To use an evidence-based design process, you have to know what the best available evidence is. But research is published faster than anyone can read it. In this blog series, The Center for Health Design’s research team will provide insight into a few healthcare design research matters through a snapshot of 10 studies published since the 2016 Healthcare Design Expo & Conference. Serving as an inside look at a session held at the 2017 HCD Expo, the blogs will identify why this research matters and help readers ride the waves of an ocean of research without drowning.

The research
A 2017 article by Joseph and colleagues offers insight into pre-op/post-op design and how these environments can either support or hinder nursing work and care team interactions.

Why does it matter?
Major advances in medical technology paired with changes in Medicare reimbursement policy have led to rapid growth in outpatient surgery. While many of these advances are beneficial for healthcare organizations and patients alike, there are challenges. There is still very little research focused on how the design of pre-op and post-op areas affect nursing work, or the critical interactions between staff, patients, and families.

How was the study done?
In this study, researchers explored the relationship between the physical environment in pre-op and post-op areas of two ambulatory surgery centers (one built in 1990; one built in 2000) and the interactions among staff, patients, and their families. They also looked at how the spatial layout and configuration affected the integration of new technology, electronic medical records (EMRs) in particular. The team took a multi-method approach, using behavior mapping, shadowing, spatial analysis, and semi-structured interviews with staff to gather data.

What was learned?
The in-depth systematic nature of this study resulted in rich detailed information about key environmental facilitators and barriers to nurses’ work in surgery centers. Many findings mirror what we tend to see in research on inpatient settings. For instance, nurses were observed spending a majority of their time on their feet, standing and walking. The most common activity for nurses is talking and listening face-to-face with each other, patients, and caregivers (family). Nurses conduct their work everywhere: at the central nurses' station, in corridors, and in patient bays. But the primary work area for nurses is the patient bay, where most of the direct patient care (e.g. bedside care and charting) happens.

Regarding technology integration, the study showed slightly better integration at the newer site, but there were challenges at both sites. The researchers gathered several data points on the difficulty with integrating workstations on wheels (WoWs) into these spaces that were not originally designed to support computerized charting. Despite the potential ergonomic advantage these WoWs offer in height adjustment and portability, the space constraints and nature of nurses’ work did not allow for nurses to sit while charting, and nurses shared their frustration in finding and reaching power outlets to plug the stations in.

At the other site, nurses were not able to chart while also talking to patients unless they pulled the WoW into the corridor at the foot of the patient’s bed, crowding the corridor and impairing patients’ privacy. And while EMRs have reduced paperwork, paper records have not been completely eliminated and there is little space to accommodate both systems.

A major finding in this study is a distinct ebb and flow of activities and space usage, which leaves the post-op areas underutilized during the morning and the pre-op areas underutilized in the afternoon. While this may seem like an obvious conclusion, few organizations have taken the logical step to turn this into an opportunity for more efficient usage of space. (This will be explicitly allowed in the 2018 FGI Guidelines.) The authors of this study suggest that locating the pre-op and post-op areas in close proximity could enable more flexibility in the use of bays during off-peak times.

Are the results definitive?
This study included only two sites, both of which were part of the same healthcare organization. Additional research will be required to tell if these findings can be generalized to other facilities.

While the observation methods in this study yielded important insight into work patterns and specific activities and behavior, the observational findings are mainly representative of where certain activities occurred, and less about the reasons why. Researchers were unable to observe all ongoing activity that occurred in patient bays if the curtains were drawn or doors were closed. Findings from interviews helped to round out the full picture, but more investigation is needed to truly understand underlying processes.

Additionally, while this study aimed to clarify the role of technology in the relationship between design and nurse work, the study took place only two weeks after the organizations had transitioned to electronic records. Another six to 12 months is needed to understand the impact of technology integration.

The takeaway
This study highlights the vital importance of a systems view and human-factors approach to understanding the healthcare environment. Architects and interior designers should consider the complexities at play to support the critical tasks and interactions, the range of activities, people, technologies, processes, and culture. Design teams can take the detailed findings and inform critical design thinking. For instance, ask if ASC nurses are on their feet all day and what flooring options can reduce standing fatigue? Or how can a renovation or remodel of an existing facility enable better integration, especially for WoWs and other new technologies?

Taking a close look at the results, design teams may see opportunities to support better workflow through innovative design, including ways to locate pre-op and post-op areas to increase efficient use of the space at all times, not just at peak times.

Interested in the topic? Visit The Center for Health Design Knowledge Repository for more.

Summary of:
Joseph, A., Wingler, D., & Zamani, Z. (2017). Balancing the Human Touch with the Need for Integrating Technology in Ambulatory Surgical Environments: Barriers and Facilitators to Nursing Work and Care Team Interactions. Journal of Interior Design, 42(1), 39–65. https://doi.org/10.1111/joid.12089