HCD_2007_Childrens Atlanta Study

1. View From a Far: The Influence ofe o a a e ue ce o
The View Content & Duration on
Nurse Stress LevelsNurse Stress Levels
Debajyoti Pati, PhD, AIIA, HKS Architects
Paul Barach, MD, MPH, University of Utrecht, Netherlands
Tom E Harvey, AIA, FACHA, MPH, HKS Architects
Health Care Design 2007, Dallas TX 1

2. Questions
• What constitutes “View”?
• Can technology play a role in addressing the
need for view?
• How do we balance the potential benefits of view
and the patient’s need for privacy?
O ti l d t bilit i i f i• Operational adaptability versus provision of view
– can both be accommodated satisfactorily?
H d b ildi f t i t (fl i ) l• How does building footprint (floor area size) play
into this issue? (European building codes often
mandate/limits distance from a window)mandate/limits distance from a window)
May 31, 2007 EDRA 38 Sacramento 2

3. Definitions
• Chronic Stress:
is a prolonged stress that
• Arousal:
a state of readiness to– is a prolonged stress that
exists for weeks, months,
or even years.
A t t
– a state of readiness to
respond
• Acute stress:
– is usually for short time and
may be due to work
pressure, meeting
deadlines pressure or
minor accident, over
e ertion increasedexertion, increased
physical activity, searching
something but you
misplaced it
3
misplaced it...
Health Care Design 2007, Dallas TX

4. What do you think?
• How should chronic stress change between beginning
and end of a shift?and end of a shift?
• How should alertness change between beginning and
end of a shift?
• How should acute stress change between beginning and
end of a shift?
H h ld t i i t l t ?• How should exposure to view impact alertness?
• What role should view content play in modulating
alertness?alertness?
• How should exposure to view impact acute stress?
• What role should view content play in modulating acute
stress?
May 31, 2007 EDRA 38 Sacramento 4

5. Contents
Why the inquiry?
• Objective
• Hypotheses
• Methods
– Definitions
– Instruments
• Results
• Discussion
Limitations of St d• Limitations of Study
• Recommendations
5Health Care Design 2007, Dallas TX

6. We want to see
• The impact of view on staff alertness and stress.
• What does that mean to healthcare
organizations?
May 31, 2007 EDRA 38 Sacramento 6

7. Why the inquiry?
• Stressed Nurses
Data S ggest N rse – Fatigue and sleep– Data Suggest Nurse
Fatigue Threatens Patient
Safety1
70 5% of nurses surveyed
– Fatigue and sleep
deprivation common
among medical personnel3
– 70.5% of nurses surveyed
indicated ‘acute/chronic
effects of stress and
overwork’ as one of theiroverwork as one of their
top three concerns: injury,
disease, assault, allergy,
accident2acc de t
1 Tabone (2004)
2 Houle (2001)
3 AHRQ (2001)
7Health Care Design 2007, Dallas TX

8. Why the inquiry?
• Impacts of stress
Cogniti e performance4 – slowed reaction time– Cognitive performance4
– Errors and near errors 5
– decreased alertness,
– slowed reaction time,
lapses of attention to detail,
errors of omission,
compromised problem
problems with task
completion, problems with
concentration, irritability,
unsafe actions and unsafe
compromised problem
solving, reduced
motivation, and decreased
energy 7
unsafe actions, and unsafe
decision making 6
4 Reiling, 2005g
5 ONA, 2005-6
6 Tabone, 2004
7 AHRQ, 2001; Page, 2004
8Health Care Design 2007, Dallas TX

9. Why the inquiry?
• Physical environment as
stressor
– Visual environment:
• Patients : stress painstressor
– The built environment
– Auditory environment
Patients : stress, pain,
mood satisfaction 11
• Patients : blood pressure,
heart rate, sleep deprivation,
pain 8
Staff occ pational stress 9• Staff : occupational stress 9
– Informational environment
• Patients : stress, heart rate 10 8 Topf et al, 2001; Baker, 1984
9 T f 19889 Topf, 1988
10 Carpman, 1984; Nelson-Shulman, 1983-
84
11 Ulrich et al, 1991, 2003; Leather et al,
2003
9
2003
Health Care Design 2007, Dallas TX

10. Why the inquiry?
• Influence of view
Patients– Patients
• LOS, pain drugs, minor
complications 12
• Memory time orientation• Memory, time orientation,
hallucination, delusion 13
– Staff
• Windowless room : lower
reported well being 14
12 Ulrich, 1984
13 Keep et al, 1980; Wilson, 1972
14 Verderber, 1987
10Health Care Design 2007, Dallas TX

11. Questions
• How does the view influence staff stress and
arousal levels?
• How does nature view (as opposed to non-
t i i ) i fl th t ffnature view or no view) influence the staff
stress and arousal levels?
11Health Care Design 2007, Dallas TX

12. Study Objective
• To study the association between the view
duration and content on stress and arousalduration and content on stress and arousal
levels
Other Factors Other Factors
Ph i l
Staff
Outcome
O i i lPhysical
Environment
Patient
Outcome
Organizational
Outcome
12Health Care Design 2007, Dallas TX

13. Hypotheses
1. Between the beginning and end of the shift
CHRONIC STRESS levels (as measured byCHRONIC STRESS levels (as measured by
PSS-10 scale) should not change
2 f2. Between the beginning and the end of the
shift AROUSAL levels (as measured by
SACL) should generally go downSACL) should generally go down
3. Between the beginning and the end of the
shift ACUTE STRESS levels (as measured byshift ACUTE STRESS levels (as measured by
SACL) should generally go up
13Health Care Design 2007, Dallas TX

14. Hypotheses - continued
4. At the end of the shift,
R d t d t t l i h ld• Respondents exposed to external view should
demonstrate higher arousal state.
• Respondents exposed to external view should• Respondents exposed to external view should
demonstrate lower acute stress.
• Those with a nature view should demonstrate
higher arousal state as opposed to a non-
nature and no view.
Th ith t i h ld d t t• Those with a nature view should demonstrate
lower acute stress as compared to a non-
nature and no view.
14
nature and no view.
Health Care Design 2007, Dallas TX

15. Methods
• Setting
– CHOA at Egleston and
• Predictor:
Vie d rationCHOA at Egleston and
Scottish Rite Hospitals
• Data collection: Nov 2006
– 12 hours day shift
– View duration
– View content: nature; non-
nature
12 hours day shift
– Sample 32 of 55 personnel
– Unit types: 19
• Design
• Control Group:
– Stress from lighting,
auditory, thermal andDesign
– Observational; single
measurement
• Outcome measure:
y
ergonomic environment
– Organizational stress
– Work load
– Chronic stress
– Acute stress
– Arousal
Work load
– Work experience
– Personal data: age,
education position
15
education, position
Health Care Design 2007, Dallas TX

16. Methods - Statistical
• Paired sample comparison
• Multivariate regression
• Joint partial F-test
• Multivariate regression with interaction terms
16Health Care Design 2007, Dallas TX

17. Instruments
Measure Instrument
Ch i P i d S S l (PSS 10) 0 40Chronic stress Perceived Stress Scale (PSS-10); 0 to +40
Acute stress; arousal Cox’s Stress/Arousal Adjective Checklist
(SACL); -12 to +18
View duration; view content Investigator designed questionnaire
Lighting, auditory, thermal,
ergonomic stress
Investigator designed questionnaire
ergonomic stress
Organizational stress Revised Nursing Work Index (NWI-R)
Work load Investigator designed questionnaireg g q
Work experience Investigator designed questionnaire
Age, education, position Investigator designed questionnaire
17
g p g g q
Health Care Design 2007, Dallas TX

18. RESULTS
18Health Care Design 2007, Dallas TX

19. A. Chronic Stress
Mean chronic
stress – before
Mean chronic
stress – after
Difference
between
t-statistics Significance
shift shift means
14.5953 13.6961 -0.89923 1.897 0.062
*** significant at 0.001 ** significant at 0.01 * significant at 0.05
• NO STATISTICALLY
Chronic Stress
SIGNIFICANT DIFFERENCE
BETWEEN MEAN PSS
SCORES
19
7:00 am 7:00 pm
Health Care Design 2007, Dallas TX

20. B. Arousal
Mean arousal –
before shift
Mean arousal
– after shift
Difference
between
t-statistics Significance
means
7.9714 4.4551 -3.51634 8.052 0.000***
*** significant at 0.001 ** significant at 0.01 * significant at 0.05
• STATISTICALLY
SIGNIFICANT DIFFERENCE
BETWEEN MEAN AROUSAL
SCORES
Arousal
SCORES
• DIRECTION OF
DIFFERENCE SUPPORTED
20
7:00 am 7:00 pm
Health Care Design 2007, Dallas TX

21. C. Acute Stress
Mean acute stress
– before shift
Mean acute
stress – after
Difference
between
t-statistics Significance
shift means
-3.925 -1.835 2.0897 4.535 0.000***
*** significant at 0.001 ** significant at 0.01 * significant at 0.05
• STATISTICALLY
SIGNIFICANT DIFFERENCE
BETWEEN MEAN ACUTE
STRESS SCORES
Acute Stress
STRESS SCORES
• DIRECTION OF
DIFFERENCE SUPPORTED
21
7:00 am 7:00 pm
Health Care Design 2007, Dallas TX

22. D. Arousal after shift
R R
2
R
2
adjusted F Significance
0.624 0.389 0.372 22.103 0.000***
Parameters Estimate Beta t Significance
Constant 13.28 7.006 0.000***
View duration 0.1 0.273 4.109 0.000***
Arousal- Before Shift 0 511 0 502 7 106 0 000***Arousal- Before Shift 0.511 0.502 7.106 0.000
Env Stress -0.46 -0.236 -3.693 0.000***
AE Index 0.47 0.159 2.464 0.015*
Work Load -0.867 -0.191 -3.119 0.002*
NWI-R -3.664 -0.307 -4.851 0.000***
*** significant at 0.001 ** significant at 0.01 * significant at 0.05
• View significant
Joint Partial F-Test
2 • View significant
• + 4.8% explanatory
power
R2
full model 0.372
R2
sub model 0.324
R
2
change 0.048
22Health Care Design 2007, Dallas TX

23. E. Acute stress after shift
R R
2
R
2
adjusted F Significance
0.669 0.447 0.431 28.063 0.000***
Parameters Estimate Beta t Significance
Constant -13.223 -6.348 0.000***
View duration 0.117 0.266 4.956 0.000***
f S f 0 99 0 9 616 0 000***Arousal- Before Shift 0.499 0.5 9.616 0.000***
Env Stress 0.847 0.362 6.453 0.000***
AE Index -0.864 -0.244 -4.174 0.000***
Work Load 0.599 0.11 1.998 0.047*
NWI-R 0 902 0 063 1 157 0 249NWI-R 0.902 0.063 1.157 0.249
*** significant at 0.001 ** significant at 0.01 * significant at 0.05
• View significantJoint Partial F-Test • View significant
• + 6.4% explanatory
power
Joint Partial F Test
R2
full model 0.431
R2
sub model 0.367
R
2
change 0.064
23Health Care Design 2007, Dallas TX

24. F. Arousal and view content
R R
2
R
2
adjusted F Significance
0.643 0.413 0.39 17.983 0.000***
Parameters Estimate Beta t Significance
Constant 15.759 8.79 0.000***
Non-nature view 0.286 0.021 0.256 0.798
Nature view 1.877 0.178 2.51 0.013*
A l B f Shift 0 185 0 199 3 067 0 002*Arousal- Before Shift 0.185 0.199 3.067 0.002*
Env Stress -0.679 -0.384 -6.283 0.000***
AE Index 1.157 0.44 6.505 0.000***
Work Load -0.357 -0.091 -1.186 0.237
NWI-R -2.862 -0.266 -3.728 0.000***
*** significant at 0.001 ** significant at 0.01 * significant at 0.05
N t Vi
Arousal
Nature View
Non-Nature View
No View
24
7:00 am 7:00 pm
Health Care Design 2007, Dallas TX

25. DISCUSSION: Arousal and view content
• Of all nurses whose response
readiness level remained the
• The presence or absence of view
in the nurses’ workplace trailed
same or improved: 58 percent had
exposure to a view (100 percent of
the 58 percent were exposed to a
nature view)
p
behind only the organizational
stressors as the factor bearing
most influence on response
readiness in nursesnature view)
• Of all nurses whose response
readiness levels deteriorated
readiness in nurses
• Physical environmental stressors
(light noise thermal comfort andreadiness levels deteriorated
between the beginning and end of
the shift 67 percent had no view or
only a non-nature view
(light, noise, thermal comfort, and
ergonomics) ranked third in the
order of influence on response
readiness in nurses
25Health Care Design 2007, Dallas TX

26. Acute stress and view content
R R
2
R
2
adjusted F Significance
0.506 0.256 0.227 8.801 0.000***
Parameters Estimate Beta t Significance
Constant -9.252 -4.077 0.000***
Non-nature view -0.657 -0.043 -0.429 0.668
Nature view -0.724 -0.061 -0.727 0.468
Acute stress- Before Shift 0.316 0.328 4.651 0.000***cute st ess e o e S t 0 3 6 0 3 8 65 0 000
Env Stress 0.513 0.256 3.759 0.000***
AE Index -0.924 -0.31 -4.238 0.000***
Work Load 0.561 0.127 1.466 0.144
NWI-R 1.322 0.108 1.356 0.177
*** significant at 0.001 ** significant at 0.01 * significant at 0.05
Acute Stress
N t Vi
Non-Nature View
No View
Nature View
26
7:00 am 7:00 pm
Health Care Design 2007, Dallas TX

27. Acute stress and view content
• Of all nurses whose acute stress
condition remained the same or
• The presence or absence of view
in the nurses’ workplace trailed
improved between the beginning
and end of the shift, 64 percent
had exposure to views (71 percent
of that 64 percent were exposed
p
behind only the physical
environmental stressors (light,
noise, thermal comfort, and
ergonomics) as the factor bearingof that 64 percent were exposed
to nature view)
• Of all nurses whose acute stress
ergonomics) as the factor bearing
most influence on acute stress in
nurses
• Demographic factors (age,Of all nurses whose acute stress
levels deteriorated between the
beginning and end of the shift, 56
percent had no view during the
hift h d l t i
g p ( g ,
experience, education, and pay
scale) ranked third in the order of
influence on acute stress
shift or had only a non-nature view
May 31, 2007 EDRA 38 Sacramento 27

28. STUDY LIMITATIONS
• Sample size: nurses
• Sample size: shifts
• Follow-up recommendations:
– Natural experiment design
– Objective and subjective measures
L l– Larger sample
– More settings

29. CONCLUSIONS
• Summary
Vie has positi e infl ence
• Next step
Slope parameters– View has positive influence
on arousal
– View has positive influence
on acute stress
– Slope parameters
– Patient outcomes
– Organizational outcomes
on acute stress
– View explains a
considerable proportion of
variance in arousal andvariance in arousal and
acute stress
– Nature view has positive
influence on arousalinfluence on arousal
– Nature view has positive
influence on acute stress
29Health Care Design 2007, Dallas TX