With the advancement of technology in the healthcare setting, staff communication is suffering.5 While technology has an ability to provide a previously unknown sense of independence in the access and use of information, the once liberating freedom can lead to isolation. This disconnect not only exists within the environment, but between the people who share it. In a work environment such as healthcare, where collaboration and communication are essential, interaction with co-workers has implications beyond mere job satisfaction. Technology is greatly changing how health 7 employees work, and is also changing how they interact. Now as the work environment begins to react and engage with the technology to support and encourage its use, it must also focus on fostering staff engagement and ensuring face-to-face interaction. 6
In exploring how to better improve communication between staff, it was discovered that shift change is key in how patient information is transferred and is a significant link in process of patient safety and care. In preparing for this competition entry, we have developed a hypothesis and three design objectives that illustrate our research findings and our design intent.
Shifting Gears in Healthcare Communication In a Technology-first Environment: How Collaboration is Vital to Shift Change an urban renovation site at University of Kentucky Albert B. Chandler Hospital in Lexington, KY A four-person team submission to the
Nurture by Steelcase 2012 Collegiate Healthcare Design Competition
HYPOTHESIS Research shows that shift change is a crucial period for patient safety and quality of care as it relies heavily on accurate and effective message transmission, both in the forms of hard technology and informal dialogue. Therefore, it is vital to provide a collaborative environment that facilitates clear communication and access to information in order to provide a healthy and safe environment for both staff and patient.
Design Objectives Working toward the end environmental goal: to ensure high quality of care and patient safety.
Design Implementation - Standing height working surfaces
Staff Collaboration
- Large, sit-down work surfaces - Alcove huddle spaces outside rooms
- Standing work stations
Effective Message Transmission/Communication
- Acoustic separation from Nurses Station - Smartboard/Message Boards
- Simulated skylights
Improved Work Environment
- Task-lighting - Acoustic ceilings
Floor 6
The Site UK Albert B. Chandler Hospital, Lexington, KY
ICU
ICU Team Station
Acute
Progressive
ICU
Team Station
Center Core Support
Acute
Acute
ICU
Central Corridor
Waiting Area
Tower 200 12 ICU, 6 Progressive, 14 Acute Beds
Support Services
Waiting Area
Stroke
ICU
ICU
Team Station
Team Station
Center Core Support
ICU
Stroke
Tower 100 12 ICU, 20 Stroke Beds
Art
Public Elevators
Staff Elevators
From the New Pavilion Guide for the UK Albert B. Chandler Hospital Produced by UK HealthCare, Lexington, KY.
Service Elevators
Stairs
Stroke
Existing Floorplan
Highlighted areas are spaces that have been altered with the design proposal.
Proposed Floorplan Changes
Huddle Spaces Enclosed Area in Nurse Station
Enclosed Space for Shift Change
Shift Change Room Floor 6
The goal when designing the shift change room was to create a quiet space for nurses to handover the necessary information to the incoming nurses. Interruptions and distractions are common issues occurring during this process. Creating a separate room for shift change would help eliminate problems and allow for more effective transfer of information to improve the patients’ safety. With glass dividing walls, there are views into and out of the space. Art
Public Elevators
Staff Elevators
From the New Pavilion Guide for the UK Albert B. Chandler Hospital Produced by UK HealthCare, Lexington, KY.
Service Elevators
Stairs
IMPROVED ENVIRONMENT Acoustic Ceiling “Environmental interventions that have proven especially effective for reducing noise and improving acoustics in hospital settings include: installing high-performance sound absorbing ceiling tiles...” 11
COMMUNICATION Separation from Nurse Station “A combination of open-counter work spaces with adjacent small work rooms with doors is helpful in having the flexibility for staff to minimize interruptions as required by the tasks... Within the open-counter work area, a certain portion could be enclosed to reduce disruptions from noise and reduce interruptions, yet allowing visual connection with the hallways” 2
COLLABORATION Large Work Surface
COLLABORATION Multi-level Seating
COMMUNICATION Smart Board/Message Board Nurses assemble and disassemble information about the patients. “Shift reports posted on the whiteboards usually contain shift-specific activities and patient information that the outgoing nurse has performed and gathered. “ 10
Inside the shift change room, nurses prepare for their shift with personal notes and/or an annotated patient care summary, and “[obtain...] the latest patient information from the large whiteboards which had been updated by the nurses working in the previous shift.” 10 During charge nurse handover, nurses were observed “[preparing] some.form of personal notes, either on a separate sheet of paper and/or as annotations on the printed patient care summary. ... [T]he majority (83%) wrote down the notes from the previous shift, either from the large whiteboard inside the shift change room or from the verbal report by the outgoing nurse.” 10
Nurses’ Station
Floor 6
Art
When designing the layout of the nurses’ station, an open layout with standing height workspace was desirable. Plenty of counter space and computers are easily accessed without having to sit down inside the nurses’ station. From this space the views into the patient rooms as well shift change room are preserved. Task lighting was incorporated to better serve both paper tasks and computer tasks. Public Elevators
Staff Elevators
From the New Pavilion Guide for the UK Albert B. Chandler Hospital Produced by UK HealthCare, Lexington, KY.
Service Elevators
Stairs
IMPROVED ENVIRONMENT Acoustic Ceiling
IMPROVED ENVIRONMENT Simulated Skylights
COMMUNICATION
Smart Board/Message Board
IMPROVED ENVIRONMENT Task Lighting “Research has revealed that the indoor environment has the biggest effect on productivity in relation to job stress and job dissatisfaction” 9 “Computer-based tasks benefit from significantly lower light levels, with carefully controlled direct and reflected glare, while the remaining paper-based tasks still demand high levels of light for individual tasks.” 3
COMMUNICATION Standing Work Station
COLLABORATION Multi-level Seating
User satisfaction for paper based tasks was elevated with higher illuminance levels beyond the current minimum of 500lx. However a VDT computer screen monitor the minimum light level should be 100lx and the maximum at 350lx. A higher light level than 350 is when dissatisfaction begins and the computer monitor needs to be lit at a higher level as well. Because hospital environments require both paper based and computer based tasks, there should be a lower ambient light and separate task lighting for paper based work. 3
Huddle Space
Floor 6
Art
Public Elevators
Staff Elevators
Service Elevators
Stairs
The goal when designing the huddle space was to create a work area that both nurses and residents have easy access to while in the hallway. Since much dialog is exchanged between staff in the hallway, the huddle space provides a new location where a quick exchange of information and impromptu meetings can occur.
From the New Pavilion Guide for the UK Albert B. Chandler Hospital Produced by UK HealthCare, Lexington, KY.
IMPROVED ENVIRONMENT Acoustic Ceiling
COMMUNICATION Standing Work Station “Curbside is where impromptu meetings take place-quick consultations, chart reviews, etc. ...and is best served by a standing-height work surface that two or more can gather around easily. This type of space is even more important when groups work and roam the floor, such as during physician rounds.” 1 “Informal interactions are often undervalued, yet studies in office and educational environments show that these interactions play an important role in successful collaborative relations. 8
COLLABORATION Huddle Space
COLLABORATION
Standing height Work Surface
IMPROVED ENVIRONMENT Views of Nature Artwork “Investigators have reported consistently that stress-reducing or restorative benefits of viewing nature are manifested as a constellation of positive emotional, psychological, and physiological changes. Positive feelings such as pleasantness and calm increase, while anxiety, anger or other native emotions diminish,”12
During resident’s rounds and nurse shift changes, the hallway is a critical location for dialog.. “[M]edical interns and physicians spend a significant part of their time in the hallway... [and] ... choose [it] to discuss the health condition of a patient with colleagues or relatives. Thus, the hallway is used as an ‘availability space’ where many discussions and information exchanges take place. These opportunistic interactions are used among other things to hand physicians a form to sign, ask about the status of a patient, or discuss a clinical decision.” 8
ICU Nurses’ Station
Floor 6
While designing the layout of the nurses’ station in the ICU, an open furniture layout with standing height workspace was desirable. Plenty of counter space and computers are easily accessed without having to sit down inside the nurses’ station. Views into the patient rooms and also into the quiet pods were preserved throughout the design. Art
Public Elevators
Staff Elevators
From the New Pavilion Guide for the UK Albert B. Chandler Hospital Produced by UK HealthCare, Lexington, KY.
Service Elevators
Stairs
IMPROVED ENVIRONMENT Acoustic Ceiling
IMPROVED ENVIRONMENT Simulated Skylights
“[N]urses function more effectively in an environment with minimal artificial lighting and in an environment that facilitates the use of natural daylight.” 2 The product specified for this space would emmulate natural daylight in an area without access to direct exterior views or light.
COLLABORATION Standing-height Work Surface “Step-in [spaces are] for more involved work such as charting, dictation, or going over a treatment plan. Seated-height tools are beneficial here, possibly with some medium-height panels to provide some acoustic privacy. “ 1
COLLABORATION Multi-level Seating “To support the social ecology and work processes while allowing for maximum control and flexibility, it is important to incorporate different types of workstations in support of different work activities, (i.e., sitting versus standing, groups versus individuals, private versus shared). “ 1
COMMUNICATION Separation from nurse station
“Technology can enable real-time updating of information at satellite nurses’ stations, reducing cognitive load and enhancing work processes.” 1
Quiet Pod
Floor 6
Art
Public Elevators
Staff Elevators
Service Elevators
Stairs
From the New Pavilion Guide for the UK Albert B. Chandler Hospital Produced by UK HealthCare, Lexington, KY.
The idea for adding the quiet pod was to create a separate space where nurses can go and fully immerse themselves in the work with very little distractions.
IMPROVED ENVIRONMENT Acoustic Ceiling
“[N]urses preferred unit layout in which they have a visual link to the patients, yet have audio privacy. Small alcoves within the nursing station were found to be beneficial, as nurses can communicate with other staff members regarding patients while still maintaining low noise levels within the nursing unit. Nursing units closed off with Plexiglas were also found to be beneficial due to high patient visibility with low levels of noise.” 2
COMMUNICATION
Separation from nurse station “Immersive space allows for concentration and privacy for planned meetings or work where participants not only need to fully immerse themselves in the work, but also have access to tools like computers, whiteboards, or other information displays.” 1
While this was our first time participating in the EBD process and our experience was limited, we relished the opportunity to dive into research and then apply it directly to a design project.
At this stage, careful attention and observation would be paid to how well the established design objectives and standards were being carried out.
After our own observation and experiences with technology in the healthcare setting, we set our primary goal on fostering staff engagement and face-to-face interaction. Measure Post Occupancy Performance Results
Monitor Implementation of Construction + Design
While outside our scope and ability, we feel that patient incident reports, staff satisfaction surveys and behavioral mapping techniques would be suitable methods for this stage.
Find Sources for Relevant Evidence
The focus of our research was on nursephysician relationships, the clinical environment including stress and satisfaction levels, and communication and collaboration issues.
Our Evidence-Based Design Process
Collect Baseline Performance Measures
Critically Interpret Relevant Evidence
Develop a Hypothesis
Our three design objectives drove the generation of our hypothesis and we were able to clearly identify an environmental problem, and suggest a solution through design.
Eight-Step EBD Process
Define EBD Goals + Objectives
Create + Innovate EBD Concepts
While research regarding poor communication levels due to technology supported our initial suspicions, it was nurse and physician surveys which revealed how essential shift change is in the patient care process.
As we investigated shift change, its role, and process within the routine of the hospital, the development of our design objectives and design intent began to form.
Further Research For the final stage in the EBD process,, we would focus on research techniques that could be easily compared with results from initial testing, hopefully resulting in evidence that shows environments designed for collaboration might improve patient care and safety. This team would also like to propose other research on the same topic, specifically on staff satisfaction, as well as patient satisfaction as a result of the change in design. Below is listing of possible research techniques, broken down by each of our design objectives.
∙ Monitor incident reports
Staff Collaboration
∙ Evaluate efficiency of design comparing current and former shift change time duration ∙ Survey staff about environmental perceptions and satisfaction ∙ Monitor incident reports ∙ Annual Performance Reviews regarding efficiency and
Effective Message Transmission/Communication
group work ∙ Compare utilization of previous and current work surfaces
∙ Monitor incident reports ∙ Survey staff about environmental changes throughout the work stations
Improved Work Environment
∙ Observe attitudes during shift changes to ensure positive improvement ∙ Test acoustic and lighting levels according to ASHRAE standards
Summary By using the steps of the Evidence Based Design process, we found a need to improve the communication among staff, specifically during the shift-change process between nurses. Interruptions and distractions are a concern during the shift change process, making it last much longer than it should. By adding an enclosed space used for the nurses’ shift change, it makes the process quicker and improves the patient safety through better hand-off techniques. The other major issue addressed was dialogue which occurs when healthcare professionals move between patient rooms, the hallway is a critical space for the transfer of a patient’s information. ‘Huddle spaces ‘ were created in the hallway so that nurses, doctors, and residents can quickly access information as a group. The addition of the shift change room, huddle spaces, and minor environmental modifications significantly improves communication among health care workers and improves the safety of patients.
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