Art, Music | Evidence-Based Design | Methodology | Patient Rooms

Executive Summary of Key Concepts

April 16, 2014     HERD Volume 7, Issue 3

Beginning with the spring issue of HERD (7:3), readers will find a new feature: Executive Summary of Key Concepts, which will appear in the front of each issue, following the Table of Contents. Preview this new feature now.

Evidence-Based Design

Disseminating Knowledge and Writing for Publication

April 15, 2014     Jaynelle F. Stichler, DNSc, RN, EDAC, NEA-BC, FACHE, FAAN and Philip Nielsen, MArch, LEED AP


One of the last steps of evidence-based design (EBD) is disseminating the new knowledge via numerous outlets and in-service presentations. Such presentations take place in hospitals, design firms, through posters or podium presentations at national conferences, and in articles in professional journals such as HERD. In this article we describe the methodology of writing for publication in a peer-reviewed, scholarly journal (for example, a submittal to HERD). We seek to assist aspiring and beginning authors in successfully disseminating their experience and knowledge through case studies of their projects, results of evidence-based design projects, and actual research projects with findings that help others to design better healthcare facilities. Although this article is not primarily directed at seasoned academic scholars or researchers in practice who have experience in writing scholarly pieces, some aspects of this article may remind such scholars of common problems that often delay publication. As such we intend to help you learn the process of systematically recording your thoughts, summarizing your projects, and disseminating the knowledge that you hold to others in the healthcare design field who can benefit from what you know and have experienced.


Lessons Learned: Clinicians' Post-Occupancy Perspective of Facility Design Involvement

April 8, 2014     Kathy Reno, PhD, MBA, RN, EDAC; Kathy Okland, RN, MPH, NA, EDAC; Nanne Finis, RN, MS; Gina LaMantia, MS, MEd; Roger Call, AIA, ACHA, LEED AP; Kerrie Cardon, RN, AIA, ACHA; Deborah Gerber, RN, MPH, FACHE, EDAC; and Janet Zeigler, RN, MN, MBA, EDAC


OBJECTIVE: The research was conducted to determine clinician knowledge needs for competent involvement with the facility design process as well as to gather lessons learned on building stronger design teams.

BACKGROUND: As clinical stakeholders are invited to the healthcare facility design table, the question arises as to the ability of professionally diverse team members to translate each other's comments and ideas accurately. In the past, hospitals were designed by a handful of hospital leaders and architects. More recently, multiple players have become involved throughout the design and construction of new healthcare facilities. Clinical consultants from two international healthcare companies observed that many clinicians were unprepared to effectively translate their needs to the architectural community or to competently utilize architectural tools and documents.

METHODS: A qualitative, post-occupancy cross-case study was conducted to understand how clinicians could increase their competencies for successful involvement in facility design. Focus group interviews were held with teams from healthcare facilities occupying their new facility for more than 6 months and less than 2 years.

RESULTS: Curriculum topics were validated and additional areas recommended based on the interviews. Open-ended questioins on lessons learned provided several new dimensions to the research.

CONCLUSIONS: Although validating the curriculum was the initial intent, the feedback from the focus groups on lessons learned provided rich concepts for practice implications and further research on post-occupancy.

KEYWORDS: Decision-making, design process, interdisciplinary, planning, post-occupancy

PREFERRED CITATION: Reno, K., Okland, K., Finis, N., LaMantia, G., Call, R., Cardon, K., … Zeigler, J. (2014). Lessons learned: Clinicians' post-occupancy perspective of facility design involvement. Health Environments Research & Design Journal, 7(2), 127-139.


Examination of How and Why Over-the-Bed Tables Are Used: Use Cases and Needs from Healthcare Providers

March 31, 2014     Joe Manganelli, PhD; Anthony Threatt, PhD; Johnell O. Brooks, PhD; Stan Healy, DHA, NHA, FACHE; Jessica Merino, MS; Paul Yanik, PhD; Ian Walker, PhD; and Keith Green, RA, PhD


OBJECTIVE: This article presents the results of an exploratory study in which 14 clinical and staff subject matter experts (SMEs) at a regional rehabilitation hospital were interviewed in order to understand how and why over-the-bed tables are used.

BACKGROUND: It is important to understand how and why a device or environment is used when designing it, and not just what features and functions are preferred. This knowledge is valuable both for contextualizing user feature and function preferences and for characterizing and prioritizing design challenges and opportunities.

METHODS: Fourteen hospital clinical and support staff subject-matter experts participated in semi-structured interviews with scenario enactments in a medium-fidelity, full-scale mock-up of a typical patient room. During these interviews, they interacted with two personas played by actors and were asked to enact an example of a normal visit, from entering the room through treatment/service and then exiting. Data were analyzed via methodological triangulation including frequency analysis, content analysis, and affinity diagramming.

RESULTS: The results include a use-case analysis with illustrative sketches, a list of needs statements, and final observations.

CONCLUSIONS: Successfully using the over-the-bed table is dependent upon proper positioning, especially in bed during meals. There are fewer problems associated with over-the-bed table use while seated in a chair than when in the bed. The over-the-bed table is a key component in acute care, inpatient therapies. Clinicians are generally open to “smart” furniture in the patient room but question its cost-effectiveness, robustness, and flexibility.

KEYWORDS: Evidence-based design, human factors, patient-centered care, quality care, technology

PREFERRED CITATION: Manganelli, J., Threatt, A., Brooks, J. O., Healy, S., Merino, J., Yanik, P., … Green, K. (2014). Examination of how and why over-the-bed tables are used: Use cases and needs from healthcare providers. Health Environments Research & Design Journal, 7(2), 104-126.


Patient Visibility and ICU Mortality: A Conceptual Replication [CEU Available]

March 25, 2014     Yi Lu, PhD; Michelle M. Ossmann, MSN, PhD(c); David E. Leaf, MD; and Philip H. Factor, DO


OBJECTIVE: This study reanalyzes the data from a study by Leaf, Homel, and Factor (2010) titled “Relationship between ICU Design and Mortality” by adopting and developing objective visibility measures.

BACKGROUND: Various studies attribute healthcare outcomes (patient falls, satisfaction) to a vague notion of patient room visibility. The study by Leaf and colleagues was the first to draw an independent association between patient mortality and patient room visibility, however “visibility” remains imprecise.

METHODS: The original patient dataset was obtained from Dr. Leaf. The 664 patient sample assigned across 12 rooms at the medical ICU at Columbia University Medical Center was reanalyzed in terms of targeted visibility; the unit of analysis was the room, n = 12. Several computer-based visibility measures of patient rooms were used: patient head visibility, patient room visibility, and field of view to nursing station. Patient head visibility was defined as the percentage of area within the central nursing station from which the patient head could be seen; patient room visibility was defined as the percentage of area within the central nursing station that could see the patient room (average value of all patient room grids); field of view was defined as the maximum viewing angle from the patient head to the central nursing station.

RESULTS: Among the sickest patients (those with Acute Physiology and Chronic Health Evaluation II > 30), field of view accounted for 33.5% of the variance in ICU mortality, p = 0.049

CONCLUSIONS: Subtle differences in patient room visibility may have important effects on clinical outcomes.

KEYWORDS: Case study, critical care/intensive care, methodology, outcomes

PREFERRED CITATION: Lu, Y., Ossmann, M. M., Leaf, D. E., & Factor, P. H. (2014). Patient visibility and ICU mortality: A conceptual replication. Health Environments Research & Design Journal, 7(2), 92-103.

Evidence-Based Design

Challenging Research: Completing Participatory Social Research with Children and Adolescents in a Hospital Setting

March 17, 2014     Katherine Bishop, PhD


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

PREFERRED CITATION: Bishop, K. (2014). Challenging research: Completing participatory social research with children and adolescents in a hospital setting. Health Environments Research & Design Journal, 7(2), 76-91.


Rehabilitation Centers in Change: Participatory Methods for Managing Redesign and Renovation

March 10, 2014     Marjaana Lahtinen, PhD; Suvi Nenonen, PhD; Heidi Rasila, PhD; Jouni Lehtelä, MSc; Virpi Ruohomäki, PhD; and Kari Reijula, MD, PhD


OBJECTIVE: The aim of this article is to describe a set of participatory methods that we have either developed or modified for developing future work and service environments to better suit renewable rehabilitation processes. We discuss the methods in a larger framework of change process model and participatory design.

BACKGROUND: Rehabilitation organizations are currently in transition; customer groups, financing, services, and the processes of rehabilitation centers are changing. The pressure for change challenges the centers to develop both their processes and facilities. There is a need for methods that support change management.

METHODS: Four participatory methods were developed: future workshop, change survey, multi-method assessment tool, and participatory design generator cards. They were tested and evaluated in three rehabilitation centers at the different phases of their change process.

RESULTS: The developed methods were considered useful in creating a mutual understanding of the change goals between different stakeholders, providing a good picture of the work community's attitudes toward the change, forming an integrated overview of the built and perceived environment, inspiring new solutions, and supporting the management in steering the change process.

CONCLUSIONS: The change process model described in this article serves as a practical framework that combined the viewpoints of organizational and facility development. However, participatory design continues to face challenges concerning communication between different stakeholders, and further development of the methods and processes is still needed. Intervention studies could provide data on the success factors that enhance the transformations in the rehabilitation sector.

KEYWORDS: Design process, methodology, organizational transformation, planning, renovation

PREFERRED CITATION: Lahtinen, M., Nenonen, S., Rasila, H., Lehtelä, J., Ruohomäki, V., & Reijula, K. (2014). Rehabilitation centers in change: Participatory methods for managing redesign and renovation. Health Environments Research & Design Journal, 7(2), 57-75.

Evidence-Based Design

Space Allocation in the Award-Winning Adult ICUs of the Last Two Decades (1993-2012): An Exploratory Study

March 3, 2014     Mahbub Rashid, PhD, RA


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

PREFERRED CITATION: Rashid, M. (2014). Space allocation in the award-winning adult ICUs of the last two decades (1993-2012): An exploratory study. Health Environments Research & Design Journal, 7(2), 29-56.

Sustainable Design

Sustainable Healthcare Architecture 2nd Edition

February 26, 2014     Kelly T. Cuddeback, MBA, MHA, PMP

As an individual continuously striving to stay current in the healthcare construction field, Sustainable Healthcare Architecture, Second Edition, was instantly appealing, if initially by title only. Sustainable building and the concept of “less is more” in terms of resource consumption are appealing both personally and professionally. Many will agree with the notion of leveraging renewable resources, water conservation, and the creation of a holistic healing environment as a worthy goal; however, one aspect of this edition of Sustainable Healthcare Architecture caused this reader significant cognitive dissonance. In Part 1, “Context,” throughout Chapter 1, “Design and Stewardship,” and mentioned occasionally throughout the book, the argument of global warming, or climate change, as caused by human activities appeared.

Art, Music

Neural Correlates of Nature Stimuli: An fMRI Study [CEU Available]

February 19, 2014     Debajyoti Pati, PhD; Michael O'Boyle, PhD; Cherif Amor, PhD; Jiancheng Hou, PhD; Shabboo Valipoor, MA; and Dan Fang, BS


OBJECTIVE: Examine whether there are unique patterns of brain activation associated with exposure to photographic sky compositions (representing nature stimuli) as compared with other positive, negative, and neutral images.

BACKGROUND: The positive impact of nature images on health outcomes traditionally has been measured using behavioral and physiological indicators. However, there is a lack of understanding of the underlying neural mechanism that explains this positive influence.

METHODS: A combination of behavioral responses and functional magnetic resonance imaging (fMRI) technology was used to address research questions. Ten participants belonging to five age groups were subjected to short (25 seconds) exposures of 32 images while their brain activation was monitored via the BOLD response. In a separate run, participants were subjected to extended exposures (12 minutes) of a sky composition and an image of a traditional ceiling.

RESULTS: The results show that the activation patterns produced by sky compositions and positive images were quite similar as compared to negative or neutral images. However, sky compositions also produced some unique areas of activation, including those associated with spatial cognition, the expanse of space, circadian rhythm, and perceived motion. In the extended exposure condition, sky compositions tended to activate regions associated with dreaming, while traditional ceiling images activated regions that are related to face processing and potentially visual hallucinations.

CONCLUSIONS: Nature stimuli, with a combination of vegetation and sky, may produce unique beneficial effects not present in general positive stimuli.

KEYWORDS: Evidence-based design, hospital, healing environments, outcomes, patient-centered care

PREFERRED CITATION: Pati, D., O'Boyle, M., Amor, C., Hou, J., Valipoor, S., & Fang, D. (2014). Neural correlates of nature stimuli: An fMRI study. Health Environments Research & Design Journal, 7(2), 9-28.