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Research Finding a Middle Ground: Exploring the Impact of Patient- and Family-Centered Design on Nurse–Family Interactionssagepub.com/journalsPermissions.nav DOI: 10.1177/1937586715593551 herd.sagepub.com Allyn S. Rippin, MS, EDAC , Craig Zimring, PhD , Owen Samuels, MD , and Megan E. Denham, MAEd, EDAC Abstract Objective: This comparative study of two adult neuro critical care units examined the impact of patient- and family-centered design on nurse–family interactions in a unit designed to increase family involvement. Background: A growing evidence base suggests that the built environment can facilitate the delivery of patient- and family-centered care (PFCC). However, few studies examine how the PFCC model impacts the delivery of care, specifically the role of design in nurse–family interactions in the adult intensive care unit (ICU) from the perspective of the bedside nurse. Methods: Two neuro ICUs with the same patient population and staff, but with different layouts, were compared. Structured observations were con- ducted to assess changes in the frequency, location, and content of interactions between the two units. Discussions with staff provided additional insights into nurse attitudes, perceptions, and experiences caring for families. Results: Nurses reported challenges balancing the needs of many stakeholders in a complex clinical environment, regardless of unit layout. However, differences in communication patterns between the clinician- and family-centered units were observed. More interactions were observed in nurse workstations in the PFCC unit, with most initiated by family. While the new unit was seen as more conducive to the delivery of PFCC, some nurses reported a loss of workspace control. Conclusions: Patient- and family-centered design created new spatial and temporal opportunities for nurse–family interactions in the adult ICU, thus supporting PFCC goals. However, greater exposure to unplanned family encounters may increase nurse stress without adequate spatial and organizational support. Keywords critical care, patient- and family-centered care, evidence-based design, nurse–family interactions, stress Plural Space, LLC, Atlanta, GA, USA Georgia Institute of Technology, Atlanta, GA, USA Neuroscience Critical Care, Emory Healthcare, Atlanta, GA, USA To earn continuing education units on this article visit h e r d . s a g e p u b . c o m / s u p p l e m e n t a l Corresponding Author: Allyn Rippin, MS, EDAC, Plural Space, LLC, PO Box 77891, Atlanta, GA 30357, USA. Email: alrippin@hotmail.com " id="pdf-obj-0-4" src="pdf-obj-0-4.jpg">

Finding a Middle Ground:

Exploring the Impact of Patient- and Family-Centered Design on Nurse–Family Interactions in the Neuro ICU

Health Environments Research & Design Journal 2015, Vol. 9(1) 80-98 ª The Author(s) 2015 Reprints and permission:

Research Finding a Middle Ground: Exploring the Impact of Patient- and Family-Centered Design on Nurse–Family Interactionssagepub.com/journalsPermissions.nav DOI: 10.1177/1937586715593551 herd.sagepub.com Allyn S. Rippin, MS, EDAC , Craig Zimring, PhD , Owen Samuels, MD , and Megan E. Denham, MAEd, EDAC Abstract Objective: This comparative study of two adult neuro critical care units examined the impact of patient- and family-centered design on nurse–family interactions in a unit designed to increase family involvement. Background: A growing evidence base suggests that the built environment can facilitate the delivery of patient- and family-centered care (PFCC). However, few studies examine how the PFCC model impacts the delivery of care, specifically the role of design in nurse–family interactions in the adult intensive care unit (ICU) from the perspective of the bedside nurse. Methods: Two neuro ICUs with the same patient population and staff, but with different layouts, were compared. Structured observations were con- ducted to assess changes in the frequency, location, and content of interactions between the two units. Discussions with staff provided additional insights into nurse attitudes, perceptions, and experiences caring for families. Results: Nurses reported challenges balancing the needs of many stakeholders in a complex clinical environment, regardless of unit layout. However, differences in communication patterns between the clinician- and family-centered units were observed. More interactions were observed in nurse workstations in the PFCC unit, with most initiated by family. While the new unit was seen as more conducive to the delivery of PFCC, some nurses reported a loss of workspace control. Conclusions: Patient- and family-centered design created new spatial and temporal opportunities for nurse–family interactions in the adult ICU, thus supporting PFCC goals. However, greater exposure to unplanned family encounters may increase nurse stress without adequate spatial and organizational support. Keywords critical care, patient- and family-centered care, evidence-based design, nurse–family interactions, stress Plural Space, LLC, Atlanta, GA, USA Georgia Institute of Technology, Atlanta, GA, USA Neuroscience Critical Care, Emory Healthcare, Atlanta, GA, USA To earn continuing education units on this article visit h e r d . s a g e p u b . c o m / s u p p l e m e n t a l Corresponding Author: Allyn Rippin, MS, EDAC, Plural Space, LLC, PO Box 77891, Atlanta, GA 30357, USA. Email: alrippin@hotmail.com " id="pdf-obj-0-19" src="pdf-obj-0-19.jpg">

Allyn S. Rippin, MS, EDAC 1 , Craig Zimring, PhD 2 , Owen Samuels, MD 3 , and Megan E. Denham, MAEd, EDAC 2

Abstract

Objective: This comparative study of two adult neuro critical care units examined the impact of patient- and family-centered design on nurse–family interactions in a unit designed to increase family involvement. Background: A growing evidence base suggests that the built environment can facilitate the delivery of patient- and family-centered care (PFCC). However, few studies examine how the PFCC model impacts the delivery of care, specifically the role of design in nurse–family interactions in the adult intensive care unit (ICU) from the perspective of the bedside nurse. Methods: Two neuro ICUs with the same patient population and staff, but with different layouts, were compared. Structured observations were con- ducted to assess changes in the frequency, location, and content of interactions between the two units. Discussions with staff provided additional insights into nurse attitudes, perceptions, and experiences caring for families. Results: Nurses reported challenges balancing the needs of many stakeholders in a complex clinical environment, regardless of unit layout. However, differences in communication patterns between the clinician- and family-centered units were observed. More interactions were observed in nurse workstations in the PFCC unit, with most initiated by family. While the new unit was seen as more conducive to the delivery of PFCC, some nurses reported a loss of workspace control. Conclusions:

Patient- and family-centered design created new spatial and temporal opportunities for nurse–family interactions in the adult ICU, thus supporting PFCC goals. However, greater exposure to unplanned family encounters may increase nurse stress without adequate spatial and organizational support.

Keywords

critical care, patient- and family-centered care, evidence-based design, nurse–family interactions, stress

1 Plural Space, LLC, Atlanta, GA, USA 2 Georgia Institute of Technology, Atlanta, GA, USA 3 Neuroscience Critical Care, Emory Healthcare, Atlanta, GA, USA To earn continuing education units on this article visit herd.sagepub.com/supplemental

Corresponding Author:

Allyn Rippin, MS, EDAC, Plural Space, LLC, PO Box 77891, Atlanta, GA 30357, USA. Email: alrippin@hotmail.com

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Introduction

Critical care stands at an important moment of transition. The trend toward patient- and family- centered care (PFCC) is steadily transforming attitudes and behaviors toward family members with a loved one in the adult intensive care unit (ICU). For many years, restrictions have been placed on family presence in these highly charged environments in an effort to protect the critical patient and staff privacy. However, an emerging body of evidence confirms what has long been intuited: Families play a vital role in patient and family healing, particularly during an acute med- ical crisis (Davidson et al., 2007). In response, ICUs across the United States are increasingly opening their doors to families (to varying degrees), with policies and processes that recog- nize family as valuable partners—not just visi- tors—in the care and recovery of their loved one. While the traditional, clinician-centered appro- ach to critical care has limited family involvement, PFCC invites families to take a more active role. The intent is to bring wholeness to the patient through collaboration and personalized care that respects the values, beliefs, and experiences of the individual. This collaborative approach, catalyzed by an increasingly consumer-driven marketplace, is bringing policy and departmental changes. Phys- ical spaces, too, are being redesigned to better support the multifaceted needs of families. Comfor- table waiting areas, designated family zones inside the patient room, thoughtful amenities, and flexible visiting hours encourage longer stays and ongoing communication with the care team. While family presence benefits patients, fami- lies, and providers, PFCC requires substantial cultural and procedural change for ICU staff. Organizational and consumer expectations of timely, well-coordinated care are high, and transi- tioning to this new care environment can create stress for staff. This is particularly cogent in the ICU workplace where rates of nurse burnout are high (France et al., 2008; Poncet et al., 2007). While much of the conversation in healthcare has focused on improving the patient and family experience, less is known about the impact of this new care environment and culture on frontline care- givers, particularly the bedside nurse who works in

close contact with families each day. Even less is known about the impact of patient- and family- centered design on nurse–family interactions within the adult critical care setting.

While much of the conversation in healthcare has focused on improving the patient and family experience, less is known about the impact of this new care environment and culture on frontline caregivers

This exploratory study takes first steps in understanding the context of caring for patients and families in a high-acuity ICU from the per- spective of the bedside nurse. Using a U.S. univer- sity teaching hospital as a case study, this article explores how the design of the family-centered ICU impacts the nurse’s ability to deliver PFCC and the relationship between nurse and family, including its potential to create workplace chal- lenges for the nurse. Patterns of behavior derived from observational research and conversations with staff are examined in relation to the built environment. Key recommendations and opportu- nities for future research are also presented.

Background

Literature Review

Family members of an adult patient in the ICU have traditionally been restricted when visiting their loved one during hospitalization. Concerns for patient safety and staff privacy prevailed despite growing awareness of the need for fam- ily presence in the care of patients. This began to change in 1988 when The Picker Institute rec- ommended the inclusion of patient and family in care delivery (Ciufo, Hader, & Holly, 2011). Since then, advocacy groups and professional organizations continue to define the standards of PFCC and set forth guidelines that encourage family partnership (Conway et al., 2006; David- son et al., 2007; Kohn, Corrigan, & Donaldson, 2001). These guidelines reflect a wealth of research demonstrating the needs of family, including proximity to loved ones, assurance of good care, and honest, timely information (Lam

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& Beaulieu, 2004; Leske, 1986; McAdam, Arai, & Puntillo, 2008; Molter, 1978).

alerting staff to changes in patient condition (Davidson, 2009).

PFCC in practice. The Institute for Patient- and Family-Centered Care (IPFCC, 2010) defines PFCC as ‘‘an approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients and families.’’ According to the institute, PFCC is guided by four key con- cepts: Respect and dignity for individual knowl- edge, beliefs, and values that are incorporated into the planning and delivery of care; timely, complete, and accurate information sharing; par- ticipation in care and decision making at their level of choice; and collaboration with patients and families on the development, implementa- tion, and evaluation of PFCC policies and pro- grams (IPFCC, 2010). Inviting family presence during episodes of care (e.g., cardiopulmonary resuscitation [CPR], invasive procedures [IPs], and physician rounding) and creating flexible vis- itation policies are several ways to translate PFCC into practice (Davidson et al., 2007). More recently, facility design has become a recognized vehicle to support PFCC. A review of award- winning ICU designs over the past two decades shows increased acceptance of family as an inte- gral part of the healing process (Cadenhead & Anderson, 2009; Rashid, 2014).

Perceived benefits of PFCC. Studies highlight many advantages of family presence and involvement in the care of critical patients. Family can help calm an agitated or disoriented patient, increase a patient’s sense of safety and comfort, and assist in decision making when a loved one is unable to speak (Hupcey, 1999). Families receive therapeu- tic benefits from their participation as well (Hammond, 1995). Presence during CPR or IP can help a family grasp the seriousness of the patient’s condition (Duran, Oman, Abel, Koziel, & Szymanski, 2007; Tawil et al., 2014), reassure them that everything was done for their loved one (Meyers et al., 2000), and help facilitate the grief process (Robinson, Mackenzie-Ross, Hewson, Egleston, & Prevost, 1998). Family members can also provide personalized information to guide the plan of care and reduce medical errors by

Perceived concerns of PFCC. Despite its many bene- fits, family presence brings its share of concerns. Much of the available literature focuses on family presence (FP) during episodes of care (e.g., CPR) rather than day-to-day family presence on the unit. One common concern among staff is that family can disrupt patient care (Egging et al., 2011). In one study, nurses perceived family as taking focus away from patient duties, which could result in medication errors (Farrell, Joseph, & Schwartz- Barcott, 2005). Other concerns include patient pri- vacy, prolonged futile resuscitation, and litigation (Pankop, Chang, Thorlton, & Spitzer, 2013). According to the American Association of Critical-Care Nurses (AACN, 2010) recommenda- tions, however, there is little concrete evidence that family presence negatively impacts safety or interferes with patient care or staff performance. In fact, a comparison of data between 2004 and 2010 shows that concerns about family interrup- tions during CPR/IP have decreased, with no reports of litigation (Pankop et al., 2013). More- over, when staff gains clinical confidence and experience working alongside families, attitudes appear to change (Mian, Warchal, Whitney, Fitz- maurice, & Tancredi, 2007; Robinson et al., 1998). There is a robust body of literature and well- founded concern, however, for the psychological health of families. Davidson, Daly, Agan, Brady, and Higgins (2010) report that up to 80% of fam- ily members may experience long-lasting anxi- ety, depression, and symptoms of post-traumatic stress disorder (PTSD) following a stay in the ICU—a condition known as post-intensive care syndrome-family. Exposure to an unfamiliar, frightening environment, coupled with pressures to make life and death decisions on behalf of loved ones, can significantly heighten stress (Azoulay et al., 2001; Engstro¨m, Uusitalo, & Engstro¨m, 2011). Consequently, nurses may be reluctant to include family in potentially disturb- ing events such as CRP (Robinson et al., 1998), although recent studies suggest nurses have more favorable views of FP than other health profes- sionals (Duran et al., 2007; Meyers et al., 2000). In a prospective, cluster-randomized control trial,

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Jabre et al. (2013) report a significantly lower

incidence of PTSD-related symptoms in family

members given the option to observe CPR.

et al., 2012). This trend in family-centered design

comes as part of a broader movement of basing

design decisions on the latest credible evidence,

or evidence-based design (EBD). Facility design

PFCC from the nurse perspective. Despite its bene- has been shown to play an important role in heal-

fits, PFCC can introduce challenges in the deliv-

ery of care. The Nursing Stress Scale was one of

the first measures to acknowledge that nurses

may feel unprepared to meet the emotional needs

of patients and families within a demanding ICU

environment (Gray-Toft & Anderson, 1981).

Numerous studies since have shed light on the

challenges of balancing the needs of critical

patients and loved ones (Cassem & Hackett,

1972; Corr, 1999; Farrell et al., 2005; Stayt,

2009; Yetman, 2009). When caring for two criti-

cal patients, the bedside nurse must make difficult

choices between attending to a family’s needs,

while another critical patient needs attention in

the next room (Hupcey, 1999). Patient and family

needs can also compete. For example, a patient

may need to rest, while the family seeks rea-

ssurance by the bedside (Yetman, 2009). When

communicating with family, striking a balance

between transparency and sensitivity is a widely

reported challenge (Stayt, 2009; Vreeland &

Ellis, 1969). Even the way in which a provider

delivers news can be more important to the reci-

pient than the news itself (Haskard, DiMatteo,

& Heritage, 2009; Jurkovich, Pierce, Pananen,

& Rivara, 2000). Managing family visitation

poses an additional layer of workplace complex-

ity. In an open-access ICU, the nurse must con-

tinuously evaluate the condition of the patient,

the needs of the family, and his or her own work-

load while integrating flexible visitation into

daily treatment and care (A ˚ ga˚ rd & Lomborg,

2011). An inconsistent enforcement of such poli-

cies can lead to tensions among nurses and with

family (Livesay, Gilliam, Mokracek, Sebastian,

& Hickey, 2005).

PFCC and design. Healthcare organizations are

increasingly recognizing the value of design in

supporting PFCC goals and practices. Private

consult areas, dedicated space for family in the

patient room, kitchen and laundry areas, and so

on, are a few of the recommended ways to help

meet a family’s needs in the ICU (Thompson

ing for patients, families, and staff by reducing

infections and medical errors, decreasing stress,

and improving privacy, among other positive out-

comes (Zimring et al., 2008).

An emerging body of literature suggests that

the built environment can increase family pres-

ence and satisfaction, involvement with care,

and other desired outcomes of PFCC (Choi &

Bosch, 2012; Jongerden et al., 2013; Olausson,

Ekebergh, & O ¨ sterberg, 2014; Zimring et al.,

2008). One study reported an increase in family

satisfaction and perceptions that nurses were

more supportive, compassionate, and courteous

after a series of changes were made in the ICU

(e.g., single-bed rooms and more space around

the bedside; Jongerden et al., 2013). One author

suggests design may encourage more family-

centered staff behaviors (Hartog & Jensen,

2013). Private consult areas (e.g., patient room)

may increase the quality , frequency, and dura-

tion of interactions (A ˚ stedt-Kurki, Paavilainen,

Tammentie, & Paunonen-Ilmonen, 2001). In a

recent study by Choi and Bosch (2012), family

presence at the bedside increased in rooms that

provided a family zone with comfortable seating

for several members. Conversely, nurse reports

suggest that design can also hamper PFCC. In one

study, nurses discouraged family from staying over-

night when the room was considered uncomfortable

(Farrell et al., 2005). Another study found that

small ICU rooms limit family presence during

rounds (Santiago, Lazar, Jiang, & Burns, 2014).

An emerging body of literature suggests that the built environment can increase family presence and satisfaction, involvement with care, and other desired outcomes of PFCC

Communication is a key driver for safe and

effective healthcare delivery (Hua, Becker, Wurm-

ser, Bliss-Holtz, & Hedges, 2011). Unplanned

encounters are especially important for ‘‘realizing

workplace and patient safety’’ (van Marrewijk &

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Health Environments Research & Design Journal 9(1)

Yanow, 2010, p. 45) and managing the complexity

of patient care. Corridors, for example, can support

ad hoc teaching moments and information sharing

among staff. A growing body of literature in office

and healthcare settings demonstrates an important

link between design and communication (Rashid

& Zimring, 2005; Zimring et al., 2008). However,

the relationship between design and nurse–family

interactions in the adult ICU is less well under-

stood. This article aims to address this gap in the

literature by exploring how space influences pat-

terns of behavior and communication between

nurse and family in a unit specifically designed

with family needs in mind.

Research Setting

Two neuroscience ICUs at a leading U.S. univer-

sity teaching hospital served as the research set-

tings for this study. In the neuro ICU, patients

have suffered a traumatic brain injury or illness

and often require life-sustaining intervention.

Mortality is high (1:5), which means family pres-

ence is important to coordinate care and make

difficult end-of-life decisions. In 2007, one of

the two units underwent renovations that incor-

porated EBD and principles of PFCC with the

intent to increase family involvement and improve

outcomes. This study was completed as a post-

occupancy evaluation 3 years after opening the

new unit. Data were collected from both the reno-

vated 20-bed patient- and family-centered unit

(FCU) and the older 7-bed clinician-centered unit

(CCU). The setting posed a unique opportunity

to compare two ICUs that share many of the same

workplace characteristics yet differ significantly in

terms of layout. Both units are located on the same

floor of the hospital and share the same patient

population and staff. Nurses work in one unit per

shift but may alternate units during the week. The

units also share the same patient- and family-

centered culture and policies, which were enacted

at the same time the FCU opened. Visiting hours

are 24/7, and family members are invited to stay

overnight and be present during shift changes.

While both units support PFCC, their layouts

reflect the dramatic shift toward family involve-

ment in the ICU. In the smaller CCU—the

control group of this study—staff work in a

84 Health Environments Research & Design Journal 9(1) Yanow, 2010, p. 45) and managing the complexity

Figure 1. Clinician-centered unit (CCU), floor plan. Reprinted with permission from WHR Architects.

centralized station, while families are situated

in waiting areas connected by a semiprivate cor-

ridor around the periphery (Figures 1 and 2).

Separate entrances and hallways keep staff and

family flow separate and limit most interactions

to the patient room. Small rooms (180 sq ft) and

reduced visibility to the nursing station from the

family hallway further inhibit family presence

and communication with the care team.

In contrast, the FCU physically integrates fam-

ily into the fabric of the unit (Figures 3 and 4).

Nurses work between centralized nursing stations

and decentralized alcoves just outside patient

rooms for improved monitoring and safety. Rooms

are larger (245 sq ft) with more space around the

bedside. In addition, a private studio adjacent to

the patient room allows family to gather during the

day and stay overnight within footsteps of staff and

loved one. Staff and visitors have separate

entrances but share the same interior hallway,

which means family members walk past clinical

workstations to access the patient room and studio.

There is also a main waiting area just outside the

clinical entry with a family coordinator and a range

of amenities (e.g., kitchen and shower) to support

long-term and out-of-town visitors.

Study Rationale

Three years after

the unit reopened, nurses

reported high levels of workplace

stress. An

in-house survey found that 42% of registered

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85

Rippin et al. 85 Figure 2. Images of clinician-centered unit (CCU). (a) Clinician hallway with centralized

Figure 2. Images of clinician-centered unit (CCU). (a) Clinician hallway with centralized nursing station. (b) Semiprivate family hallway, facing patient room. Reprinted with permission from WHR Architects.

Rippin et al. 85 Figure 2. Images of clinician-centered unit (CCU). (a) Clinician hallway with centralized

Figure 3. Patient- and family-centered unit (FCU), floor plan. Reprinted with permission from Blake Marvin and HKS, Inc.

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Health Environments Research & Design Journal 9(1)

86 Health Environments Research & Design Journal 9(1) Figure 4. Images of family-centered unit (FCU). (a)

Figure 4. Images of family-centered unit (FCU). (a) Shared hallway with central nursing station (left), nurse alcove (center), and patient rooms to the left and right of alcove. (4b) Private family studio, facing patient room. Reprinted with permission from Blake Marvin and HKS, Inc.

nurses (RNs) rated ‘‘interactions with an upset/

challenging family’’ as the leading cause of emo-

tional distress—above ‘‘death of a patient’’

(22%). This striking finding prompted an immedi-

ate concern: Was increased family presence and

involvement—facilitated by the new design—

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87

contributing to nurse stress? The following explora-

tory questions formed the basis for this study:

What defines a ‘‘challenging’’ family from

the nurse perspective? More broadly, what

are the challenges of PFCC?

What role does the built environment play

in these (real and perceived) challenges?

How does patient- and family-centered

design impact the quality of nurse–family

interactions?

Method

Structured observations and on-site discussions

with nursing staff were conducted in the CCU and

FCU over a 2-month period.

Structured Observations

Two methods of data collection were used. First,

a series of structured observations were con-

ducted using behavior mapping as the primary

tool. Behavior mapping is a quantitative tech-

nique that relates behavior to the space in which

it is observed (Proshansky, Ittelson, & Rivlin,

1970). Behaviors are recorded directly onto a

floor plan using a defined set of criteria and are

collected over a specified period of time (Figure 5).

In this study, nurse and family behaviors were

observed at both a ‘‘global’’ and ‘‘local’’ level.

First, systematic walk-throughs of the entire unit

offered a global, bird’s-eye perspective of nurse

and family presence along with the frequency and

location of interactions. Each unit was observed

for 4 days in one given week (Wednesday/Fri-

day/Saturday/Sunday). One walk-through (or

‘‘set’’) was recorded every 15 min in 2-hr time

intervals for approximately 6 hours each day

(9–11 a.m., 1–3 p.m., and 6–8 p.m.). To protect

family privacy, interactions in the family studio

were recorded only when observable from the

hallway. Time, frequency, and duration of obser-

vations were selected to (1) allow global and

local observations to be conducted in tandem

due to time constraints and (2) maximize oppor-

tunities to observe interactions (e.g., day shift,

shift change, etc.). Upon completion of the

walk-throughs, individual maps were aggregated

into a digital file to create a ‘‘snapshot’’ of activ-

ity. Snapshots of the two units were then com-

pared to see how layouts generated different

patterns of behavior.

Second, nurses were shadowed locally in and

around workstations to capture interactions at a

more granular level. Frequency, location, and

content of interactions, as well as instances of

copresence, were recorded over a 4-day period

(see above). In this study, ‘‘interaction’’ is

defined as a one- or two-way verbal communi-

cation initiated by a nurse or family member.

‘‘Copresence’’ is defined as the potential for

interaction when nurse and family are colocated

in the patient room. The observation period was

bound by (1) whether or not the nurse made a

trip into the patient room and/or (2) whether

an interaction was observed. Nurses were typi-

cally assigned to care for two patients (i.e., two

‘‘room pairs’’) at a time. Nurses were shadowed

after visual identificat ion and/or nurse confir-

mation that at least one family member was

present on the unit (e.g., in the room, hallway,

and bathroom). In the event of no interactions,

observations were limited to a 10-min cap to

ensure all room pairs were observed at least

once. Room pairs were drawn at random. Once

all rooms meeting family presence criteria were

observed, the cycle repeated.

Nurse Discussions

In addition to behavior mapping, informal dis-

cussions were held with frontline staff to gain

richer insight into the day-to-day life of the ICU

and attitudes toward PFCC. Twelve RNs and

six additional care team members (one cha-

plain, one nurse practitioner, two doctors, and

two family coordinators) were approached at

individual workstations and asked for feedback

and opinions about their experiences working in

a FCU. Conversations lasted between 20 min

and 1 hour each. Unstructured questioning

allowed participants to lead the discussion and

show the researcher what was most important

to them. The majority of conversations were not

recorded, with most participants preferring to

speak off the record. Their identity was pro-

tected throughout the study. Field notes

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Health Environments Research & Design Journal 9(1)

88 Health Environments Research & Design Journal 9(1) Figure 5. Sample behavior maps, structured observations, CCU

Figure 5. Sample behavior maps, structured observations, CCU (global and local).

containing key words, scenarios, and quotes

were manually coded and categorized by theme

as patterns emerged from the data.

Results

Structured Observations

In the seven-bed CCU, 65 global walk-throughs

(or sets) were recorded, yielding nine inte-

ractions and 12 counts of copresence (Figure 6;

Table 1). All interactions took place in the

patient room. No family members or nurse–fam-

ily interactions were observed in the clinician

hallway. A high frequency of interactions and

copresence in the CCU suggests that the patient

room is the primary locus for family to interact

with staff and be near their loved one. Thus,

family may feel the need to be present in the

room for longer periods of time. In the 20-bed

FCU, 82 global walk-throughs were recorded,

yielding 47 interactions and 19 counts of copre-

sence (Figure 7; Table 1). Most interactions

took place in the patient room (n ¼ 35), with

88 Health Environments Research & Design Journal 9(1) Figure 5. Sample behavior maps, structured observations, CCU

Figure 6. Frequency and location of nurse–family interactions and copresence in CCU, behavior map (global).

12 additional interactions in various locations.

In contrast to the CCU, fewer instances of copre-

sence suggest that the availability of proximal

spaces to wait or communicate with staff may

reduce the need to stay by the bedside.

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Table 1. Frequency and Location of Nurse–Family Interactions and Copresence in Clinician-Centered Unit (CCU) and Patient- and Family-Centered Unit (FCU; Global).

Location

Interactions

Copresence

CCU

Nurse hallway

0

0

Nursing station

0

0

Patient room

9

12

Family hallway

0

0

Waiting room

0

0

Total

9

12

FCU

Alcove

6

0

Hallway

3

0

Patient room

35

19

Nursing station

1

0

Family studio

2

0

Total

47

19

While layout appeared to change interaction

behaviors, it did not make a difference in the

overall global distribution pattern. Nurse and

family tended to cluster in their respective

domains in both units. In other words, nurses

were located most often in workspaces, while

family members were located primarily in dedi-

cated family domains. Family members were

located in the patient room more often than

nurses. In this study, ‘‘domain’’ is defined as a

spatial area intended to support activities specific

to nurse or family. For example, a waiting room is

a family domain, a nursing station is a nurse

domain, and the patient room is a shared domain.

In addition, family presence varied from room to

room regardless of layout, thus suggesting an

unpredictable caseload for the nurse.

Local observations revealed notable patterns

as well. In the CCU, 27 shadowing periods (trips)

yielded 24 total interactions and one instance of

Rippin et al. 89 Table 1. Frequency and Location of Nurse–Family Interactions and Copresence in Clinician-Centered

Figure 7. Frequency and location of nurse–family interactions and copresence in FCU, behavior map (global).

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Health Environments Research & Design Journal 9(1)

Table 2. Comparison of Interaction Frequency, Location, and Who Initiated Interactions Where in Clinician- Centered Unit (CCU) and Patient- and Family-Centered Unit (FCU; Local).

Location

Interaction Frequency

Nurse Initiated

Family Initiated

CCU Nurse hallway (nurse domain)

FCU

5

1

4

Patient room (shared domain)

17

13

4

Family Hallway (family domain)

2

2

0

Total

24

16

8

Nurse alcove (nurse domain)

16

4

12

Patient room (shared domain)

14

7

7

Family studio (family domain)

2

2

0

Total

32

13

19

copresence (Table 2). Nurses made three trips

without family in the room, thus no interactions.

Of the 24 interactions, most took place in the

patient room (n ¼ 17), with a few in the clinician

hallway. Nurses initiated more than half of the

total interactions, and most of these took place in

the patient room. Family initiated most hallway

encounters in the CCU to which nurses responded

with an immediate trip into the patient room

(Table 3). This suggests that in a restricted unit

family may delay communication with staff until

a matter is urgent or staff seek to enforce the rules

of the unit. For local observations in the FCU, 43

total trips yielded 32 interactions and six instances

of copresence (Table 2). There were four trips

without family in the room, thus no interaction.

Of these 32 interactions, slightly more took place

in alcoves (n ¼ 16) than in patient rooms (n ¼

14). Overall, family initiated contact more often

than nurses, and mostly in alcoves. When family

initiated contact in alcoves, nurses stayed seated

about half the time rather than make an immediate

trip into the patient room (Table 3). When nurses

initiated contact in alcoves, they always stayed

seated. This behavior suggests that some interac-

tions do not require immediate action and may

be perceived as less urgent in nature.

During local observations, topics of conver-

sation were also recorded (Table 4). Interactions

in the clinical hallway in the CCU were directly

related to patient care or redirecting family

flow. In the FCU, topics in alcoves ranged from

discussions around patient care to informal

social exchanges (e.g., family making requests

Table 3. Nurse Response Immediately Following Interaction in Clinician-Centered Unit (CCU) and Patient- and Family-Centered Unit (FCU) Workspace (Local).

Frequency of nurse trips and CCU/Nursing FCU/

who initiated interactions

Station

Alcove

Trip into room

5

4

Family initiated

4

4

Nurse initiated

1

0

No trip into room

0

10

Family initiated

0

6

Nurse initiated

0

4

on behalf of the patient, nurse inquiring about

family, etc.). Conversations in patient rooms

were diverse and included discussions about the

plan of care, family education, formal introduc-

tions, and mutually supportive gestures (e.g.,

nurse offering emotional support to family, fam-

ily praising nurse for good work, etc.).

While nurse and family body language was

not formally assessed, a few observations are

worth noting. In the CCU, some family members

appeared tentative when approaching the nurse

in the central work area. Several were observed

gesturing to their nurse from the patient room

doorway rather than crossing the threshold into

the hall. When family did enter the hallway, they

appeared to do so without knowing the rules

and were quickly directed by staff back to the

room or visitor’s entrance. In contrast, families

appeared to approach nurses with greater ease

and familiarity in the FCU. Some paused at the

Rippin et al.

91

Table 4. Content of Nurse–Family Interactions by Location (Local).

Clinician-Centered Unit (CCU)

Location

Content type

Nurse Hallway

Patient Room

Family Hallway

Total

Patient advocacy (PA)

1

1

2

Patient care (PC)

2

7

1

10

Staff introduction (SI)

2

4

6

Verbal support for nurse (NS)

3

3

Plan of care (PC)

1

5

6

Family education (EDU)

9

9

Social interaction (SO)

5

5

Verbal support for family (FS)

4

1

5

Notification (NT)

Request for doctor (MD)

 

Patient- and Family-Centered Unit (FCU)

 
 

Location

Content type

Alcove

Patient Room

Family Studio

Total

Patient advocacy (PA)

7

2

9

Patient care (PC)

1

10

2

13

Staff introduction (SI)

2

2

Verbal support for nurse (NS)

2

2

Plan of care (PC)

2

4

6

Family education (EDU)

4

4

Social interaction (SO)

2

2

Verbal support for family (FS)

1

2

3

Notification (NT)

2

2

Request for doctor (MD)

1

1

alcove before entering th e patient room or leav-

ing the unit, and others engaged in longer conver-

sations. This is explained, in part, by the location

of alcoves in the shared hall and just outside the

patient room—a necessary route for visitors. In

some cases, nurses appeared receptive, turning

their faces and bodies toward approaching family

and, at times, initiating contact. Other times they

appeared to delay or avoid interaction. For exam-

ple, one nurse kept her body facing the computer

while a family member stood by, only turning her

head when spoken to.

Nurse Discussions

In addition to structured observations, conver-

sations were held with nursing staff to gain

insight into their experiences working in a

PFCC unit. While many participants described

family care as an important and satisfying

aspect of their work, discussions tended to

focus on challenges faced. Nurses described a

range of challenging family behaviors (e.g.,

disruptive, passive aggr essive, and confronta-

tional) that could flare during certain times

(e.g., soon after admis sion) and potentially

impede the team’s work. Religious differences

and moral and ethical disagreements over the

plan of care could also raise tensions. How-

ever, challenging family behaviors were con-

sidered the minority of cases and were not

ascribed to a specific unit. As conversations

progressed, a more nuanced portrait of the

complexities of balancing patient and family

care in a high-acuity clinical setting emerged.

The following three major themes were

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Health Environments Research & Design Journal 9(1)

identified: (1) The ICU is unpredictable, so are

families; (2) Patient an d family care is complex

and, at times, paradoxical; and (3) Patient- and

family-centered design creates a paradoxical

nurse–family dynamic.

The ICU is unpredictable, so are families. Partici-

pants described the neuro ICU as a volatile

workplace where patient condition can change

at any moment and caseloads vary each day.

Treatments, procedures, and communications

with colleagues are often unplanned, which

means much of a nurse’s work is conducted

‘‘on the fly.’’ Nurses reported that family pres-

ence and interactions are also ad hoc. Families

rarely arrive as a group, which makes it difficult

to predict who, when, and how many family

members will be present. The definition of fam-

ily included pastors, friends, neighbors, and so

on, which means identifying the best family

spokesperson can be a challenge. In addition,

each member brings a di fferent personality, set

of coping skills, and expectation of care (Every

family is different.), further increasing the unpre-

dictable nature of encounters.

Patient and family care is complex and, at times,

paradoxical. Overall, participants painted a com-

having to prioritize one critical patient over

another at the risk of upsetting the other

patient’s family (who see their loved one as the

priority). Some nurses experienced increased

stress when answering a family’s question while

an unstable patient needed attention in the next

room. Sharing information also required a deli-

cate balancing act, where family might misinter-

pret a nurse’s tone or manner in the urgency to

attend to the next patient.

Several nurses described PFCC as ‘‘good in

theory’’ yet questioned the degree of appropriate-

ness in the neuro ICU. While most believed

hands-on family involvement was best for

‘‘intact’’ (e.g., conscious) patients, unstable, neu-

rologically impaired patients were seen as need-

ing additional safeguarding, even from a

family’s good intentions. This included prohibit-

ing or supervising feeding, limiting physical

touch (which in some cases, was believed to

increase intracranial pressure), and terminating

conversations viewed as tiring or stressful for the

patient. Conversely, nurses also expressed con-

cern for the well-being of family after prolonged

stays. In some cases, distressed or overwhelmed

family members were encouraged to take time

away from the unit.

plex picture of caregiving in the ICU where the

Patient- and family-centered design creates a

needs of patients and families can conflict and

paradoxical nurse–family dynamic. When asked

compete. While families were often seen as a

about the design of the two ICUs, most part-

valuable presence (e.g., a source of comfort for

icipants agreed the CCU hampered their ability

the patient and an ‘‘extra pair of eyes and ears’’

to deliver family-centered care. Participants

for staff), the majority of participants worried that

reported greater difficulty locating family, shar-

family could, at times, impede their ability to care

ing information, and gaining consent quickly. In

for the patient. Troubleshooting family queries,

addition, the CCU waiting areas were seen as

for example, consumed time and resources that

uncomfortable and discouraging visitor stays.

could result in missed tests, delayed treatments,

However, the unit was perceived as more con-

and falling behind on work. Nurses described

ducive to teamwork due to its small size and

wearing many hats (e.g., therapist, educator, con-

central nursing station. In contrast, the FCU was

fidante, even a spiritual, and financial advisor) to

viewed as more conducive to the delivery of

support a family in crisis. Consequently, some

PFCC. Greater proximity and visibility meant

felt torn between their dual roles (‘‘The patient

family could see everything being done for their

is the focus

family takes away your focus

loved one. It also helped staff gain consent and

from what you have to do, but you don’t want

consensus more quickly.

to dismiss them.’’).

The design of the FCU brought advantages,

Another reported challenge was simultane-

ously caring for two critical patients and their

respective families. Of tentimes, this meant

but also trade-offs, for nurses. On one hand, the

family studio allowed nurses to work at the bed-

side, while family had their own space nearby.

Rippin et al.

93

On the other hand, continuous family presence

meant that interactions were often peppered

throughout the day rather than all at once.

While this pattern of frequent communication

increased opportunities for education and rela-

tionship building, it could also lead to repetitious

questioning and/or interruptions that could fatigue

the nurse. This paradoxical dynamic—created

by spatial conditions of c o-visibility and colo-

cation—was also reporte d in alcoves. Seeing

nurses at work built familiarity and trust but

also led to misperceptions (‘‘Family see me on

the computer and think I’m on the Internet surf-

ing, but I’m charting.’’). Some nurses cited fre-

quent approaches by family in alcoves, which

added to a perceived loss of workspace privacy

and ‘‘breathing room’’ to reflect. (‘‘The only

time I have alone is in the bathroom stall.’’)

A staff break room was available on the unit,

yet some perceived it as ‘‘too far’’ from patients

requiring vigilant monitoring.

To reassert workspace boundaries, nurses used

verbal and nonverbal strategies, such as avoiding

eye contact with an approaching family member,

‘‘diverting’’ to another area of the unit, and ‘‘put-

ting families to work’’ at the bedside. Managing

information was another tactic used to modify

family behaviors and interactions. This included

adjusting equipment parameters to reduce the fre-

quency of alarms to minimize family ‘‘hypervigi-

lance’’ by the bedside. Nurses also reported using

eye contact and verbal instruction to keep fami-

lies moving in the shared hallway to protect

patient privacy.

The complex nature of PFCC was further

underscored by the need for organizational

resources to support staff in meeting the needs

of patients and families (as well as their own).

Several RNs expressed a desire for greater depart-

mental structure to help navigate potentially chal-

lenging family interactions and scenarios. This

included regimented protocols and team-based

strategies, nurse education and training (e.g.,

communication skills, role playing, etc.), and

education for families (e.g., clear behavioral

codes and guidelines, family contracts, etc.). Oth-

ers expressed a need for greater clarity about the

definition of PFCC and the extent of their roles

and responsibilities.

Conclusions

Together, these results suggest that the built envi-

ronment has the potential to help or hinder the

nurse’s ability to deliver PFCC. Nurses perceived

the FCU as more conducive to the delivery of

PFCC. Moreover, behavioral changes in the fre-

quency, location, and content of interactions that

were observed in this study supported this per-

ception. In the traditional unit (CCU), architectural

boundaries emphasize separation rather than inte-

gration. As such, interactions were largely confined

to the patient room, while family appeared more

cautious when initiating contact inside the clinician

hallway. Nurses also tended to get up from their

seats to enforce workspace boundaries. In contrast,

greater co-visibility and colocation in the new unit

created new spatial and temporal opportunities

for family to interact with staff. As staff andfamily

mixed and intermingled in the shared hallway, clin-

ical workspaces became public domain. Impor-

tantly, alcoves emerged as a key locus of

interaction beyond their intended use as a charting

and patient monitoring station. More than half of

interactions took place in alcoves, most of which

were initiated by family members—a notable find-

ing in a unit designed to empower families and

increase their participation. Observed communica-

tion behaviors around alcoves point to an overall

finding that the new unit relaxed physical bound-

aries, body language, and communication styles.

Nurses tended to stay seated when approached and

informal social exchanges were observed.

...

greater co-visibility and colocation in

the new unit created new spatial and temporal opportunities for family

to interact with staff.

Design appears to f acilitate some of the

important communications that define PFCC.

However, this study raises an important ques-

tion: Is PFCC easier to deliver in theory than

in practice? Caring for patients and their loved

ones in a high-stakes ICU is complex and para-

doxical work. Over several decades, nurses have

reported numerous benefits—but also inherent

challenges—when caring for the needs of many

in an ever-shifting clinical and social landscape.

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Health Environments Research & Design Journal 9(1)

Discussions with staff reinforce existing research

that suggests the complexities and contradictions

of caring for critical patients and their loved ones

are part and parcel of PFCC, regardless of unit

layout. However, the findings presented in this

research add new insights into the role of the

built environment. Increased exposure to the

unplanned, unpredictable nature of family interac-

tions (and families themselves) that is facilitated,

in part, by design may add to this complexity.

On one hand, the dissolving of physical and tem-

poral boundaries around workstations in the FCU

may create opportunities for information sharing,

patient advocacy, and social rapport. Conversely,

increased visibility and proximity between nurse

and family may also lead to interruptions, misper-

ceptions about nurse activities, and loss of work-

space privacy. Findings suggest these encounters

may not always be timely for the nurse. This study

proposes that nurse stress increases in this new

care setting without adequate spatial and organiza-

tional support measures in place.

Over several decades, nurses have reported numerous benefits—but also inherent challenges—when caring for the needs of many in an ever-shifting clinical and social landscape.

Hospitals are increasingly opening their doors,

expanding visitation policies, and carving out

spaces that invite family presence and participa-

tion in the ICU. PFCC seeks to enhance commu-

nication and collaboration between families and

care providers. This study is one of the first to

examine nurse–family interactions within its spa-

tial and cultural context. Special attention to the

physical setting and how it connects to nurse per-

ceptions and stakeholder behaviors has been inte-

gral to the research. In order to fully assess the

impact and effectiveness of PFCC in critical care

in the future, connecting these dots is essential.

The findings presented here capture a unit in tran-

sition but also an industry. Designing for family

participation and mutually beneficial partnerships

in the adult ICU continues to be an evolving prac-

tice. Adapting to this new environment can be a

challenge for staff. Design is a powerful organi-

zational resource that can aid or inhibit the

success and sustainability of PFCC. In the end,

PFCC is neither good nor bad but complex.

Design interventions must be considered within

this broader context, including the day-to-day

realities of the critical care nurse working in close

contact with family. As hospitals continue to

redefine policies and spaces within the adult ICU,

a holistic view is needed more than ever.

Recommendations

It is critical that architects and healthcare profes-

sionals work together to design PFCC ICUs that

support the functions and needs of nurses, while

remaining hospitable to families. Achieving this

balance requires consideration of both architec-

tural and organizational factors that support this

complex ecosystem. From a design perspective,

nurses need spaces that allow them to be at times

separate from, yet still connected to, family.

This means redefining ‘‘backstage’’ as a means

to support both connectivity and privacy, with

an ability to flex between the two. The staff

break room offers backstage retreat, albeit with

reduced proximity to patient and family. Thus,

a variety of backstage spaces are recommended

to act as both a tether to and a pressure valve

from work demands, family purview, and so

on. For instance, the family studio in the FCU

created this opportunity for ‘‘breathing room’’

while allowing the nurse to remain accessible

to family. While separa ting staff and family flow

is a common approach in ICU design, this study

suggests that alcoves set within a shared hallway

create opportunities for social rapport. Separate

circulations could potentially eliminate these

vital microclimates. Alte rnatively, a partial wall

around the alcove could invite family engage-

ment while still giving privacy to the nurse.

While design plays an important role in facil-

itating PFCC, a well-designed unit alone does

not guarantee staff will transition smoothly to

the new environment or fully integrate family

as active participants—even when the benefits

are widely acknowledged. Rather, space must

be supported by organizational culture. Conver-

sations with staff highlight the importance of

building shared understanding about the extent

of their roles, responsibilities, and expectations

Rippin et al.

95

in relation to family—in addition to design stra-

tegies. This includes clearly defining PFCC in

the context of the organization. Building con-

sensus also involves empowering staff with

tools and training to prepare them for a variety

of circumstances that will undoubtedly arise

when working with families under duress. Role

playing, scripting, team-based strategies, and

other structured appro aches to managing chal-

lenging cases—while providing an outlet for

staff to share issues in a safe, respectful environ-

ment—are some examples. Connecting their

work with positive outcomes, in terms of family

feedback and res earch illustrating the benefits

of PFCC (e.g., lower rates of litigation, etc.),

can also help overcome concerns and bolster a

sense of mission. In sum, design and culture

must work hand-in-hand to encourage family-

centered behaviors in an environment that sup-

ports patients and families and the nurses who

care for them.

While design plays an important role in facilitating PFCC, a well-designed unit alone does not guarantee staff will transition smoothly to the new environment or fully integrate family as active participants—even when the benefits are widely acknowledged.

Limitations and Future Research

The purpose of this exploratory study is to present

preliminary findings on the important dynamic

between design, communication, and the delivery

of PFCC; to identify potential areas for further

research; and to stimulate discussion within the

design community. There are, however, metho-

dological limitations. Nurses reported frequent

interactions with family; however, the observed

frequency of interactions was low. This discre-

pancy between actual and perceived frequency

can be attributed to several factors. Reported

observations represent a snapshot in time. While

this methodology captures a global perspective

on a complex system with many activities occur-

ring simultaneously, it is less likely to account for

all interactions over a span of time. In addition,

family members in the neuro ICU often stay for

weeks or months, leading to lower turnover rates

than in other types of ICUs. It is unclear how fam-

ily behaviors change depending on length of stay.

Additional research is needed to evaluate how

nurse–family interactions change across a range

of ICUs with various lengths of stay. Future

directions include exploration of nurse percep-

tions of patient flow, factors that shape feelings

and perceptions, and ways to address them. This

includes a more formal interview process via

one-on-one interviews and/or focus groups to

elicit feedback.

While the results of this research are based

on a study of one organization, many of the

findings are generalizable to other hospitals

engaged in PFCC as well as to other ICU popu-

lations. This is supported, in part, by strong

similarities between this and previous studies

illustrating the complex nature of PFCC. How-

ever, nurses raise an important question about

the degree of appropriateness of PFCC for neu-

rologically impaired patients. While the need

for family involvement is especially high in the

neuro ICU, there may be special considerations

that impact the way care is delivered and family

is engaged. Future study should take a recipro-

cal and complementary look at the patient and

family perspectives in a unit designed specifi-

cally for them. As the movement toward PFCC

in critical care co ntinues, additional research by

multidisciplinary teams is needed to ensure this

new care model is adapted seamlessly and

effectively.

Implications for Practice

A combination of patient- and family-

centered design strategies (i.e., a dedicated

family studio, shared hallway, and decentra-

lized alcoves)—along with an open visita-

tion policy—may increase spatial and

temporal opportunities for nurse–family

interactions.

The built environment holds the potential

to help or hinder the delivery of PFCC and

nurse–family communication. However,

design and organizational culture must

96

Health Environments Research & Design Journal 9(1)

work hand-in-hand to create a model of

care and clinical environment that is both

sustainable for the nurse and hospitable

to families.

PFCC is a complex approach to care deliv-

ery that requires careful consideration of

the needs and challenges of all stake-

holders, including the bedside nurse.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of

interest with respect to the research, authorship,

and/or publication of this article.

Funding

The author(s) received no financial support for

the research, authorship, and/or publication of

this article.

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