HCD_2007_Childrens Atlanta Study

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

3

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

5Health Care Design 2007, Dallas TX

We want to see

• The impact of view on staff alertness and stress.• What does that mean to healthcare

organizations?


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)


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


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

9

2003


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


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?


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


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


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


Methods - Statistical

• Paired sample comparison• Multivariate regression• Joint partial F-test• Multivariate regression with interaction terms


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


RESULTS


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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7:00 am 7:00 pm


B. Arousal

Mean arousal – before shift

Mean arousal – after shift

Difference between


means

7.9714 4.4551 -3.51634 8.052 0.000***


• STATISTICALLY SIGNIFICANT DIFFERENCE BETWEEN MEAN AROUSAL SCORES

Arousal

SCORES• DIRECTION OF

DIFFERENCE SUPPORTED

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7:00 am 7:00 pm


C. Acute StressMean acute stress

– before shiftMean acute

stress – after Difference between


shift means

-3.925 -1.835 2.0897 4.535 0.000***


• STATISTICALLY SIGNIFICANT DIFFERENCE BETWEEN MEAN ACUTE STRESS SCORES

Acute Stress

STRESS SCORES• DIRECTION OF

DIFFERENCE SUPPORTED

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7:00 am 7:00 pm


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***


• View significantJoint Partial F-Test2 • View significant

• + 4.8% explanatory power

R2 full model 0.372R2 sub model 0.324

R2 change 0.048


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


• 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


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***


N t Vi

ArousalNature ViewNon-Nature View

No View

247:00 am 7:00 pm


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


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


Acute Stress

N t ViNon-Nature View

No View

Nature View

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7:00 am 7:00 pmHealth Care Design 2007, Dallas TX

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


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
