Abstract
Objective:
The purpose of this study is to evaluate staff perceptions of environmental quality before and after the renovation of an existing open-bay neonatal intensive care unit (NICU) and the addition of 23 single-family NICU rooms in the Wasie Neonatal ICU at Joe DiMaggio Children's Hospital.
Methods:
This study utilized pre- and post-move surveys to investigate staff perceptions of the NICU.
Results:
Overall, staff members perceive the quality of the work environment, and the safety and quality of the environment provided to patients and their families, as better in the renovated, combination NICU design (SFR and open bay) when compared to the open-bay, pre-move design.
Conclusion:
In spite of the potential drawbacks of having SFRs in the NICU, the study demonstrates that nurses may perceive associated benefits, such as a reduction of job stress and improvements in parental privacy, along with other positive outcomes.
Keywords
Objective
The purpose of this investigation is to evaluate staff perceptions of environmental quality before and after the renovation of an existing open-bay neonatal intensive care unit (NICU) and the addition of 23 single-family NICU rooms in the Wasie NICU at Joe DiMaggio Children's Hospital. The study specifically examines perceptions in two categories: (1) quality of the work environment for staff; and (2) safety and quality of the NICU environment for infants and their families.
Background
A growing body of research evidence demonstrates that environmental conditions affect the well-being of patients, family members, and staff (Ulrich et al., 2008). Perhaps nowhere in the healthcare environment is this more important than in the NICU, where fragile infants fight for survival. For many years the NICU setting has consisted of open-bay multibed environments, but in recent years there has been a surge in the design and construction of single-family rooms (SFRs) and a trend toward providing more family-centered care in the NICU (Domanico, Davis, Coleman, & Davis, 2010). An individual room allows each infant to receive levels of stimuli appropriate for its developmental needs and affords privacy to family members (White, 2003). Yet there are also disadvantages to implementing the SFR model, such as increased costs and the increased isolation of staff members. Hospital decision makers today wrestle with whether to implement the SFR model when designing or redesigning a NICU, and few studies document the advantages and disadvantages of the SFR design approach.
SFRs have become popular because of the potential benefits they offer. There is evidence that providing individualized developmental care for preterm infants is important for their well-being (Als et al., 1994). The SFR environment may better support developmental care by providing greater control over environmental stimuli including noise and light, although rigorous evidence to substantiate this claim is lacking (Smith, Schoenbeck, & Clayton, 2009). However, at least one study demonstrates adverse effects for neonates exposed to high levels of noise (Bremmer, Byers, & Ermalynn, 2003) and bright light.
For parents, SFRs offer increased privacy when breastfeeding and providing kangaroo care (skin-to-skin contact), which have demonstrated benefits for infants (Ferber & Makhoul, 2004). True privacy—particularly auditory privacy—cannot be achieved in an open-bay environment (White, 2003). Private rooms help hospital staff comply with the requirements of the Health Insurance Portability and Accountability Act (HIPAA), which protects patient privacy (Mathur, 2004). SFRs might even reduce infection rates, although this has yet to be demonstrated in the NICU population (Mathur, 2004; Shepley, Harris, & White, 2008).
Stevens, Helseth, Khan, Munson, and Reid (2011) demonstrated that parental satisfaction in the SFR environment (post-move, new) was greater compared to the traditional open-bay NICU (pre-move, older). Using a mailed survey (58 open-bay, 89 SFR), researchers found statistically significant differences in the survey categories of environment, overall, and total survey scores. Additionally, they found that the median score for family-centered care was significantly higher in the SFR.
Domanico et al. (2010) surveyed staff members (n = 42) and family members (n = 61) regarding their perceptions of open-bay and SFR NICU environments at Cabell Huntington Hospital in West Virginia. The staff surveyed belonged to one of two groups: the medical doctor/nurse practitioner (MD/NP) or the nurse subgroup. Surveys were administered before and soon after the move, and again 18 months after the move. All staff members surveyed experienced both the older open-facility design, then the new SFR design. Regarding issues of complying with HIPAA requirements, noise, lighting control, problematic foot traffic, and general privacy, the MD/NP and nurse subgroups both preferred the SFR facility. Regarding issues associated with the work environment and parental involvement, MD/NPs favored the SFR, whereas nurses did not.
In another study by Stevens, Helseth, Khan, Munson, and Smith (2010), researchers concluded that staff perceptions of workplace quality were significantly better in the SFR compared to an open-bay NICU. Using a survey tool, the study evaluated staff satisfaction in nine categories including overall satisfaction. Staff rated the SFR more positively (with statistical significance, p < 0.001 for each) in quality of the work environment, quality of patient care, job quality in the NICU, safety and security, interaction with technology, and overall satisfaction.
Shepley, Harris, and White (2008) explored the preferences of medical staff (n = 75) in two facilities: an SFR unit and a combination unit with both open-bay stations and SFRs. They reported that SFR nurses (in both hospitals) had higher job satisfaction than those in the open-bay unit and also reported lower levels of stress. Descriptive statistics indicated that staff members in the SFR units had higher satisfaction with the physical environment as well. Harris, Shepley, White, Kolberg, and Harrell (2006) demonstrated that SFRs are associated with perceived lower stress levels for both family members and staff.
A survey by Carlson, Walsh, Wergin, Schwarzkopf, and Ecklund (2006), conducted 6 months before and 6 months after transitioning to the SFR model, demonstrated that staff members had higher levels of job satisfaction, a greater feeling of team member support, and a greater feeling that they had input on improvements in the SFR unit. Investigators also surveyed parents and found improvements in privacy, lighting, noise, and confidentiality.
The SFR also has potential pitfalls. A NICU composed of SFRs typically requires more square feet per bed (Moon, 2005), costs more to build (Harris et al., 2006), and possibly increases nurse travel distances. For staff members, the SFR may be associated with the isolation of caregivers (White, 2003) and increased demands. Staff members may also need to rely more heavily on technology to monitor patients and communicate with one another than is comfortable for them. In the SFR environment, nurses may not know who else is on their team and may have fewer opportunities to collaborate and socialize with other nurses (White, 2003). Carlson and colleagues (2006) found that overcoming the fear of change was a big challenge in transitioning to the SFR model.
Domanico and colleagues (2010) found that nurses perceived the open bay as better for staff communication, mutual parental support, and coworker access than the SFR environment. In the initial post-move survey, nurses rated the open-bay unit higher in all aspects of the work environment and some aspects of parental involvement. The perceptions of MD/NP regarding patient care did not differ between the two unit types, but nurses perceived the open-bay design to be more favorable in terms of early crisis detection and managing intensive care patients. Whether SFRs are indeed less safe or whether they are merely perceived to be so by nurses warrants further investigation. The Domanico et al. (2010) study demonstrated that staff perceptions of the two NICU environments varied with previous experience, acclimation time, and employment position.
Family members can also experience isolation in the SFR environment. Shepley, Harris, White, & Steinberg (2008) demonstrated that SFRs are associated with fewer interactions among family members from different families, although the interactions that occurred in the SFR were longer in duration.
The Study Site: Wasie NICU at Joe DiMaggio Children's Hospital
In response to increasing evidence regarding the relationships between the physical environment and infant well-being, the Joe DiMaggio Children's Hospital in Hollywood, Florida, constructed a NICU addition designed to improve safety and quality. After a literature review, three site visits, and many discussions with families and staff, decision makers chose to add 23 single-family patient rooms to support the hospital's family-focused program, bringing this level-III NICU to 64 beds. Rubber floors (with recycled content), noise-reducing ceiling tiles, and a fully integrated digital communication system were used to quiet the environment. Task lighting, individual refrigerators, computers, and bar code scanners in the rooms were added to improve the safety of care provided. Amenities such as sofa beds and personal storage cabinets are provided in each patient room to promote family presence. Indirect, soft-lighting design creates a calm and relaxing environment. In the open-bay portion of the NICU, the number of square feet (sf) per bed ranges from 67 to 133 sf (including circulation). The SFRs were designed with approximately 150 sf per bed. Phase I (20 beds) of the project opened in June 2009, and Phase II (three isolation beds, family space, on-call) was completed in November 2009.
Research Questions
This study explored two research questions:
How do staff members' perceptions of the work environment differ regarding the older open-bay NICU compared to the newer combination NICU that includes both open-bay and SFR environments? How do staff members' perceptions of the safety and quality of the NICU environment for infants and their families differ regarding the older open-bay NICU compared to the newer combination NICU that includes both open-bay and SFR environments?
Methods
A survey method was used in this investigation. Pre- and post-occupancy surveys were administered to measure caregiver perceptions of both NICU environments. Following a literature review, survey tools were developed. Some of the survey questions were developed by the NICU director and other staff members. Several of the questions were derived from a survey tool developed by Smith, Clayton, and Schoenbeck (2005), which was also the basis of the tool used in Stevens et al. (2010) and Smith et al. (2009). The pre-move survey was conducted in April 2009, and the post-move survey was conducted in February 2010, approximately 9 months after the majority of the addition and renovations was completed, allowing time for staff to get used to the new environment before taking the post-move survey. The pre-move survey comprised 30 seven-point Likert scale items and three open-ended questions. The post-move survey was nearly identical, with minor differences in the open-ended questions, as indicated in Table 1.
Open-Ended Survey Questions
The open-ended response items were analyzed using content analysis. Based on the literature, a code list was created to include possible fears and obstacles as well as possible benefits of moving from an open-bay to a combination NICU. A few codes representing unanticipated constructs were added during the analysis. All of the open-ended answers entered by respondents were printed out on paper. One of the researchers reviewed the text and noted, by hand, each time that a comment related to a code was made. For example, in response to a question regarding pre-move fears about moving into the new unit, a respondent stated, “I really like the ‘ward style’ unit. I like being able to visualize my patients. Walls make me a little nervous.” The code VISP (visibility of patients) was entered next to the text. This process was followed for all of the open-ended responses. A tally of responses related to each code was developed to identify the most often-cited fears, obstacles, and benefits of moving into the new unit.
A separate-variances t-test for the differences between two means at the 0.05 level of significance was conducted for each of the 30 survey items. This t-test was most appropriate, because it assumes unequal population variances for pre- and post-move respondents. The reasons for using this test were as follows: (1) There were 82 responses for the pre-move survey and only 40 responses for the post-move survey; (2) respondents were not tracked from the pre-move survey to the post-move survey, rendering the use of the matched-pairs t-test inappropriate; and (3) responses were anticipated to be coming from populations with the same means but different variances, an assumption validated by appropriate tests for equal variances. Finally, depending on how a survey item was phrased, lower-tailed and upper-tailed tests were conducted to appropriately identify the direction of improvement in staff perceptions from pre-move to post-move. Tables 2 and 3 summarize test results with p-values for all survey items.
Pre- and Post-Move Perceptions of Work Environment Quality
Indicates statistically significant results
WEQ = work environment quality
Pre- and Post-Move Perceptions of Safety and Quality for Patients and Families
Indicates statistically significant results
SQ = safety and quality of the environment for patients and families
The pre-move survey was given to 148 staff members, with a response rate of 55%, and the post-move survey was given to 158 staff members, with a response rate of 25%. The first survey was handed out at a strategic planning session with mandatory staff attendance. Attendees were given time to complete the survey during the meeting. The second survey was given (in hard copy) to staff in the unit. Participants either completed the survey during their shift, or took it home to complete it. All staff members were asked to answer both surveys, but we believe the low response rate to the post-move survey is related to the manner in which it was distributed. The surveys were anonymous and subjects were not paired.
Immediately prior to the move-in, an orientation was completed by 18 new NICU nurses. There was little NICU staff turnover during the time period between the pre- to post-move surveys. Overall nursing ratios pre- and post-move stayed effectively the same, but the assignment configuration is somewhat different in the SFR portion. In the open-bay unit, one nurse typically cares for two level-III babies or four level-II babies. In the SFRs, patient acuity is mixed. One nurse typically cares for one level-III baby and two level-II infants. This is in part because once the infants are moved into the SFR they usually stay there until they are discharged from the hospital.
An Institutional Review Board (IRB) exempt review was granted by the Memorial Healthcare System IRB because the study meets exemption category #2 (survey involving no identifiers linked to subjects and there are no disclosures of the human subjects' responses outside the research that could reasonably place the subjects at risk of criminal or civil liability or be damaging to the subjects' financial standing, employability, or reputation).
Results
Findings are grouped in two categories: (1) work environment quality, and; (2) safety and quality of the NICU environment for infants and their families. Although some questions relate to both categories (e.g., ease of communication affects both the work environment and the safety and quality of the NICU environment for infants and their families), each is grouped into one of the two categories. The findings can be summarized as follows:
Staff members' fears of moving into the new unit principally focused on adverse changes to work environment quality, such as less teamwork and more isolation. Staff members' perceived benefits of moving into the new unit were principally focused on the quality of the environment for patients and family members (e.g., reduced noise, increased privacy, enhanced family involvement). Staff members' perceptions of work environment quality significantly improved on 13 of 20 items. The remaining items stayed the same. Staff members' perceptions of the safety and quality of the NICU for patients and their families significantly improved on 8 of 10 items. No items were rated worse for the new combination NICU compared to the older open-bay NICU.
Work Environment Quality
Overwhelmingly, staff members preferred the renovated and expanded NICU with the SFRs over the older open-bay unit. Although they had some reservations about moving into the SFR environment, these fears were mostly unrealized. During the pre-move survey, when asked “What is your biggest fear about moving into the new unit?” issues involving staff support were cited most often. Respondents noted isolation, reduced staff support, and a decline in teamwork as concerns. The second most commonly reported fear was working in an unfamiliar environment—how to find things and transitioning to a new environment. Technology-related concerns were mentioned a few times, as was the issue of dealing with family member conflicts. Table 4 lists staff members' primary concerns and how many times this fear was noted in response to the pre-move survey. Most of these fears are related to the quality of the work environment.
Biggest Fears Expressed in Pre-Move Survey
In the post-move survey, however, when asked whether their biggest fear about moving into the new unit had become a reality, only nine respondents answered “Yes.” These fears were related to staff support and teamwork, working in an unfamiliar environment, and the NICU becoming a “hotel” for family members.
Table 2 identifies staff members' perceptions of work environment quality as measured by 20 of the 30 survey items. Perceptions improved on 13 of the 20 items and stayed the same on the remaining 7 items. In particular, statistically significant improvements with p-values of less than 0.05 were noted in job satisfaction, quality of the work environment, staff privacy, ease of communication, task lighting, storage space, a hectic work environment, convenience, orientation, the availability of room in the work area, ease of reaching things, stress, and fatigue. No items were perceived as worse in the new unit compared to the older open-bay unit.
Safety and Quality for Infants and Their Families
In response to the pre-move survey, anticipated benefits of moving into the new unit included simply having more space, enhanced family involvement, more privacy, better acoustic quality, and improved overall quality of patient care. In the post-move survey, staff members did indeed report that the actual benefits were similar to what they had anticipated. Not only did they have more space, but staff members reported that the new NICU provided a better quality environment for infants and their families—notably in privacy, noise reduction, and family involvement. Parents seemed to like the private rooms better and some families demanded a private room.
In terms of patient safety, one respondent to the post-move survey indicated that patient safety was a fear that had been realized in the new unit. Another respondent who expressed concern about patient safety remarked that this fear had not been realized in the new unit. When asked about the biggest obstacles in emergency situations, there was agreement in the pre- and post-move surveys that staff support, travel distances/size of the unit, and early crisis detection/quick response were among the top concerns. In the pre-move survey, however, there were five mentions of staff communication as an anticipated barrier. None of the post-move respondents noted that staff communication had been an obstacle during an emergency.
Table 3 identifies staff members' perceptions about the safety and quality of the work environment for infants and their families as measured by 10 of the 30 survey items. Perceptions improved on 8 of the 10 items and stayed the same on the remaining 2 items. In particular, statistically significant improvements with p-values of less than 0.05 were noted in parental privacy, noise levels, overall lighting, the extent to which the environment is beneficial for patient therapy and recovery, contribution to patients' physical and brain development, the extent to which the environment is beneficial for emergency treatment, the extent to which the environment helps parents contribute to providing care, and staff members' ease of concentration. No items were perceived worse in the new unit compared to the older open-bay unit.
Study Limitations
Although this study provides a valuable contribution to the field, it is limited by the fact that the sample size of the post-move survey was relatively smaller than the sample size of the pre-move survey, the surveys were not validated, content analysis of the free responses was conducted by only one researcher, respondents were not matched between pre- and post-move surveys, and the standard controversy surrounding Likert data analysis. A matched-pair t-test would have been ideal, but it was not feasible given the elapsed time between pre- and post-move surveys. The standard controversy surrounding Likert data analysis has to do with whether researchers treat Likert responses as ordinal or interval, thus analyzing results using nonparametric or parametric methods, respectively. Because the authors were not interested in developing a scale, they analyzed individual Likert-type items, i.e., responses to individual items. Many statisticians, including the authors, who are interested only in location measures such as the mean response, analyze individual Likert-type items using parametric methods such as t-tests (Sisson & Socker, 1989).
Conclusions
Overall, staff members perceive the quality of the work environment and the safety and quality of the NICU environment for infants and their families to be better in the new NICU (combination SFR and open-bay) compared to the open-bay pre-move condition. However, the pre-move survey indicated that although nurses perceived their older space to be noisy and lacking privacy, they described their work as exciting and the quality of care provided high. In fact, there was no difference in perception of the quality of care provided in the old and new units, and staff members described their work as exciting in both pre- and post-move surveys.
The data demonstrated that staff members perceived the quality of their work environment to be higher post-move. The most-often reported fears of moving into the new space were related to staff support (e.g., isolation, fewer opportunities to mentor newer nurses, reduced ability to get help quickly when needed), working in an unfamiliar environment, patient visibility, and potential conflicts with family members. Post-move results, however, indicate that staff satisfaction is higher in the new unit, communication is better, staff members do not feel more isolated, and that the new design is more beneficial for patients' therapy and recovery, their physical and brain development, and emergency treatment. The new unit is perceived as more private for staff, enabling them to concentrate without distraction. The new unit design is associated with lower perceptions of fatigue and stress and is considered less hectic. Ambient conditions, including noise and lighting, are rated as better in the new unit, as are parental privacy and parents' ability to be involved in providing care for their infants.
There were no statistically significant differences in staff perceptions regarding ease of procuring supplies or preparing medications. The level of staff morale was unchanged, as were staff perceptions of staffing levels and workloads as appropriate for patient volume and acuity. This study helps in understanding the issues faced by staff and facilitates the search for operational and process changes that could enhance staff communication and mentorship. More research is needed to investigate the advantages and disadvantages of single-family NICU design across multiple sites. Additionally, research involving family perceptions of open-bay versus SFR settings would be of great interest and value.
Footnotes
Implications for Practice
References
Supplementary Material
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