unit (FCU), floor plan. Reprinted with permission from Blake Marvin and
HKS, Inc.
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Figure 4. Images of family-centered unit (FCU). (a) Shared hallway with central nursing station (left), nurse
alcove (center), and patient rooms to the left and right of alcove. (4b) Private family studio, facing patient room.
Reprinted with permission from Blake Marvin and HKS, Inc.
(22%). This striking finding prompted an immediate concern: Was increased family presence and
involvementfacilitated by the new design
Rippin et al.
contributing to nurse stress? The following exploratory questions formed the basis for this study:
What defines a challenging family from
the nurse perspective? More broadly, what
are the challenges of PFCC?
What role does the built environment play
in these (real and perceived) challenges?
How does patient- and family-centered
design impact the quality of nursefamily
interactions?
Method
Structured observations and on-site discussions
with nursing staff were conducted in the CCU and
FCU over a 2-month period.
Structured Observations
Two methods of data collection were used. First,
a series of structured observations were conducted using behavior mapping as the primary
tool. Behavior mapping is a quantitative technique that relates behavior to the space in which
it is observed (Proshansky, Ittelson, & Rivlin,
1970). Behaviors are recorded directly onto a
floor plan using a defined set of criteria and are
collected over a specified period of time (Figure 5).
In this study, nurse and family behaviors were
observed at both a global and local level.
First, systematic walk-throughs of the entire unit
offered a global, birds-eye perspective of nurse
and family presence along with the frequency and
location of interactions. Each unit was observed
for 4 days in one given week (Wednesday/Friday/Saturday/Sunday). One walk-through (or
set) was recorded every 15 min in 2-hr time
intervals for approximately 6 hours each day
(911 a.m., 13 p.m., and 68 p.m.). To protect
family privacy, interactions in the family studio
were recorded only when observable from the
hallway. Time, frequency, and duration of observations were selected to (1) allow global and
local observations to be conducted in tandem
due to time constraints and (2) maximize opportunities to observe interactions (e.g., day shift,
shift change, etc.). Upon completion of the
walk-throughs, individual maps were aggregated
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into a digital file to create a snapshot of activity. Snapshots of the two units were then compared to see how layouts generated different
patterns of behavior.
Second, nurses were shadowed locally in and
around workstations to capture interactions at a
more granular level. Frequency, location, and
content of interactions, as well as instances of
copresence, were recorded over a 4-day period
(see above). In this study, interaction is
defined as a one- or two-way verbal communication initiated by a nurse or family member.
Copresence is defined as the potential for
interaction when nurse and family are colocated
in the patient room. The observation period was
bound by (1) whether or not the nurse made a
trip into the patient room and/or (2) whether
an interaction was observed. Nurses were typically assigned to care for two patients (i.e., two
room pairs) at a time. Nurses were shadowed
after visual identification and/or nurse confirmation that at least one family member was
present on the unit (e.g., in the room, hallway,
and bathroom). In the event of no interactions,
observations were limited to a 10-min cap to
ensure all room pairs were observed at least
once. Room pairs were drawn at random. Once
all rooms meeting family presence criteria were
observed, the cycle repeated.
Nurse Discussions
In addition to behavior mapping, informal discussions were held with frontline staff to gain
richer insight into the day-to-day life of the ICU
and attitudes toward PFCC. Twelve RNs and
six additional care team members (one chaplain, one nurse practitioner, two doctors, and
two family coordinators) were approached at
individual workstations and asked for feedback
and opinions about their experiences working in
a FCU. Conversations lasted between 20 min
and 1 hour each. Unstructured questioning
allowed participants to lead the discussion and
show the researcher what was most important
to them. The majority of conversations were not
recorded, with most participants preferring to
speak off the record. Their identity was protected throughout the study. Field notes
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Figure 5. Sample behavior maps, structured observations, CCU (global and local).
Results
Structured Observations
In the seven-bed CCU, 65 global walk-throughs
(or sets) were recorded, yielding nine interactions and 12 counts of copresence (Figure 6;
Table 1). All interactions took place in the
patient room. No family members or nursefamily interactions were observed in the clinician
hallway. A high frequency of interactions and
copresence in the CCU suggests that the patient
room is the primary locus for family to interact
with staff and be near their loved one. Thus,
family may feel the need to be present in the
room for longer periods of time. In the 20-bed
FCU, 82 global walk-throughs were recorded,
yielding 47 interactions and 19 counts of copresence (Figure 7; Table 1). Most interactions
took place in the patient room (n 35), with
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Interactions
Copresence
0
0
9
0
0
9
0
0
12
0
0
12
6
3
35
1
2
47
0
0
19
0
0
19
Figure 7. Frequency and location of nursefamily interactions and copresence in FCU, behavior map (global).
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Table 2. Comparison of Interaction Frequency, Location, and Who Initiated Interactions Where in ClinicianCentered Unit (CCU) and Patient- and Family-Centered Unit (FCU; Local).
Location
CCU
Nurse hallway (nurse domain)
Patient room (shared domain)
Family Hallway (family domain)
Total
FCU
Nurse alcove (nurse domain)
Patient room (shared domain)
Family studio (family domain)
Total
Interaction Frequency
Nurse Initiated
Family Initiated
5
17
2
24
1
13
2
16
4
4
0
8
16
14
2
32
4
7
2
13
12
7
0
19
5
4
1
0
0
0
4
4
0
10
6
4
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Nurse Hallway
Patient Room
Family Hallway
Total
1
2
2
1
7
4
3
5
9
5
4
2
10
6
3
6
9
5
5
Alcove
Patient Room
Family Studio
Total
7
1
2
1
2
1
2
10
2
2
4
4
9
13
2
2
6
4
2
3
2
1
alcove before entering the patient room or leaving the unit, and others engaged in longer conversations. This is explained, in part, by the location
of alcoves in the shared hall and just outside the
patient rooma necessary route for visitors. In
some cases, nurses appeared receptive, turning
their faces and bodies toward approaching family
and, at times, initiating contact. Other times they
appeared to delay or avoid interaction. For example, one nurse kept her body facing the computer
while a family member stood by, only turning her
head when spoken to.
Nurse Discussions
In addition to structured observations, conversations were held with nursing staff to gain
insight into their experiences working in a
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Conclusions
Together, these results suggest that the built environment has the potential to help or hinder the
nurses ability to deliver PFCC. Nurses perceived
the FCU as more conducive to the delivery of
PFCC. Moreover, behavioral changes in the frequency, location, and content of interactions that
were observed in this study supported this perception. In the traditional unit (CCU), architectural
boundaries emphasize separation rather than integration. As such, interactions were largely confined
to the patient room, while family appeared more
cautious when initiating contact inside the clinician
hallway. Nurses also tended to get up from their
seats to enforce workspace boundaries. In contrast,
greater co-visibility and colocation in the new unit
created new spatial and temporal opportunities
for family to interact with staff. As staff and family
mixed and intermingled in the shared hallway, clinical workspaces became public domain. Importantly, alcoves emerged as a key locus of
interaction beyond their intended use as a charting
and patient monitoring station. More than half of
interactions took place in alcoves, most of which
were initiated by family membersa notable finding in a unit designed to empower families and
increase their participation. Observed communication behaviors around alcoves point to an overall
finding that the new unit relaxed physical boundaries, body language, and communication styles.
Nurses tended to stay seated when approached and
informal social exchanges were observed.
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Recommendations
It is critical that architects and healthcare professionals work together to design PFCC ICUs that
support the functions and needs of nurses, while
remaining hospitable to families. Achieving this
balance requires consideration of both architectural and organizational factors that support this
complex ecosystem. From a design perspective,
nurses need spaces that allow them to be at times
separate from, yet still connected to, family.
This means redefining backstage as a means
to support both connectivity and privacy, with
an ability to flex between the two. The staff
break room offers backstage retreat, albeit with
reduced proximity to patient and family. Thus,
a variety of backstage spaces are recommended
to act as both a tether to and a pressure valve
from work demands, family purview, and so
on. For instance, the family studio in the FCU
created this opportunity for breathing room
while allowing the nurse to remain accessible
to family. While separating staff and family flow
is a common approach in ICU design, this study
suggests that alcoves set within a shared hallway
create opportunities for social rapport. Separate
circulations could potentially eliminate these
vital microclimates. Alternatively, a partial wall
around the alcove could invite family engagement while still giving privacy to the nurse.
While design plays an important role in facilitating PFCC, a well-designed unit alone does
not guarantee staff will transition smoothly to
the new environment or fully integrate family
as active participantseven when the benefits
are widely acknowledged. Rather, space must
be supported by organizational culture. Conversations with staff highlight the importance of
building shared understanding about the extent
of their roles, responsibilities, and expectations
Rippin et al.
in relation to familyin addition to design strategies. This includes clearly defining PFCC in
the context of the organization. Building consensus also involves empowering staff with
tools and training to prepare them for a variety
of circumstances that will undoubtedly arise
when working with families under duress. Role
playing, scripting, team-based strategies, and
other structured approaches to managing challenging caseswhile providing an outlet for
staff to share issues in a safe, respectful environmentare some examples. Connecting their
work with positive outcomes, in terms of family
feedback and research illustrating the benefits
of PFCC (e.g., lower rates of litigation, etc.),
can also help overcome concerns and bolster a
sense of mission. In sum, design and culture
must work hand-in-hand to encourage familycentered behaviors in an environment that supports patients and families and the nurses who
care for them.
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