hcd_2007_childrens atlanta study
TRANSCRIPT
View From a Far: The Influence of e o a a e ue ce oThe View Content & Duration on
Nurse Stress LevelsNurse Stress Levels
Debajyoti Pati, PhD, AIIA, HKS ArchitectsPaul Barach, MD, MPH, University of Utrecht, Netherlands
Tom E Harvey, AIA, FACHA, MPH, HKS Architects
Health Care Design 2007, Dallas TX 1
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
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
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misplaced it...
Health Care Design 2007, Dallas TX
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
ContentsWhy the inquiry?
• Objective• Hypotheses• Methods
– Definitions– Instruments
• Results• Discussion
Limitations of St d• Limitations of Study• Recommendations
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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
Why the inquiry?
• Stressed NursesData 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)
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Why the inquiry?
• Impacts of stressCogniti 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, 2005g5 ONA, 2005-66 Tabone, 20047 AHRQ, 2001; Page, 2004
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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, 198810 Carpman, 1984; Nelson-Shulman, 1983-
8411 Ulrich et al, 1991, 2003; Leather et al,
2003
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2003
Health Care Design 2007, Dallas TX
Why the inquiry?
• Influence of viewPatients– 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, 198413 Keep et al, 1980; Wilson, 197214 Verderber, 1987
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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?
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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
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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
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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.
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nature and no view.Health Care Design 2007, Dallas TX
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-
nature12 hours day shift
– Sample 32 of 55 personnel– Unit types: 19
• Design
• Control Group:– Stress from lighting,
auditory, thermal and Design– Observational; single
measurement
• Outcome measure:
yergonomic environment
– Organizational stress– Work load
– Chronic stress– Acute stress– Arousal
Work load– Work experience– Personal data: age,
education position
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education, position
Health Care Design 2007, Dallas TX
Methods - Statistical
• Paired sample comparison• Multivariate regression• Joint partial F-test• Multivariate regression with interaction terms
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Instruments
Measure InstrumentCh 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 questionnaireergonomic 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
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g p g g q
Health Care Design 2007, Dallas TX
A. Chronic StressMean 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
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Health Care Design 2007, Dallas TX
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
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Health Care Design 2007, Dallas TX
C. Acute StressMean acute stress
– before shiftMean 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
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Health Care Design 2007, Dallas TX
D. Arousal after shiftR R2 R2 adjusted F Significance
0.624 0.389 0.372 22.103 0.000***
Parameters Estimate Beta t SignificanceConstant 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 significantJoint Partial F-Test2 • View significant
• + 4.8% explanatory power
R2 full model 0.372R2 sub model 0.324
R2 change 0.048
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E. Acute stress after shift
R R2 R2 adjusted F Significance0.669 0.447 0.431 28.063 0.000***
Parameters Estimate Beta t SignificanceConstant -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 TestR2 full model 0.431R2 sub model 0.367
R2 change 0.064
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F. Arousal and view content
R R2 R2 adjusted F Significance0.643 0.413 0.39 17.983 0.000***
Parameters Estimate Beta t SignificanceConstant 15.759 8.79 0.000***
Non-nature view 0.286 0.021 0.256 0.798Nature 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 0.237NWI-R -2.862 -0.266 -3.728 0.000***
*** significant at 0.001 ** significant at 0.01 * significant at 0.05
N t Vi
ArousalNature ViewNon-Nature View
No View
247:00 am 7:00 pm
Health Care Design 2007, Dallas TX
DISCUSSION: Arousal and view content
• Of all nurses whose response readiness level remained the
• The presence or absence of viewin 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)
pbehind 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
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Acute stress and view contentR R2 R2 adjusted F Significance
0.506 0.256 0.227 8.801 0.000***
Parameters Estimate Beta t SignificanceConstant -9.252 -4.077 0.000***
Non-nature view -0.657 -0.043 -0.429 0.668Nature 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 000Env 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 0.144NWI-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 ViNon-Nature View
No View
Nature View
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Acute stress and view content
• Of all nurses whose acute stress condition remained the same or
• The presence or absence of viewin 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
pbehind 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
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STUDY LIMITATIONS
• Sample size: nurses• Sample size: shifts• Follow-up recommendations:
– Natural experiment design– Objective and subjective measures
L l– Larger sample– More settings
CONCLUSIONS
• SummaryVie has positi e infl ence
• Next stepSlope 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
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