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HERD VolumE 5, NumbER 1, PP 23-42 CoPyRigHt ©2011 VENDomE gRouP, llC ENViRoNmENtAl CoNgRuENCE iN mEDiCAl/SuRgiCAl uNitS

23 WWW.HERDJOURNAL.COM iSSN: 1937-5867 HERD Vol. 5, No. 1 FALL 2011 • HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 23

Environmental Congruence and Work-Related Stress in Acute Care Hospital Medical/Surgical Units: A Descriptive, Correlational StudyNancy Dendaas, RN, PhD

Abstract

Objective: To describe the degree to which Environmental Congruence (EC) is present in sampled units and considered important/desirable by staff RNs; staff RNs’ reported level of work-related stress (WRS); the perceived contribution of the physical environment to WRS; and the relationship between existing levels of EC and WRS.Background: Few studies have focused on how the physical environment might contribute to nurses’ WRS and chronic nursing shortages. The construct of EC can be used, within a Person Environment (PE)-Fit framework, to assess the fit among nurses, nursing work, the physical work environment, and WRS.Methods: EC was measured using investigator-developed, lit-erature/criterion-based survey instruments. Staff RNs reported WRS variables by using two single-item self-reportmeasures. The final convenience sample consisted of 471 staff RNs from 39 medical/surgical units from 12 hospitals in the upper Midwest. Data were collected over a 7-month period.Results: The mean level of existing EC in the sample was

Author Affiliation: Dr. Dendaas is Clinic Coordinator, Radiation Oncology, at the University of Wisconsin Hospital and Clinics in Madison, WI.Corresponding Author: Nancy Dendaas, RN, PhD, L7/B15 WIMR Building, 1111 Highland Avenue, Madison, WI 53792 ([email protected])

roughly 70% percent of highest capacity and that of important/desired EC in the sample was 93%. Staff RNs’ mean level of WRS was 6.7; the mean contribution of the physical environ-ment to WRS was 5.8. Moderate negative correlations were found between EC and WRS (r = −.41, p < .05), and between physical environment contribution to WRS and EC (r = −.55, p <.001).Conclusions: Staff RNs in the sampled units wanted a signifi-cantly higher level of EC. They rated their WRS moderately high and the contribution of the physical environment to it as mod-erate. A moderately negative relationship was found between EC and WRS. EC may be a useful construct in research that attempts to improve hospital nursing work environments.Key Words: Nurses, nursing work, physical environment, work-related stressPreferred Citation: Dendaas, N. (2011). Environmental congru-ence and work-related stress in acute care hospital medical/surgical units: A descriptive, correlational study. Health Environ-ments Research & Design Journal, 5(1), 23–42.

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BackgroundStressful, unsupportive hospital nursing work en-vironments are considered a contributing factor to chronic nursing shortages, a significant public health problem (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Buerhaus, 2002; McNeely, 2005;

R E S E A R C HHERD VolumE 5, NumbER 1, PP 23-42 CoPyRigHt ©2011 VENDomE gRouP, llC ENViRoNmENtAl CoNgRuENCE iN mEDiCAl/SuRgiCAl uNitS




Sochalski, 2002). They are also associated with laps-es in patient safety and decreased levels of health-care quality (Agency for Healthcare Research and Quality, 2007; Page, 2004). Although the need to improve nursing work environments has been ac-knowledged by multiple stakeholders (Agency for Healthcare Research and Quality, 2007; American Nurses Association, 2002; Joint Commission on Accreditation of Healthcare Organizations, 2002), how to accomplish such improvement is less well understood (Carayon, 2006).

Hospital Work Environments

Contemporary work environments are viewed as multidimensional, dynamic phenomena with in-ternal, external, social/organizational, and physi-cal dimensions (Proshansky, Ittelson, & Rivlin, 1976). Existing nursing research related to hospi-tal nursing work environments has focused on so-cial and/or organizational dimensions (Hinshaw & Atwood, 1983; Kramer & Schmalenberg, 2005; Laschinger & Shamian, 1994; Porter-O’Grady, 2004). The physical dimension of work environments, i.e., the physical environment, has received less attention (Dendaas, 2004). This is problematic given that a fairly extensive body of research continues to demonstrate the impor-tance of the physical environment on worker and organizational outcomes (Brill, 1984; Ulrich & Zimring, 2004).

Work-Related Stress

Work-related stress (WRS), also known as work stress, job stress, or occupational stress, can be defined as “the harmful physical and emotional responses that occur when the requirements of

the job do not match the capabilities, needs, or resources of the worker” (Sauter et al., 1999). A sustained, high level of WRS is considered a significant factor in decreased productivity and occupationally induced disease at the population level (Sauter et al., 1999). It is also associated with negative individual outcomes such as de-creased performance, turnover/absenteeism, and health problems (Caplan, 1975; Dunham, 2001; McLean, 1979).

In healthcare settings, excessive, chronic WRS has traditionally been associated with clinician burnout (Felton, 1998). It is now being linked to negative patient outcomes (Williams, Mc-Murray, Baier-Manwell, Schwartz, & Linzer, 2007). Hospital nursing work is associated with high levels of burnout and WRS (Hertel, 2009; Lawrence & Lawrence, 1987; McNeely, 2005; Ross, Jones, Callaghan, Eales, & Ashman, 2009; Wheeler, 1997). WRS has also been found to be a major factor in decreased job satisfaction levels among nurses (Blegen, 1993; Zangaro & Soeken, 2007).

The Role of the Physical Environment

Human factors engineers have noted a relation-

Environmental psychologists

argue that the physical

environment is an under-

appreciated factor in work-

related stress.



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ship between the physical environment in health-care settings and worker/organizational outcomes (Alvarado, 2007). Architectural scholars have also identified multiple studies that link the physical environment with patient and staff outcomes (Ulrich & Zimring, 2004). Environmental psy-chologists argue that the physical environment is an under-appreciated factor in WRS (Heerwa-gen, Heubach, Montgomery, & Weimer, 1995). One theory that can be used to examine the rela-tionship between workers and the physical work environment is Person-Environment Fit theory.

Person-Environment Fit Theory

Person-Environment (PE) Fit theory is a 20th-century macro-level theory associated with so-cial psychologist Kurt Lewin. Lewin argued that human behavior is a function of the individual within his or her environment (Lewin, 1951). PE Fit theory has been used within a variety of disciplines including vocational counseling psy-chology (Holland, 1992), environmental geron-tology (Lawton, 1980), and correctional psychol-ogy (Gibbs, 1987). Environmental psychologists have argued that PE Fit theory can be used to study the relationship between the worker, the physical environment, and WRS (Heerwagen et al., 1995). In such a context, basic propositions within the theory argue that a “good fit” between workers and the physical environment promotes positive outcomes such as improved performance and job satisfaction, and a “poor fit” promotes negative outcomes such as excessive WRS.

Environmental Congruence

The term environmental congruence (EC) has been

conceptualized as the capacity of the work envi-ronment to promote a good fit between workers and the physical environment (Heerwagen et al., 1995). High levels of EC are thought to be nec-essary to develop and sustain positive worker and organizational outcomes. EC is conceptualized as having two major components: functional congru-ence (FC) and psychosocial congruence (PC).

Functional Congruence

FC is conceptualized as the capacity of the physi-cal environment to facilitate the execution of work by the worker. What FC “looks like” in particular work environments varies based on the work conducted therein. Hospital nursing work has been conceptualized as encompassing four major domains: surveillance, care execution, pa-tient/family support, and care integration (Page, 2004). By the application of the EC framework, these domains can be reconceptualized as capaci-ties within FC. Nursing units with high levels of FC will exhibit attributes within the physical en-vironment that facilitate optimum levels of sur-veillance, care execution, patient/family support, and care integration. What FC looks like within particular units will vary based on the nature of the nursing work done therein. Indeed, data show that nursing practice environments vary across hospital settings (Estabrooks et al., 2002). Optimum surveillance capacities within intensive care units, for example, might look significantly different than optimum surveillance capacities within rehabilitation or long-term care units.

In the present study, the first FC capacity ad-dressed is related to surveillance. It is concep-





tualized as the degree to which patients can be seen and heard from nursing stations and unit corridors. The importance of hospital corridors to patient care has been articulated (Carthey, 2008). Additionally, nurses have been shown to walk extensive distances over the course of a shift (Sturdevant, 1960; Welton, Decker, Adam, & Zone-Smith, 2006). Surveillance is an important, complex component of nursing work directly related to patient safety and healthcare quality. Although it is beyond the scope of this paper to fully examine the nature of nursing surveillance, an example may serve to highlight its salience: Although many hospital patients are admitted in “stable” condition, patients admitted in “guarded” condition require closer surveillance. Impeded surveillance of such patients because of attributes of the physical environment can potentially lead to the development of “failure-to-rescue” sce-narios. Additionally, unexpected deteriorations of stable patients can and do occur. Facilitating nurs-ing surveillance via attributes within the physical environment is, therefore, an important consider-ation when designing hospital units.

The second FC capacity examined in the pres-ent study is care execution, which is assessed by considering a number of attributes including the configuration of the nursing station, i.e., whether it is centralized or decentralized, and whether seating and computers for nurses are readily avail-able. Clearance space around patient beds is also addressed, e.g., is it adequate to accommodate wheelchair and/or gurney transfers? (because pa-tients are frequently transported off unit for diag-nostic tests and procedures). Adequate amounts

of space and clearances are also needed in patient bathrooms because hospitalized patients are fre-quently impaired in functional abilities and need assistive devices (wheelchairs/walkers) to safely access and use toilets. Another issue addressed is whether adequate space exists for routinely used patient care supplies. Large amounts of highly technical equipment are routinely used in con-temporary hospital settings, and it is frequently unaccounted for in space planning. Additionally, nurses cannot efficiently execute patient care tasks if they have to run back and forth to a central-ized storage area for needed supplies (Harrison, 2005). Task lighting must also be adequate.

The third capacity of FC addressed is the degree to which the physical environment facilitates nurses’ support of patient/family psychosocial needs. The relevant attributes examined include, Do patient rooms have designated space and furniture for a family member’s overnight stay? If a family mem-ber does stay overnight, is there enough space for the nurse to continue to access the patient eas-ily or must obstacles be navigated? Is there space and furniture allocated for the nurse to sit and talk with the patient and/or family about impor-tant clinical issues such as discharge plans and/or medication regimens? Is a conference room present on the unit for multimember family dis-cussions? What sorts of nutritional supports are available for patients and families? Patients are of-ten unable to meet mealtime schedules required in large institutions.

The final capacity of FC addressed in the present study is the degree to which the physical envi-



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ronment facilitates nursing work related to care integration. Attributes examined include: Is an adequate amount of seating for nurses present for the most heavily staffed shift report? Are admin-istrative supplies (lab requisitions, patient labels, phone numbers, pager numbers, etc.) readily ac-cessible in commonly used work areas? And al-though electronic health records are converting a lot of administrative work into an electronic for-mat, once again, are the space requirements for technology (i.e., computers and related equip-ment) within the physical environment acknowl-edged and accounted for?

In summary, functionally congruent nursing work environments are conceptualized as environments adequately sized, designed, and equipped for the type of nursing work done within them. In the present study, attributes within the physical en-vironment that are thought to facilitate nursing work on medical/surgical units are assessed. If the conceptual framework for the study is valid, functionally congruent work environments will promote efficiency and productivity, reduce nurs-es’ WRS, and may thereby enhance patient safety and healthcare quality. Work environments that are not functionally congruent will not promote efficiency and productivity, will increases nurses’ WRS, and may subsequently diminish patient safety and healthcare quality.

Psychosocial Congruence

Psychosocial congruence (PC), the other major component of EC, is conceptualized as the capac-ity of the physical environment to support the psychosocial well-being of workers. Heerwagen

and colleagues (1995) note that the psychosocial needs of workers can be conceptualized using a variety of theoretical frameworks. In the present study, a Maslovian human developmental frame-work is used (Maslow, 1943). Maslow’s theory posits that human development requires sequen-tially addressing lower-level needs related to safe-ty and personal security, midlevel needs related to belonging and self-esteem, and higher-level needs related to goal achievement, the search for meaning, and attaining fulfillment. Lower-level needs must be successfully addressed before work on higher-level needs can be initiated. Design attributes within the physical environment that address these three levels of needs are conceptual-ized as subcomponents of PC.

The first capacity of PC addressed in the present study is nurses’ need for safety and security. These needs are conceptualized to include the accessibil-ity of staff restrooms, personal protective equip-ment (PPE), and patient transfer equipment. Restroom accessibility is important because units can be large and nurses’ patient assignments are generally based on illness acuity rather than ge-ography. Hospital patients (especially those on medical units) are generally not admitted in a systematic fashion. Thus nurses may cover large distances during their shifts because their as-signed patients may be scattered throughout the unit. For similar reasons, appropriate types and amounts of PPE and patient transfer equipment must be readily accessible.

The second capacity of PC examined is nurses’ need for belonging and self-esteem. Nurses pe-





rennially lament that they “get no respect.” The manifestation of this within the physical environ-ment may have to do with the absence of per-sonal work space allocated for nurses within most hospital unit designs. Fully addressing the lack of personal work space for nurses within hospitals is, again, beyond the scope of this paper because larger historical and socio-cultural issues are in-volved. Within the present study, the attributes conceptualized to address belonging and self-es-teem needs within the physical environment are the presence, size, and location of personal lock-ers and work space for nurses.

The third and final capacity of PC addressed in the present study is nurses’ higher-level needs for professional achievement, meaning, and fulfill-ment. These needs are conceptualized as address-ing the amount of space for respite and privacy, necessary for critical reflection and professional development. It also examines the amount and type of space allocated for continuing education resources, professional accomplishments, and pa-tient/family communication.

In summary, psychosocially congruent nursing work environments are conceptualized as envi-ronments designed and equipped to meet the multilevel psychosocial needs of a highly trained, professionally oriented work force engaged in challenging, complex knowledge work. In the present study, attributes within the physical envi-ronment that are thought to facilitate the attain-ment of nurses’ psychosocial needs are assessed. If the study’s conceptual framework is valid, psy-chosocially congruent work environments will

promote trust, teamwork, reflective practice, and job satisfaction and may thereby enhance patient safety and healthcare quality. Work environments that are not psychosocially congruent will not promote trust, teamwork, reflective practice, and job satisfaction and will increase nurses’ WRS and possibly subsequently diminish patient safety and healthcare quality.

Taken together, FC and PC constitute EC. Be-cause the degree to which EC is present in hospi-tal nursing work environments has not been stud-ied, a descriptive study was undertaken to assess existing and desired levels of FC, PC, and EC. Medical/surgical units were chosen as the type of nursing unit to examine because of their ubiquity in acute care hospitals, the acknowledged high levels of WRS that exist within such environ-ments (Hertel, 2009), the fairly homogenous na-ture of the nursing work performed therein, and their designation as a distinct type of unit within American Institute of Architecture (AIA) design and construction standards (Facilities Guidelines Institute, 2006). Additionally, the relationship between existing levels of EC and nurses’ WRS was explored. A schematic representation of the conceptual framework for the study is shown in Figure 1.

PurposeThe purpose of the study was to describe existing and important/desired levels of EC in acute care hospital medical/surgical units and to describe the relationship between existing EC levels and perceived levels of WRS. The specific research questions were:



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• TowhatdegreeisECpresentinacutecarehos-pital medical/surgical units?

• Towhat degree is EC considered important/desirable by staff nurses (RNs) working on such units?

•WhatoveralllevelofWRSisreportedbystaffRNs working on such units?

• Towhatdegreedoesthephysicalenvironmentcontribute to their WRS?

•Whatistherelationshipbetweenexistinglevelsof EC and WRS?

MethodsStudy Design and Sample

A descriptive correlational survey design was used; the study was conducted using a conve-nience sample. Data from a preliminary study using three medical units were used to calculate

minimum sample sizes. Based on the preliminary study’s variance data, a 95% confidence inter-val, and accepted sample indices for a descriptive study design (Hulley et al., 2001), a minimum sample size of 27–32 units and 270–320 staff RNs was calculated as being needed. Medical/surgical units from acute care hospitals located in the upper Midwestern United States, and the staff RNs working on the units, were targeted. The in-clusion criteria for hospitals included designation as an acute care facility. The inclusion criteria for units included designation as a medical, surgical, and/or medical/surgical unit. The exclusion crite-ria for hospitals included designation as a specialty care facility (such as psychiatric or rehabilitation); the exclusion criteria for units included designa-tion as a unit oriented toward long-term care, rehabilitation, intensive care/step-down, and/or

Figure 1. Conceptual framework.

Nursing Work Surveillance Care Execution Patient/Family Support Care Integration

Physical Environment Size/Space Design Furnishings/Supplies

Nurses’ Psychosocial Needs Safety/Security Belonging/Self-Esteem Achievement/Meaning/Fulfillment

Functional Congruence (FC)

Psychosocial Congruence (PC)

Environmental Congruence (EC)

Work-Related Stress (WRS)





pediatric-only populations. Inclusion criteria for nurses included staff RN status, and full- or part-time employment for a minimum of 6 months on the assessed unit. The exclusion criteria for nurses included designation as a manager, educator, and/or advanced practice RN.

Recruitment Activities

The sample was recruited using a two-pronged, stepwise approach. The first prong utilized a pro-fessional networking approach. The investigator sent a recruitment e-mail (in the form of an an-nouncement/invitation to participate) to students in the doctoral nursing listserv maintained by the University of Wisconsin, Milwaukee College of Nursing. The e-mail was sent in July 2007. A number of positive responses were generated from this e-mail, and contact with administrators and unit managers was initiated.

The second prong utilized a personalized recruit-ment letter mailed to the chief nursing adminis-trator of acute care hospitals within a 200-mile radius of the investigator’s home address. The recruitment letter was sent shortly after the e-mail was sent to professional colleagues. The list of potentially eligible hospitals/administrators was generated by using the “quality check” link within The Joint Commission Web site (http://www.JointCommission.org/). The recruitment letter included a stamped postcard, addressed to the investigator, with a check box to indicate level of interest and a space to designate contact infor-mation. An initial mailing of 80 letters/postcards was sent in July 2007. The mailing resulted in 36 returned postcards (a 45% return rate). Twenty-

three nursing administrators (63%) indicated in-terest in participating, 10 (27.7%) indicated no interest, and three (8%) indicated possible inter-est.

Whether obtained via e-mail or letter, adminis-trators interested in participating were contacted on a first-come, first-served basis. Information was obtained related to type and number of eli-gible units, the names of the respective unit man-agers, the number of eligible RNs on staff, and whether the hospital had an institutional review board (IRB).

The response to the two-pronged recruitment ap-proach was such that within a couple of months, 39 units from 12 hospitals were scheduled to par-ticipate. The total number of eligible staff RNs within the 39 units was 1,510. Because obtaining the minimum number of units and staff RN par-ticipants was anticipated, further efforts to recruit additional hospitals/units were suspended.

IRB Approvals

IRB approval for the study, including plans re-lated to recruitment and human subject protec-tions, were obtained from the investigator’s home institution prior to the initiation of recruitment efforts. Prior to the start of data collection, IRB approvals were obtained from all hospitals with IRBs.

Instruments

EC was measured using two investigator-de-veloped, criterion-based, survey-type instru-ments: the Environmental Congruence Index



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(ECI) and the Nurses’ Assessment of Environ-mental Attributes (NAEA). The content for both instruments was generated from existing literature including the AIA Guidelines for Design and Construction of Health Care Fa-cilities (Facilities Guidelines Institute, 2006) and the Institute of Medicine report, Keeping Patients Safe: Transforming the Work Environ-ment of Nurses (Page, 2004). As noted earlier, hospital nursing work was conceptualized as encompassing surveillance, care execution, patient/family support, and care integration domains; nurses’ psychosocial needs were con-ceptualized within a Maslovian framework and grouped into three levels: safety/secu-rity; belonging/self-esteem; and achievement/meaning/fulfillment. An expert panel consist-ing of two practicing hospital architects and three nursing administration researchers was used to assess the initial face/content validity of the instruments. The instruments were also pilot-tested with staff RNs on three medical/surgical units not included in the final sample. Clarifications and modifications were made to the instruments following the expert review and pilot testing.

Environmental Congruence Index

The ECI is a 35-item instrument that measures the capacity of the physical environment to sup-port and/or facilitate the execution of nursing work (FC) and the attainment of nurses’ profes-sionally oriented psychosocial needs (PC). Items are scored using a Likert-type scale (1 = lowest level of support; 4 = highest level of support). Items are scored using direct observation, review

of architectural floor plans, and consultation with unit managers and facilities/engineering personnel. Possible FC, PC, and EC scores range from 22–88, 13–52, and 35–140, respectively.

Nurses’ Assessment of Environmental

Congruence

The NAEA is a 40-item instrument, the first 35 of which mimic the first 35 items of the ECI. NAEA items are also scored using a 1–4 Likert-type scale (1 = strongly disagree, 2 = disagree somewhat, 3 = agree somewhat, 4 = strongly agree). Nurses are asked to rate the degree to which specified items are currently present in the physical environment as well as the degree to which it is important/de-sirable for items to be present in the physical en-vironment. Present and important/desired levels of FC, PC, and EC range from 22–88, 13–52, and 35–140, respectively. Two additional NAEA items ask nurses to rate WRS (item #36) and the contribution of the physical environment to WRS (#37). These items are scored using a 1–10 scale, with 1 = no stress/no contribution, 5 = moderate stress/moderate contribution, and 10 = extreme stress/extreme contribution. Three final, open-ended items within the NAEA ask nurses to de-scribe best, worst, and other noteworthy aspects of the physical work environment (items 38–40, respectively).

Examples of two items from the ECI and NAEA instruments are shown in Table 1. Demograph-ic data at the hospital, unit, and staff RN levels thought to be pertinent to the variables of interest were also collected. A copy of the complete instru-ments can be obtained by contacting the author.





ProcedureAfter obtaining IRB approvals as needed, site visits were scheduled with unit managers and facilities maintenance personnel at participating hospitals. Additionally, the investigator prepared an appropriate number of NAEA questionnaire packets (one packet for each eligible staff RN) for each unit included in the sample. NAEA ques-tionnaire packets consisted of a cover letter/invi-tation to participate, a hospital- and unit-coded NAEA questionnaire, a piece of wrapped choco-late, and a stamped return envelope addressed to the investigator. During site visits, the investiga-tor collected ECI data with assistance as needed from unit managers and facilities maintenance personnel. NAEA packets were left with the unit managers for distribution at a time deemed ap-propriate by the manager.

Data were collected over a 7-month period (September 2007–April 2008). Following col-lection, data were numerically coded and en-tered into data files using SPSS for Mac soft-ware (v.16). The resulting data matrices were then inspected for irregularities and cleaned using techniques described by Polit and Beck (2004). Corrections were made when errors were attributable to simple transcription error. NAEA questionnaires with missing data for congruence and WRS variables were removed from the data set.

Data Analysis

The plan for data analysis included (1) generating descriptive statistics for the demographic vari-ables within the ECI and NAEA data sets; (2) ex-amining data from the open-ended NAEA ques-

Instrument/Item No. ECI/NAEA Score ECI/Item 8: Percentage of patient rooms with recommended AIA minimum clearance around the patient bed.

1 0–24

percent

2 25–50

percent

3 51–74

percent

4 75–100 percent

NAEA/Item 8a: There is enough space around patient beds for easy wheelchair-to-bed and/or gurney-to-bed transfers.

1 Strongly Disagree

2 Disagree

Somewhat

3 Agree

Somewhat

4 Strongly

Agree NAEA/Item 8b: There should be enough space around patient beds for easy wheel chair -to-bed and/or gurney-to-bed transfers.

1 Strongly Disagree

2 Disagree

Somewhat

3 Agree

Somewhat

4 Strongly

Agree ECI/Item 30: Percentage of RN/LPN staff with individual storage space for work-related supplies.

1 0–24

percent

2 25–50

percent

3 51–74

percent

4 75–100 percent

NAEA/Item 30a: Nursing staff has personal workspace for work-related supplies.

1 Strongly Disagree

2 Disagree

Somewhat

3 Agree

Somewhat

4 Strongly

Agree NAEA/Item 30b: Nursing staff should have personal workspace for work-related supplies.

1 Strongly Disagree

2 Disagree

Somewhat

3 Agree

Somewhat

4 Strongly

Agree

Table 1. Examples of ECI and NAEA Items



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tions to assess for substantive missing content; (3) assessing the reliability of staff RN responses by using the Cronbach’s alpha test statistic; (4) describing FC, PC, and EC levels within the ECI and NAEA data sets at the item, subscale, scale, and instrument level; and (5) computing bivari-ate Pearson correlation coefficients for the EC and WRS variables.

ResultsECI data were collected from 39 units in 12 hospitals; the final ECI data set used for statis-tical analysis consisted of these 39 units. Mean/SD for total unit size in square footage was 16,782/6,004 with a range from 6,021–30,983 (n = 36; data not obtained for three units). Fif-teen hundred ten (1,510) NAEA questionnaire packets were delivered to unit managers. Five hundred thirty four (534) NAEA question-naires were returned for an overall response rate of 35.4%. NAEA response rates by hospital ranged from 18.8%–52.5%. NAEA response rates by unit ranged from 12.5%–75%. After removing NAEA questionnaires with missing data for the congruence and WRS variables, a final NAEA data set containing 471 cases was generated. Additional hospital, unit, and RN demographics are shown in Tables 2 and 3.

Level of EC Present

The raw mean scores at the subscale, scale, and instrument level are shown in Table 4. The investigator and nurses scored the attributes similarly. Fairly significant standard deviations indicate that a range of FC, PC, and EC scores was observed. The conversion of raw scores to

percentage of highest possible score (capacity) revealed that both the investigator and nurses found existing levels of EC (the capacity of the work environment to promote a good fit between the physical environment and the worker) to be moderately high (73% and 68.5% of highest capacity, respectively). Moderately high mean levels of FC (the capacity of the physical envi-ronment to facilitate the execution of work by the worker) and PC (the capacity of the physical environment to promote the psychosocial well-being of the worker) were also found. The inves-tigator scored FC and PC at 68.5% and 73.0% of highest capacity; the nurses scored FC and PC at 65.7% and 73.2% of highest capacity. Reliability statistics for the 471-case NAEA data set, using the Cronbach alpha test statistic, were .845 for the FC scale, .833 for the PC scale, and .895 for the instrument.

Additional Analysis

Although not asked within the original research questions, the number of units in the sample (n = 39) allowed for an additional question to be posed during data analysis: Did the date of last major renovation relate to existing mean levels of FC, PC, and EC? The range of reno-vation dates within the sample was such that two groups of units could be generated: those renovated before 2000 (n = 18) and those reno-vated in 2000 or later (n = 20). FC, PC, and EC levels were then compared in both ECI and NAEA data sets using paired sample t-tests (the 471-case NAEA data set of attributes “present” in the environment was aggregated into a 39-case set of unit-level means).





Findings from the ECI data set revealed that FC, PC, and EC levels were higher in units renovated in 2000 or later, and the differences were statistically significant (see Table 5). The NAEA data set demonstrated similar findings with the exception of PC levels (the difference between pre- and post-2000 levels was not

statistically significant). The results support existing theory of hospital design as an evolv-ing phenomenon (Thompson & Goldin, 1975; Verderber & Fine, 2000).

Variable Frequency Percentage Hospital type Academic medical center 01 8.3 Community-based 10 83.3 Critical access 01 8.3 Total 12 99.9 Unit type Medical 12 30.8 Surgical 07 18.0 Medical/surgical 20 51.2 Total 39 100.0 Unit configuration Racetrack 18 46.2 Single corridor 4 10.3 Intersecting corridor 17 43.6 Total 39 100.1 Number of beds on unit 20 or fewer 7 17.9 21–30 10 25.6 31–40 12 30.8 >41 10 25.6 Total 39 99.9 Room types within units Private only 22 56.4 Semiprivate only 1 2.6 Mixed private and semiprivate 16 41.0 Total 39 100.0 Date of last major renovation 1960s 02 53 1970s 10 26.3 1980s 0 0 1990s 06 15.8 2000s 20 52.6 Total 38* 100.0 *Data missing for one unit

Variable Frequency Percentage Number of years RN 0–5 191 40.6 6–10 68 14.4 11–15 45 9.6 >15 166 35.2 Missing 1 .2 Total 471 100.0 Years on unit 0–2 135 28.7 3–5 113 24.0 6–8 58 12.3 >8 163 34.6 Missing 2 .4 Total 471 100.0 Shift worked Days 112 23.8 Evenings 53 11.3 Nights 61 13.0 Combination 243 51.6 Missing 2 .4 Total 471 100.0 Age 21–30 135 28.7 31–40 106 22.5 41–50 110 23.4 >50 115 24.4 Missing 5 1.1 Total 471 100.0 Education Diploma 50 10.6 Associate 187 39.7 Bachelor’s 215 45.6 Graduate 18 3.8 Missing 1 .2 Total 471 100.0

Variable Frequency Percentage Hospital type Academic medical center 01 8.3 Community-based 10 83.3 Critical access 01 8.3 Total 12 99.9 Unit type Medical 12 30.8 Surgical 07 18.0 Medical/surgical 20 51.2 Total 39 100.0 Unit configuration Racetrack 18 46.2 Single corridor 4 10.3 Intersecting corridor 17 43.6 Total 39 100.1 Number of beds on unit 20 or fewer 7 17.9 21–30 10 25.6 31–40 12 30.8 >41 10 25.6 Total 39 99.9 Room types within units Private only 22 56.4 Semiprivate only 1 2.6 Mixed private and semiprivate 16 41.0 Total 39 100.0 Date of last major renovation 1960s 02 53 1970s 10 26.3 1980s 0 0 1990s 06 15.8 2000s 20 52.6 Total 38* 100.0 *Data missing for one unit




Table 2. Hospital and Unit Demographics Table 3. Staff RN Demographics



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Table 4. “Present/Existing” Raw Scores at Subscale, Scale, and Instrument Level (n = 39)

Table 5. “Important/Desirable” Versus “Present/Existing” NAEA Raw Scores at the Subscale, Scale, and Instrument Level (n = 471)

Item No. Variable ECI Mean (SD) NAEA Mean (SD)

1–4 Surveillance capacity (possible range 4–16, midpoint = 10)

9.31 (3.35) 10.18 (1.24)

5–13 Care execution capacity (possible range 9–36; midpoint = 22.5)

26.38 (5.86) 24.77 (3.30)

14-19 Patient family support capacity (possible range 9–36; midpoint = 21)

15.38 (4.52) 14.45 (2.73)

20-22 Care integration capacity (possible range 3–12; midpoint = 7.5)

9.21 (2.14) 8.43 (1.07)

1-22 Functional Congruence (possible range 22-88; midpoint = 55)

60.28 (13.36) 57.84 (6.72)

23–26 Safety/security capacity (possible range 4–16; midpoint = 10)

12.69 (1.75) 12.33 (0.83)

27–31 Belonging/self-esteem capacity (possible range 5–20; midpoint = 12.5)

14.79 (2.43) 13.65 (2.32)

32–35 Achievement/meaning/fulfillment capacity (possible range 4-16; midpoint = 10)

14.45 (1.21) 12.11 (1.45)

23–35 Psychosocial Congruence (possible range 13–52; midpoint 31.5)

41.93 (3.46) 38.08 (3.69)

1–35 Environmental Congruence (possible range 35-140; midpoint 105)

102.21 (15.40) 95.92 (9.52)

Scoring: 1 = strongly disagree/lowest level of support; 4 = strongly agree/highest level of support

Item No. Variable Mean (SD)

“Important/Desirable” Mean (SD)

“Present/Existing” Mean

Difference t(df = 470)

Sig (2-tailed)

1–4 Surveillance capacity (possible range 4-16, midpoint = 10)

13.53(2.07) 10.17(2.33) 3.36 27.38 .000

5–13 Care Execution capacity (possible range 9-36; midpoint = 22.5)

34.06(1.69) 24.84(4.84) 9.22 38.86 .000

14–19 Pt/Family Support capacity (possible range 9-36; midpoint = 21)

20.88(2.67) 14.59(3.99) 6.29 29.72 .000

20–22 Care Integration capacity (possible range 3-12; midpoint = 7.5)

10.92(1.20) 8.55(1.78) 2.37 27.67 .000

1–22 Functional Congruence (possible range 22-88; midpoint = 55)

79.39(5.18) 58.15(9.99) 21.24 41.98 .000

23–26 Safety/Security capacity (possible range 4-16; midpoint = 10)

15.63(0.82) 12.31(2.27) 3.33 31.83 .000

27–31 Belonging/Self-Esteem capacity (possible range 5-20; midpoint = 12.5)

19.17(1.48) 13.88(3.58) 5.29 29.60 .000

32–35 Achievement/Meaning/Fulfillment capacity (possible range 4-16; midpoint = 10)

15.38(1.18) 12.15(2.65) 3.23 26.04 .000

23–35 Psychosocial Congruence (possible range 13-52; midpoint 31.5)

50.18(2.80) 38.34(6.74) 11.84 36.28 .000

1–35 Environmental Congruence (possible range 35-140; midpoint =89)

129.57(6.85) 96.50(15.10) 33.12 43.71 .000

Item scoring: 1 = strongly disagree/lowest level of support; 4 = strongly agree/highest level of support





Level of EC Considered Important/Desirable

The mean raw scores for the attributes, both im-portant/desirable and existing (present), at the subscale, scale, and instrument levels are shown in Table 5. The scores for important/desirable levels were higher than existing (present) levels and the differences were statistically significant at the subscale, scale, and instrument levels. The conversion of raw scores to percentage of high-est possible score (capacity) revealed that nurses wanted significantly higher capacities of FC, PC, and EC to be present within the work environ-ment (90.2%, 96.5%, and 92.6% of highest ca-pacity, respectively).

Additional Analysis

Again, although not addressed in the original research questions, the number of staff RN par-ticipants in the sample (n = 471) allowed such additional questions to be posed as whether dif-ferences in FC, PC, and EC importance/desir-ability levels exist among demographic variables: Do older RNs want higher levels of FC, PC, and/or EC than younger RNs? Do education and/or years of experience affect desired levels? Do age and/or years of experience relate to WRS and/or the perceived contribution of the physical envi-ronment to WRS? Does the size/type of unit or date of last renovation have an impact on per-ceived levels of congruence and/or WRS? These are somewhat complex issues and will be ad-dressed in a secondary analysis of the data.

One additional analysis that can be presented within the present report involves importance/desirability data at the item level. The five items

that staff RNs ranked highest in importance/desirability were (1) Item 8b: There should be enough space in patient rooms for easy bed-to-gurney or bed-to-wheelchair transfers (mean/SD = 3.98/0.15); (2) Item 11b: There should be enough lighting for performing patient-related tasks (mean/SD = 3.96/0.20); (3) Item 23b: Per-sonal protective equipment (PPE) should be read-ily accessible on the unit (mean/SD = 3.96/0.20); (4) Item 9b: There should be enough space in pa-tient bathroom; and (5) Item 10b: There should be enough space in patient rooms for patient care-related supplies (mean/SD = 3.95/0.22).

The five items that staff RNs ranked lowest in importance/desirability were (1) Item 5b: Nurs-ing station(s) should be decentralized (mean/SD = 2.78/1.04); (2) Item 17b: There should be desig-nated seating for the nurse in patient rooms (mean/SD = 2.86/0.96); (3) Item 1b: Patients should be visible from the nursing station(s) (mean/SD = 3.02/0.78); (4) Item 22b: Patient rooms should be equipped with work-related supplies (phone numbers, lab slips, etc.) (mean/SD = 3.19/0.91); and (5) Item 3b: Patients should be audible from the nursing station(s) (mean/SD = 3.20/0.78).

The five items judged to have the greatest discrep-ancy between what was present versus what was deemed important/desirable to be present were Item 9b: space in patient bathrooms for easy wheelchair-to-toilet transfers (mean difference = −1.84); Item 8b: space in patient rooms for easy bed-to-gurney or bed-to-wheelchair transfers (mean difference = −1.61); Item 31b: adequately sized personal work space for nurses (mean dif-



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ference = −1.44); Item 1b: patient visibility from nursing station (mean difference = −1.37); and Item 30b: presence of personal work space for nurses (mean difference = −1.30).

Staff RN Ratings of Work-Related Stress

The staff RNs rated their mean (SD) level of over-all WRS at 6.73 (1.79). Roughly 4.2% of nurses rated their overall WRS as low (1–3); 54.0% rat-ed it as moderate (4–7); and 41.0% of the nurses rated their overall WRS as extreme (8–10).

Contribution of Physical Environment to WRS Staff RNs rated the mean (SD) contribution of the physical environment to WRS at 5.83 (2.01). Twelve percent of nurses judged the contribution as none to minor (1–3); 64.5% rated the con-tribution as moderate (4–7), and 23.4% rated the contribution of the physical environment to WRS as extreme (8–10).

Relationship Between Environmental

Congruence and Work-Related Stress

A moderately strong positive correlation was present between level of WRS and level of physi-cal environment contribution to WRS (r = .76, p < .001), i.e., higher WRS levels were associated with higher scores for the contribution of the physical environment to WRS. Moderate nega-tive correlations were present between level of WRS and FC (r = −.39, p < .001), WRS and PC (r = −.39, p < .05), and WRS and EC (r = −.41, p < .05). In other words, higher levels of WRS scores were moderately associated with lower lev-els of FC, PC, and EC. Moderate negative cor-relations were also present between the level of

the physical environment’s contribution to WRS and FC (r = −.57, p < .001), the level of the physi-cal environment’s contribution to WRS and PC (r = −.43, p < .01), and the level of the physical environment’s contribution to WRS and EC (r = −.55, p < .001). In other words, units where the contribution of the physical environment to WRS was judged to be high were associated with lower levels of FC, PC, and EC.

DiscussionThe meanings associated with the findings are considered sequentially, as they relate to the re-search questions.

Research Questions 1 and 2: Existing Versus

Desired Levels of EC

Both the investigator and nurses found exist-ing levels of EC to be roughly 70% of capacity. Although this level has been labeled as moder-ately high, it is a somewhat arbitrary labeling at this point because the level of EC associ-ated with optimal outcomes of interest such as WRS, healthcare quality, patient safety, worker performance, and organizational productivity is unknown. Future research, for example, might reveal that a higher level of FC is needed for pa-tient safety outcomes, such as time to adminis-tration of first antibiotic, failure-to-rescue rates, or patient/family satisfaction scores. Higher levels of existing PC might be shown to be asso-ciated with greater levels of engagement, team-work, and/or job satisfaction. Additionally, dif-fering levels and aspects of EC might be needed within different types of units; i.e., maximum levels of visual/auditory surveillance capacity





might be vital in intensive care units, and pri-vacy issues may be more salient in rehabilitation and/or long-term care units.

If this study sample is a fairly accurate representa-tion of reality (i.e., if the results are generalizable to the larger population of acute care medical/surgical units), the fact that nurses wanted EC levels at approximately 93% of capacity is an in-dication that a serious deficit of environmental congruence may be present in acute care hospi-tal medical/surgical units. If this is the case, and if EC is related to outcomes of interest (WRS, patient safety, healthcare quality, etc.), then de-veloping and testing interventions based on the conceptual framework may be a promising area for future research.

On the other hand, the finding that significant discrepancies between existing and important/desired levels of EC are present may not be inher-ently noteworthy, i.e., the desire for “more” may be a common desire among modern workers. However, the fact that nurses assigned relatively low levels of importance/desirability to decentral-ized nursing stations (Item 5b) and furniture for nursing in patient rooms (Item 17b) is an indica-tion that the nurses did discriminate and draw distinctions among the attributes presented in the NAEA instrument.

Another aspect of the significant differences between existing and important/desired lev-els of attributes within the physical environ-ment is that the finding may be a reflection of the gendered, overwhelmingly female nature of

the nursing profession. Feminist architects and scholars have argued that women’s needs for space and resources have traditionally been ne-glected and/or marginalized (Ahrentzen, 1996; Spain, 1992; Weisman, 1992). It is only recently that the importance of nurses and nursing work for patients’ health-related outcomes have been recognized (Aiken et al., 2002). It would be in-teresting to examine existing versus important/desired levels of EC in primarily male service-oriented professions (i.e., firefighters or police officers).

Finally, it is noteworthy that three of the five at-tributes rated highest in importance/desirability involved issues related to space, and that four of the five attributes with the greatest discrepancy between existing and desired levels also involved issues related to space. The impact of crowding on human behavior and stress has been noted for decades (Altman, 1975; Baum & Epstein, 1978; Nagar, 1998). If nurses on medical/surgical units are experiencing WRS because of crowding, it

If nurses on medical/surgical

units are experiencing WRS

because of crowding, it may be

important to continue to assess

the adequacy of AIA minimum

recommendations for room

size and clearances in patient

rooms and bathrooms.



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may be important to continue to assess the ad-equacy of AIA minimum recommendations for room size and clearances in patient rooms and bathrooms.

Research Questions 3, 4, and 5: WRS, the

Physical Environment’s Contribution to WRS,

and the Relationship Between EC and WRS

The finding that nurses rated their overall WRS as moderate to high was not particularly surprising and supports existing evidence about the stressful nature of hospital nursing work. Two new find-ings did emerge from the study data, and both supported propositions within the conceptual framework. The first was that nurses judged the physical environment as contributing moderately to their WRS. The second was that WRS was moderately negatively associated with EC levels. Two systematic reviews (Blegen, 1993; Zangaro & Soeken, 2007) have shown WRS to be the ma-jor factor in low levels of job satisfaction among nurses. If the study’s conceptual framework is valid, enhancing EC should theoretically lead to reduced WRS and enhanced job satisfaction. The findings for the last two research questions offer support for the propositions within the conceptual framework. The findings also suggest avenues for further research by nursing research-ers searching for ways to improve nursing work environments as well as architects and designers interested in developing evidence-based design.

Human factors engineers contend that work en-vironments in healthcare settings are complex socio-technical systems comprising smaller sub-systems: workers, work-related tasks, the tools

and technologies used to execute tasks, the physi-cal environment, and organizational factors (Car-ayon, 2006). This perspective maintains that to understand and improve problematic work sys-tems one must understand both the small subsys-tems that comprise it, and the larger system(s). Although the present study’s conceptual frame-work has been placed within the more broadly abstract PE Fit theory, it could also be adapted to Carayon’s human factors framework because it reports on three of the subsystems (workers, tasks, physical environment) within a distinct type of complex socio-technical system (medi-cal/surgical nursing units in acute care hospitals). Human factors engineering has much to offer to-ward the development of FC in hospital nursing work environments.

On the other hand, contemporary architectural and environmental theorists have argued for the importance of incorporating nature or biophilia-based design elements into built environments (Heerwagen & Orians, 1993; Porteous, 1996; Ulrich, 1995). Indeed, incorporating nature-based elements into healthcare environments may be a good way to address workers’ higher level PC needs. Addressing these needs more concretely may in turn ameliorate or mitigate WRS.

Finally, although the present study has attempt-ed to address a relatively understudied aspect of nursing work environments (i.e., the physical environment), the most environmentally con-gruent work environment is still going to need enlightened and supportive management practic-es. Indeed, the theoretical underpinnings for the





conceptual framework are fairly rudimentary at present in that the instruments used in the study were based on existing AIA design and construc-tion guidelines and the broad brushstrokes of the nursing work domains (surveillance, care execu-tion, etc.) articulated in the 2004 IOM report, Keeping Patients Safe (Page, 2004). Fully realized EC may need to encompass attributes within both the physical and the social/organizational environments. For example, although nurses’ psychosocial needs for belonging and self-esteem might be enhanced by the allocation of more dedicated personal work space in the physical en-vironment, their higher-level needs for achieve-ment, meaning, and fulfillment might be more readily addressed via the social/organizational environment. Additionally, the complexity of the nursing work domains may necessitate that fu-ture theoretical and research work become much more focused; i.e., what is the nature of surveil-lance in hospital nursing work? How can or how should surveillance be optimized given the cur-rent efforts to maximize patient privacy?

Limitations of the Study

The present study has several limitations: First, it used a small convenience sample, heavily weighted toward smaller community hospitals in the upper Midwest. It is not known whether similar findings could be demonstrated in urban academic medical centers or in other parts of the country. Second, the focus on medical/surgical units precludes the findings being generalized to other types of nurs-ing units. Third, the fact that the dates for the last major renovation of the units ranged over decades

makes it inappropriate to generalize the findings to more recently designed units. Fourth, only one measure of EC was conducted using the ECI. Fifth, the instruments used in the study have had limited psychometric testing.

Conclusion As the demand for safe, high-quality healthcare con-tinues to grow, researchers must continue to search for long-term solutions to chronic nursing shortages associated with problematic work environments. EC, within a conceptual framework based on PE Fit theory, may be a useful construct with which to study the relationships among nurses, nursing work, the work environment, and a variety of nurse, patient, and organizational outcomes of interest.

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