Nurses' Assessment of Environmental Comfort in Their Physical Work Environments

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Nurses' Assessment of Environmental Comfort in Their Physical Work Environments
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1 online resource (183 p.)
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english
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Prebor, Paige E
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University of Florida
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Gainesville, Fla.
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Degree:
Master's ( M.I.D.)
Degree Grantor:
University of Florida
Degree Disciplines:
Interior Design
Committee Chair:
Portillo, Margaret B
Committee Members:
Carmel-Gilfilen, Candy N

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Subjects / Keywords:
comfort -- design -- environment -- healthcare -- hospital -- interior -- portillo -- prebor -- vischer
Interior Design -- Dissertations, Academic -- UF
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Interior Design thesis, M.I.D.
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theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
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Abstract:
The key nurse work areas (nursestation, medication dispensing area, and supply room) in four medical-surgicalnursing units were under study at two healthcare facilities in north centralFlorida. Registered nurses answered a detailed questionnaire concerning the conditionsencompassing (1) lighting, (2) noise level, (3) thermal quality, (4) spatialfactors, and (5) privacy of their work areas. Focus groups and researcherobservations were also conducted to identify how design conditions impact theirperceived environmental comfort. These data were used to characterize whichlevel of environmental comfort the nurses were experiencing, interpreted withJacqueline Vischer’s model of Environmental Comfort (2007). In particular, twounits (Units C and D) from the South Tower demonstrated a higher overallenvironmental comfort than the remaining two nursing units (Units A and B) fromthe North Tower. The spatial factors were consistently the lowest ratedcondition on each of the four units. In sum, the results confirmed theimportant role of design on enhancing registered nurses’ work flow, and themeaningful insights on workspaces in healthcare environments that can begleaned from the staff perspective.
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In the series University of Florida Digital Collections.
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Includes vita.
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Description based on online resource; title from PDF title page.
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This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility:
by Paige E Prebor.
Thesis:
Thesis (M.I.D.)--University of Florida, 2013.
Local:
Adviser: Portillo, Margaret B.
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RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2014-05-31

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1 WORK ENVIRONMENT S By PAIGE E. PREBOR A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF INTERIOR DESIGN UNIVERSITY OF FLORIDA 2013

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2 2013 Paige E. Prebor

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3 To all nurses for being part of such an altruistic profession, specifically my mom

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4 ACKNOWLEDGMENTS I wish to ackno wledge the contribution of those who helped me through this process. This research project would not have been possible without their support. My deepest gratitude goe s to my thesis chair Dr. Margaret Portillo, who has offered her guidance and expertise f reely. I feel fortunate to h ave such a talented and highly qualified advisor Furthermore, h er encouraging words hav e helped me gain confidence in my writing abilities and that is priceless I also wish to express my appreciation to my co chair member, Pro fessor Candy Carmel Gilfilen, who has always been eager to help, l isten and advise. Her passion is inspiring and her concern for her students is admirable and appreciated more than words can express I would like to thank Brad Pollitt and Tina Mullen for t heir assistance in gaining access to the Shands HealthCare fa cilities. My special thanks go to the nurse m anagers Larry Neill, Sherry Augustine, Rose Phillips, and Joanne McNeil. I am also grateful to the registered nursing staff for participating and mak in g this research study possible. The camaraderie of my friend s, Sa ra Bayramzadeh, Allison Trainor, Lyndall Brezina and Lindsay Maielli has helped me stay focused and gave me a vision for finishing this study. Most importantly, this would not have been p ossible without the support from my parents and the constant love and concern from my husb an d. My parents have encouraged me to pursue my dreams and they help ed in many ways to make my graduate studies possible My husband, my closest friend and biggest su pport has been a constant reminder of the t rue prize: glorifying God For that, I am very grateful.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 8 LIST OF FIGURES ................................ ................................ ................................ .......... 9 LIST OF ABBREVIATIONS ................................ ................................ ........................... 11 ABSTRACT ................................ ................................ ................................ ................... 12 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .... 13 Theoretical Model ................................ ................................ ................................ ... 15 Purpose ................................ ................................ ................................ .................. 17 Significance ................................ ................................ ................................ ............ 17 Research Questions ................................ ................................ ............................... 19 Assumptions ................................ ................................ ................................ ........... 20 Delimitations ................................ ................................ ................................ ........... 20 Conclusion ................................ ................................ ................................ .............. 21 2 LITERATURE REVIEW ................................ ................................ .......................... 2 2 Introduction ................................ ................................ ................................ ............. 22 Theoretical Frame Work: Environmental Comfort ................................ ................... 23 Medical Care Environments ................................ ................................ .................... 24 Nursing Staff Demands ................................ ................................ ........................... 27 Environmental Conditions ................................ ................................ ....................... 29 Summary of Literature Review ................................ ................................ ................ 37 3 RESEARCH METHODOLOGY ................................ ................................ ............... 41 Ethical Considerations ................................ ................................ ............................ 41 Research Design ................................ ................................ ................................ .... 42 Participants ................................ ................................ ................................ ............. 43 Research Setting ................................ ................................ ................................ .... 44 The North Tower ................................ ................................ .............................. 45 The South Tower ................................ ................................ .............................. 48 Data Collection ................................ ................................ ................................ ....... 51 Phase I: Preliminary Staff Survey ................................ ................................ ..... 52 Phase II: Field Measurements and Observations ................................ ............. 53 Phase III: Standardized Survey and Focus Group ................................ ........... 54 Summary of Research Me thodology ................................ ................................ ....... 57

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6 4 RESULTS ................................ ................................ ................................ ............... 79 Research Question One ................................ ................................ ......................... 80 Unit A ................................ ................................ ................................ ................ 80 Unit B ................................ ................................ ................................ ................ 87 Unit C ................................ ................................ ................................ ............... 93 Unit D ................................ ................................ ................................ ............... 98 Research Question Two ................................ ................................ ....................... 103 Research Question Three ................................ ................................ ..................... 104 Research Question Four ................................ ................................ ....................... 106 Research Question Five ................................ ................................ ....................... 110 Unit A ................................ ................................ ................................ .............. 111 Unit B ................................ ................................ ................................ .............. 111 Unit C ................................ ................................ ................................ ............. 113 Unit D ................................ ................................ ................................ ............. 114 Conclusion ................................ ................................ ................................ ............ 115 5 DISCUSSION ................................ ................................ ................................ ....... 131 Narrative Inquiry ................................ ................................ ................................ ... 133 Orientation to Narrative ................................ ................................ ......................... 134 ................................ ................................ .... 135 Interpretation ................................ ................................ ................................ .. 137 Orientation to Narrative ................................ ................................ ......................... 140 ................................ ................................ ... 140 Interpretation ................................ ................................ ................................ .. 143 Utilizing the Findings from the Environmental Comfort Method ............................ 146 Unit A Synthesis and Application ................................ ................................ .. 148 Unit B Synthesis and Application ................................ ................................ .. 150 Unit C Synthesis and Application ................................ ................................ .. 153 Unit D Synthesis and Application ................................ ................................ .. 155 Design Trade offs ................................ ................................ ................................ 157 Design Recommendations ................................ ................................ .................... 158 Recommendations for Future Research ................................ ............................... 158 Conclusion of Discussion ................................ ................................ ...................... 159 APPENDIX A INSTITUTIONAL REVIEW BOARD PERMISSION ................................ ............... 161 B LETTER TO NURSE MANAGERS REQUESTING PAR TICIPATION .................. 162 C ................................ ................................ .... 163 D OBSERVATION SCHEDULE ................................ ................................ ............... 165 E ORIGINAL DICONFON SURVEY ................................ ................................ ......... 166

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7 F MODIFIED DICONFON SURVEY ................................ ................................ ........ 172 LIST OF REFERENCES ................................ ................................ ............................. 176 BIOGRAPHICAL SKETCH ................................ ................................ .......................... 183

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8 LIST OF TABLES Table page 3 1 Summary of units. ................................ ................................ ............................... 51 4 1 Assessment of envi ronmental factors Unit A ................................ ................... 81 4 2 Assessment of envi ronmental factors Unit B ................................ ................... 87 4 3 Assessment of envir onmental factors Unit C ................................ ................... 94 4 4 Assessment of envir onmental factors Uni t D ................................ ................... 99 4 5 ................................ .......... 117 4 6 ................................ ...... 118 4 7 ................................ ...... 119 4 8 .................. 120 4 9 ................................ ..... 121 4 10 ................................ ................. 122

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9 LIST OF FIGURES Figure page 1 1 The habitability pyramid ................................ ................................ ...................... 16 2 1 Concept map ................................ ................................ ................................ ...... 30 2 2 Analysis of how an d where nurses spend their time ................................ ........... 39 2 2 Continued ................................ ................................ ................................ ........... 40 3 1 Comparison of research settings. ................................ ................................ ....... 45 3 2 Unit A f loorplan. ................................ ................................ ................................ .. 59 3 3 Unit B floorplan. ................................ ................................ ................................ .. 60 3 4 Unit C flo orplan. ................................ ................................ ................................ .. 61 3 5 Unit D floorplan. ................................ ................................ ................................ .. 62 3 6 Unit A nurse station ................................ ................................ ............................ 63 3 7 Unit A medication dispensing area ................................ ................................ ..... 64 3 8 Unit A supply room ................................ ................................ ............................. 65 3 9 Unit A corridor ................................ ................................ ................................ ..... 66 3 10 Unit A medication car t ................................ ................................ ........................ 67 3 11 Unit A task chair and C OW located outside patient room ................................ ... 68 3 12 Unit B nurse station ................................ ................................ ............................ 69 3 13 Unit B medication dispensing area ................................ ................................ ..... 70 3 14 Unit B supply room ................................ ................................ ............................. 71 3 15 Unit C centralized nurse station ................................ ................................ .......... 72 3 16 Unit C medication dispensing area ................................ ................................ ..... 73 3 17 Unit C supply room ................................ ................................ ............................. 74 3 18 Unit D centralized nurse station ................................ ................................ .......... 75 3 19 Unit D medication dispensing area ................................ ................................ ..... 77

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10 3 20 Unit D supply room ................................ ................................ ............................. 78 4 1 mental comfort levels of Unit A ........................... 86 4 2 mental comfort levels of Unit B ........................... 93 4 3 The nurses perceived environ mental comfort levels of Unit C ........................... 98 4 4 The nurses perceived environ mental comfort levels of Unit D ......................... 102 4 5 Unit comparison: lighting. ................................ ................................ ................. 107 4 6 Unit comparison: noise level. ................................ ................................ ............ 108 4 7 Unit comparison: thermal quality. ................................ ................................ ..... 108 4 8 Unit comparison: spatial factors. ................................ ................................ ....... 109 4 9 Unit comparison: privacy. ................................ ................................ ................. 109 4 10 U nit comparison ................................ ................................ ................................ 110 4 11 mprovements to their work areas ..................... 11 3 4 12 Unit A light meas urements ................................ ................................ ............... 123 4 13 Unit A sound measurements ................................ ................................ ............ 124 4 14 Unit B light measurements ................................ ................................ ............... 125 4 15 Unit B sound measurements ................................ ................................ ............ 126 4 16 Unit C light measurements ................................ ................................ ............... 127 4 17 Unit C sound measurements ................................ ................................ ............ 128 4 18 Unit D light measurements ................................ ................................ ............... 129 4 19 Unit D sound measurements ................................ ................................ ............ 130

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11 LIST OF ABBREVIATIONS ASHRAE American Society of Heating, Refrigeration, and Air conditioning Engineers COW Computer On W heels D I C ON F ON Standardized survey developed to measure workplace environmental comfort GRET Work Environments Research Group HIPPA Health Insurance Portability and Accountability Act HVAC Heating, Ventilation, and Air Conditioning IAQ Indoor Air Quali ty ICU Intensive Care Unit IESNA Illuminating Engineering Society of North America IRB Institutional Review Board IV Intravenous O MNICELL Automated medication distribution cabinet OSHA Occupations Safety and Health Administration PCA Patient Care Assistant RN Registered Nurse Wall A Roo Wall mounted work stations

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12 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Interior Design ASSESSMENT OF ENVIRONMENTAL COMFORT IN THEIR PHYSICAL WORK ENVIRONMENT S By Paige E. Prebor May 2013 Chair: Margaret Portillo Major: Interior Design The key nurse work areas (nurse station, medication dispensing area, and supply room) in four medical surg ical nursing units were under study at two heal thcare facilities in north central Florida Registered nurses answered a detaile d questionnaire concerning the conditions encompassing (1) lighting, (2) noise level, (3) thermal quality, (4) spatial factors, a nd (5) privacy of their wor k areas F ocus groups and researcher observations were also conducted to identify how des ign conditions impact their perceived environmental comfort These data were used to characterize which level of environmental comfort the n urses were experiencing, interpreted with Jacqueline (2007) In particular, two units (Units C and D) from the South Tower demonstrated a higher overall environmental comfort than the remaining two nursing units (Un its A and B) from the North Tower The spatial factors were consistently the lowest rated condition on each of the four units. In sum, the r esults confirmed the important ro le o f design on enhancing work flow and the meaningful insights on workspaces in healthcare environments that can be gleaned from the staff perspective

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13 CHAPTER 1 INTRODUCTION As humans we are influenced by the spaces we inhabit; for example, when entering a dimly lit concert hall one may instinctively lower their v oice due to the surrounding physical cues, or while having a meal inside a fast food restaurant customers may find themselves eating more quickly due to the bright colors lights, furniture and relatively hard surfaces throughout the space. Likewise, the p hysical environment of a healthcare setting can have an e ffect on the productivity of the occupants specifically the caregivers (State of the Field Report, 2009 ; Cesario, 2009 ). on The field of enviro nmental psychology implies a dynamic and reciprocal relationship between individuals and th e environment in which they occupy (Frumkin, 2005). R ese arch confirms this notion; Ulri ch et al. conducted a review of empirical research and found over 2,000 studies that offer insight in to the relationship between the physical design of hospitals and key outcomes (2008). Three types of general outcomes surfac ed in the literature review: patient safety, other patient outcomes, and staff outcomes (Ulrich et al., 2008) Compared to the research on patient outcomes, a limited amount of environmental research has addressed nursing staff outcomes (Ulrich, 2010). Giv en that n urses are the primary care givers in the hospital workplace it would be beneficial to investigate the affects of the physical environment on this critically important group of personnel. Traditionally the design of health facilities has emphasized the functioning of medical technology which often produced hospitals that were operationally effe (Mycek, 2007). These large and

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14 from the healing design equation. Fo rtunately, there is a broad movement to implement evidence based principles in the design and construction of the healthcare facility (Ulrich, 2010) The Center for Health Design defines evidence based design as the process of ba sing decisions about the built environment on empirical research to achieve the best possible out comes ( 2008). Just as medicine has increasingly moved toward evidence based treatments where clinical choices are informed by research, the design of health fa environments to healthcare outcomes (Hamilton, 2003). This evidence based design (EBD) process utilizes research from multip le professions involving health care such as environmental sc ience, interior design, architecture, engineering, etc. to make building decisions (Cesario, 2009). The goal of EBD is to create an environment that promotes healing, supports family involvement, facilitates efficient staff performance, and reduces stress in all users of the facility (Brown & Gallant, 2006). There is an increasing understanding that an appropriately designed built environment can help create a safe, nurturing, and positive work environment for caregivers; and help achieve organizational and business objectives (Joseph, 2011). When looking from hospital to hospital around the United States it is apparent that there are multiple design solutions for nursing work areas which vary cons iderably, yet due to the gaps in the research, it is unknown if nurses perceive certain approaches or design attributes as more or less effective for supporting their tasks (Ulrich, 2010) Therefore this study explores nurse work areas from two hospital facilities a new construction versus a longstanding hospital throug h a multi site field study assessment.

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15 This in depth investigation of four nursing units involved on site observations, photographs and physical measurements of environmental characteristics, surveys, and focus group sessions. Five environmental cond itions constituted by lighting, noise level, thermal quality, spatial factors, and privacy were assessed in the key nurse work areas nurse station, medication dispensing area, and supply room of each unit. End results of this study were synopses of each nursing unit that revealed key considerations relating hand experiences and percepti ons of their work environments. Theoretical Mo del A theoretical model will be used in this study to provide an u nderstanding of human inter action with the environment. The model developed by Vischer (2007) explores the phenomenon called environmental comfort. This ecological model suggests that when a person behaves in a work environment they are experiencing a level of environmental co mfort that can be placed on a continuum. T he environment is characterized according to three hierarchical interrelated categories: physical comfort, functional comfort a nd psychological comfort. Figure 1 1 illustrates the levels of environmental comfort through the depiction of 2005 ). At the foundation of the pyramid is physical comfort which involves the satisfaction of basic human n eeds such as safety, hygiene and accessibility; these needs are generally met through the application of current building codes and standards. Functional comfort is defined in terms of ergonomic related activities. The top level of environmental comfort psychological comfort results in feelings of belonging and control over the

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16 workspace through choice and information provided to the employee (Vischer, 2007). Conversely, functionally uncomfortable workspaces require e mployees to make excessive adjustments in order to adapt to the conditions in which they have to work. Uncomfortable conditions are deemed adverse if they draw energy out of the worker and affect work performance. Figure 1 1. The habitability p yramid [ Adapted from Vischer, J. C. (2005). Space meets status: Designing workplace performance. (Page 85, Figure 4 2) London: Routledge ] supportive workplace encourages worker performa nce, allowing occupants to conserve their energy for the tasks, as opposed to expending it to cope with adverse environmental conditions. The more support workers receive from the physical environment in completing their tasks, the more comfortable the wor kspace (Vischer, 2007). Therefore, improving the environmental comfort of a workspace can affect the

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17 Purpose The purpose of this study is to further investigate how the designs of nurses work areas relates to (RNs) per ceived environmental comfort This study assesses hospital workplace conditions through the theoretical lens of the environmental comfort model proposed by Jacqueline Vischer (2007). The theory of environ mental comfort is most often applied to office space design and employee behavior (Jacqueline Vischer, personal communication, April 3, 2012); however, this study begins to bridge the gap into other work settings by applying the theory of environmental com fort to the healthcare work environment. T his study will examine whether the framework and the corresponding DiConFon questionnaire (Vischer, 201 0) extend into a healthcare workplace in an applicable way. The findings fr om this research will relate to the environmental comfort model through the analysis of human interaction with the work environment Increased awareness of the characteristics of nurse work areas that nurses perceive as comfortable enables designers to understand t he impact of specific varia bles such as lighting, noise level, thermal qualities, spatial factors, and privacy, in order to design supportive environments. Significance The need to investigate the design of healthcare environments is e specially pertinent given that he built envi the wo care providers [can] do their work more Ulrich and colleagues state that supportive design in sta ff areas can be a positive feature in marketing a fa cility to prospective employees; in increasing productivity or efficiency; enhancing job

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18 satisfaction; a nd perhaps reducing turnover (2004). The designs of nurse work environments are often critical in or der to attract and retain high quality nursing workforce. When hospitals retain their nursing workforce costs associated with voluntary RN turnover is minimized (Buerhaus et al., 2009) which is estimated as $82,000 to $88,000 per RN (Jones, 2008). However, the reality is that the re is a sho rtage of registered nurses which is estimated to escalate to about 500,000 by 2025 in the U.S. (Buerhaus, Staiger, & Auerbach, 2009). The PricewaterhouseCoopers' Health Research Institute report noted that hospitals can save from $1.7 to $5.4 million per year, if the average annual RN turnover ranges between 17.1% and 5.5% respectively (2007) A main predictor of voluntary nurse turnover is job satisfaction (Hayes et al., 2006; Holtom, Mitchell, Lee, & Eberly, 2008). Job satisfaction is important because it diminishes the ef fects of a number of adjustable work environment factors on turnover intention (Kovner, Brewer, Greene, & Fairchild, 2009; Lee, Gerhart, Weller, & Trevor, 2008). Therefore, identifying the aspects rela ted to nurses' job satisfaction, like a supportive physical work environment (Mroczek et a l 2005, Tyson, Lambert & Beattie, 2002), further develops an evidence base framework from which designers and hospital management can build effective strategies for improving nurses' job satisfaction. The majority of empirical literature on the design of healthcare settings have focused on the impact of the physical environment on nurses' job performance/efficiency and has identified noise (e.g., Bayo, Garcia, & Gar cia, 1995; Blomkvist, Eriksen, Theorell, Ulrich, & Rasmanis, 2005; Hodge & Thompson, 1990; Topf, & Dillon, 1988), lighting (e.g., Alimoglu & Donmez, 2005; Mroczek, Mikitarian, Vietra, & Rotarius, 2005; Scott, 2004), and nursing unit and patient room design (e.g.,

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19 Janssen, Harris, Soolsma, Klein, & Seymour, 2001; Page, 2004) as environmental features that can negatively contribute to staff job performance. Most of these studies indicate that noise from various sources, artificial lighting/inadequate lighting improper or inadequate ventilation, and disorienting layouts of nursing units create a negative impact on nursing staff that leads to fatigue, stress, or burnout (Mahood, Chaudhury, & Valente, 2011). While the results of these studies are important contr ibutions to this field of research, more studies are needed to develop a greater understanding of the physical components nurses themselves consider influential to their performance This information would be invaluable to healthcare providers, adminis trat ors, and design professionals because it provides an opportunity to reexamine hospital design to place emphasis on improving staff outcomes. Research Questions In order to examine the affect of the interior design features of health care facilities on th between the activities and behaviors associated with nursing and the work environment of medical surgical n ursing units. A multi site field study analysis of two hospitals was employed a s a means to understand this relationship. The research questions central to this s tudy are summarized as follows: 1. What level of environmental comfort (physical, functional, and psychological) characterizes the work spaces in hospital environments which ar e under study, as perceived by the nursing staff? 2. How important are the design considerations of lighting, noise levels, privacy, thermal quality, and spatial factors in relation to perceived environmental comfort? 3. What other design considerations impact t he perceived environmental comfort?

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20 4. between the two hospital settings? 5. relate to physical, functional, or ps ychological dimensions of perceived environmental comfort? Assumptions A number of assumptions underlie this study. First, it assumed that all data were collected under normal working conditions at the two healthcare facilities, without any extraneous circ example, if the hospital had recently laid off a large number of employees, or if employees had an unusually large workload, this might negatively impact employee morale causing potential impac participants provided truthful and accurate answers when completing questionnaires and participating in focus group discussions concerning their workplace experiences. Delimitations Data was largely b reported assessments of perceived environmental comfort through the use of questionnaires and focus group sessions. A total of 17 registered nurses working for Shands Healthcare participated in the study. Despite the sma ll sample size of the nursing staff and the corresponding limitation for generating quantifiable data, focus groups with participants uncovered rich in setting involved t wo hospitals from a single healthcare system, Shands Healthcare, the findings may not repr esent all hospital facilities.

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21 Conclusion A greater understanding of the workplace conditions that registered nurses perceive as influential to their performance woul d be invaluable to design professionals Ho wever, the large number of important issues that remain under researched is sobering (Ulrich, 2010) As a result, this study investigated the role of interior design in ed env ironmental comfort. A mul t i site field study of two hospitals from the Shands Healthcare system was conducted through focus groups, questionnaires, photography, and on site observations. Two medical surgical units from each hospital were studied, making a total of four unit s The end product of this study is detailed profiles of the units, including perceived environmental comfort

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22 CHAPTER 2 LITERATURE REVIEW The challenge for design profession als lies in creat ing health care facilities that are functional ly supportive of patient care while simultaneously foster ing health and wellbeing for both the patients and the staff. Registered nurses are the primary patient care givers on a daily basis and consequently they have a significant vested interest in the design of a hospital workplace. The refore, c onsulting the nurses who interact within the hospital offers unique insights to d esign professionals ; for instance, they are able to det ermine the factors that the nurses find to be effective in creating the best possible healing environment for the pa tient, as well as what nurses have discovered to be important to their productivity. Research has found that a well designed physical env ironment can positively impact the nurses. As Cesario (2009) sugges design of health care facilities, when combined with considerations regarding air quality, noise level, and light, can positively affect the health and productivity of nurs es (p. 293) productivity of the nurses. This is why understanding the design preferences of nursing staff is essential in order to provide a work environment supportive of their needs. Introduction The review of the literature examines environmental design of health care work (2007) provides a conceptual framework that focuses on the relationship between individuals and their physical work environment. The review will begin by examining the history of medical care environments, followed by reviewing the typical demands on nursing staff. Specific environmental concerns that need to be addressed when designing or evaluating supportive environm ents for nursing staff will

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23 also be discussed (i.e., lighting, noise level, thermal qualities, spatial factors, and privacy). This chapter will conclude by discussing ways to establish environmentally comfortable wo rk areas for registered nurses. Theoretic al Frame Work: Environmen tal Comfort s a theoretical framework for examinin g how individuals perceive their work environments and suggests method s of measuring the impact of enviro nmental conditions in the workplace This classic model has been widely c ited over the past twenty years; t he repertoire of topics investigated by Vischer and her colleagues includes building evaluation, users' needs in buildings, indoor air quality, user manager communication facilities management, and architectural programming A number of her peer reviewed journal publications can be found in the Journal of Environmental Psychology, Architectural Science Review, Building Research and Information, and Stress and Health Whil e the majority of her research findings are applied to office space design and employee behavior (Jacqueline Vischer, personal communication, April 3, 2012), this study begins to bridge the gap into other work settings by applying the theory of environment al comfort to the healthcare work environment. This theoretical model of environmental c omfort serves as the lens through which the data i n this study will be analyzed. In this model, comfort is conceptualized as a rising continuum of physical, functional, and psychological comfort. Viewing comfort as a continuum is a way to assess the overall quality of the work environment and to prioritize change according to what is anticipated to have the greatest impact. At the foundation of the continuum is the categ ory of physical comfort, which includes the nonnegotiable prerequisites for a habitable work environment such as

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24 enough light, no extreme temperatures of too hot or too cold, safe noise levels, and an adequate number of functioning toilets. These condition s are usually met through building codes and regulations which ensure health safe ty, and welfare. or safety and basic convenience are in question, the n other aspects of environmental comfort are of little consequence (Vischer, 2005 p. 84 The next element of environmental comfort is identified as functional comfort. According to Vischer (2005) the environment must support work relat ed activities and specifically functional comfort is described as lighting, but the right lighting for the task, not just ventilation, but clean conditioned air that is free of contaminants, not just heati ng, but thermal comfort ( p. 84) the environment in other ways increases your psychological comfort the last level of environmental comfort because it gives you practicality of having a task light, but also the perception of control in being able to manipulate that light. Psychological comfort also incorporates territoriality: psychological comfort depends on owning, controlling and having responsibil ity for territory. Being deprived of personal territory in a work environment can cause stress, produce low morale, and sometimes aggression in the form of resi stance to change Medical Care Environments Healthcare facilities have gone through many transfo rmations throughout history, in both positive and negative directions. Ancient Greek healing temples are one example of the earliest attempts at creating a holistic healing environment. These early healing centers were sited among shrines, libraries, theat ers, spas, gymnasiums, and

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25 gardens, often drawing from the healing powers of nature. Essential for restoring health, they integrated exercise, visual and performing arts, and nature; however, such diligent attention to the healthcare environment was later neglected. Instead, facilities became unkempt and dirty overcrowded wards that developed into institutions regarded as places for disposal and even death (de Vos, 2004). At the end of the 19th century a nurse named Florence Nightingale challenged the lack of regard for creating healing environments and brought the importance of the physical environment in quality patient care back to the forefront. Through her efforts, hospital design once again incorporated the use of natural light, warmth, cleanliness, an d a maximum number of patients in clinical areas (d e Vos, 2004; McCullough, 2001). Modern advancements in medical technology later became integral in reforming hospital design yet again. This period in health care history concentrated on creating buildings that reduced infection and succeed as functionally efficient delivery platforms for new medical technology. This emphasis on functional efficiency and the pathogenic conception of disease and health often resulted in institutional and stressful environmen ts detrimental to care quality (Ulrich, 1992; Ulrich et al., 1991) and once psychological and social needs fr om the healing design equation. Fortunately, current tre nds in healthcare have reverted back to the healing environments first demonstrated by the ancient Greeks and much later by Florence Nightingale. Inspired by the Asclepius hospitals in ancient Greece, Angelica Thierot founded the Planetree healthcare model hospital would combine the best of spas with the best of hotels and the best of

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26 Planetree concept has spread quickly and h ospital administrators are acknowledging Research regarding the impact of the healthcare environment on healthcare outcomes has been growing rapidly in recent years (Joseph et al., 2011) and design professionals recogn ize the value of designing medi cal care facilities based on rigorous empirical research (Cesario, 2009) This evidence based design (EBD) process utilizes research from multip le professions involving health care su ch as environmental science, interior design, architecture, engineering, etc. to make building decisions (Cesario, 2009). The goal of EBD is to create an environment that promotes healing, supports family involvement, facilitates efficient staff performanc e, and reduces stress in all users of the facility (Brown & Gallant, 2006). At the same time, the design should produce employee productivity, customer satisfaction, and cult ural congruency (Hamilton, 2003). Numerous peer reviewed journal articles have collected empirical evidence which demonstrate connections between the environmental design of healthcare facilities and outcomes that are important for patients, families, heal thcare staff, and healthcare organizations (Ulrich et al., 2008). As a result, the field of EBD is gaining recognition and creditability. T here is an increasing understanding that an appropriately designed built environment can help to improve patient outc omes; create a safe, nurturing, and positive work environment for caregivers; and help achieve organizational and business objectives (Joseph, 2011) So much so that t based Design Accreditation and Certification progr am awards credentials to individuals

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27 who demonstrate a thorough understanding of how to apply an evidence based process to the design and development of healthcare settings (Joseph, 2011) The environmental research applicable to this study will be discuss ed in depth later in the chapter. Nursing Staff Demands When studying the design of nursing work areas it is critical t o be aware of the exceptional demands nurses face on a daily basis. An understanding of how nurses spend their time managing numero us res ponsibilities is necessary to illustrate which do Medical Skierczynski, & Zhenqiang (2008) identifies how real time and work contexts and is one of the few studies that measures this holistically. The researchers undertook a time and motion study of 767 nurses from 36 medical surgical units who participated in research pro tocols designed to assess how nurses spend their time, nurse location and movement, and nurse physiologic response. related functions, nonclinical activities, and waste, seen in Fi gure 2 2 ) and locations (patient room, nurse station, on unit, off unit, seen in Figure 2 2 ) during a ten hour shift (Hendrich, et al., 2008). Findings indicate that more than three quarters of all reported time was devoted to nursing practice. The thre e subcategories that accounted for most of nursing practice time were: documentation (35.3%; 147.5 minutes), medication administration (17.2%; 72 minutes), and care c oordination (20.6%; 86 minutes); these activities were found to be performed most often in the nurse station and in other administrative areas

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28 throughout the unit (excluding patient rooms). For that reason, the nurse work areas under investigation in this study will occur in the zones in which nurses spend the majority of their time the nurse station, medication dispens ing area and supply room (see Figure 2 2 ) Hendrich et al. (2008) used activity categories (i.e., nursing practice, unit related functions, nonclinical activities, and waste) to comprehensively define nurse workflow tasks. These activity categories will be defined below with the purpose of Nursing practice. Hendrich et al. (2008) demonstrated that the nurses under study devoted 417 minutes (77.7%) of their 1 0 hour shift on nursing practice related activities. Nursing practice activities include five subcategories: (1) patient care activities, (2) care coordination, (3) medication administration, (4) documentation, and (5) assessment/reading vital signs. Patie nt care activities with tasks such as bathing, conducting intervention activities such as intravenous (IV) site changes, and preparing the patient for hospital admission or discharge, plus assessing patient care while off uni t. Assessment/reading vital signs involve direct patient care of physically assessing the patient. Interestingly, in the study conducted by Hendrich et al. (2008) patient assessment only comprised 7.2% (31 minutes) of nursing practice time. Documentation o f patient care and completing other bureaucratic tasks being time consuming, required documentation is often redundant, irrelevant, not followed through (Page, 2004; Hendric h et al., 2008) and results in reduced time for the monitoring of patients through direct therapeutic care. Care coordination is defined as

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29 In the study by Hendrich et al. (2008), it accounted for approximately one fifth of nursing time. Medication administration involves preparation of medication and subsequent delivery to the patient. Unit related functions. activitie s such as preparing equipment, using a fax or copy machine, and transporting patients between departments. Although these tasks do not account for a significant hour shift), they may contribute to inefficiencies and phy sical fatigue (Hendrich et al., 2008). Nonclinical activities. of a 10 hour shift) involves nonclinical activities such as personal time, patient/family care, and administration/teaching (Hendrich et al., 2008). Waste. eled as waste by Hendrich and colleagues (2008). Behaviors within this category include waiting, looking/retrieving, delivering viors. A nursing activities such as performing housekeeping duties or performing ancillary services such as the delivery of food trays or medical equipment or supplies (Page, 2004). The ineff icient assignment of provision of therapeutic patient care, and interaction with patients and family members (Page, 2004). Environmental Conditions An extensive review of literature was conducted in the area of health care design and nurse performance. As illustrated in Figure 2 1, t he subsequent overview explores

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30 lighting, noise level, therma l qualities, spatial factors, and privacy. Figure 2 1. Concept map. Lighting Most medical facilities are lit by a combination of daylight (natural light) and electric light sources (artificial lig ht) (Applebaum, et al., 2010). Research has found that l i ghting conditions, such as quality, level, and type (natural or artificial light) may found that as exposure to daylight increases, nurses are less likely to experience st ress and dissatisfaction with their jobs, reducing their levels of burnout (Alimoglu & Donmez, 2005). On the other hand, a different study determined that exposure to artificial lights cause nurses to feel drained, having a negative effect on their product ivity (Scott, 2004). Fluorescent tube light is commonly mentioned by caregivers as one of the most draining

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31 aspects of work (AHRQ, 2010). Therefore, it appears that nurses are more satisfied with, and function more effectively, in an environment that facil itates the use of natural light, with minimal artificial lighting (Chaudhury et al., 2009). Center for Health Design researchers confirm that the most evident effect of light on human beings is that of making vision possible which allows the performance of visual tasks. The need for light increases as someone ages because of reduced transmittance of aging eye lenses (Edwards & Torcellin i, 2003). This is significant because the nursing work force is aging (Applebaum et al., 2010). Therefore, it is necessary to critically assess the illumination levels available for different types of tasks performed by the aging nurse workforce. Electrical light sources can have different effects on the human body depending on the wavelength or spectral distributions. Full sp ectrum fluorescent lighting has similar properties to that of natural light, however, most artificial light sources lack the spectral distribution needed for complete biological functions (Edward & Torcellini, 2002). According to Boyce and colleagues (2003 ), the nature of the task as well as the amount, spectrum, and distribution of the light affects the level of worker performance. Results from a large scale study of the effects of different illumination levels on dispensing error rates strongly suggested that such errors are reduced when work surface light levels are relatively high (Buchanan et al., 1991). In this study, three different illumination levels were evaluated (450 lux; 1,100 lux; 1,500 lux). Medication dispensing erro r rates were 2.6% at 1,500 lux, compared to a higher error rate of 3.8% at an illumination level of 450 lux. Therefore, lower light levels in medication dispensing areas can be expected to worsen error rates.

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32 Noise level According to the World Health Organ ization (Berglund, Lindvall, & Schwela, 1999) and the U S Abatement and Control hospital noise levels are recommended to be a maximum of 45 dB during the day and 35 dB at night. Sound levels exceeding the se recommendations could produce stress, however, noise in hospitals often exceed the recommended levels with background noise levels typically ranging from 45 68dB, and peaks commonly exceeding 85 90dB (Blomkvist et al 2005). The research reviewed sugge sts two general reasons for the excessive noise in hospitals: (1) noise sources are abundant including telephones, staff voices, trolleys, and paging systems among other, and (2) the environmental surfaces such as floors, walls, and ceilings often create p oor acoustic conditions because they usually reflect rather than absorb noise (Ulrich et al., 2004). Inadequate acoustic environments may interfere with communication between patients and nurses or between healthcare employees, resulting in compromise of p atient confidentiality (Page, 2004; Chaudhury et al., 2009; Cesario, 2009). Many researchers have examined the effects of noise on patients, but comparatively few studies are available that explore the effects on healthcare staff (Applebaum et al., 2010, C haudhury, 2009). Healey, Prim us, and Koutaintji (2007) found that noise may be linked to staff medical errors There is also evidence that high noise levels have adverse affects on nurses such as increased stress and annoyance, fatigue, emotional exhaustio n, and burnout (Joseph & Ulrich, 2007, Topf & Dillon, 1988). As feelings of noise related stress and burnout increase, this can lead to an increase in turnover intention (Applebaum et al., 2010). A study by Blomkvist and colleagues (2005) examined the effe cts of noise levels over a period of three months on a group of

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33 coronary intensive care nurses. The researchers collected psychosocial work environment data from start and end of each of the morning, afternoon, and night shifts during which either sound re flecting or sound absorbing tiles were installed. Lower noise levels due to the sound absorbing tiles were found to have positive effects on staff, including reduced perceived work demands, increased workplace social support, better speech intelligibility, and an improved quality of care for patients. These positive (Applebaum et al., 2010). Thermal quality environment and the health of the people in it (Kopec, 2006). According to Rediich associated with indoor environments. Indoor air quality of hospitals can be linked with health problems incl uding airborne infection outbreaks, latex allergies, and exposure to chemical agents, anesthetic gases and pharmacological agents that can spread throughout the hospital (Brownson, 2000). As defined by the American Society of Heating, Refrigeration, and Ai r conditioning Engineers (ASHRAE), acceptable indoor air determined by cognizant authorities and with which a substantial majority (80% or more) of the people exposed do Maintaining safe air quality has been associated to health and lower stress levels in the workplace. The quality of air at work is often regarded as one of the most important factors in the building. Feeling as though the air in the workplace is of poor

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34 quality can result in dissatisfaction with one's job and the work environment (Mroczek, 2005). Odors are negative components of air quality. Olfactory receptors have a direct connection to the limbic system, the b rain's emotional hub, and are therefore smells are more memorable than sights or sounds because they often provoke emotional responses (Jones, 1996). The perception of odor is dominated by the pleasant or unpleasant dimension. Medicinal smells, which can b e perceived as negative odors, arouse anxiety, fear and stress; while pleasant aromas, such as the scent of vanilla and essential oils of particular flowers and fruits, can reduce blood pressure, slow respirations and lower pain perception levels (Jones, 1 996). The presence of negative odors in the healthcare environment may lead to increased nursing stress, which leads to job dissatisfaction and eventually turnover intention. Spatial factors Studies show that the layout of a nursing unit and the arrangemen t of the nurse work areas in relation to one another has a direct impact on nurse productivity and fatigue levels (Carayon, Alvarado, & Hundt, 2003; Ulrich, 2006). The nurse station is the primary work area on a nursing unit, and nursing units have typical ly been organize d around a central nurse station where unit reception, charts, orders, medications, and supplies are often locate d in one place (McCarthy, 2004 ; Zborowsky et al., 2010). Thus, nurse stations are important hubs of activity where almost all t ypes of hospital functions overlap (Broomberg, 2006) but, unfortunately, t he centralized nurse station patients] (McCarthy, 2004, p. 406).

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35 Nurses walk an average of thre e miles hunting and gatherin g supplies during a ten hour shift which is identified as wasteful activity (Hendrich et al., 2008; Ulrich, 2006). However, recent studies have found that thoughtful floor layouts and the implementation of decentralized nursi ng stations reduce staff walkin g which translates into more time spent on patient care activities, especially when supplies are stored near patient rooms (Hendrich & Lee, 2005; IOM, 2004). Advances in information technology such as electronic medical records have enabled nurses to move away from traditional centralized paper charting stations to smaller, decentralized work stations which are located closer to patient rooms (Zborowsky et al., 2010). Although decentralized nurse stations may reduce walking distance, nurses report feeling m ore isolated from their colleagues and losing the sense of camaraderie in comparison to centralized nurse stations (Tyson et al., 2002). The model consists of decentralized nurse stations located near the patient rooms as well as a c ollaborative centralized nurse station ; this offers an alternative solution to help maintain staff communication in addition to decreasing travel distances (Zborowsky et al., 2010). Additional factors such as e rgonomic design are importa nt to create the optimal conditions for workers to perform their tasks efficiently and safely (Carayon, Alvarado, & Hundt, 2003). Workstation design and spatial comfort affect both collaborative teamwork productivity and individual task performance (Vischer, 2005). I f the task requires long conversations or lengthy paperwork procedures ergonomics become especially important (Brand, 2009). Improving ergonomics in the work environment primarily creates a safer and more healthful workplace. The organization may experience othe r benefits as well such as increased productivity, work quality, and

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36 morale. Kroemer and Kroemer (2001) reviewed ergonomic elements of design; they nurses spending a signi ficant time standing. For instance, sufficient space should be The built environment should be convenient and accessible and should enable patients to connect with staff members, should being, should be safe and secure, and should foster connections to the outside world (Lowers, 1999). According to Springer (2007), the workplace should be designed to adapt to workers. Workers may be able to acc ommodate poor design and hostile environments, but adaptation takes a toll on users, causing decreased performance and fatigue. Appropriately adaptive equipment and environments relieve strain on the workers by reducing their need to adapt to shortcomings in the workplace (2007). Providing ergonomically correct work surfaces, heights, and access for staff can reduce injuries and therefore lessen stress and risk for the caregiver staff. Privacy Studies have found that nurses prefer unit layouts in which they have a visual link to the pa tients, yet have audio privacy (Chaudhury et al., 2009). A dditionally, a sense of personal space provides employees with the opportunity to balance privacy with interaction. Nurses often need a place to focus on a task, have a private conversation or phone call, or distance themselves from interruptions. In a healthcare environment it is important to provide personal work zones for employees who seek privacy (Mudgett, 2000). Workers assess their privacy at two levels: the functi onal level, related to separateness and freedom from distraction in order to concentrate, and the

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37 psychological level, related to exclusivity, status in the organization, and environmental control (Vischer, 2005). Since clinical work can be considered as b oth individual and collaborative in nature, the nursing work environment must aim to achieve maximum interaction while at the same time not affecting concentrated individual work (Haynes & Price, 2004). Confidentiality is a concern that is seen in researc h studies which have found physicians and nurses very frequently breaching patient confidentiality and privacy by talking in spaces where they are overheard by others (Ubel, Zell, & Miller, 1995). The significance of the issue is pointed out in the example of a study in an emergency department that showed that 100 percent of physicians and other clinical personnel committed confidentiality and privacy breaches (Mlinek & Pierce, 1997). HIPAA, the Health Insurance Portability and Accountability Act of 1998, h as underscored the importance of providing necessary precautions to safeguard the confidentiality of staff conversations with and about patients. While the importance of the physical environment for patient confidentiality may seem self evident, only a few studies have directly examined the role of unit design or architecture. Summary of Literature Review The preceding review of the literature discussed the history of medical care environments, followed by reviewing the typical demands of registered nursing staff. Additionally, the review examined the design of healthcare work areas which revealed s pecific environmental conditions essential to designing or evaluating supportive environments for nursing staff (i.e., lighting, noise level, thermal qualities, s patial factors, and privacy). A well supported nursing staff is integral to the fu nctioning of a hospital facility and t here is mounting evidence that the physical environment impacts many

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38 aspects of employee well being and productivity such as job perform ance, job satisfaction, and employee fatigue and injuries (Applebaum, Fowler, & Fiedler, 2010). Design professionals can optimize the overall healthcare experience for employees b y understanding how the design of the healthcare facility impacts the staff m perceptions of their environment and then subsequently using this knowledge to make design decisions ( Mroczek, Mikitarian, Vieira, & Rotarius, 2005). The theoretical model of environmental comfort provides a conceptual framework that focuses on the relationship between individuals and their physical work environment which will serve as the lens through which the data in this study will be analyzed.

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39 A B Figure 2 2. Analysis of how and where nurses spend their time. A) Reported nurse time spent by location B) Reported nurse time spent by category C) Nurse practice by location D) N urse practice by subcategory

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40 C D Figure 2 2. Continued

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41 CHAPTER 3 R ESEARCH METHODOLOGY This study explores the linka ge between the design of nurse work areas and investigation were thr eefold. The first phase aimed at gain ing a general understand ing of the usage and perceived functionality of the key nurse work areas: the nurse station, the medication dispensing area, and the supply room. Aspects of the RNs satisfaction with their work areas were revealed in this phase through the use of surveys. The each work area under study. This involved observations of the nurses performing their daily tasks in relation to the physical characteristics of the nursing units. The third an d final phase group discussions revealed key considerations relating to environmental comfo rt. To enrich the findings from each of phase of the study, two workplace narratives were created that are set in the new and existing healthcare facilities under study. These of their the design of their work areas revealed key dimensions of environmental comfort, and will pave the way of research informed design choices in future clinical s ettings. Ethical Considerations The University of Florida Institutional Review Board (IRB) and Shands HealthCare (i.e., the organization in which the data collection took place) reviewed the design of the study, research methodology and procedures. IRB app rovals for the study

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42 can be found in Appendix A. Four nursing units were selected from the Shands facilities to participate in the study under the condition that the units were medical/surgical patient care units. Medical/surgical units were chosen as the type of unit to be studied because of their ubiquity in acute care hospitals. The target population of the study was, therefore, registered nurses working in adult me dical, surgical, and/or medical surgical acute care (non ICU) inpatient units. After consu lting a Shands staff member and determining four units that through a letter to the nurse managers of the units explaining the purpose of the study and the amount of time required for par ticipation, refer to Appendix B Upon written agreement from the nurse managers, the investigation proceeded. Throughout the study the nurse managers acted as a liaison between the researcher and the sample of participating nurses on their respective units in order to protect the identity of the nurses. The researcher supplied the nurse managers with a (Appendix C) which they then emailed to each of the registered nurses on their unit encouraging participation in the study. The nurses were info rmed that participation in the study was not a requirement for their employment, nor would it impact performance evaluations or potential for continued employment or promotion. The participants could withdraw from the study at any time for any reason, and all information was treated confidentially. Research Design This multi site field study employs mixed methods that are further enriched with workplace narratives revealing perceptions of the nursing staff under study. More research on understanding nurses nsight into the performance of the built environment can be found through post

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43 how and why people use these spaces the way they do they may not have a strong impact on healthcare building design (Chalfont & Rodiek, 2005). With narrative inquiry on nursing personnel. These types of questi ons are often answere d through qualitative research. Data from qualitative studies can be derived from interviews and focus groups, researcher observations, and analysis of documents and materials such as detailed descriptions, pictures, and records gather ed from the research setting. Qualitative research delves into perceptions and experiences in the environment with a depth and richness of data that often not captured using quantitative methods (State of the Field Committee, 2009). The qualitative researc h method is useful for healthcare investigations because it is difficult to quantitatively measure emotions that care providers may frequently experience such as relief, fear, joy, and surprise. The result of this qualitative study is a detailed, complex r eport that takes the reader within the setting being studied and expresses narratives of the participants (Creswell, 2003) that can be f ound in discussion chapter. Participants The total sampl e of registered nursing staff (n=17) voluntarily and anonymously participated in the study Exclusion criteria included RNs who worked in an advanced practice capacity, this is, managers, clinical nurse specialists, educators, and/or practitioners. Participant demographic data was not collected, however, t he literature reveals that the registered nursing workforce is predominat ely female (94.6%) (Page,

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44 2004) with an average of 46 years of age which is older than the total U.S. workforce standard (U.S. Department of Health and Humans Services, 2010) Research Setting A case study is an in depth investigation of a single instance, and represents a holistic approach to research (Sommer & Sommer, 2002). Case studies can be done alone or together to compare across projects (Yin 1994). Accordin g to the suggestion of Yin ( 200 3 ) the case selection was based on two factors: feasibility and sample variation in crucial categories. The first factor, feasibilit y willingness to participate in the study and to provide the required information Not only did this include the provision of resources, ( e.g. to release staff members from work to participate in the data collection) i t also included the researcher access it. To satisfy the second factor sample variat ion in crucial categories the definition of crucial categories needs to be determined. As nurse work areas are investigate d, cases that contain comfortable vs. uncomfortable environments need to be differentiated The selection of multiple cases is based on experimentation logic, i.e. replication logic. Each case must be carefully selected so that it either (a) predicts similar results (a literal replication) or (b) produces contrasting results but for predictable reasons (a theoretical replication) (Yin, 1994). In this study two case study settings were chosen based on the predicted contrasting results of comfortable vs. uncomfortable environments This study w as conducted in two separate hospital facilities which are a part of the healthcare organization Shands HealthCare. Located in north central Florida the Shands hospital system offers a broad range of inpatient and outpatient settings. Established in 1958 as a teaching hospital, Shands HealthCare has since expanded

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45 medical services to include nine n ot for profit hospitals. From this pool, two of the Shands HealthCare facilities, (1) Shands at the University of Florida and (2) Shands Cancer Hospital at the University of Florida, were selected as the settings for the study. Due to the close proximity o f the two hospitals and their geographic locations with respect to one another, the community and staff often refer to the buildings as the North and South Towers. For ease of understanding, Shands at the University of Florida will standing facility where as the newer Shands Cancer Hospital at the University of Florida will be referred to as the Figure 3 1. Comparison of research settings. The North Tower Shands at the University of Flo rida is an 852 bed tertiary care center with approximately 1,300 RNs (Hospitals and Services). This 1,129,462 square foot faci lity was built in the late 1950 s and the building has expanded through renovations and numerous smaller additions. Two nursing uni ts, referred to as Unit A and Unit B, were selected from the North Tower to participate in the study under the condition that the units were medical/surgical patient care units. Unit A U nit A is a cardiovascular medical unit supporting treatment of pre an d post heart transplant patients and other cardiothoracic surgery patients (such as aorta

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46 and valve repair, and coronary bypass). At capacity, the unit can accommodate 35 patients; the average number of patients is 27.6 and the average length of stay is 2. 96 days. Unit A typically staffs at a one to five nurse to medical surgical patient ratio and a one to four nurse to intermediate care patient ratio. A day shift is typically staffed with three unit secretaries/monitor technicians, nine registered nurses, one charge nurse, one clinical leader, and one nurse manager. Other hospital staff that can be found working on the units include physicians, therapists, environmental service, food service, and medical students. Unit A building characteristics As i llustr ated in Figure 3 2 Unit A consists of 13 single patient rooms and 11 shared patient rooms and is spread over an area of because the patient rooms are pulled to the outs ide walls creating a support space in the center area (Verderber, 2000). The core service area in the middle of the unit contains the nurse station (Figure 3 6) supply room (Figure 3 8) soiled linen rooms, shafts for mechanical requirements, general sto r age, staff offices, break room, and the staff restroom The windows on the unit are located in the patient rooms leaving all staff/support spaces windowless. All medications are administered from an automated distribution cabinet, manufactured by Omnicell which is located on each hospital unit. To dispense selected, the dispensing cabinet opens and the medication is dispensed. Every dose is released individually from th e dispensing cabinet such as pre filled syringes, vials, oral solid medication and ampoules. The pharmacy department refills and updates the

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47 cabinet throughout the day. Each dispensing cabinet incorporates a keyboard, a screen and a magnetic card reader al lowing interfacing with a central workstation for purposes of automatic record keeping and patient billing for each medication dose dispensed. Nurses access the system by entering their assigned password or conducting a finger print scan. The Omnicell syst em is used as the primary means of medication administration in both the North and South Towers; however the physical spaces housing the Omnicell cabinets vary greatly between the two facilities. Unit A does not have a dedicated medication roo m. As illust rated in Figure 3 7 back of the nurse station. The Omnicell is accessible from the rear entrance into the nurse station. Nurses are also provided a mobile medical cart with lockable storage (see Figure 3 10) that is located outside the patient rooms. After retrieving the medications from the Omnicell the nurses use the medical cart as a work surface for preparing and storing medications. Unit B Unit B is a general unit that most frequently supports the treatment of cardiac illness, resp iratory issues, and diabetes At capacity, the unit can accommodate 36 patients; the average number of patients on the unit at any given time is 30.9 and the average length of stay is 3.43 days. Unit B is typically staffed at a one to five nurse to patient ratio, however this ratio can vary depending on the shift and the amount of patients being serviced at the time. A day shift is typically staffed with two unit secretaries, eight register ed nurses, one charge nurse, one clinical leader, and one nurse manager.

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48 Unit B building characteristics Unit B consists of 12 single patient rooms and 12 shared patient rooms and is spread over an area of 14,000 square feet (Figure 3 3 ) Nearly identical in design support spaces are located in the center of the unit and the patient rooms are located around the perimeter. The nurse station (Figure 3 12) in Unit B has a somewhat different configu ration than Unit A due to the two entry points in rear of the nurse station Omnicell cabinets) is integrated in the back of t he nu rse station ( Figure 3 13 ), and again mo medications (Figure 3 10) The South Tower Opening in November of 2009, the Shands Cancer Hospital is the newest addition to the healthcare complex. The facility is 468, 436 square feet with 192 private beds and approximately 400 RNs servicing the hospital (Hospitals and Services). Two nursing units, referred to as Unit C and Unit D, were selected from the South Tower to participate in the study under the condition that th e units were medical/surgical patient care units. Unit C The majority of the patient populat ion serviced in Unit C is from p ancre aticobiliary and colorectal s urgery services. The unit also frequently cares for minimally i nvasive surgery ( bariatric ) and br east/melanoma/sarcoma/e ndocrine patients. The most frequent types of patient illnes ses treated on the unit include small bowel obstruction, pancreatitis, and colon/rectal c ancer. Unit C accommodates a maximum of 24 patients, with an average census of 22. T and is most commonly staffed at one to five nurse to patient ratio. The day shift in this

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49 unit is typically staffed with two support technicians, five registered nurses, a charge nurse, a clinical leader and a n urse manager. As seen in the other units under study, additional hospital staff can be found working on this unit at any given time including physicians, therapists, environmental service, food service, and medical students. Unit C building characteristics Unit C contains 24 private patient rooms over hybrid nurse station model with a central ized nurse station as well as a series of small decentralized nurse stations located just out side eac h patient room. The decentralized nurse stations are equipped with computers, task lamps, and lockable storage. The physical lay out of the unit can be seen on the floo r plan diagram in Figure 3 4 Adjacent to the central ized nurse station (Figure 3 15) wa s the designated medication dispensing room (Figure 3 16) Two password protected Omnicell distribution cabinets are located in this locked room which is accessible from either hallway. Access to the medication room is granted after entering a unique code shelving with the supplies necessary to administer IVs, a computer with a barcode scanning gun, a small refrigerator, a sink, and a counter top used as a work surface. The counter space is divided in to t wo areas with the use of a splash guard. The medication preparation area is separated from the sink by the splash guard; this is to avoid splashing and contamination of medication. Supplies for medication preparation such as pill crushers and splitters are required to stay in this prep area, and medication preparation is prohibited on the countertop opposite side of the splash guard. Unit D The majority of the patient population serviced in Unit D is from surgery services. Unit D accommodates a maximum of 24 patients. The day shift in this unit is

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50 typically staffed with two support technicians, five registered nurses, a charge nurse, a clinical leader and a nurse manager. As seen in the other units under study, additional hospital staff can be found workin g on this unit at any given time including physicians, therapists, environmental service, food service, and medical students. Unit D building characteristics Identical to unit C, Unit D contains 24 single patient rooms over 15,800 square feet. The physical lay out of the unit can be seen on the floo r plan diagram in Figure 3 5 hybrid nurse station model with a central ized nurse station (Figure 3 18) and a series of small decentralized nurse stations locat ed outside each patient room. Just west of the centralized nurse station is the medication room (Figure 3 19) and the supply room (Figure 3 20) is located just east of the nurse station. Two Omnicells are located in the medication room along with a sink, s torage cabinets, a computer with a barcode scanning gun, a small refrigerator and countertop work surfa ce The counter space is divided in to two areas with the use of a splash guard. Summary of nursing units The unit configuration of the four medical /sur gical units under study is commonly This typology places patient rooms on the perimeter of a corridor and staff support spaces on the interior of the loop. The main distinction between the layouts of the units lies in t he support spaces in the center of the unit. The centralized support spaces include clean and soiled utility rooms, a nourishment room a staff break room, management offices additional storage space and medication dispensing areas Units A and B do not have d esignated medication rooms; the medication dispensing cabinets are located in the back of the n

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51 Conversely, Units C and D have medication dispensing rooms that are only accessibl e through the use of a key code. Unlike Units A and B th e medication dispensing rooms in Units C and D contain counter space, a sink and other medical supplies. One element that all four units have in common i s centralized nurse stations; however none of them are laid out exactly the same Units C and D have d ecentralized nurse stations located outside of the patient rooms to supplement the central ized nurse station Table 3 1 compares the square footage amounts of the nurse work areas Table 3 1. Summary of units Unit Gross sq. f t. of unit Central n urse s tation Medication dispensing a rea Supply r oom Total sq. ft. of nurse work a reas Percentage of nurse work area sq. ft. to gross sq. ft. of u nit Unit A 15,850 1,127.59 196.88 266 .00 1590.47 7.11% Unit B 15,850 977.12 211.12 287.03 1475. 27 9.31% Unit C 16,950 572.14 184.21 192.75 949.1 0 5.6% Unit D 16,950 582.75 186.86 192.75 962.36 5.68% Data Collection The present study proposed two overarching questions to assess the environmental comfort levels of hospital work areas. (1 ) What level of environmental comfort (physical, functional, or psychological) characterizes the work spaces in hospital environments which are under study, as perceived by the nursing staff? (2) How important are the design considerations of lighting, noi se levels, privacy, thermal quality, and spatial factors in relation to perceived environmental comfort? To address these questions the participants employed in two healthcare facilities completed three sequential phases of data collection: Preliminary Sta ff Survey; Field Observations and Measurements; Standardized Survey (V ischer, 2010 ) and Focus Groups.

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52 Phase I: Preliminary Staff Survey The first phase of the research involved surveying the aggregate nursing staff at both hospitals under study. A cross se ctional, self administered questionnaire was developed to provide a basis for determining which nursing work areas would be studied further in the subsequent phases of the study. To this end, an online survey was given to potential participants in order to collect data on their perceptions of the environment. A hyperactive link to the survey was distributed via email to each registered nurse employed in the two hospitals, and the employees voluntarily chose to answer the survey questions. In order to initia te participation in the web based survey, the subjects had to click on the provided web link that was included in the e mail letter. After clicking on the provided web link, the participants were taken to the SurveyGizmo web based platform where they had t o anonymously log in to the survey. Th is procedure allowed the nurses to protect their identities, and after the survey period was over, the researcher gained access to the data through SurveyGizmo.com. The electronic survey provided an overall understandi ng of the usage and perceived functionality of eac h nursing work area. It is important to note that this initial survey was comprised of a portion of relevant questions taken from a larger study being conducted by the Facilities Development Department of S hands HealthCare, Flad Architects from Madison, Wisconsin and the University o f Virginia. Permission to use 5 selected items relating to this study was given by the principle investigators and helped inform this study. The selected questions were on the to pics of noise, size, layout, location, and lighting in regards to the nurse station, the medication dispensing area and the supply room. The responses to these questions helped focus the subsequent data collection. The results

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53 revealed that the nurs ing wor k areas yield opposing amounts of satisfaction ; This lead to further examination of these areas in order to determine which environmental c haracteristics are having the greatest impact on the nursing staff. Phase II: Field Measurements and Observations The second phase of the research methodology included the collection of facility data; field measurements of physical characteristics and photographic documentation; and observations of the nursing staff. This information was useful in creating a nursing unit profile, specifically pertaining to the nurse work areas to be studied: the nurse station, the medication dispensing area, and the supply room. The following details outline each step. Phase II: Collection of existing facility information The first step o f phase II characteristics of the nursing units including the square footages of each un it, floor plans of the unit, locations of various nursing work areas, and other valuable information which built the groundwork for the researcher to expand upon. Phase II: Photographic documentation and f ield measurement s An onsite walk through oriented the researcher to the units and provided the opportunity to capture the physical characteristics of the nursing work areas through photographs. Select photographs were then used in phase III, focus groups. Measurements of the light levels and sound levels in each of the nurse work areas were conducted through the use of a light meter and decibel meter instruments. Phase II: Observations T he final step of phase II was a series of focused observations of the staff performing their daily activities in the pri mary work areas. This

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54 methodological approach was selected because it allowed the researcher to study and understand the function of each unit wi thout actually participating Two observations were completed in each work area between 8:30am and 5pm during a typical week day shift (see Appendix D) The observation consisted of a twenty minute window where each of the specific work areas the nurse station, medication dispensing area, and supply room were observed to better under how well the unit functione d. Data collection assessed: who was using the various work areas, how many people were in the area, and how the staff worked in the area. Other data such as tasks (the types of tasks and the needs related to the tasks) and physical characteristics of each nursing work area (spatial allowances, noise sources, lighting, etc.) were also captured during some of the observations. Phase III: Standardized S urvey and Focus Group The third and final phase of the data collection involved surveying and conducting fo cus groups with nursing staff from each unit. The survey was distributed to the participants at the start of the four focus group sessions which were conducted in the break rooms of the respective nursing units. The survey inquired further about the nurses he designs of first research question by evaluating which level of environmental comfort characterizes the nurse work area. Phase III: Standardized survey A modification of th e DiConFon surv ey (Vischer, 2010) a 52 concerning building performance, was administered to the participants. The DiConFon survey was adapted for this study to include 35 specific feature evaluations which were rated on a five point scale and one open ended question. The 35 items were chosen on

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55 the basis that these items formed 5 key dimensions applicable to the health care workplace: lighting, noise level, thermal quality, spatial factors, and privacy. The following questions were omitted from the original questionnaire because they were irrelevant to t he scope of this research study or the questions were not applicable to the healthcare work environment: 1 6, 11, 14, 16, 22, 23, 27, 29 31, 36, 37, 41, 44, 46. Furthermore, questions 28 and 40 were separated to create two additional questions The separation of these questions allow ed the participants to provide more in depth responses regarding noise sources and lighting levels. Additionally, minor adjustmen ts were made to the wording of the survey questions; for example, the British spelling of odour and colour were interchanged with the American English spellings of the words. A copy of the instrument, in its original form and the modified versi on, can be f ound in Appendices E and F theoretical model of the worker workspace relationship in which stress a nd comfort play a critical part suggests a methodological a pproach on which to base empirical studies nvironment typically focuses on psychosocial factors that affect job performance, strain and employee health, and addresses the growing body of work on the environmental psychology of workspace. Her theory of environmental comfort can be applied to the rel ationship between worker behavior and physical features of the work environment. This framework can us efully be applied to analyze the physical environment in which peop le work, in terms of the control they have over their space The questionnaire is desig ned so that the information derived from it may be directly applicable to building related and workplace related issues (Vischer, 2005).

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56 The pencil and paper survey required approximately 5 minutes of time to complete. This survey provided a clear understa environmental comfort level (physical, functional, psyc hological) of their work areas. After the nurses completed the survey the researcher facilitated focus groups to identify design variables which impact the enviro nmental comfort of the nursing staff; recommendations for improvements of the work areas were also discussed. Phase II I : Focus groups The focus group discussions were held for approximately 20 minutes and provided insights into the nursing work areas on t he unit (not surfacing through the surveys alone ) Topic s of discussion included: how the central ized nurse work station, medication dispensing area, and supply room mee ts the needs of the nurses; why the built environment does or does not meet the needs a nd support the tasks of the nursing staff, and what preferences nursing staff have when it comes to the areas that they use and work in most often. The conversation was guided be certain of which area in particular was under discussion. The researcher used audio recording devices during the discussions which allowed the researcher to perform content analysis of the data. The focus group discussion entailed a series of discussio n prompts that were divided into the following three sections: the nurse station, medication dispensing area, and supply room. The discussi on was further divided into five sub sections on the basis of the effects of the environmental conditions: lighting, noise level, thermal quality, spatial factors and privacy. The focus group format entailed open ended questions resulting in unstructured in depth discussions between the nursing staff In an

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57 unstructured interview the main goals are to explore all the al ternatives in order to pick up information, to define areas of importance, and to allow the respondent to take the lead to a great extent (Sommer & Sommer, 2002, p. 114). The researcher asked participants about the facts of a matter as well as thei r opini ons. T his method assures complete freedom in the terms of the wording that can be used and the way questions are explained to the respondents (Kumar, 2005). According to McArthur (2010), open ended questions are a powerful tool to use in a consultation. Th ey are characterized by questioning which opens a line of inquiry and permits full elaboration of content. This is in contrast to closed ended questioning which can shape a response and typically derives a single word answ er to a specific question Summar y of Research Methodology This multi site field study involved two hospital facilities referred to as the No rth Tower and the South Tower. Within this setting, t wo medical/surgical units were selected from each h ospital in which to conduct the research stu dy The method ology entailed three phases of research: (1) an initial survey to gain a general understanding of the usage and perceived functionality of the key nursing work areas: the nurse station, the medication dispe nsing area, and the supply room; (2) observation of the performing their daily activities in each work area ; (3) surveys and focus group discussions to perceptions of the lighting, noise level, thermal qualities, spatial factors, and privacy The data were anal yzed through the lens of Vischer all perception of healthcare work areas.

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58 T able 3 2 List of environmental conditions and their subcategories under study Comfort category Environmental items rated by occupants Lighting Overall lighting High light levels Low light levels Light reflections on surfaces or screens Access to daylight Noise level General noise distractions Noises from voices Noises from equipment Thermal quality Temperature comfort General temperature Temperature shifts Ventilation comfort Air freshness Odors Spatial f actors Furniture layout of nurse station Size of nurse station Nurse station work surfaces Computer configuration Personal storage space W ork storage space Privacy Visual privacy Conversation privacy Telephone privacy

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59 Figure 3 2 Unit A floorplan.

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60 Figure 3 3 Unit B floorplan

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61 Fi gure 3 4 Unit C floorplan.

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62 F igure 3 5 Unit D floorplan.

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63 A B Figure 3 6 Unit A nurse station. A) E xterior B) I nterior (Photographs courtesy of author, Paige Prebor)

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64 Figure 3 7 Unit A medication dispensing area. (Photographs courtesy of author, Paige Prebor)

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65 A B Figure 3 8 Unit A supply room. A) Supp ly room color coded shelving B) A corner of the supply room contains the electrical equipm ent for the computer network (Photographs courtesy of author, Paige Prebor)

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66 Figure 3 9 Unit A corridor. (Photograph courtesy of author, Paige Prebor)

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67 Fi gure 3 10 Unit A medication cart. (Photograph courtesy of author, Paige Prebor)

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68 Figure 3 1 1 Unit A task chair and COW located outside patient room (Photograph courtesy of author, Paige Prebor)

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69 A B Figure 3 12 Unit B nurse station. A ) Exterior. B) Interior. (Photographs courtesy of author, Paige Prebor)

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70 A B Figure 3 13 Unit B medication dispensing area. A) View of Omnicell at rear of nurse station. B) View of Omnicell from corridor. (Photographs courtesy of author, Pai ge Prebor)

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71 A B Figure 3 14 Unit B supply room. A) Cabinet used as a make shift work surface to hold computer, hand held barcode scanner, and various supplies B) Color coded shelving. (Photographs courtesy of author, Paige Prebor)

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72 A B Figure 3 1 5 Unit C centralized nurse station. A) Exterior. B) Interior. (Photographs courtesy of author, Paige Prebor)

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73 A B Figure 3 16 Unit C medication dispensing area. A) View of Omnicells and a computer which is located on a mobile cart. B) Sink separated from medication preparation area through the use of a splash guard. (Photographs courtesy of author, Paige Prebor)

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74 A B Figure 3 17 Unit C supply room. A) Color coded shelving B) Hand held barcode scanner, Omnicell, and color coded shelving. (Photographs courtesy of author, Paige Prebor)

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75 A B Figure 3 18 Unit D centralized nurse station. A) Nurse station reception B) Nurse station exterior with hand washing station. (Photograph s courtesy of author, Paige Prebor)

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76 A B

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77 C Figure 3 19 Unit D medication dispensing area. A) Sink separated from medication preparation area throug h the use of a splash guard B) Omnicells C) Com puter located on counter top (Photographs courtesy of author, Paig e Walker)

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78 A B Figure 3 20 Unit D supply room A) O mnicell B) Color coded shelving. (Photographs courtesy of author, Paige Prebor)

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79 CHAPTER 4 RESULTS This chapter examines the ways in which different environmental conditions affect user com fort. Visc omfort ranks workplace environments in a rising continuum of physical, function al, and psychological comfort. At the base of the continuum is the category of physical comfort, which includes the nonne gotiable prerequisites for a habitable work environment such as enough light, no extreme temperatures of too hot or too cold, safe noise levels, and an adequate number of functioning toilets. These conditions are usually met through building codes and regu lations which ensure health safe ty, and welfare. The next element of environmental comfort is identified as functional comfort. A functionally comfortable environment is support ive of work related activities as Vischer lly comfortable workspace is a tool for work: not just lighting, but the right lighting for the task, not just ventilation, but clean conditioned air that is free of contaminants, not just heating, but thermal comfort (2005, p. 84) o environment in other ways increases the psychological comfort the last level of environ mental comfort because it provides the practicality of having a task light, bu t also the perception of control in being able to manipulate that light The habitability pyramid (Figure 2 1 ) illustrates how the three levels of comfort are not mutually exclusive or even truly separate, but merge together as a continuum, from the basic needs of physical comfort, through the task related needs of functional comfort, to the emotional needs of psychol ogical comfort

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80 Five research questions we re posed to identify and compare the environmental comfort levels of hospital wor k areas among regis tered nurses completed th e DiConFon survey (Vischer, 2010 ) inquiring on the environmental conditions of lighting, noise level, thermal quality, spatial factors, and privacy in relation to the nurse station, the medication dispensing area, and the supply room of their respective units The environmental conditions were rated on a five point scale where 1 is uncomfortable and 5 is comfortable. Mean values were derived from the data to represent the comfort level of each environmental condition. This data, along with the focus group dialogs and triangulated to answer th e following research questions. Research Question One What level of environmental comfort (physical, functional, and psychological) characterizes the work spaces in hospital environments which are under study, as perceived by the nursing staff? This question analyzes the built environment of their workplace with the intention of identifying which level of environmental comfort they are experiencing. Unit A Mean scores were calculated for each of the five environmental conditions addressed in the DiConFon survey. The mean scores of the f ive categories are presented in bar chart s in Figure 4 5 through Figure 4 9 The bar chart s illustrate that the conditions of Unit A range between x = 2.0 and x = 3.4, where the lowest ranked environmental condition is the noise level ( x = 2.0 ) and the highest ranked con dition is the lighting ( x = 3.4 ) The mean calculations reveal that the nurses perceive a relatively low amount of comfort in multiple dimensions of their workplace. Congruently, t he RNs

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81 verbalized their experiences and perceptions regarding t he comfort of their work areas during the focus group session; observat ion data gave further insight into the unit and to the users who worked in the various work areas. Table 4 1 displays the sample means and standard deviation scores for each question fr om the DiConFon survey. This information reveals key considerations relating to environmental comfort which is dissected below Table 4 1. Assessment of environmental factors Unit A (n=3) Comfort category Environmental items rated by occupants Mean SD Lighting q uality Overall lighting 3.33 1.15 High light levels 3.67 1.15 Low light levels 3.67 1.15 Light reflections on surfaces or screens 3.33 0.58 Access to daylight 3. 0 0 2.0 0 Noise l evel General noise distractions 3.33 0.82 Noises from voic es 3. 0 0 1.1 0 Noises from equipment 3.33 0.82 Thermal q uality Temperature comfort 3. 0 0 0.0 0 General temperature 3. 0 0 0.0 0 Temperature shifts 3. 0 0 0.0 0 Ventilation comfort 3. 0 0 0.0 0 Air freshness 2.33 0.58 Odors 2.66 0.58 Spatial f actors Furnit ure layout of nurse station 2.33 0.58 Size of nurse station 3.33 1.15 Nurse station work surfaces 2.67 1.15 Computer configuration 3. 0 0 1.0 0 Personal storage space 2.33 0.58 Work storage space 2.33 0.58 Privacy Visual privacy 2.33 0.58 Convers ation privacy 2.33 0.58 Telephone privacy 2.33 0.58 Lighting As the highest ranked environmental condition, the lighting was not perceived as a concern by the nurses on Unit A. During the focus group discussion the indicated that they woul d like views to the outdoors with accompanying natural light The break roo m

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82 is the only staff space on U nit A that has access to a window, and the nurses mentioned that the vertical blinds wer e usually close d so they rarely saw the view overlooking the tree tops and nearby parking garage It was noted during the observation periods that the nurses have access to light switches to operate the lights throughout the unit; during the observations t he canister lights at the front of th e nurse station were turned off and the rest of the nurse station was lit with 2x4 recessed fluorescents. The nurses perceive the overall lighting on Unit A as functionally comfortable due to their expressed satisfacti on with the amount of light and their control over the fixtures; however, the lighting is not characterized at the top level of the environmental comfort continuum, psychological comfort, because the nurses are lacking proximity to windows in their work ar eas. Daylight is deficient on Unit A and this has a pronounced effect on Noise l evel N oise levels from voices and equipment were rated as loud and distracting by the RNs on Unit A Complementing the survey results it wa s apparent during the focus group discussion that the noise level was a concern : Nurse 2: All the telemetr y machines are always going off. I guess you get used to it. And the thing that really g stressed out and all that noise is going on and then the [resident] flute Nurse 3: Yeah, uh huh, one more irritation! Nurse 1: Nurse 2: Right! And when I get in the car my husband will have the music playing are you going to do about that? Nurse 1: Nothing. The noise level overall on the unit is loud t elemetry alarms, bed

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83 Nurse 2: Sometimes people are yelling. Like there are some people with really loud voices, and they talk re al loud The noise source s on the unit are both the medical equipment and the vo ices of other staff members. Vischer (2005) explains the relationship between noise and the levels of environmental comfort as such: N oise control has an important effect on psychological comfort, in much the same way as privacy. Intrusive noise does more than dis tract people from Functionally, problems arise for most people because their attention is distracted by noise nearby when they are trying to concentrate on a task. Physical comfort co mes in to play where sound levels are so high that users become fatigued and strained struggling to hear in adverse acoustic conditions even risking deafness ( p. 100 ). According to the environmental comfort theory the conditions in Unit A correspond to th e lowest level of the comfort continuum, physical comfort, because the nurses are often aggravated and distracted from the surro unding sounds resulting in increased fatigue at the end of the day. intrusive noise, ruling out the top level s of the comfort continuum. Thermal q uality The nurses assessed the thermal qualities neutrally in both the on what temperature is comfortable: Nur se 1: but some other people would put it on 60 Nurse 2: The thing too with here is that the air conditioning is old in this building. person will be t has problems so they can only do so much. The staff usually if they get too cold they will get a blanket out of the blanket warmer but now tha t is forbidden. The thermal condition on Unit A does not meet the top tier of the comfort continuum, psychological comfort, because the nurses are lacking the aspect of control

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84 over their thermal condition due to the old air cond itioning system and due to the wide variation in how people experience thermal comfort. However, the nurses do not express continual thermal discomfort that cannot be moderated by the use of added clothing; therefore, the thermal comfort on the unit is bes t categorized in the functional comfort level. Spatial f actors As seen in Table 4 1 the furniture layout of the nurse station was rated at a mean value of x = 2.33. D uring the observations it was immediately noted that the nurse station was not furnished suitably. The nurses in Unit A are lacking adequate seating with computers to complete required paperwork and their functions are often slowed down due to this impediment. The nurses explain: Nurse 1: e st ation during shift change, or enough chairs to give report because everyone sits at the same time to give report. Nurse 2: When a nurse comes across an available chair in Unit A they will often move it in to the hallway and completing their computer tasks. One nurse admitted that although they are not permitted to sit in the hallway because it is a fire hazard she brings her own stool from hom e, places it in the corridor near the patient rooms, and sits on it while charting at her computer on wheels (COW) (see Figure 3 11) supposed to be sitting in the halls but people do because they need to take a r est and si The other nurses expanded on this topic : Nurse 1: be near their rooms. I like to be by my patients so I can see if there are

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85 any issues, I hear them getting out of bed, or I hear them calling out for sit in the hallway. Nurse 2: Yeah before we got more people a t their COWs trying to sit near their Everybody, the PCAs [patient care assistants] the nurses, everybody, would be there trying to [trails off] a Roo [wall mounted work station] to do the acuities on the wall, but that was a thrash and I wanted some coffe of people sitting on bedside tables and starting acuities at the Wall a Roos, which was forbidden, but we did it anyway. The RNs are unable to find a place to sit and are being deprived of a basic workplace expectation negatively impacting psychological, functional, and physical comfort levels. The nurses are experiencing discomfort (below the habitabili ty threshold). Privacy As the second lowest rated environmental condition on Unit A, privacy is a concern for the majority participants in t his study The nurses discuss their experiences in the medication dispensing area: Nurse 1: you. Transporters are running over you, the dietary girl hits you with the food tray cart and x ray takes you out with their machine. Nurse 3: We get phone calls left and right, people still bother you left and right, and patients walk by. Nurse 1: fifteen things to go, com Nurse 3: by walking up and talking to me Nurse 1: Me too! They tried to make cubby holes to yeah.

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86 Nurse 2: there is any way around it. And even then you still have a phone so they can find you. Nurse 1: The patients can even be looking for you, and then they go in the medicine area! The expressed lack of privacy is psychologically and functionally ta xing; psy chologically, the nurses appear to lack control over their e nvironment and functional ly this interferes with concentration. This indicates that the nurses are experiencing the next lower level, physical comfort. Summary of U nit A From the amalgamation of the low survey ratings of the environmental conditions supplemented with the feedback in the focus group discussion, RNs appear to be more comfortable with the functional comfort levels of lighting and thermal qu ality than with the physical comfort levels associated with the noise level and privacy conditions (Figure 4 1) Figure 4 T he nurses find themselves distracted and interrupted almost continuall y throughout the day. Although t he co nditions causing the most discomfort in this unit were related to spatial factors and these were associated with the highest discomfort level Barriers to

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87 productivity include in adequate task seating and work surfaces, and they are often displaced into the Unit B The bar graphs in Figures 4 5 through Figures 4 9 present the mean values of each environmental condition of the work areas in Unit B The lowest ranked environmental factor is therma l quality ( x = 3.0 ) while the highest ranked factor i s lighting ( x = 3.52 ) T able 4 2 shows the mean and standard deviation scores for eac h condition question in the DiConFon survey. Table 4 2. Assessment of environmental factor s Unit B (n=5) Comfort category Environmental items rated by occupants Mean SD Lighting q uality Overall lighting 4.0 1.22 High light levels 4.4 0.55 Low light levels 3.6 1.52 Light reflections on surfaces or screens 4.0 1.22 Access to daylight 1.6 0.55 Noise l evel General noise distractions 3.0 0.71 Noises from voices 3.2 0.45 Noises from equipment 3.8 0.45 Thermal q uality Temperature comfort 1.8 0.84 General temperature 4.6 0.55 Temperature shifts 3.2 1.3 0 Ventilation comfort 2.6 1. 14 Air freshness 3.0 0.71 Odors 4.4 0.55 Spatial f actors Furniture layout of nurse station 3.4 0.89 Size of nurse station 3.2 1.3 0 Nurse station work surfaces 2.6 1.34 Computer configuration 4.0 0.71 Personal storage space 3.0 0.89 Work stor age space 3.2 1.48 P rivacy Visual privacy 3.0 1.58 Conversation privacy 3.4 1.52 Telephone privacy 3.0 1.22 Lighting Although the rating for lighting fell between average and good in the survey, it still presented a concern for the nurses in Unit B. For instance, the recessed

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88 canister lights in the dropped ceiling of the medication dispensing area are intentionally turned off by the nurses because the lights generate an uncomfortable amount of heat when standing under them. However, this results in t he nurses pe rforming their tasks in less than optimal lighting conditions According to the e nvironmental comfort theory, the need for good lighting is critical because the nurses are counting and dispensing medication, yet the heat radiating from the fixt ures causes discomfort. Further, t he nurses do not have control over the lights on the east side of the lling it. So this side stays s and natural light in the unit. Unfortunately the only rooms on the unit with access to windows are the patient rooms and administration offices. The lighting condit ions on Unit B do not meet the top tier of the criterion of psychological comfort given the lack of natural light and control over lighting conditions Additionally, the lighting in the me dication dispensing area is in sufficient for the type of work being performed; therefore, th is represents physical comfort: the lowest tier of the theoretical continu um. Noise l evel During the focus group discussion the nurses commented on the ambient noise on the ir unit: Nurse 1: There is no privacy. Nurse 2: And it i s loud. Nurse 5: We are loud! Nurse 3: Nurse 5: :

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89 The nurses suggested that the noise in the area could best be controlled through ru unit. The noise conditions are best characterized at a functional level because the nurses are experiencing unwanted sound, but it i s not put ting them at risk fo r hearing loss nor did they express concerns about noise exhaustion. Noise exhaustion would be defined as sound levels so high that users become fatigued and struggle to hear in adverse acoustic conditions However, the noise is intrusive, distracting, and the nurse do not have control over their surrounding noise levels. Thermal q uality The thermal quality of Unit B is rated as the lowest environmental co ndition ( x = 3.0 ) average reasons for their assessment became clear in the focus grou p dialog : Nurse 1: Nurse 2: Nurse 3: There are thermostats and we are supposed to have control over the A/C Nurse 2: Nurse 3: Nurse 4: Uh huh. Yeah. working properly, and when the staff reported the issue to maintenance they were not given a solution or any expectation of it being repaired. Vischer (2005) explains that having a sense of control over the environment is essential to reach the level of psychological comfort:

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90 responsiveness of facilities managers and getting results from service calls. The re assurance of a responsible management, and the evidence that someone has acted comfort ( p. 91 B is lacking thermal control and this is adversely affecting the nurses Therefore, nurs es in Unit B seem to be experiencing the lowest level on the environmental comfort continuum, the physical comfort leve l. Spatial f actors Another prevalent topic of the focus group discussion was the absence of proper furnishings and equipment necessary fo r the RNs to perform their daily responsibilities. There are not enough chairs on the unit to service all the staff members, and many of the chairs are broken and the height can no longer be adjusted. One nurse expressed physical effects from sitting in th down. One chair is stuck in the low position and it just kills my knees to sit down and try The broken and inefficient amount of chairs and COWs on Unit B confines the (2005) ll being may suffer when furniture is old, un ergonomic for computer use, and d ifficult to use ( p. 93) However, when considering the use of space on the unit, particularly regarding the staff restrooms, Unit B is experiencing a level of discomfort (the l evel bel ow the habitability threshold): Nurse 1: We need two staff bathrooms. Nurse 3: Oh yeah

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91 Nurse 5: We have a shower room in the back useless that is being used as a and everything is there, the water. Nurse 3: Yeah I think that space is bigger than our break room! And we only have one toilet for all of us! When the single staff toilet located on Unit B is occupied the staff member is required to come back at another time or leave the unit in search of an available staff conditions were discussed during the focus group as well such as the supply room having no work surfaces to prep m edical supplies, and the isles of the nurse station being too narrow and crowded making it difficult to maneuver with a COW. On the continuum of the environmental comfort theory, the physical comfort level implies an adequate number of work surfaces, task chairs, as well as toilets for employees. Since Unit B does not offer these components the RNs are experiencing discomfort on a regular basis Privacy During the focus group discussion the nurses mentioned two design compo nents of the unit that increased their sense of privacy: (1) the individual mobile carts assi gned to each nurse (see Figure 3 10 ) and (2) the privacy panel on t he front of the nurse station (Figure 3 12 ) In the following example, t he nurses discuss the mobile carts: Nurse 1: I like havi ng the little carts out there. Nurse 3: Nurse 2: your syringes, your pill crushers, your cups, alcohol pads, everything is th

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92 Nurse 1: patient who is on a lot of antibiotics you can get the little mini bags and put them in there for the day. So medications; however, the carts are located in the corridors where visual privacy, conversation privacy, and te lephone privacy are nearly non existent. A ccording to the environmental comfort theory wh level (freedom from distractions in order to concentrate) they do have control and ownership for their personal territory which led to satisfac tion. According to Vischer (2005) expectation of privacy and their perceptio n of the privacy they have ( p. 96 the nurses on Unit B do not have enclosure and exclusiv ity in their immediate workplace the key components of comfortable privacy meets their expectations The nurs es acknowledge d that the nature of their work involves contact with many people patients and staff, and involves constant movement; the y do not w ant or expect private offices Yet a degree of privacy is appreciated. For example, t he privacy panel on the front of the nurse statio n offers the nurses the opportunity to sit without being seen (albeit in a crowded place that does not always have a cha [the privacy panel] because if Taking perception of their per sonal territory on the mobile carts, t perceive a degree of psychological comfort. However the nurses are lacking control over their environment and their exclusivi ty, and

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93 distractions often inhibit their concentration. This indicates that the nurses are experiencing the lower level of the continuum physical comfort. Summary of Unit B When examining the survey results in conjunction with the mes from the focus group discussion, it appear s that the RNs are more comfortable with the noise level (functional comfort level) and privacy (functional comfort level) than with the lighting (physical comfort level) or thermal cond itions (physical comfort level). Yet, the conditions causing the most discomfort in this unit rel ated to spatial factors For example, t he nurses do not have an adequate amount of task chairs, computers, or work surfaces, and they need more staff toilets on the unit Figure 4 2 The perceived environmental comfort levels of Unit B. Unit C The bar graphs in Figure 4 5 through Figure 4 9 illustrates the results of the collective DiConFon questions by displaying the calcul ated mean values of the category responses. The lowest ranked environmental factors in Unit C inc ludes both the privacy and the noise level at mean values of x = 3.33, while the highest ranked factor is lighting at a mean value of x = 4.23. Table 4 3 shows the mean and standard deviation

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94 scores for each of the five categories of questions from the DiConFon survey regarding the work environment in Unit C. Table 4 3. Assessment of environmental factors Unit C (n=6) Comfort category Environmental items rated by occupants Mean SD Lighting q uality Overall lighting 4.33 0.52 High light levels 4.5 0 0.55 Low light levels 4.0 0 0.63 Light reflections on surfaces or screens 4.0 0 0.63 Access to daylight 4.33 0.52 Noise l evel General noise distractions 3.0 0 0.71 Noises from voices 3.2 0 0.45 Noises from equipment 3.8 0 0.45 Thermal q uality Temperature comfort 4.16 0.75 General temperature 3.33 0.82 Temperature shifts 4.0 0 0.63 Ventilation comfort 4.0 0 0.63 Air freshness 4.0 0 0.0 0 Odors 4.0 0 0.0 0 Spatial f actors Furniture layout of nurse station 4.17 0.75 Size o f nurse station 4.6 0 0.52 Nurse station work surfaces 4.33 0.82 Computer configuration 3.5 0 0.84 Personal storage space 4.17 0.41 Work storage space 4.17 0.75 Privacy Visual privacy 3.17 1.47 Conversation privacy 3.5 0 0.84 Telephone privacy 3. 33 0.82 Lighting The survey results reveal a mean value of x = 4.23 for the overall comfort of the lighting. The nurses discussed lighting during the focus group, with a strong emphasis on the natural light: Nurse 1: like is the overhead light in the patient room. Nurse 2: Uh huh, but I love the windows; it offers a lot of light. The best thing about this building is the windows. There is a lot of natural light and I love the view out the windows. Nurse 3: If you are on this side [of the building] during the day the windows actually warm the rooms up. A lot of the patients actually complain of it getting warm because the sun is actually beaming in there. Nurse 1:

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95 Nurse 3: Ye overall, just wellbeing. The results in this study replicate the well established findings that d aylight has a pronounced effect on psychological comfort. The tasks performed by RNs do not require natural light, but they value prox imity to windows day light and outdoor views (Scott, 2004 ) As discussed in the literature review, healthcare research indicates that views of nature and access to natural light can have positive effects on the nurse performance and stress levels (Chaudhury et al., 2009; Alimoglu & Donmez, 2005 ). During the observations of Un it C the nurses were noted adjusting t he light levels of the medication room and nurse station W ith functionally supportive light ing, and psychologically comfortable amounts of natural light the nurses seemed to achieve the level of psychological comfort. Noise l evel D uring the focus group discussion it became apparent that the general noise i n the unit was a concern: Nurse 1: I the convers ation outside the door. talk loudly or anything, they are just using inside voices, but it can still be heard. Nurse 3: s the closer you get to the nurse st hear, and that is something that we could probably control better, but I Nurse 4: If you close the patient doors it helps with the noise and traffic outside. Nurse 2: spot whe Nurse 4: You can actually try to char t a little bit in there because sometimes you can sit o ut in the hallway [ decentraliz ed nurse station] constant

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96 keep being tagged on you. negatively affecte d by the amount of distractions which interfere with their concentration. The RNs recounted their attempts to control the noise levels by shutting patient doors or retreating into the medication room The findings suggest that their working environm ent is best described as meeting t he functional comfort category. Thermal q uality Each nursing work area as well as each patient room, has a thermostat that controls the temperature of that space. The nurses expressed that th e temperatures in the building are then the thermo stats or amount of clothing, can be adjusted. The nurses in Unit C seem to be e xperiencing the highest level on the environmental comfort continuum of psychological comfort, in terms of thermal co nditions. Spatial f actors T he nuances of workstation layout and ergonomics were the greatest concern for the nurses on Unit C F or instance, the nurses commented on the locati on of the patient nourishment supplies: Nurse 5: In the cupboard where we have s uppl ies like juices, drinks, cereal the computer is below that cabinet which makes it really hard to access it. Nurse 3: Yeah i t should be in a separate area computers and everybody is on top of wh oever is sitting there like our cupboard space is right there so they have to reach over, like she said, and get under and you can hardly find the little key hole to unlock the cabinet. Nurse 5: Yeah, rse st ation Nurse 3: Other units stock these in different places; we just need a locked cabinet. Nurse 2 : Yeah we have them put in the nurse station, not a nourishment room.

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97 The inconvenient location and size of the computer in the medication room was also verbali zed: Nurse 1: I really wish we had a larger computer in there. Nurse 2: You know what, I think if it was higher, because I found myself like hunched over. Nurse 4: Yeah, somehow the placement of that computer is inconvenient to me. And I would like a la rger screen. Nurse 2: And higher up. Yea h Nurse 2: The laptop computer in the medication room is sitting on a rolling cart (seen in Figure 3 16a ) which places the computer at an uncomforta ble height and position Additionally the nurses find the location of the nourishment supplies in the nurse station inconvenient However, the nurses expressed satisfaction wit h many other factors of their work areas; for example, the furniture layout and size of the nurse station, and the amount of work and personal storage is highly rated by the nurses. The refore, the nurses seem to be experiencing a level of functional comfor t regarding the spatial factors of the work areas. Privacy The level of perceived privacy was rated as one of two lowest conditions on the unit (x = 3.33 ) The nurses expressed that they are often distracted by nearby noise making it difficult to concentra te on a task However, the nurses appreciate being able to work in an enclosed medicat ion area with minimal distractions in a ddition to having personal territory provided through decentralized nurse station s According to the environmental comfort theory t he nurses seem to perceive functional comfort in their work areas

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98 Summary of Unit C When viewing the survey results in conjunction with t he focus group discussion it appears that the nurses on Unit C are more comfortable with the lighting and thermal qua lities of their unit than with the noise level and privacy Therefore, the work environment has two perceived comfort levels: psychological and functional. The noise on the unit is distracting to the nurses particularly when they frequently hear one anoth the most adverse effect on comfort were related to the spatial factors (functional comfort level), which beco me s quite problematic in the medication room as the nurses access the space multiple t imes a day. Figure 4 3. The perceived environmental comfort levels of Unit C. Unit D The graph s in Figure 4 5 through Figure 4 9 illustrate the mean values of the responses regarding the five environmental conditions on Unit D The survey results showed that the nurses perceive the environmental factors quite positively with 4 of the 5 factors ranking above a x = 4.0. The lowest ranked dimension is thermal quality with a mean value of x = 3.83 and the highest ranked dimension is spatial factors with a

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99 mean value of x = 4.89. This suggests that the nurses are experiencing c omfort and support in multiple dimensions of their workplace Table 4 4 shows the mean and standard deviation scores for each of the five catego ries of ques tions from the modified DiConFon survey regarding the work environment in Unit D Table 4 4. Assessment of environmental factors Unit D (n=3) Comfort category Environmental items rated by occupants Mean SD Lighting q uality Overall lighting 4.33 0.58 High light levels 4.67 0.58 Low light levels 4.33 0.58 Light reflections on surfaces or screens 3.67 1.53 Access to daylight 4.67 0.58 Noise l evel General noise distractions 4.33 0.58 Noises from voices 4.0 0 1.0 0 Noises from equipme nt 4.33 0.58 Thermal q uality Temperature comfort 4.67 0.58 General temperature 3.33 0.58 Temperature shifts 2.33 1.15 Ventilation comfort 4.0 0 0.0 0 Air freshness 4.0 0 1.0 0 Odors 4.67 0.58 Spatial f actors Furniture layout of nurse station 4.67 0 .58 Size of nurse station 4.67 0.58 Nurse station work surfaces 5.0 0 0.0 0 Computer configuration 5.0 0 0.0 0 Personal storage space 5.0 0 0.0 0 Work storage space 5.0 0 0.0 0 Privacy Visual privacy 4.67 0.58 Conversation privacy 4.17 1.33 Telephon e privacy 4.0 0 1.0 0 Lighting The sample of nurses in Unit D are e xperiencing the highest level on the environmental comfort continuum, the psychological comfort level, in terms of lighting (i.e., x = 4.3 3 for the overall lighting comfort ) The medication room, nurse station, and decentralized nurse stations are supplied with task lights that can be Similar to Unit C, the nurses expressed satisfaction with both the levels of artificial light and natural li ght o n the unit. A ccording

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100 to one nurse th e natural light is the best part about the hospital and her colleague s in the focus group agree d with her observation. Noise l evel During the focus group discussion it was apparent that t he noise level on the u nit wa s a concern for the nurses : Nurse 1: that people are saying. Nurse 2: Yeah. Even from in here [the break room] you can hear people talking out there. Nurse 1: [trails off] You can hear it clearly! According to the survey results the greatest source of unwanted noise on the unit comes from voices. Conversations are eas ily over heard which lends itself to HIPA A violations if patient cases are being d iscussed within earshot of others. The researcher noted during observations that she could hear conversations a t the central ized nurse station from various other parts of the unit. The nurses mentioned during the focus groups tha oud their own conversation s Functionally, nurses are trying to concentrate on a task but their attenti on is distracted by adjacent noises According to the environmental comfort theory these types of experienc es are indicativ e of a functional comfort level which does not support optimal work environments. Thermal q uality T he thermal quality is the lowest ranked environmental co ndition in Unit D at a mean value of x = 3.93, but that still indicates good performance. N onetheless, the nurses participating in the focus group seem fairly content with the thermal control and quality of the unit: Nurse 1: The temperature we can pretty much adjust i t; issue.

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101 Nurse 2: Yeah there is a thermostat in the med room, one in the supply room, and two in the hallways near the nurse station that we can change whenever we want. Similar to Unit C, e ach nursing work area has a thermostat that controls the temperature of that space. The nurses expressed contentment with th e temperatures in the building and if they feel uncomfortable then the thermo s tats, or amount of clothing, could be adjusted. Spatial f actors seemed to have both positive and negative features. In ge neral, nurses were satisfied with the hybrid design of the central ized and decentralized nurse s tations The decentralized nurse stations provide greater visibility and accessibility to the patient rooms, and at the same time the decentralization provides reduced interruptions from cowo rkers and seemed effective in diminishing noise disruptions that normally occur in a typical centralized nurse station. On the other hand, the size of the medication room seemed less than ideal from the perspective of a few n urses. The amount of counter space was perceived as insufficient and physical computer access is inconvenient. During the observation period the researcher noted a sign posted near the computer station with a word of caution will hit you! Danger! S Obviously this suggests previous mishaps. Privacy The perception of privacy on U nit D varie s depend ing on the work are a. For example, t he medication room and supply room provide a supportive amount of visual privacy : Nurse 1: I seem to like the medication area to be in a separate locked area Nurse 2: Or like patients doing. I like the privacy. And it feels more secure a nd safe.

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102 Nurse 1: The phone can still ring, however you can put it on hold or whatever, but people stopping you, asking you different things off The enclosed medication area offers a place for the nurses to prepare medical supplies with limited distractions. However, the nurses a ppeared less satisfied with the privacy in the nurse station as well as other areas throughout the unit such as the patient rooms and hallway work stations As discussed above the conversation and telephone privacy was a concern for the nurses because they frequently overhear d each conversation s T he nurses mentioned in the focus group that this poses a confidentialit y concern to st aff and patients. Therefore, given that the nurses have the ability to retreat into the medication room for increased privacy, the environmental comfort level is best categorized as functional comfort Summary of Unit D The results from the questionnaires and focus groups show similarities between the perceived environmental comfort in Unit C and Unit D Figure 4 4. The perceived environmental comfort levels of Unit D. T he nurses on Unit D are more comfortable with the lighting (psycholog ical comfort level) and thermal qualities (psychological comfort level) than with the noise

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103 level (functional comfort level) and the privacy (functional comfort level). The noise on the unit is distracting to the nurses and they often lack the ability to h ave a private comfort were related to spatial factors (functional comfort level), again, particularly in regards to the medication room. Research Question Two How importan t are the design considerations of lighting, noise levels, thermal quality, spatial factors and privacy in relation to perceived environmental comfort? This question inquires about the significance of the conditions posed in the environmental comfort th eory. The study found that e ach of the five environmental conditions a re determined to be was established in two ways: (1) through the liter ature review, which compiled existing research on the importanc e of t he conditions, and (2) the study participants environmental comfort appears to be impacted by the conditions posed in the theory. Figure 4 5. Supportive and unsupportive environmental features. Figure 4 5 displa ys which conditions were found to s and in three cases there were instances of both supportive and unsupportive features.

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104 Research Question Three What other design considerations impact the perce ived environmental comfort? The third question offers the opportunity to evaluate which other design considerations, if any, impact beyond the lighting, noise level, thermal quality, spatial factors, or privacy dimensions of the environmental comfort model. During the observations focus group discussions and open ended survey results, the general census was that the proximity of the nurse work areas in relation to each other and in relation to the p atient room s was critical to nur se operation. While the proximity of work areas to patient rooms is not addressed in the environmental comfort theory, it seems to be an important factor in determining environmental comfort. The importance of this topic was revealed b across the four focus groups. The nurses in Unit A and Unit B expressed that the medications and supplies should be located closer to each other. Similarly, the nurses in Unit C and Unit D articulated that the supply room is in an inco nvenient location causing additional walking. In Unit A the location s of the supply room and the medication dispensing area Nurse 3: [patient] rooms 1 through [trails off] Nurse 1: I think the frustrating part is that now all three Omnicells are basically in the back of the unit. All your supplies are in the front and all your Ominicells are in the back. Nurse 2: Yeah, so you either have easy access to the meds and bad access to the supplies or the other way around.

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105 Nurse 3: f getting exercise. I always lo se a c oupl e pounds on my work week! While one nurse mentions in j est the exercise benefits to retriev ing supplies, the inconvenient location of items ultimately slows down the w ork processes and can consume The RNs from Unit B share their frustration with a nearly identical situation: Nurse 1: You have to pull your meds from the Omnicell and then come down here to the supply room and get your IV tubing and then go find somewhere else to set it up. The nurse s expl ain that t he medication dispensing areas on Unit A and Unit B do not house the medical items necessary for administering an intravenous drip feed (IV). station, and on Unit B they are located in the supply room. This is an inconvenience because the nurses must take two trips one to the Omnicell that stores the IV medication, and then another trip to an Omnicell that stores the IV bag and tubing. The nurses on Unit C and Unit D also share a similar concern: Nurse 1: I feel as though some areas could be changed slightly to make the some supplies centralized a little bit better because we end up going fr om the clean holding [supply room] over to the med room because some of the lab supplies are in clean holding [supply room] but not in the medication room. Likewise, a Unit D nurse expressed that the location of the supply room is not central on the unit a nd is very inconvenient Patien t rooms at the extreme ends of U nits A and B measured 87 linear feet from the nurse station in one direction and 105 linear feet in the other; Patient rooms at the extreme e nds of U nits C and D measured 45 linear feet from th e nurse station in one direction and 145 linear feet in the other. A dditionally, a walk from the most remote pa tient room to the supply room was around 115 linear feet in

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106 Units C and D vs. 135 linear feet in Unit s A and B ho spitals are expending time and energy to gather supplies due to the poorly situated medication area and supply room. Studies show that t he layout of a nursing unit has a direct impact on nurse p roductivity and fatigue levels (Carayon, Alvarado, & Hundt, 20 03; Ulrich, 2006 ) Walking has been identified as a major time consumer for nurses who walk an average of 3 miles during a ten hour shift (Hendrich et al., 2008); Thoughtful design helps decrease fatigue by reducing the amount of walking distance o n the job. Although this condition is not addressed in the environmental comfort theory, t he configuration of a workplace, in this case, specifically the location s of the nurse station, medication dispensing area, and supply room is an important design co nsideration that impacts the perceived environmental comfort and physical fatigue Research Question Four compare between the two hospital settings? The fourth question compares the two hospitals under study: the North Tower (containing Unit A and Unit B), and the South Tower (containing Unit C and Unit D) The perceptions of the nurse work areas were compared within and among the facilities regarding t he five key dimensions: noise level, lighting, temperature and air quality, spatial comfort, and privacy. These comparisons of comfort levels across sample group s are presented in Table 4 5 thr ough Table 4 10 Lighting The results in Table 4 5 show compar able ratings of the lighting among the four units for all the physical dimensions except for one A considerable difference was found in the ac cess to daylight score between the four groups. The nurses in the

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107 South Tower (Units C and D) view their access t o daylight as better than the staff in the North Tower (Units A and B). Additionally, the nurses on Unit A rated the access to daylight more highly than the nurses in Unit B. This is noteworthy because the nurses on Unit A have slightly more access to dayl ight than do their Unit B counterparts. The break room in Unit A contains a window, while all the staff spaces in Unit B are perception of daylight adequacy. Figure 4 5. Unit comparison: lighting. Noise level The data implies a perceived difference in the noise level between the four groups T he general noise distractions of Unit A were rated as most problematic across the units (see Table 4 6) As seen in Table 4 7, the nurses in Unit A experience noises from voices and the ratings. The bar graph in Figure 4 6 displays the mean values of the survey responses regarding noise level.

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108 Figure 4 6. Unit comparison: noise level. Thermal quality A difference surfaced in the temperature comfort ratings between the four groups. Unit B rated the temperature as warmer and more uncomfortable than the other units (see Table 4 8) malfunctioning air conditioning system revealed in the focus group discussion Figure 4 7 Unit comparison: thermal q uality. Spatial factors The results in Table 4 9 show ed differ ent perceptions of t he spatial factors a cross the four units for all the physical dimensi ons. T he nurses in the

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109 South Tower (Units C and D) view the furniture layout and size o f their nurse station as more comfortable than the other two units. Units C and D rate the nurse sta tion work surfaces, storage for personal effects, as well as work storage as more adequate when compared to the staff in t he North Tower (Units A and B). Figure 4 8 Unit comparison: s patial f actors. Privacy The privacy rati ngs were compared among nurses from the four units under study The results in Table 4 10 identified comparable ratings on the three privacy factors: visual privacy, conversation privacy, and telephone privacy. Figure 4 9 Unit comparison: p rivacy.

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110 A B Figure 4 10. Uni t c omparison. A) erceived environmental comfort levels. B) Bar graph illustrating mean values of the five environmental conditions. Research Question Five How do areas relate to physical, functional, and/ or psychological dimensions of perceived environmental comfort? Du ring the focus group s the participants made recommendations for i mprovements to their w ork areas. Their responses address the final research question of this study and frame the overall recommendations from the findings. The implications of the results address the three categories of environmental comfort: physical, functional, and psycholog ical.

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111 Unit A The nurses on Unit A unanimously recommend that decentralized nurse stations be added outside the patient rooms to provide an area t o sit and chart near their patients The nurses explain: Nurse 1: I think that is the whole key thing if you have a nice comfortable area where you can sit by your patients that would be per fect. Nurse 2: Kind of like they have [in the South T the hallway with the stools where they have storage space with computers. And y ou can make a nice visual [eye contact] on the patient. Implementing t his recommendation w ould improve the environmental comfo rt level threefold : (1) the spatial factors c ould improve by decreasing crowd ing in the nu rse mount of storage, and the number of seati ng areas; (2) the noise levels c ould decrease through the decentralizing of the nurse station ; (3) the nurses would gain greater pr ivacy (personal territory). T he addition of dec entralized nurse stations also would increase the visibility to the patient rooms, and create closer proximity to their patients. The first and most important design recommendation would be to design decentralized nurse stations rather than allowing work areas to form organically in the hallways as an afterthought. Unit B T he nurses on Unit B overwhelmingly agree that additional task chairs were desperately needed on the u nit. The lack of seat ing was quite problematic and one hey are i n dire need of some new office chairs Th ey also recommend that future nurse station s be desig ned with wide r aisles than the current nurse station the issue:

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112 Nurse 3: owded. On the other side where people are trying to sit, where there is the [storage unit], there is the crash cart and there is where we used to keep our sodas and stuff and people are trying to get thr ough there all the time especially with a COW It j Nurse 2: By the cabinets. Yeah, r ight by the charge nurse s desk. The a isles all need to be twice as wide. Nurse 3: the doctors, nurses, residents, everybody is pretty much ful crazy. The size of the nurse station is not large enough to meet the needs of all the staff members, and the y also would prefer more seating options. Investments to improve the physical comfort, such as providing ad d itional task chairs are fully worth making because without physical comfort people cannot or will not perform their work there, at least, not well (Vischer, 2005) The addi tion of task chairs would mak e it easier on the nurses to perform their tasks. It was noted that the nurses have strong opinions regarding the spatial layout, etc. of their work areas. For example, both the medication dispensing area and supply room to pre p their antib iotics and IV bags, or arrange their medical supplies which is not its intended use The nurses recommend adding more work surfaces : Nurse 1: like I said, antibiotics and IV bags a nice place to get stuf f ready to go. have a place to spike your bag and prime it and get it ready so you can just walk in the room and get things going. Nu rse 2: right now we have to set it up outside. That was the one thing t hat I liked in the South T ower about the counter space. That was the only time I used it but it was nice when you have it all set up and everything you need is rig ht there. We have to use the little bedside table in the room to do anything, which is cluttered up with a lot of the patients stuff.

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113 The staff prefers multiple work surfaces thr oughout the unit. It was pointed out that additional counter space would save travel time and reduce potential for errors, as the nurses walk back and forth several times between the medication room and patient rooms. Discomfort would be eased if additional work surfaces were added in the medication dispensing area and supply room. Figure 4 Unit C As discussed in research question one, the nurses o n Unit C suggest that the nourishment supplies be moved to a more convenient location. Currently the se supplies are loc ated in upper cabinets of the nurse station making access difficult when staff members are sitting at the workstation below. The lock on the cabinet is inconvenient to open, and the nurses constantly have to reach over other employees to retrieve the

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114 suppl ies. The RNs prefer the nourishment supplies to be in a locked cabinet in the nourishment room, or to be in the back area of the nurse station that is less inhabited, to diminish the interruptions in the nurse station. Additionally, t he computer configurat ion in the medication room was a concern for the nurses The laptop computer is placed on a mobile cart that is ergonomically uncomfortable The nurses frequently find thems elves hunched over the computer, and they recommend a larger screen with an adjusta ble arm to enable modifying the height and angle of the screen. In the current location the nurses find themselves unintentionally knocking the hand held supply scanner out of the holster. The nurses would prefer a more supportive arrangement th at would reduce fatigue and inefficiencies. T he general consensus was that the counter space in the medication room i s insufficient During the 9 AM medication round s multiple nurses needed access to the medication room at one time and they are struggling t o use the allotted amount of prep space. The comfort of the nurses would increase if the medication room was large enough to support small groups of nurses at once rather than 1 2 at a time U nit D The nurses overwhelmingly recommend additional space in th e medication room of Unit D The nurses are having the same issue as the RNs in Unit C; they would like more horizontal surfaces to prep medications. The nurses in Unit D expressed that when there are multiple nurses in the medication room at one time ther e is not enough space for them to spread out comfortably. Also, the nurses explained that the refrigerator and computer are inconveniently located because when you are accessing When the pharmacy staff is refilling the

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115 Omnicell there is not enou gh circulation space with the pharmacy cart in the room discussed in the following comment: Nurse 1: nearest to the sink to prepare things, so that a t can be d one about that. Because there are many of us in there at the same time so we gotta spread out somewhere. We can section there. prepare our meds there, not over here, I guess becaus e of the splashing of the water but generally everyt h ing is in a place I guess, bending down you get bopped by the door Nurse 2: Yeah, or if pharmacy is replacing meds sometimes, with their cart in there it is pretty tight near the door area. Nurse 3: In that general area [in the medicine room] ould be eased through the addition of counter space. It is noteworthy that future medication rooms should be designed with more circulation s pace to accommodate medical carts and at least three staff members at a time Conclusion This chapter assesses hosp ital workplace conditions through the theoretical lens of the environmental comfort model proposed by Jacqueline Vischer (2007). The framework ranks workplace environments in a rising continuum of physical, function al, and psychological comfort. Five resea rch questions we re posed and addressed to identify and compare the environmental comfort levels of hospital wor k areas among registered nurses and participated in focus group discussions inquiring of the environmental conditions of lighting, noise level, thermal quality, spatial factors, and privacy in relation to the nurse station, the medication dispensing area, and the supply room of their respective units

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116 This data, along with the focus group d triangulated to answer th e research questions. According to the results, the nurse work areas in Unit A and Unit B appear to be experiencing a lower level of environmental comfort than Unit C and Unit D. The sp atial factors of the nurse work areas seem to be less than ideal from the perspective of the nurses on each unit under study.

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117 Table 4 Unit A (n=3) Unit B (n=5) Unit C (n=6) Unit D (n=3) Physical d imensions Mean S D Mean S D Mean S D Mean S D Overall l ighting (1 Uncomfortable; 5 Comfortable) 3.33 1.15 4.0 1.22 4.33 0.52 4.33 0.58 High light l evels (1 Uncomfortable; 5 N ot a p roblem) 3.67 1.15 4.4 0.55 4.50 0.55 4.67 0.58 Low light l evels (1 Uncomfortable; 5 Not a p roblem) 3.67 1.15 3.6 1.52 4.00 0.63 4.33 0.58 Light r eflections (1 Uncomfortable; 5 No g lare) 3.33 0.58 4.0 1.22 4.00 0.63 3.67 1.53 Access to d aylight (1 Inadequate; 5 Adequate) 3.00 2.00 1.6 0.55 4.3 3 0.52 4.67 0.58

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118 Table 4 6. ualities Unit A (n=3) Unit B (n=5) Unit C (n=6) Unit D (n=3) Physical dimensions Mean S D Mean S D Mean S D Mean S D General noise distractions (1 Too d istracting; 5 C omfortable) 1.67 0.58 3.0 0.71 3.33 0.82 4.33 0.58

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119 Table 4 ualities Unit A (n=3) Unit B (n=5) Unit C (n=6) Unit D (n=3) Physical d imensions Mean S D Mean S D Mean S D Mean S D Specific n oises from v o ices (1 Too n oisy; 5 Comfortable) 2.34 1.15 3.2 0.45 3.0 0 1.1 0 4.0 0 1.0 0 Specific n oises from e quipment (1 Too n oisy; 5 Comfortable) 2. 0 0 1. 0 0 3.8 0.45 3.33 0.82 4.33 0.58

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120 Table 4 8. ir q uality Unit A (n=3) Unit B (n=5) Unit C (n=6) Unit D (n=3) Physical d imensions Mean S D Mean S D Mean S D Mean S D Temperature c omfort (1 Uncomfortable; 5 Comfortable) 3.0 0.0 1.8 0.84 4.16 0.75 4.67 0.58 Gene ral t emperature (1 Too cold ; 5 Too warm) 3.0 0.0 4.6 0.55 3.33 0.82 3.33 0.58

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121 Table 4 9 Unit A (n=3) Unit B (n=5) Unit C (n=6) Unit D (n=3) Physical d imensions Mean S D Mean S D Mean S D Mean S D Furniture l ayout of nurse s tation (1 Uncomfortable; 5 Comfortable) 2.33 0.58 3.4 0.89 4.17 0.75 4.67 0.58 Size of n urse s tation (1 Uncomfortable; 5 Comfortable) 3.33 1.15 3.2 1.3 0 4.6 0 0.52 4.67 0.58 Nurse s tation work s urfaces (1 Inadequate; 5 Adequat e) 2.67 1.15 2.6 1.34 4.33 0.82 5.0 0.0 0 Computer c onfiguration keyboard, screen, mouse, etc. (1 Uncomfortable; 5 Comfortable) 3. 0 0 1. 0 0 4.0 0.71 3.5 0 0.84 5.0 0.0 0 Storage for personal e ffects (1 Inadequate; 5 Adequate) 2.33 0.58 3.0 0.89 4.17 0.41 5.0 0.0 0 Work s torage s pace (1 Inadequate; 5 Adequate) 2.33 0.58 3.2 1.48 4.17 0.75 5.0 0.0 0

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122 Table 4 10 Unit A (n=3) Unit B (n=5) Unit C (n=6) Unit D (n=3) Physical d imensions Mean S D Mean S D Mean S D Mean S D Visual p rivacy in nurse s tation (1 Uncomfortable; 5 Comfortable) 2.33 0.58 3.0 1.58 3.17 1.47 4.67 0.58 Conversation p rivacy (1 Uncomfortable; 5 Comfortable) 2.33 0.58 3.4 1.52 3.5 0 0.84 4.17 1.33 Telephone p r ivacy (1 Uncomfortable; 5 Comfortable) 2.33 0.58 3.0 1.22 3.33 0.82 4. 0 0 1. 0 0

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123 Figure 4 12 Unit A light measurements

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124 Figure 4 13 Unit A sound measurements

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125 Figure 4 14 Unit B light measurements

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126 Figure 4 15 Unit B sound meas urements

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127 Figure 4 16 Unit C light measurements

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128 Figure 4 17 Unit C sound measurements

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129 Figure 4 18 Unit D light measurements

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130 Figure 4 19 Unit D sound measurements

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131 CHAPTER 5 DIS CUSSION The purpose of this field study was to more thoroughly understand registered contributes to their perceived performance This study involved two hospital facilities referre d to as the North Tower and South Tower and t wo medical/surgical units were selected from each hospital facility as the research settings. T h ree primary nurse work areas were under study from each unit : (1) the nurse station, (2) the medication dispensing area, and (3) the supply room. Jacqueline V comfort (2007) provided a theoretical framework for examinin g how individuals perceive these work environments. This theory and research program investigating the impact of environmental conditions in the office workplace ha s been widely cited in the literature over the past twenty years The repertoire of topics investigated by Vischer and her colleagues includes building evaluation, users' needs in buildings, indoor air quality, user manager communication, facilities manage ment, and architectural programming A number of her peer reviewed journal publications can be found in the Journal of Environmental Psychology, Architectural Science Review, Building Research and Information, and Stress and Health While t he majority of h er research findings are applied to office space design and employee behavior (Jacqueline Vischer, persona l communication, April 3, 2012), this study begins to bridge the gap into other work settings by applying the theory of environmental comfort to the h ealthcare work environment. This study identifies and compared the environmental comfort levels among four nursing units by employing th e DiConFon survey (Vischer, 2010 ), observations, and

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132 focus group discus sions The elements of this model were researched by measuring the RNs perceptions of the lighting, noise level, thermal quality, spatial factors, and privacy pertaining to the primary nurse work areas As a result these work areas were categorized based on which level of environmental comfort (physical, functional, or psychological) characterized them best. The environmental comfort model ranks comfort in a rising continuum of physical, functional, and psychological comfort (Figure 1 1) At the base of the continuum is the category of physical comfort, which includes the nonnegotiable prerequisites for a habitable work environment such as enough light, no extreme temperatures of too hot or too cold, safe noise levels, and an adequate number of functioning toilets. The next category of environmental comf ort is identified as functional comfort. According to requirements of the tasks they are performing ( 2008 ) other words, it poses the question: does the environment suppo rt work related activities? Further, the ability to personally manipulate the environment, such as turn off a light, close a door for added privacy or adjust the temperature on the thermostat increases psychological comfort the last level of environmental comfort. To identify and compare the environmental comfort levels of hospital work areas among registered nurses, five research questions were addressed. The final step was to create narratives entitl actors together as a real life example showing how lighting, thermal comfort, noise level, spatial factors, and privacy link together to determine which level of environmental comfort the RNs are perceiving. This study provides insight into the efficacy of the

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133 nursing units as examined in this thesis research that can be used t o plan future nurse work areas. The following section of the study employed narrative inquiry to delve even Narrative Inquiry finition, narrative inquiry is a qualitative method for questioning and analyzing information that has a form and protocol in a story (Dohr & Portillo, 2011, p. Narrative research is frequently used to carry out qualitative research and has recently gained popularity, particularly in nursing (Holloway & Freshwater, 2007). The contribution of the narrati ve approach to nursing practice is reasonably well documented (Holloway & Freshwater, 2007) ; for example, see Jon es, 1990; Younger, 1990; Darbyshire, 1995; Greenhalgh and Hurwitz, 1998; Charmaz, 1999; Aranda and Sreet, 2000; Hurwitz et al., 2004 ; Price, 2011 There are a number of applications and benefits of narratives in nursing research which ar e outlined by Frid and colleagues (2000) : The narrative creates an innovative imitation of something that previously occurred by imitating the practical action. However, the narration does not function as repetition it creates a new reformulated description. The narrative is thereby able to cast new light on that which has previously been experience d as familiar ( p. 697). frame central issues and relationships between humans and places (Dohr & Portillo, Due to the increase in narrative research in both the fields of interior design and nursing, this method was selected to develop and analyze the study findings. It is worthy to acknowledge that s ampling in narrative researc h can rely on a very small number of people as depth rather than breadth is sought. As Patton (2002, p.

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134 qualitative inquiry have more to do with the information richn ess of the cases selected and the observational/analytical capabilities of the researcher than with the sample The subsequent narratives fall into the category of research narrative because they were formed by collecting several types of informatio n focus group data, observations, and empirical findings Research narratives are triangulated whereby multiple sources of data are gathered and compared for veracity ; they are verifiable, authoritative, and add to the body of kno wledge (D ohr & Portil lo, 2011 p. 44 ). Orientation to Narrative The following true life experiences working at two Shands HealthCare hospitals: the North Tower (University of Florida Health Science Center) and the South Tow er (Cancer Hospital at the University of Florida). Each story hypothetically follows two registered nurses working on a medical surgical unit in their respective hospital as they perform their daily tasks. The narratives illustrate how the nurses function as how they perceive the built environment affecting their comfort. work day of two main characters: Carol, an experienced RN in her forties, who has worked at Shands for nine years, and Amber who is in her early twenties and just joined the Shands hospital system in Gainesville a few months earlier. The following story illustra tes an eight hour shift on a medical unit at the Univer sity of Florida Health Science Center and gives insight into how the environment supports or inhibits productivity on a day to day basis.

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135 A ll in a Day To the untrained ear, the constant beeping, ringing, and buzzing accompanied by th e sound of carts rolling through the corridors might seem a bit strange. To Carol, a seasoned nurse with about twenty four years n a break attended an impromptu staff meeting, followed by a hurried session of passing out the first round of meds to her patients. Now she is carefully of her shift. ead, she found a bedside table to sit on gets up about every ten minutes or so and rolls her shoulders forwards and then backwards. The poor thing looks terribly uncomfortable. App arently that is why Amber, the nurse down the hall, brought her stool from home to no casters to make it roll and no levers to adjust the height just something better to perch on than a bedside table. Of course the nurses ar e not supposed to be sitting in the corridor but there usually being used by physicians, unit clerks, nursing students, and everyone is a bit tired of fighting for a seat. So, the next best option is to, well, chart at the COW in the hallway. The problem is patients and families see the nurses in the hall and think they are just twiddling their thumbs or doing something non important things so the nurses constantly get interrupted. A family member will ask where the nearest vending machine is. Managem ent will pass along a message. Recovering p atients will request a cup of ice. The interruptions are endless. *** cheerfully says as she walks into the room where a groggy eyed patient welcomes her as a cup of water, He does his best to accommodate her requests, shifting his weight so she

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13 6 ng feel free to call my phone or press this button accommodating an eye at calling for the smallest of matters answering one of her phone calls right now. Amber overhears Car *** isiting you! I have your extra pillow right here. Is there anything else I can get you? Sure, Carol heads for the nourishment room and feels herself break into a light perspirat ion. Becoming flushed hampers the professional image she works so hard to maintain. Quickly stopping to adjust the thermostat a facilities on the staff thermostat, but without doing a complete overhaul there is only Just then, their attention is caught by a nursing student across the hall an issue trying t says. that extensive. But, as soon as the opportunity hurries off to retrieve the apple juice hoping to avoid another phone call from Mrs. Anderson. ***

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137 Amber glanced up at the clock. It is 3:45 PM and she is behind on her five feet awa y in his hospital gown. your medication right now, and I need to concentrate. I will come by your dosage when once again she can sense someone standing over her environmental services worker with her cart. her, maneuvering the cart into the nurse station by making a three point turn. Finally Amber opens the drawer of the Omnicell and gets the medication. *** Eight hours later, w ith the end of her shift in sight Amber gives report to the night nurse and retrieves her belo ngings from the locker. She stops at the restroom on the way out only to find it occupi ed. No surprise there since the entire staff of about 20 people share one toilet which is frequently messy ou robably better elevator. goes home nearly every day feeling a sense of satisfaction for helping others This fulfillment is priceless. Interpretation at Shands Health Science Center, following two employees as they perform their daily tasks necessary to care for their patien ts. The two main characters in the story are Carol, an older more experienced RN and Amber, a young relatively new nurse on the unit. Yet despite the differences in age and job level, both employees participate in the same activities, including administer

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138 promoting, or in some case s hindering, workplace comfort. The narrative can be divided into five major themes based o n the model of environmental comfort. These themes are the key environmental conditions of the theory: (1) lighting, (2) noise level, (3) thermal qualities, (4) sp atial factors, and (5) privacy. When examining the relationship between the lighting of the n urse work areas characters expose their dissatisfaction with the amount of natural light in their work areas by exaggeratedly stating that they have no access to windows withi n a mile radius. During this scene their underlying frustration is revealed regarding both the windowless nurse work areas as well as the constant ringing of the mobile phones. shows the value employees place on visual access to the outdoors. The next concept explored in the narrative is noise level This topic was examined indirectly as the nurses completed their tasks throughout the day. The opening sentence of the narrative se ts the ambiance, stating that a typical day on the features is the noise made from the mobile phones that the nurses carry with them ubiquitously. While the phones are intended to allow patients or doctors prompt contact with the nurse, particularly in the case of an emergency, the phones often ring at undesirable times. For example, since a nurse keeps a phone with her at all times she

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139 may receive calls while dispensing medications or performing other serious procedures. Ideally, the nurses would be more comfortable working in these situations with no noise disruptions. Next, the relationship betw een thermal quality through the dialogue between Carol and the facilities maintenance worker. The staff on the unit is provided with a thermostat to adjust the temperature of the work areas with ease. However, as illustrated in the scene, the thermostat has not been working correctly, and the staff consistently complains of being hot. This shows that the thermal qualities are a source of discomfort for the nurses while working. The next theme explored by the narrative is the spatial factors of the nurse work areas. This subject is depicted in the incidence of Carol and Amber having to sit in the corridors to chart due to the insufficient number of workstations in the nurse station. Amber brought her own stool from home, and Ca rol was obligated to use a bedside table as a chair because of the inadequate number of seats. This produces uncomfortable working conditions for the nurses. The narrative also illustrates that the employees are inconvenienced with the number of staff toi lets. When Amber was leaving for the day she stopped by the restroom only to find it occupied. This is a common occurrence for the staff in the North Tower because the units contain one toilet for all the employees to share. For some the annoyance may caus e a need to find another staff restroom throughout the building while others may wait outside the do or, or come back later; t his suggests that the work area is not supportive of basic need s.

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140 The final theme in the narrative based on the model of environmen tal comfort is the condition of privacy the spatial factors and noise level. As a scene of the narrative describes, when the nurses are sitting in the corridors completing their computer task s they are frequently approached by patients, visitors, and other staff members. This shows that the spatial factors do not provide the nurses the ability to control their exclusivity. This theme is also explored when Amber is retrieving medication. She is interrupted twice because of in a secure and locked cabinet, the location of the medication area is too accessible, even allowing patients to walk right up if they see their nurse. The privacy conditions of the unit are a constant source of irritation for the nurses. Orientation to Narrative T ll in a Da is based on two Shands Cancer Hospital at the University of Florida. The story follows two registered nurses in a medical surgical unit, Becky and Mark as they work a typical 8 hou r shift. The story illustrates how the work environment supports or inhibits their productivity, as well as how this influences their com fort. Becky is an expe rienced RN in her early fifties and has worked in the Cancer hospital since it opened three year s ago. On the other hand, Mark is in his mid twenties who joined the Shands hospit al system a few months earlier. A Becky quickly closed the break room door behind her. It was 12:43 PM and take a breather since she got to work. It was no surpri se that she was so busy. This i s a typical shift for the nurses in

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141 the South Tower. Becky was just happy to finally be done with her morning medication rounds. The unit is a full house today, proven b y the amount of nurses lined up in the med room this morning. Luckily Becky got there early. She was able to get her meds and grab a spot on the counter to crush the pills without waiting in line for her turn Mark Ma rk got to the med room the line was already three deep, and as he swung open the door he bopped a nurse who was standing at the computer station. Mark at that computer they know the risk. It really is in a bad spot. Not to mention how uncomfortable that computer is to use. Nurses stand hunched over the keyboard, and leave rubbing their sore necks. Mark glanced at his watch. H o waste so he apologizes again for the collision and hurrie s off to the supply room. *** As Mark knelt down and tied his shoe, he realized how tense his bo dy feels As odd as it sounds, the action of kneeling an d taking the pressure off of his feet was act ua lly a relief. Recognizing that he needed to rest for a second he headed to his decentralized nurse station just outside his pati and plopped into his chair. Coincidentally just as he was sitting he glanced through the observation window and sa w Mr. Robbins, a high fall risk patient, climbing out of bed. Mark hopped up to assist him. my upper arm so that I can help you brace. There you go. Okay Mr Mark arrives at the nurse station to grab a b oxed juice for his patient. As he ng to unlock the upper cabinet he realizes that he just int errupted a private conversation. Mark quickly grabs the juice to get out of the way allowing Becky to continue talking on the phone about a change in treatment As Mark leaves not leaving; it must have been about a patient. I mean, there really is no point in trying to have a personal conversation up Mark convinces him self, he continues on his way. Mr. Robbins reluctantly accepts the juice after making a grumpy rem ark about the difficult straw and Mark returns to his decentralized nurse station

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142 room in hopes of finishing some charting. H e quickly switch es on the task la mp, adjusts the arm rests of his ch air, and gets down to business. *** Becky gazes out the window at the end of the hall and takes a deep breath as she is walking toward the supply room. pression becomes visibly less tense as she takes in the view outdoors. She types in the key code, steps inside the supply room and the surrounding noises disappear. Grabbing what she needs she feels she has just entered a walk in freezer. She adjusts the thermostat and walks out the heavy door which slams securely behind her She passes room after room until she finally reaches her assigned patients ery difficult or very simple, depending on what type of patient you have. Fortunately Mrs. Johnson is as laid back as they come. Mrs. Johnson smiles, grateful for the new dressings and Becky reminds her to try to monitor keep them dry before she closes the door behind her. 3:30 PM a lready? Unlocking the cabinet of her decentralized nurse station she pulls out her notepad. Becky makes a note to hers elf, and quickly begins the work for Mrs rge on her computer. *** The ringing of Mark Mark Yes Mrs. Trainor, I will be there in just one moment. I need to run down t The ph one is the biggest distraction in this place. The nurses each carry one, and it seems to ring at the mos t inopportune times. Well, more accurately they seem to ring all the time. Mark peeks out the door of the med room to try to find an other nurse to do wa ste with him Easy enough, Becky happens to be walking by. They finish Mark Mark *** Becky ca n hear the nurse station teaming with people from inside Mrs.

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143 Mrs. Johnson walks out of the restroom dressed in a flowy Hawaiian p rint dress ready for discharge. eyes the way The patient transporter arrives to the room to help Mrs. Johnson find her way downstairs to leave. Becky felt exhausted, but happy to help Mr s. Johnson get ready for discharge station to wrap up for the day. Interpretation at Shands Cancer Hospital by fo llowing two employees as they perform their daily tasks necessary to care for their patients. The two main characters in the story are Becky, an older more experienced RN and Mark a young nurse who is new to the unit. Through one can see the role of interior design in promoting, or in some cases hindering, workplace comfort. Congruent with the first narrative, this story can be divided into five major themes based on the model of environmental comfort. These themes are the ke y environmental conditions of the theory: (1) lighting, (2) noise level, (3) thermal qualities, (4) spatial factors, and (5) privacy. When examining the relationship between the lighting of the nurse work areas mental comfort, it is important to Mark looks out the window at the end of the hall whil e walking to the supply room. H e takes a deep breath, and while these ideas are not directly stated, he appears t o be in a moment of respite. The nurses hold high value on the visual access to the outdoors.

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144 When further exploring lighting in the narrative, it is noted that Becky sat down at her decentralized nurse station adjusted the arm rests of her chair, and sw itched on her supported by the ability to manipulate the lighting such as the desk lamps and under cabinet lights in their workplace. The next concept explored in th e narrative is noise level The narrative illustrates that the unit is the noisiest during shift change, particularly at the nurse station. In the scene where Becky heard the nurse station teaming with staff room, she realized tha t the end of her shift was approaching. The nurse station is the main hub of activity on the unit, and its open environment and hard surfaces only exasperate the noise level. The narrative provides another example regarding a source of noise on the unit: Mark is in the medication room when he receives two phone calls. Since the nurses carry a phone with them at all times, they have the potential to be disturbed even while performing duties that require concentrat ion such as dispensing doses of medication. However, the medication dispensing machines are located in an enclosed room that can only be accessed with a security code, so other than the potential for the phone to ring, the room stays relatively distraction free. Yet open environments facilitate slight line access and hard surfaces are typically easier to clean. Next, the relationship between thermal quality observed in the narrative when Becky is in the supply room and quickly adj usts the thermostat. The employees are in the South Tower are provided with thermostats to

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145 adjust the temperatures of each work area. Becky and the other staff members are generally comfortable with the temperatures on the unit; however, if necessary the t emperature can be easily adjusted. The nurses have a sense of control over the thermal qualities of their work areas, which supports the nurses while working. The next theme explored by the narrative is the spatial factors of the nurse work areas. This sub ject surfaces various times throughout the work day. Becky and Mark decentralized nurse station s. During the narrative it is illustrated that these decentralized nurse station s provide the nurs es with an individual place to sit and chart on their computers, along with personal lockable storage. The decentralized nurse station s also offer a view into the patient rooms vis a vis performance is supported through the size, location, and features of the decentralized nurse station s. On the other hand, the narrative also illustrates inefficiencies in the case of the medication room. At the beginning of the narrative it is established that the location of the medication room computer station is problematic when Mark opens the door and hits the nurse who is standing at the computer. Also, the computer station is uncomfortable considering that the users s height or angle. In addition, the scene rev eals that the amount of counter space is insufficient, and the nurses often have to wait for one another to finish and waste valuable time These situations are all common occurrences for the staff in the South Tower because the medication rooms are not la rge en ough to support the tasks of more than 1 2 nurses simultaneously particularly during the morning rounds of medication.

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146 The final theme in the narrative based on the model of environmental comfort is the condition of privacy In one scene in particu lar Mark personal conversation, exposing the n The nature of an inpatient hospital unit entails easy accessibility to various spaces and people; however, designing the interior environment to suit this approach reduces the exclusivity of staff areas. This leads to the nurses desiring more visual and conversational privacy. Although this narrative reveals that access to the supply and medication rooms are restricted, which provides much needed priva cy and securi ty in these areas. Another facet of privacy, which is closely related to spatial factors, involves the personal territory. The decentralized nurse station s offer an individual place to work, and lockable storage for their belongings. This provides the nurses with a sense of personal territory, and increases their perce ption of privacy. Utilizing the Findings from the Environmental Comfort Method The environmental comfort of a workspace has been shown to impact perceived employee performance. An unco mfortable environment drains energy out of the user by creating workspace. A supportive and effective workspace allows and even encourages occupants to apply all their energy and attention to performing their duties. For example, a wo rker who expends energy propping books under her computer screen to lessen the glare from a window, and then fights to concentrate over the noise outside her office is expending time and energy on adjusting to the environment. This slo ws down employee outp ut and ul timately decreases productivity. In that sense the environment becomes a barrier to productivity. An employee would be more effective if she could concentrate that wasted energy on work rather than on

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147 struggling against features of h er workspace. Research on the workplace underscores this type of experience: degree to which occupants can conserve their attention and energy for their tasks, as opposed to expending it to cope w ith adverse environmental conditions before they can get to performing the task. The best workspaces are those that minimize the expenditure of energy by users, allowing them to apply all their energy to work activities. The best workspaces reduce the elem ents that people have to struggle against to get their work done, and increase the environmental elements that su pport task performance ( Vischer, 2005 ; p. 108 The comfort of work space features can enhance job performance in numerous ways, and conversely there are many environmental design factors that slow people down. Designers and facility managers need to determine the value of these workspace features, and the measurement system of the DiConFon questionnaire is one way of approaching these matters i n an objective and quantifiable way. This environmental comfort approach allows designers to assess the value of environmen tal features that affect users. The habitability pyramid in Fi gure 1 1 indicates how to calculate the likely impact of investing in t he comfort of environmental conditions; to judge the value of an investment in a workspace each environmental feature such as lighting needs to be located on the continuum. This allows designers to evaluate what modifications are necessary for the envi ronmental feature to slide up the scale from the physical comfort category to become a condition of functional comfort or even part of the psychological pinnacle of the pyramid. The greater the investment in the quality of the interior environment for work ers, the more upward pressure is exerted towards improved environmental comfort. This increased understanding of how people experience their

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148 environ mental comfort T h environment is applied to the categories of the habitability pyramid for the sake of determining which workspace conditions would be most beneficial to improve. The value of each fundame ntal environmental condition : ( 1) lighting, (2) noise level, (3) thermal qualities, (4) spatial factors, and (5) privacy, is assessed by categorizing it as physical, functional, or psychological comfort; this approach identifies the positive and negative e ffects and suggests follow up action by the facilities managers of the Shands Hospitals to cultivate environmental improvement. Unit A Synthesis and Application From the amalgamation of the low survey ratings of the environmental conditions and the feedba ck in the focus group discussion, it was found that the registered nurses in Unit A are more comfortable with the lighting (functional comfort level) and thermal quality (functional comfort level) than with the noise level (physical comfort level) and priv acy conditions (physical comfort level). The nurses find themselves distracted and interrupted continually throughout the day due to the noise and lack of privacy. However, the conditions causing the most discomfort in this unit were related to spatial fac tors (discomfort level). The nurses on Unit A do not have an adequate number of chairs or work surfaces, and they are often displaced into the corridors to chart. This puts the Dissecting these results and applying them to th e environmental comfort model shows that occupants of Unit A do not have to expend a large e xtent of their energy on adjusting to problematic lighting and thermal conditions in the unit. Both the lighting and

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149 thermal qualities are rated in the functional c omfort category. The nurses indicated that the lighting could have been better if there was natural light in the staff area, and the thermal quality did not meet the top tier of the continuum, psychological comfort, because the nurses experienced difficult ies in regulating the temperature of the staff areas due to the old air conditioning system. Investments in the amount of windows and repairing the air conditioning system would increase the environmental comfort of the nurses. Although, this is not the gr eatest need of the unit. The noise level and privacy conditions, both categorized in the physical comfort level, require occupants to expend energy overcoming the negative effects of these uncomfortable workspace conditions this is wasted energy that coul d otherwise be directed towards work. The medical equipment and the voices of other staff members are the noise sources which aggravate and distract the nurses, resulting in the nurses privacy is also taxing; on the psychological level, the nurses are lacking control over their environment concentration, particularly when the nurses are at the Omnic ell, the medication dispensing machines. Because the Omnicell is located at the back of the nurse station, just across the hall from patient rooms, the nurses are constantly interrupted by patients, and even other staff members. The nurses would benefit fr om the Omnicell being moved to an enclosed area; this would greatly reduce the surrounding noises and spensing medications.

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150 The spatial condition of the nurse work areas is categorized in the discomfort level of the continuum and is causing the nurses the most expense of energy. The nurse station is not furnished suitably; therefore the nurses are lacking the basic convenience of being able to sit whenever they need to rest. This leads to the nurses putting their tasks on hold while they walk the unit in search of an available chair. The nurses also expressed the need for more work surfaces. To improve the sp atial factors in the unit decentralized nurse station s should be added outside of t he patient rooms. This addition would provide a work surface and chair for each nurse, minimizing their wasted ener gy related to spatial factors. The largest negative indicator spatial factors has a more adverse effect on an those conditions that are less negative (noise and privacy) or semi supportive (lighting and thermal qualities), because the spatial factors are causing users to expend energy struggling against features of the workplace. Therefore, to increase the nurs valuable investment in workspace improvement would be to improve the spatial factors, followed by solving noise and privacy problems. Unit B Synthesis and Application When combining the survey results with the feedback in the focus group discussion, it was established that the nurses on Unit B are more comfortable with the noise level (functional comfort level) and privacy (functional comfort level) than with the lighting (physical comfort level) and th e thermal qualities (physical comfort level). The canned lights above the medication dispensing area produce an uncomfortable amount of heat when standing under them, and the lights in the east corridor of the unit must remain on all the time because there is no switch to control them. The thermostat does

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151 not function properly and the nurses are continually hot. However, the conditions causing the most discomfort in this unit were related to spatial factors (discomfort level). Similar to Unit A, the nurses do not have an adequate amount of task chairs, computers stations, or work surfaces, and they are lacking an efficient amount of staff toilets on the unit. Applying these results to the environmental comfort model conveys that occupants of Unit B do not ex pend as much of their energy on dealing with noise and privacy as they do with lighting and thermal qualities of the unit. Both the lighting and thermal qualities are rated in the physical comfort category. The nurses indicated that the lighting could be b etter if they had more control over the fixtures, produce as much heat and if they had more access to daylight The thermal quality of properly. T he nurses unanimously rated the unit as too warm. Unit B is lacking the and breaking a such as installing indirect lighting fixtures to diffuse the light and assist in creating a natural effect (Lowers, 1999), would increase the environmental comfort of the nurses. Further, repairing the air cond it ioning system would allow the nurses to work more comfortably The lighting and thermal qualities currently require occupants to expend energy overcoming the negative effects of these uncomfortable workspace conditions this is wasted energy that could o ther wise be directed towards work.

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152 The spatial condition of the nurse work areas is categorized in the discomfort level of the continuum and is causing the nurses the most expense of energy. The nurse station is not furnished suitably; therefore the nurse s are lacking the basic convenience of being able to sit whenever they need to rest. This leads to the nurses putting their tasks on hold while they walk the unit in search of an available chair. The nurses also expressed the need for more computer station s (COWs) and work surfaces. Unit B would benefit from the same s uggestion made for Unit A: decentralized nurse station s should be added outside of the patient rooms therefore improving the spatial factors of the unit. This addition would provide a work sur face and chair for each nurse, minimizing their wasted energy related to spatial factors. The other facet of spatial factors that the nurses have an issue with is the inefficient amount of staff toilets. All the staff members on the unit share one toilet w hich is very inconvenient to the nurses because if the restroom is occupied they must leave the unit in search of another staff toilet, or they must return at another time. The nurses expressed that the space of the unit is not being used in an efficient m anner. The shower room at the back of the unit is very large, but was a neglected area that no one used. Eventually the room became an unofficial storage area; however, this room could easily be turned into a staff restroo m due to the existing plumbing. Th e largest negative indicator spatial factors has a more adverse effect on qualities) or semi supportive (noise and privacy), because it is causing users to expend energy s truggling against features of the workplace, and therefore lowering their environmental comfort level. The most valuable investment in workspace improvement,

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153 then, is improving the spatial factors by adding decentralized nurse station s and another staff to Unit C Synthesis and Application When combining the survey results with the feedback from the focus group discussion, it was established that the nurses on Unit C are more comfortable with the lighting (psychological comfort level) and thermal qualities (psychological comfort level) than with the noise level (functional comfort level) and the privacy (functional comfort level). The noise on the unit is distracting to the nurses and they freq uently hear one particularly in regards to the medication room. Taking these result s and applying them to the environmental comfort model shows that occupants of Unit C do not have to expend energy on dealing with lighting and thermal quality in the nurse work areas. In fact, they are supported by these conditions. The nurses experience psychological comfort in relation to lighting and thermal qualities because they benefit from having control over the lighting in their work areas through the use of task lamps and under cabinet lights, as well as natural light that can be controlled throu gh the electronic window shades. The thermostats are also comfortable level for the nurses. The noise level and privacy conditions, both categorized in the functional comfort level, are providing nurses with slightly less comfort than the lighting and thermal qualities. This means that the noise and privacy conditions are not in full support of the always.

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154 For instance, when a nurse is sitting at her decentralized nurse station and she is interrupted by a staff member or patient, this causes the nurse to stop what she is doing and turn her focus towards that person. This distraction can ultimately a ffect the productivity of the nurse; however, the nurse may go in to the medication room and close the door, minimiz ing many of those distractions. Similar to the noise and privacy of the unit, the spatial factors of the nurse work areas are also categoriz ed in the functional level of the continuum; however, these noise and privacy and slightly less by spatial factors). The negative spatial factors are causing the nur ses the most expense of energy that they could be applying towards working. The spatial factors of the medication room in particular cause the greatest source of strain for the nurses. The medication room does not have enough counter space to service all t he nurses, especially during the morning medication rounds when multiple nurses utilize the room simultaneously. The medication room becomes crowded, especially around the northern door. The refrigerator and computer station are located in this area, and n urses often get hit with the swinging door when working in this space. However, the general layout of the unit works well, with the exception of the location of the supplies. Moving the supplies to a more central location on the unit would reduce the amoun t of back and forth walking the nurses currently encounter. The largest negative indicator spatial factors has a more adverse effect on supportive (noise and privacy) or supportive (lighting and therma l qualities), because it is causing users to expend energy against features of the workplace. Therefore in order to raise the environmental comfort

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155 level of the nurses on Unit C, the most valuable investment in workspace improvement entails the spatial fac tors, particularly in the medication room, followed by solving the noise and privacy problems in the nurse station. Unit D Synthesis and Application The results from the questionnaires and focus groups show that the perceived environmental comfort in Unit C and Unit D are similar. Reminiscent of Unit C, the nurses on Unit D are more comfortable with the lighting (psychological comfort level) and thermal qualities (psychological comfort level) than with the noise level (functional comfort level) and the pri vacy (functional comfort level). The noise on the unit is distracting to the nurses and they often lack the ability to have a private conversation. related to spatial factor s (functional comfort level), again, particularly in regards to the medication room. Taking these results and applying them to the environmental comfort model shows that the work activities of registered nurses on Unit D are supported by the conditions of lighting and thermal quality in the nurse work areas. The nurses benefit from having task lamps, under cabinet lights, and natural light in their work areas, all of which the nurses can personally control. The staff thermostats are readily accessible for t temperature and they rarely feel the need to adjust the thermostat. This aspect of control results in the nurses experiencing psychological comfort in relation to lighti ng and thermal qualities. The noise level and privacy conditions, both categorized in the functional comfort level, are perceived by the nurses as less comfortable than the conditions of lighting

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156 and thermal qualities. This means that the noise and privacy conditions are not in full privacy slows down nursing tasks because the nurses must divert their energy to combat features of their work environment. However, the medicat ion dispensing room and the supply room are both areas that the nurses perceive as private and quiet. The level of environmental comfort the nurses perceive can be increased by improving the noise quality and privacy in the nurse station. This could be ach ieved through the addition of sound attenuating materials. Similar to the noise and privacy of the unit, the spatial factors of the nurse work areas are also categorized in the functional level of the continuum. The unsupportive spatial factors in the medi cation room are causing the nurses to expense energy that they could be applying towards working. The layout of the medication rooms in Unit C and Unit D are nearly identical, and the nurses are experiencing the same issues in both units. The medication ro om does not have enough counter space to service all the nurses, especially when multiple nurses are using the room at once in the mornings. The biggest problem area is in the vicinity of the refrigerator and computer station because the northern facing do or swings directly in to this space, consequently hitting level involves the general layout of the unit. The supplies are not centrally located on the unit. Moving the supplies to a more central location on the unit would reduce the amount of back and forth walking the nurses currently encounter. The largest negative indicator spatial factors has a more adverse effect on are semi supportive (noise and privacy) or

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157 supportive (lighting and thermal qualities), because it is causing users to expend energy struggling against features of the workplace. Therefore in order to raise the environmental comfort level of the nurses on Unit D the most valuable investment in workspace improvement involves the spatial factors, particularly in the medication room, followed by solving the noise and privacy problems in the nurse station. Design Trade offs This study has confirmed that trade offs play an important role when designing a healthcare environment. A trade off is defined as a choice that involves losing one quality in return for gaining another quality It i s important for design professionals to make design choices with full compre hension of both the upside and downside of a particular decision For example in healthcare settings hard non porous work surf aces that are poor acoustic attenuators are often used to gain other desirable properties, such as durability and ease of sanitat ion. Therefore, noise levels are frequently identified as problematic in healthcare environments, and i t became apparent that the noise level and desire for more privacy were concerns for the nurses in the four units under study. Further examples of trade offs in healthcare design may include light levels patient sleep patterns staff error rate s centralized vs. decentralized nurse station s mobile communication methods and hospital security Consider the following examples specific to the hospitals set tings under study: 1. The nurse station s in the South Tower are located towards the front of the unit This allows direct visual access from the entry of the unit so that a visitor can immediately recognize where to find help. T his reassures wayfinding (Alana Schrader, personal communication, November 16, 2011) However, the trade off is that nurses when supplies and work areas are not centrally located ( Hendrich & Lee, 2005)

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158 2. The limited amount of workspace in the medication dispens ing rooms in the South Tower can accommodate 1 2 nurses preparing medications. Therefore, nurses are often spending valuable time waiting to use the computer and counter space. However, given that space is a valuable commodity in a hospital environment, the designers determined the trade off of square footage was best utilized through the implementation of decentralized nurse stations outside the patient rooms rather than increasing the size of the medication dispensing room (Alana Schrader, personal communi cation, November 16, 2011) Design Recommendations The following are specific as well as general design recommendations that can be adopted to improve the design of the healthcare workplace: 1. Design new work efficiencies for underutilized spaces. It is reco mmended that consideration be given to r enovate Unit A and Unit B. The renovation is suggested to involve convert ing the existing shower room s that are currently being used as a storage space into exclusive staff restroom s In addition, there should be ded icated space for decentralized nurse stations preferably located outside the patient rooms with an observation window to offer the nurses visual access to their patients However, since the renovation of the facility is unpredictable in the near fu ture, i t is recommended that additional task chairs be added to the unit, and the broken task chairs be replaced with functional ergonomic seating options immediately I n Unit C and Unit D, the medication dispensing room is suggested to be reconfigured. The compu ter station and refrigerator should be relocated further from the entry. 2. Implement noise reducing acoustic solutions that are appropriate for a healthcare setting. It is recommended that the nurse station and unit corridors have better acoustic al condition s to avoid the problem of noise migration throughout the unit. This can be achieved by the addition of high quality acoustical ceiling tiles, and sound reduction paint on the existing walls. Additionally, it is recommended to install a white noise machine to rectify the problem of background noise in the corridors. 3. Regulate and maintain the air temperatures in the staff areas. To provide thermal comfort to the staff members the HVAC systems should be maintained and regulated to ensure that it is working pro perly The HVAC system in the North Tower needs to be repaired to allow the staff to operate the existing (malfunctioning) thermostats in order to maintain temperature control Recommendations for Future Research This study hopes to serve as a springboard for future research in the field of

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159 perceptions of environmental comfort. Therefore, replication of this study is warranted with different sample strategies to confirm or reshape findings. Moreover, since no demographic information was collected, a future study may be beneficial to explore if gender plays a role in the research findings. Finally, since this study concludes with design recommendations to improve the environmental c omfort of the research settings, future research with the implementation of the design recommendations is needed to find out if these environmental conditions impact the perceived comfort of nursing staff. Conclusion of Discussion This study assesses hospi tal workplace conditions through the theoretical lens of the environmental comfort model proposed by Jacqueline Vischer (2007). Th e model ranks workplace environments in a rising continuum of physical, function al, and psychological comfort. Lighting, therm al quality, spatial factors, n oise level, and privacy all appear to be ved environmental comfort level indicating that the environmental comfort framework is applicable in a healthcare workplace. C ombining ces regarding the five environmental conditions created which provides true life account s of registered surgical unit. In particular, the story reflects on the role of interior design in pro moting, or in some cases hindering, nurse productivity. In sum, medical surgical units provide an excellent setting for researching environmental comfort and how it relates to healthcare design. Yet, given the lac k of empirical research that applies the en vironmental comfort theory to the healthcare workplace, additional research is needed to gain a better under s tanding Nevertheless, t he study findings clearly substantiated the premise that the constituents of the physical environment have an impact on the productivity of registered nurses. Knowle dge

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160 generated by this multi site field study formulated general and specific recommendations for improvements to nurse work areas, and the resu lts can be useful to design professionals and healthcare employees in t he future

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161 APPENDIX A INSTITUTIONAL REVIEW BOARD PERMISSION

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162 APPENDIX B LETTER TO NURSE MANAGERS REQUESTING PARTICIPATION Hi [NURSE MANAGER], arch study which examines the design efficacy of nurse work areas in Shands Cancer perceive the work areas on your unit (nurse station, supply room, and medication dispensing spaces) to identify ways to improve the design of healthcare work areas. Per the request of the IRB, I am reaching out to each of the Nurse Managers whose units I am hoping to conduct the research on. The commitment of the unit would simply include allow ing me to conduct two 20 minute observations of the nurse work areas to participate in a survey and focus group (which will require 20 25 minutes from the partici Nurse Manager forward a letter of invitation, which I will supply, to each of the registered nurses working on the unit. If you are able to agree to allowing your unit to parti cipate in this study, please print out the attached letter of support, read, and sign. Once this is complete, please let me know, and I will be happy to pick up the letter myself. If there are changes you feel are necessary to make to the letter, please let me know before printing it out and signing it. If you have any questions or concerns, please do not hesitate to let me know. Thank you, Paige Walker

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163 APPENDIX C Hello, da, and I am writing to request that you participate in a research study because you are a Shands registered nurse working on unit ___. After working as an interior design intern in the Shands Facilities Development Department for the past three years I h ave seen many positive changes take place throughout our facilities, however, there is always room to grow. Therefore my thesis study examines the design efficacy of nurse work areas. I am particularly interested in how you perceive the work areas on your unit (nurse station, etc.) to identify ways to improve the design of healthcare work areas. I hope you decide to take part in the following study. Study Title: Purpose of the research study: The research investigates the nurse station, medication dispensing areas, and supply rooms in four Shands units; two in the north tower and two in the south tower. The ultimate purpose of the research is to improve the design and functional ity of nurse work areas. What you will be asked to do in the study: If you participate, you will be asked to take a 5 minute questionnaire and then participate in a 20 minute small group discussion centered on perceptions of the nursing work areas. ____ _________, the nurse manager of unit ____, has given me approval to hold the session in room ____ on __________, 2012 at ___pm. Light refreshments will be provided during the session. Total time required: 25 30 minutes Confidentiality: The information yo u provide will be kept completely anonymous. The questionnaire will not have your name on it, and there will be no coding that could link your answers to your identity. With your permission, a confidential audio recording will be made during the discussion for future analysis. Your name or personal information will not be identified on the audio recordings, and confidentiality will be strictly maintained. Voluntary participation: Participation is totally voluntary and participants will not be obligated to participate or penalized for not participating. Right to withdraw from the study: Participants will be able to withdraw from the study at any time without consequence.

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164 Whom to contact if you have questions about the study: Paige Walker University of Florida, Gainesville, Florida Phone: Email: prebor@ufl.edu Margaret Portillo, PhD Professor and Chair, Interior Design Department, University of Florida Phone: Email:mportill@ufl.edu Whom to contact about your rights as a research participant in the study: IRB 01 Office, Box 100173, Gainesville, Fl 32610 1073; Phone: (352) 273 9600 Thank you very much for considering this request! I hope to see you on [DATE]. Sincerely, Paige Walker

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165 APPENDIX D OBSERVATION SCHEDULE July 2 nd July 5th Unit A 8:30 10:00 am 3:30 5:00 pm Unit B 10:00 11:30 am 2:00 3:30 pm Unit C 3:30 5:00 pm 8:30 10:00 am Unit D 2:00 3:30 pm 10:00 11:20 pm

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166 APPENDIX E ORIGINAL DICONFON SURVEY

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172 APPENDIX F MODIFIED DICONFON SU RVEY

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176 LIST OF REFERENCES Agency for Healthcare Research and Quality (AHRQ). The effect of health care working conditions on patient safety. Evidence Based Report/Technology Assessment. No. 74. 2003. AHRQ Publication 03 E024. Available at http ://www.ahrq.gov/clinic/epcsums/worksum.htm. Accessed January 17, 2010. Alimoglu, M. K., & Donmez, L. (2005). Daylight exposure and the other predictors of burnout among nurses in a university hospital. International Journal of Nursing Studies, 42, 549 555. Applebaum, D., Fowler, S., Fiedler, N., Osinubi, O., & Robson, M. (2010, July/August). The impact of environmental factors on nursing stress, job satisfaction, and turnover intention. JONA: The Journal of Nursing Ad ministration, 40(7/8), 323 328. Aranda S. & Street A., (2000). From individual to group: use of narratives in a participatory research process. Journal of Advanced Nursing. 33(6) 791 797. Berglund B, Lindvall T, Schwela D: Guidelines for community noise. Paper presented at: World Health Organization Expert Task Force meeting; April 26 30, 1999 Blomkvist V, Cole J, Ulrich R. Impact of acoustics on staff and patients in CCU. Hosp Dev [serial online]. 2005. Available at http//www.healthdesign.org/research/reports/documents/CHD_Issue_Paper4. pdf. Accessed January 17, 2010. [Context Link] Blomkvist, V., Eriksen, C. A., Theorell, T., Ulrich. R., & Rasmanis, G. (2005). Acoustics and psychosocial environment in intensive coronary care. Journal of Occupational and Environmental Medicine, 62, e1 e8. Boyce P, Hunter C, Howlett O. The Benefits of Daylight Through Windows. Troy, NY: Rensselaer Polytechnic Institute; 2003. Brand, J.L. (2009), Physical space and social interaction, Haworth Collaboration white paper. Retrieved December 24, 2010 from http://www.haworth.com/enus/Knowledge/Workplace Library/Pages/AllDocuments.aspx Healt hcare Design Magazine, 6(7), 80 88. Brown, K., & Gallant, D. (2006). Impacting patient outcomes through design. Critical Care Nursing, 29(4), 326 341.

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177 Buchanan, T. L., Barker, K. N., Gibson, J. T., Jiang, B. C., & Pearson, R. E. (1991). Illumination and er rors in dispensing. American Journal of Hospital Pharmacy, 48(10), 2137 2145. Buerhaus, P. I., Staiger, D. O., & Auerbach, D. I. (2009). The future of nursing workforce in the United States: Data, trends and implications. Sudbury, MA: Jones and Bartlett Pu blishers, LLC. Bureau of Labor Statistics. (2007). Number and rate of nonfatal occupational injuries and illnesses by selected industry, all U.S., private industry, 2005. Washington, DC: U.S. Department of Labor. Cesario, S. K. (2009). Designing health car e environments: Part I. Basic concepts, principles, and issues related to evidence based design. The Journal of Continui ng Education in Nursing, 40(6). Charmaz, K. (1999). Stories of suggering: Subjective tales and research narratives. Qualitative Health R esearch 9(3), 362 383. Chaudhury, H., Mahmood, A., & Valente, M. (2009). The effect of environmental design on reducing nursing errors and increasing efficiency in acute care settings: A review and analysis of the literature. Environment and Behavior, 41, 755 786. Creswell, J. W. (2003). Research design: Qualitative, quantitative, and mixed methods approaches (2nd ed.). Thousand Oaks, CA: Sage. Darbyshire, P. (1995). In defense of pedagogy: A critique of the notion of andragog y. Nurse Education Today, 13 328 335. Dohr, J., & Portillo, M. (2011). Design thinking for interiors. Hoboken, NJ: John Wiley & Sons. Edwards. L., & Torcellini P. (2002) A Literature Review of the Effects of Natural Light on Building Occupants. NREL/ TP 550 30769. Elijah Barnwell, S. A. (2008). Healing through design: Nursing perceptions of the health care environment (Doctoral dissertation, Un iversity of Nebraska). Environmental Protection Agency. Information on levels of environmental noise requisite to protect public health and wel fare with an adequate margin of safety (Report No 550 9 74 004). Washington, DC, Environmental Protec tion Agency, 1974. Flynn, E. A., Barker, K. N., Gibson, J. T., Pearson, R. E., Berger, B. A., & Smith, L. A. (1999). Impact of interruptions and distractio ns on dispensing errors in an ambulatory care pharmacy. American Frumkin Howard. (2005). Environmental Health From Global to Local. Jossey Bass, San Francisco. Journal of Health Systems Pharmacy, 56(13), 1319 1325.

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178 Greenhalgh, T., & Hurwitz, B. (1998). Wh y study narrative? In Greenhalgh & Hurwitz (Eds.) Narrative Based Medicine: Dialogue and Discourse in Clinical Practice, (pp. 3 16). London, BMJ Books. Hamilton, D. K. (2003). The four levels of evidence based practice. Healthcare Design, 18 26. Hansell H N (1984). The behavioral effects of noise on man: The patient with intensive care unit psychosis. Heart Lung, ( 13 ) 59 65 Hayes, L. J., O'Brien Pallas, L., Duffield, C, Shamian, J., Buchan, J., Hughes, F., et al. (2006). Nurse turnover: A literature r eview. International Journal of Nursing Studies, 43, 237 263. Hendrich, A., & Lee, N. (2005). Intra unit patient transports: Time, motion, and cost impact on hospital efficiency. Nursing Economic, 23(4), 157 164. Hendrich, A., Chow, M., Skierczynski, B. A. & Zhenqiang, L. (2008). A 36 hospital time and motion study: How do medical surgical nurses spend their time? The Permanente Journal, 12(3), 25 34. Healey, A., Primus C., & Koutaintji, M. (2007). Quantifying distraction and interruption inurological surg ery. Quality & Safety in Health Care, 16, 135 139. Holtom, B. C, Mitchell, T. R., Lee, T. W., & Eberly, M. B. (2008). Turnover and retention research: A glance at the past, a closer review of the present, and a venture into the future. The Academy of Manag ement Annals, 2(1), 231 274. Holloway, I., & Freshwater, D. (2007). Narrative research in nursing. Blackwell. Hospitals and services. (n.d.). Retrieved September 13, 2011, from http://shands.org/about/glance.asp Hurwitz, B., Greenhalgh, T., & Skultans V. ( Eds.). (2004). Narrative research in health and illness. Oxford: BMJ Books/Blackwell. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press. Institute of Medicine. (200 4). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academies Press. Joint Commission. (2002). Health care at the crossroad: Strategies for addressing the evolving nursing crisis. Oakbrook Terrace, IL: Joint Com mission. Jones, A.H. (1990). Literature and medicine: traditions and innovations. In Clarke & Aycock (Eds.), The body and the text: Comparative essays in literature and medicine. Lubbock, Texas Technical University Press.

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179 Jones, C. B. (2008). Revisiting nu rse turnover costs: Adjusting for inflation. Journal of Nursing Administration, 38(1), 11 18. arter 2007 report. Raleigh, NC: fmi. Joseph A, Ulrich R. Sound control for improved outcomes in healthcare s ettings. Concord, CA: The Center for Health Design; 2007. Available at http://www.healthdesign.org/research/reports/sound. php. Accessed January 31, 2010. Joseph, A. (2006). Issue paper 2: The impact of light on outcomes in healthcare settings. Retrieved Ma y 4, 2009, from www.healthdesign.org/research/reports/light.php Joseph, A., Malone, E., Pati, D., Quan, X. (2011). Healthcare environmental terms and outcome measures: An evidence based design glossary. The Center for Health Design. Kistner, U. A., Keith, M. R., Sergeant, K. A., & Hokanson, J. A. (1994). Accuracy of dispensing in a highvolume, hospital based outpatient pharmacy. American Journal of Hospital Pharmacy, 51(22), 2793 2797. K levens, R. M., Edwards, J. R., Richards, C. L., Horan, T. C., Gaynes, R. P., Pollock, D. A., et al. (2007a). Estimating health care associated infections and deaths in us hospitals. Public Health Reports, 122(2), 160 166. Kopec Dak. (2006). Environmental P sychology For Design. Fairchild Publications, Inc, New York. Kotzer, A.M., & Arellana, K. (2008). Defining an evidence based work environment for nursing in the USA. Journal of Clinical Nursing, 17, 1652 1659. Kovner, T. K., Brewer, C. S., Greene, W., & Fa irchild, S. (2009). Understanding new registered nurses' intent to stay at their jobs. Nursing Economics, 27(1), 81 98. Lawton, M.P. (1980). Environment and aging. Monterey, CA: Brooks/Cole Publishing Company. Lee, T. H., Gerhart, B. Weller, I., & Trevor, C. O. (2008). Understanding voluntary turnover: Path specific job satisfaction effects and the importance of unsolicited job offers. Academy of Management Journal, 51(4), 651 671. Levin, D. (2007). CHD president highlights Pebble Project successes and plan s for 2007. Retrieved May 4, 2009, from www.healthdesign.org/research/pebble/overview.php

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180 Lowers, J. (1999). Improving quality through the built environment. Quality Letter for Health care Leaders, 11, 2 9. Mahmood, A., Chaudhury, H., & Valente, M. (2011). Nurses' perception of how physical environment affects medication errors in acute care settings. Applied Nursing Research, 24, 229 237. Malkin, J. (2008). A Visual reference for evide nce based design. Concord, CA: Center for Health Design. McCarthy D O Ouimet M E & Daun J M (1991). Shades of Florence Nightingale: Potential impact of noise stress on wound healing. Holist ic Nurs ing Pract ice, (5) 39 48 McCullough, C. S. (Ed.). (20 01). Creating responsive solutions to healthcare change. Indianapolis, IN: Center Nursing Press. Mlinek, E. J., & Pierce, J. (1997). Confidentiality and privacy breaches in a university hospital emergency department. Academy of Emergency Medicine, 4(12), 1 142 1146. Mroczek, J., Mikitarian, G., Vieira, E. K., & Rotarius, T. (2005). Hospital design and staff perceptions: An exploratory analysis. Mycek, S. (2007 ). Under the spreading planetree. The Journal for Hospital Governing Boards, 60(3), 22 25. Page, A. (Ed.). (2004). Keeping patients safe: transforming the work environment of nurses. Washington, DC: National Academies Press. Price, B., (2011). a nalysis. Nursing Children and Young People. 23(6) 28. PricewaterhouseCoopers' Health Research Institute. (2007). What works: Healing the healthcare staffing shortage. Retrieved February 20, 2012 from, http://dwd.wisconsin.gov/healthcare/pdf/what_works.pdf Scott, H. (2004). Working environments have a direct impact on care. British Journal of Nursing, 13, 893. Shaver, K.H., & Lacey, L.M. (2003). Job and career satisfaction among staff nurses: effects of job setting and environment. Journal of Nursing Adminis tration, 33(3), 166 172. Sommer R., & Sommer, B. (2002). A practical guide to behavioral research: tools and t echniques. Oxford England: Oxford University Press.

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181 Topf, M. (2000). Hospital noise pollution: an environmental stress model to guide research an d clinical interventions. Journal of Advanced Nursing, 31(3), 520 528. Topf M & Davis J E (1993). Critical care unit noise and rapid eye movement (REM) sleep. Heart Lung ; 22: 252 258 Topf, M., & Dillon, E. (1988). Noise induced stress as a predictor o f burnout in critical care nurses. Heart Lung, 17, 567 574. Tyson, G. A., Lambert, G., & Beattie, L. (2002). The impact of ward design on behavior, occupational satisfaction and well being of psychiatric nurses. Internation al Journal of Mental Health Nursi ng, 11(2), 94 102. Ubel, P. A., Zell, M. M., & Miller, D. J. (1995). Elevator talk: Observational study of inappropriate comments in a public space. American Journal of Medicine, 99(2), 190 194. Ulrich, R.S. (2006). Essay: E vidence based health care archit ecture. Lancet 368, 538 539. Ulrich, R., Quan, X., Zimring, C, Joseph, A., & Choudhary, R. (2004). The role of the physical environment in the hospital of the 21st century: A once in a lifetime opportunity. Retrieved February 20, 2012 from, http://www.rwj f.org/files/publications/other/RoleofthePhysicalEnvironment.pdf Ulrich, R. S., Zimring, C., Zhu, X., DuBose, J., Seo, H. B., Choi, Y. S., Joseph, A. (2008). A review of the research literature on evidence based healthcare design. Health Environments Research and Design Journal, 1(3). Ventilation for acceptable indoor air quality [Fact sheet]. (2001). Retrieved from http://www.ashrae.org Verderber, S., & Fine, D.J. (2000). Healthcare architecture in an era of radical transformation New Haven, CT: Yale University Press. Vischer, J. C. (2005). Space meets status: Designi n g workplace performance. London: Routledge. Vis cher, J. C. (2007). The effects of the physical e nvironment on job performance: Towards a t heoretical model of workspace s t ress. Wiley InterScience. Stress and Health 23:175 184. Vischer, J C. (2008). Towards an environment al psychology of workspace: How people are affected by environments for work. Architectural Science Review 51.2:97 108.

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182 Walker Hamm, L. (2011). Improving the effectiveness of nursing work area design in inpatient care units (Master's thesis). Retrieved from ProQuest Disserta tions and Theses database. Younger, J.B. (1990). Literary works as a way of knowing. Image. 22(1), 39 43. Zborowsky, T., Bunker Hellmich, L., Morelli, A., & O'Neill, M. (2010). Centralized vs. decentralized nursing stations: effects on nurses' functional u se of space and work environment. Health Environments Research & Design Journal, 3 (4), 19 42.

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183 BIOGRAPHICAL SKETCH Paige Walker rec ami ly, youth, and c ommunity sciences, with a minor in e ducation from the University of Florida in 2008. She began esign in 2009. While completing her gra duate studies she worked as an interior design i ntern at Shands at the University of Florida for over three years. She assisted in the design of large additi ons, new construction builds, and small renovations in the Shands building complex. During this time her interest and knowledge in healthcare design in tensified, leading to the topic of her thesis research. After graduation she plans to work for an architecture firm specializing in healthcare design.