Macrocognition in the Healthcare Built Environment (mHCBE): A Focused Ethnographic Study of “Neighborhoods” in a Pediatric Intensive Care Unit

Abstract

Objectives:

The objectives of this research were to describe the interactions (formal and informal), in which macrocognitive functions occur and their location on a pediatric intensive care unit, to describe challenges and facilitators of macrocognition using space syntax constructs (openness, connectivity, and visibility), and to analyze the healthcare built environment (HCBE) using those constructs to explicate influences on macrocognition.

Background:

In high reliability, complex industries, macrocognition is an approach to develop new knowledge among interprofessional team members. Although macrocognitive functions have been analyzed in multiple healthcare settings, the effect of the HCBE on those functions has not been directly studied. The theoretical framework, “macrocognition in the healthcare built environment” (mHCBE) addresses this relationship.

Method:

A focused ethnographic study was conducted including observation and focus groups. Architectural drawing files used to create distance matrices and isovist field view analyses were compared to panoramic photographs and ethnographic data.

Results:

Neighborhoods comprised of corner configurations with maximized visibility enhanced team interactions as well as observation of patients, offering the greatest opportunity for informal situated macrocognitive interactions (SMIs).

Conclusions:

Results from this study support the intricate link between macrocognitive interactions and space syntax constructs within the HCBE. These findings help increase understanding of how use of the framework of Macrocognition in the HCBE can improve design and support adaptation of interprofessional team practices, maximizing macrocognitive interaction opportunities for patient, family, and team safety and quality.

Keywords

nursing pediatric intensive care unit macrocognition space syntax architecture neighborhoods

The importance of improving the healthcare environment and interprofessional team work to reduce errors and improve safety has been established by the Institute of Medicine (Reid, Compton, Grossman, & Fanjiang, 2005). A systems approach has the potential to radically improve healthcare quality and safety. Such a view goes beyond individual caregiver knowledge, skills, and performance to include adaptive interprofessional team cognitive performance within the complex environment in which healthcare teams function.

The overarching goal of this research was to empirically investigate the influence of the healthcare built environment (HCBE) on macrocognition (m). The theoretical framework for this research advances a novel conceptual framework, “macrocognition in the HCBE” (mHCBE), which is comprised of the nursing metaparadigm (person, health, nurse, and environment; Fawcett, 1984; Nightingale, 1860), macrocognition theory (Patterson & Hoffman, 2012), and space syntax theory (Haq & Luo, 2012; Hillier, 2008).

Macrocognition, the “adaptation of cognition to complexity” (Patterson & Hoffman, 2012, p. 221), provides a broad cognitive approach to improving patient quality and safety. The theoretical framework of macrocognition comprises five interrelated functions: sensemaking, replanning, detecting problems, deciding, and coordinating (Patterson & Hoffman, 2012). Macrocognition has been studied in industrial environments (Patterson, Watts-Perotti, & Woods, 1999), as well as healthcare, but the influence of the built environment on macrocognition has not been evaluated.

A key framework influencing healthcare design is space syntax theory, which assumes that the configuration of a space is created to accommodate planned functions, while the functions are influenced and changed by the shape of the space (Hillier, 2014). The space syntax theory constructs utilized in this study are openness (lack of boundaries or partitions), connectivity (adjacencies to other spaces), and visibility (line of sight; Haq & Luo, 2012; Trzpuc & Martin, 2010).

This study examines the influence of the HCBE on macrocognition in a pediatric intensive care unit (PICU). The specific aims are, in a PICU in an academic medical center, to:

describe interactions (formal and informal) in which macrocognitive functions occur and their location,

describe challenges and facilitators of macrocognition within the physical environment using space syntax constructs, and

analyze the HCBE using space syntax to explicate influences on macrocognition.

Background

In healthcare, macrocognitive functions have been analyzed. In two outpatient settings (cardiology and diabetes care), attention to macrocognitive functions offered a more structured approach to patient decision making and self-care, with some improvements in glucose regulation and adherence to medication planning (Dhukaram & Baber, 2015; Klein & Lippa, 2008). In the inpatient setting, macrocognition has been studied through formal team cognitive interactions, such as intensive care unit (ICU) rounds and handovers, which resulted in fewer medical errors and better judgment, improved communication, and better learning (Hill, 2010; Patel, Shine, & Almoosa, 2014; Patterson, 2008).

Several studies suggest that macrocognitive functions are influenced by work environment design. Designs that allow coworkers to see each other in the inpatient or emergency department settings (Fackler et al., 2009; Schubert, Denmark, Crandall, Grome, & Pappas, 2013) enhanced the relationships between novices and experienced team members, improving task prioritization and increasing overall patient care unit expertise (Patterson, Ebright, & Saleem, 2011).

Several studies suggest that macrocognitive functions are influenced by work environment design

Visibility between care teams in ICUs remains a critical factor for reducing mortality rates (Joseph & Rashid, 2007; Leaf, Homel, & Factor, 2010; Lu, Ossmann, Leaf, & Factor, 2014; Rashid, 2014) and improving collaboration (Apple, 2014; Ball & McElligot, 2003). Although researchers disagree on whether designing decentralized nurses’ stations (NSs) improves patient visibility, they concur that by distributing NSs, nursing interactions, and collaboration with other team members are reduced (Pati, Harvey, Redden, Summers, & Pati, 2015; Zborowsky, Bunker-Hellmich, Morelli, & O’Neill, 2010).

Theoretical Framework

mHCBE is a novel framework that encompasses the intersection of cognition and actions in time and space with the goal of improving patient care. The HCBE is defined as a physical space or group of spaces (campus) that incorporate clinical, architectural, and operational science as well as interprofessional teams (also referred to as team members) to provide adaptive, high-quality, culturally appropriate, and cost-efficient patient and family care. This framework has been influenced by the disciplines of nursing (environment of care), human factors engineering (macrocognition theory), and architecture (space syntax theory).

A key concept is “situated macrocognitive interaction (SMI),” which describes an interaction representative of the macrocognitive functions, situated in the built environment. It is influenced by definitions of formal and informal interactions: situated episodes or communications within work places and between colleagues (Wagner, 1994). A formal interaction is a routine or scheduled activity or meeting lasting more than a few minutes often with planned participants and agendas. Informal interactions are unplanned, spontaneous events often occurring due to proximity to another individual in a space or visual prompts (Kraut, Fish, Root, & Chalfonte, 1990).

Method

Design

A focused ethnographic study was conducted within a PICU. Focused ethnography was used to understand one aspect of a culture in a short engagement (Cruz & Higginbottom, 2013; Fetterman, 2010; Hammersley & Atkinson, 2007). This study, congruent with Cruz and Higginbottom's emphasis, is about the problem of macrocognition and the HCBE in a PICU context and with a discrete interprofessional team community. The theoretical framework provided the orientation for the principle investigator’s observations and focus group participants (n = 15 and 21). These participants held a specific knowledge of care of the PICU patient. Approval was obtained from the institutional review board.

Sample

Maximum variation sampling (Creswell, 2007) was used. Members of the clinical, operational, and therapeutic ancillary groups were all included in the observations (Table 1). PICU teams were assigned geographically as depicted in Figure 1: blue team (patient rooms [PRs] 1–21); green team (PRs 22–41), and the red team (ad hoc rooms).

Table 1.

IPT Members and Stakeholder Groups.

Data by Group	IPT Member and Stakeholder Groups
Data by Group	Clinical IPT	Operational IPT	Therapeutic Ancillary IPT
	Bedside RN Physicians	Clinical Nurse Specialist Charge RN Resource RN Discharge Coordinator RN Palliative Care NP Transport Nurse	Social worker Respiratory therapist Occupational therapist Physical therapist Pharmacist Nutritionist Equipment specialist and IV/code team
Number of individual observations	4	5	6
Number of focus groups participants	9	3	9
Worked on previous PICU	6 Yes, 3 no	3 Yes	6 Yes, 3 no

Note. Focus group: Mean years in profession: 12.38 (range 0.9–46); mean years in PICU: 6.33 (range 0.9–31). PICU = pediatric intensive care unit; IPT = interprofessional team; IV = intravenous; NP = nurse practitioner.

Figure 1.

Overall floor plan with patient care rounding configuration. Red team is “ad hoc.”

Setting

The setting was a 40-bed PICU at an academic medical center on the East coast. A pediatric critical care setting was particularly useful for this research because it includes the complexity and criticality in which emergent phenomenon occur on a healthcare unit. This 21,000 sf unit is nearly triple the size of the previous PICU unit (7,500 sf). Patients’ ages range from infant to young adults requiring medical and surgical intensive care.

Procedures

Prior to data collection, two investigators visited the unit to meet the leadership team, compare the unit to the floor plan, and finalize the study design. The floor-plan drawing file was obtained and converted to a file program (Figure 1).

Data Collection

Data collection included observation, focus groups, and collection of architectural data. The study was introduced to interprofessional team members by unit leadership prior to the preliminary visit, then via posters, e-mails, notices, and introductory meetings on the first day of data collection; access to the unit was facilitated by investigators who worked on the unit. Informed consent and voluntary participations were obtained.

Unit observation was conducted over an 11-day consecutive period between 7 a.m. and 5 p.m. The day shift allowed for maximization of interprofessional engagement. Observations took place outside PRs and in support spaces (SSs), including NSs, and circulation spaces (CSs; corridors) as consistent with healthcare architectural planning (Rashid, 2015). Participants were observed individually and within teams during formal and informal interactions. Individual observation (shadowing) of 15 representatives from interprofessional team member groups (Table 1) lasted from 30 min to 4 hr. Nursing station “observation rounds” were conducted to ascertain use and number of team members in the stations. Handwritten field notes were documented on observation and floor-plan worksheets.

Four focus groups with 21 total participants (range two to seven per group; see Table 1) were conducted on the last 2 days of data collection to minimize influence on behavior. The makeup and recruitment of the focus group was in keeping with factors described by Krueger (2014), which highlight the importance of inviting participants in keeping with the purpose of the study (Krueger, 2014, p. 82). A semistructured interview guide was used. During the focus group, each participant annotated a blank floor plan with the location of their interactions with team members and areas that depicted openness, connectivity, and visibility.

Architectural drawing files were collected, and panoramic photographs from NSs were taken to gauge visibility (privacy protected by obscuring monitors/faces and removing patient identifiers). PICU specific artifacts (rounding scripts and informational family welcome packets) were obtained to inform understanding of the unit culture.

Data Analysis

Path distances (in feet) generated a distance matrix between rooms on the unit. These were used to develop isovist views, with a 360° field of vision from NSs into PRs. These were compared to panoramic photos to assess visibility between patients and interprofessional team members.

Focus group audio recordings were transcribed verbatim. NVivo 11 Pro software and Microsoft Excel were used in analysis and coding of focus group and field observation findings. Directed content analysis as described by Hsieh and Shannon (2005) was utilized, as this approach uses predefined categories, which allowed focus on the concepts of formal and informal SMIs and space syntax constructs. The research also remained open to emergent themes.

Saturation was met during analysis of observation notes, focus groups, and artifacts. Iterative analysis was performed in stages. Initially, all observation and focus group responses were organized on a spreadsheet according to types of SMIs and space syntax constructs. In the second stage, each room on the floor plan was added to code data by location, which helped to determine where the SMIs and space syntax constructs occurred. In the third stage, cognitive analysis was performed to compare preexisting codes and emergent themes. The results of this multistage process were then compared to the data from distance matrices, isovist analyses of the floor plan (see Tables 2 and 3), and panoramic photographs. Reflection at each stage allowed for emergence of additional findings.

Table 2.

Distance Matrix Analysis Reported in Feet.

Labels	Team		Distance to
Labels	Team	From	Blue Team Room	Green Team Room	Medication Room A	Medication Room B	Linen/Nutrition 4398 A	Linen/Nutrition 4350	Break Room
Corner	Blue	NS 1	10		82		112		420
Corner	Blue	NS 3	185		118		90		419
Island	Blue	NS 2	100		42		20		385
Island	Blue	NS 4	152		202		62		391

Island	Green	NS 5		198		122		72	300
Island	Green	NS 6		86		10		14	200
Island	Green	NS 7		66		52		64	144
Island	Green	NS 8		12		88		116	108

Note. Shortest distances are in red, blue team services in blue, and green team services in green.

Table 3.

Isovist Analysis.

Location	NS	PR#	Area^a (sf)	View^b	Distance^c	See Bed?^d
Good corner	9B	36	96 sf	4′	31′-9″	No
Good corner	9B	37	289 sf	7′-10″	32′-9″	Yes
Good corner	9B	38	83 sf	2′-2″	41′-5″	No
Good corner	9B	39	233 sf	7′-7″	40′-6″	Yes
Good corner	9B	40	297 sf	7′-8″	39′-1″	Yes
Good corner	9B	41	111 sf	4′-4″	38′-7″	No
Island	8	33	146 sf	6′-10″	32′	No
Island	8	34	272 sf	8′	32′-5″	Yes
Island	8	35	105 sf	5′-4″	33′-2″	No

Note. NS = nursing station; PR# = patient room number.

^aTwo-dimensional area from each nurse station into each room. ^bTwo-dimensional width into each room taken from the centerline of the glazed patient room doors to each side of field of view. ^cFarthest distance from the nurse station into each patient room. ^dCan bed be seen from each nurse station point? Determined by whether the head of bed is visible from each nurse station point.

Trustworthiness

Trustworthiness is comprised of four criteria: credibility, transferability, dependability, and confirmability (Lincoln & Guba, 1985). Credibility criterion was established through saturation, peer debriefing, and triangulation of data from multiple sources of observation, focus groups, and architectural floor-plan data. Transferability was achieved through thick description of SMIs as evidenced by robust quoted texts. Confirmability was achieved by an audit trail for all collected data. For example, daily research notes, reflexive journaling, verbatim audio recordings, and other investigator communications were dated in field notes. Finally, dependability was achieved and assured through the audit trail document reviewed with the investigative team for consistency. Reflexive journaling occurred within each of these criteria and throughout the research.

Results

Findings are based on analyses of data collected from observations, focus groups, and architectural evaluation. To maintain confidentiality, quotations by study participants are identified by interprofessional stakeholder groups: clinical, operational, or therapeutic.

Formal and Informal SMIs

Formal SMIs (n = 21) were observed throughout the unit including patient care rounds, huddles, and meetings in both enclosed and open spaces (Table 4). While there was some variation between teams in rounding process, all the rounds followed a pattern of a sequential reporting system using a rounding script. As described by an attending physician, the process for rounds included

Table 4.

Situated Macrocognitive Interactions (SMIs): Formal.

Name (Number of Observations)	Purpose	Role	Location	Representative Quotes and Observations
Patient care rounds (7)	Review patient demographics, key events (past and planned)	Physicians (attending, fellows, residents, and students), nurse practitioners, bedside nurses, charge/resource/discharge care coordinator nurses, social workers, pharmacists, respiratory therapists, observers, and research fellows (palliative care nurse and living legacy team as needed)	Patient rooms (outside)	Prerounds occurred (replanning) by various team members gathering hard copies of notes. During rounds decisions were made, problems discussed, and plans coordinated (such as involving additional consulting teams, intraunit transfers, and discharges). Clinical IPT: “This is an ‘informational storm.’”
Whiteboard huddle (2)	Available beds, pre- and postoperative patients, and admissions and discharges were discussed	Nurse shift coordinator, charge nurses for each team, attending, and anesthesia attending	Manual whiteboard in NS 5A (open)	This area on the unit became a central place and a hub for centrally locating personnel and for real-time information gathering. Operational IPT: “I guess one of the big things is our whiteboard outside of the nurses’ station outside of 22/23, it has all the operating room admissions for the day, any transports that are going to happen throughout the day, MRI, CT, and such and…children who are transferring out of PICU to other floors so we would have a conversation there about that information.”
Huddle (8)	Daily morning shift report from night shift	Blue, green, red teams physicians (attendings, fellows, residents, anesthesia, students, charge nurses, SWs, RTs, and pharmacists)	Large conference room 4392 (enclosed)	Each fellow gives a 2–5-min report with highlights of each patient. Clinical IPT: “So I find that places I meet most frequently with all team members would be our huddle in the morning, which is a formal thing, and we huddle in the big conference room”
Goals of care meeting (1)	Review patients with complex issues	Patient coordinator, nurse practitioner, family life center provider, chaplain, palliative care nurse, occupational therapist, attending charge nurse, two chaplains, and palliative care nurse	Small conference room 4411B (enclosed)	Discussion of patient’s family meeting with translator. Clinical IPT: “We need to get stakeholders together: oncology, rheumatology, and infectious disease (ID). We need to come as a united front to parents.”
Radiology rounds (1)	Review morning X-rays	Radiology attending, PICU attending, fellow, resident, nurse practitioner, and hospitalist	Small conference room 4411B (enclosed)	Radiology attending shows findings to team. Clinical IPT moves closer to the computer screen to see the X-ray. Discussion between clinical IPTs regarding any skin lesions.
Family meeting setup (1)	Discuss with family end of life issues	Attending, senior fellow, palliative care nurse, oncology social worker, and family	Conference room 4480A (enclosed)	Operational IPT: “I usually let attending run it. Some attendings carry burden of decision-making, I can interject and guide toward a common goal. Some like to prehuddle. We kind of did that earlier.”
Patient safety meeting (1)	Review latest issues concerning PICU	Outside consultants from patient safety institute resource nurse, nursing leadership, therapeutic ancillary leadership, red team attending, social worker, nurse practitioners, unit leadership, and anesthesia attending	Large conference room 4392 (enclosed)	Meeting agenda: Electronic health record planning My research and observation on unit Weekend discharges Respiratory therapy definitions

Note. PICU = pediatric intensive care unit; NS = nurses’ stations; SW = Social Worker; RT = Respiratory Therapist; IPT = interprofessional team member.

Prerounding. I come up with a game plan, then examine with nurse and on computer, look at labs. I have an ear listening…. The resident, NP, and medical students are trainees working and learning. One, resident presents; two, fellow critiques game plan. Then go through and, three, attending critiques, asking the question, “What do we think we should do?”

The rounding teams, composed of 4–20 individuals, met for 30–180 min, and occupied from 6 to 180 sf. The unit layout influenced configurations in which the number of staff and their equipment flexibly conformed to the shape of the existing space. The rounding configurations were square, rectangular, and semicircular depending on layout, location, and adjacencies to PR being visited (Figures 1 and 2). These configurations sometimes obstructed corridors for other staff and patient’s family members, appearing to impede hearing and engagement, as exemplified by interprofessional team members moving in closer to the speaker and asking for communications to be repeated.

Figure 2.

Rounding configurations.

Informal SMIs were triggered by visual cueing (bumping into), auditory cueing (overhearing), and spontaneous searches (Table 5). The category of spontaneous searches was a finding that emerged from the data analysis.

Table 5.

Situated Macrocognitive Interactions (SMIs): Informal.

Informal SMIs	Location	Data (Observation and Focus Group)
Cueing
Visual cueing	PR 17 (between IPT and family member)	Observed therapeutic IPT in room for procedure and asked why. She said “I try to see all the higher risk patients and this one is on the list. I happened to walk by and saw her [crying].”
Visual cueing	Team rooms	Clinical IPT: “Sometimes, if I’m sitting by a team room or if I just see them in passing, I will just mention it to them, I’ll tell them this is x, y and z, this is what I’m seeing and this is what I suggest to change the plan, something along those lines, that’s what I would do.”
Auditory cueing	PR 23	Observed therapeutic IPT member and clinical IPT member at NS trying to overhear (listen in) conversation occurring with clinicians and patient and family in Room 23.
Auditory cueing	Circulation space (corridor)	Therapeutic IPT: “I would say that I’m very appreciative of all the open conversation that I hear because while I might be walking down the hall to do one thing I hear something else that makes me alert my pharmacy team about something that might be happening and/or it’s an opportunity for me to educate somebody if I hear something miscommunicated or if I know what the plan is and they’re asking – hey do you know what is going on with this, that, the other and not that I’m trying to be nosy and butt in but it’s an opportunity to share information that I might have access to already.”
Spontaneous Search
Urgent	PR 38	Observed clinical IPT see a nurse returning to patient Room 38. She says, “Are you okay?” She then runs into room and stays. Dad and mom in room. When she comes out, says, “[A] lot easier when in this corner. Three of us sitting….”
Urgent	Technology (unit phones, code, and staff call systems)	Clinical IPT: “If it’s something really acute, and they need intervention now, I would call the fellow on the electronic unit phone and say I need you to come [to] my bedside and they would come over.”
Nonurgent	PR 39	Observed nurse in Room 39 in isolation. She poked her head out and asked for help of the nurse at NS9B.
Nonurgent	Anywhere on the unit	Clinical IPT: “This is going to sound crazy but I will walk around the unit and sometimes try to find them because sometimes I feel like the physicians are busy and if it’s not an urgent thing, I don’t feel like I need to interrupt them if they are busy doing it. I can just kind of see what they are doing, like hey, by the way, this so and so and so and so and so and then tell them that and then sometimes, I will do the same thing with my charge nurse because my poor charge nurse their phone is constantly ringing, if not from nurses from like outside units.”

SMIs prompted by a visual cue (Table 5) were observed (n = 27) and described by focus group participants (n = 50). These SMIs were observed more often at a PR doorway when an interprofessional team member stood waiting for another team member to walk by, than in the corridor where they bumped into each other, or the NSs. Macrocognitive activities observed during visual cueing episodes focused on the exchange of information regarding a patient. For example, one interaction resulted in the updating of a care plan, when two clinical teams ran into each other as one exited a PR. In another example, the attending physician ran into an interprofessional colleague, and they discussed their patients’ symptoms and planning activities.

SMIs prompted by auditory cueing interactions (Table 5) were observed less often (n = 3) and described during the focus group responses (n = 18). These interactions occurred in corridors and in the NSs nearest to the team rooms. Nurses were observed to push their desk chairs closer to the open doorway of the team rooms to better hear the conversations occurring, so that they could join in when they thought appropriate. Other informal SMIs prompted by auditory cueing occurred in the NSs. At times, one conversation between interprofessional team members would occur while others, not initially included, would listen in and contribute new information or use the dialogue to inform their care plan.

SMIs prompted by spontaneous searches also emerged from observation of team members (Table 5). Nonurgent searches often occurred when one team member needed advice or assistance from another interprofessional team on something. Participants also described searching for interprofessional team members in the corridors when they needed to discuss a patient condition. This action was referred to by some interprofessional team members as “poking head in or out” (n = 21) as observed or explained by focus group participants. Urgent searches (n = 4) for team members were observed during a code blue or critical event by witnessing others actively running to or assisting a team member or by utilizing electronic notification systems. Both urgent and nonurgent searches were observed in the corridors and within NSs.

Challenges and Facilitators of Macrocognition Using Space Syntax Constructs

Observation and focus group data were used in analysis to interpret the relationship of three space syntax constructs to macrocognition and how space challenged or facilitated team interactions (Table 6).

Table 6.

Space Syntax Constructs Within Informal Situated Macrocognitive Interactions.

Space Syntax Constructs	Data (Observation and Focus Group)
Space Syntax Constructs	Challenges	Location	Facilitators	Location
Openness	Clinical IPT: “I do wish that some of these rooms were sort of opened in terms of the, you know, maybe one wall was out of a couple of rooms and then you still have that openness and where everybody was there…. I feel like we round now and then everyone sort of goes their separate ways and respiratory goes to their own little space and nursing goes back into their rooms and the fellows and the residents go into their team rooms and social work goes into their rooms and pharmacy goes into their room.”	Single patient rooms	Observed transport nurse interacting with people at nurses’ stations (NSs) from her designated area. When asked about interacting in this type of space she replied, “I sit in…easier to interact in transport space with my own team. I like ‘open’ [points to NS].”	Transport alcove and NS 1E and 1F
Connectivity	Operational IPT: “If you are in one of the sicker or one of the larger rooms with a sicker patient and you need help with something, well your two neighbors are also the sickest patients so where do get someone to double check a med or help you move your patient or because nobody often in the immediate area can help you do that.”	Near IPT assigned patient room	Observed the living legacy team in the room and asked them about using this room. “We are part of family services—first time I’ve been in this. We are guests…we are all over the place. This is perfect [referring to proximity to the current patient], but if on the other side of the unit, it’s not perfect.”	Red team room
Visibility	Observed two RNs discussing patient: “What is going on in there?” One RN adjusts the blinds from outside patient room to peek into room.	NS alcove	Clinical IPT: “I would say, like, if they are walking by the room and they are by themselves I would be more likely to stop them and ask them a question than if they are on rounds and they have periods of time too when they are in the team rooms with the door closed because they’re giving sign out and then we are not supposed to be interacting.”	NS 1 B-C

Openness

Openness (lack of boundaries or partitions) supporting connections with other interprofessional team members helped facilitate macrocognition. Openness was observed and described by focus group participants as occurring primarily in corridors, then in front of teams’ rooms, and finally NSs. As a therapeutic interprofessional team member said,

I like to use…green and blue [team] rooms…the providers sit…typically…when everybody is done rounding so during the morning, I will find most of my communication happens in the hallways, outside patients’ rooms.

However, the open design of spaces on the unit could present a challenge for macrocognitive encounters requiring privacy. Interprofessional team members described using closed doors to modify existing space for privacy needs. There was an unspoken rule about entering a closed space (crossing the threshold) whether a patient, team, or conference room. Many nurses described crossing uninvited into spaces as micromanaging or being nosy. A closed door communicated privacy was needed and often signified that something “sad” or “bad” was occurring. A therapeutic interprofessional team noted,

You guys normally shut the door…for the family to have their own space because everything is so open here that to have your own space is valuable…so shutting the door allows them to have that space.

Connectivity

Connectivity (adjacency to other spaces) was observed in spaces between interprofessional team members and between the interprofessional team members and their patients. A bedside nurse shared:

When…assignment [is]…near a team room or a place where a lot of people congregate—you can just roll your chair over…[and] go, “Hey what do you think about this,” and engage in some conversation that way, versus me thinking do I need to call for this or not .

Connectivity with other team members was a challenge when interprofessional team members did not have a designated space on the unit, or they shared a space with members of their same professional team. Further, the PICU layout of single PRs appeared to impact nurse to patient ratios and sometimes intraunit transfers.

Some rooms had a column or a gap between them or a door or corner that made it hard to go between these two rooms or contributed to their assignment bridging two NSs. The location appeared to influence whether a nurse was assigned one or two patients.

Visibility

The layout of the unit influenced visibility (line of sight) of interprofessional team members and patients. Team members used “corners and islands” to describe the best nursing assignments by marking up a floor plan and providing a walking tour to these areas. They further classified corners as “great, lovely, or good.” Some NSs were classified by interprofessional team members as islands. When discussing with one clinical team member the comparison between an island NS on this PICU to previous employment in another PICU facility, she replied,

I didn’t get stuck on these islands. Had alcove, so always had someone. I feel all alone. If anything happened…” She noted that when she needs help, she “yell[s] out loud to nurses in neighborhood, [and] wait[s] for someone to pass by.

The isovist analysis of the entire unit corroborated interprofessional team members’ descriptions of preferred work locations (corners) as exemplified with NS 9B versus an island such as NS 8 (Table 3; Figure 3). In NS 9B, the PRs with a view from the NS had a greater visual field area between 233 and 289 sf, while the rooms without a view had a range of 83–111 sf. When examining the view, rooms with a larger visual field had the ability to view the head of the bed. This visibility aids in both seeing the patient and the interprofessional team member at the bedside.

Figure 3.

Panoramic and isovist views from nurses’ stations (NS) 8 (island) and NS 9 B, C (good corner).

In one nursing station with an island configuration (NS 8), the room that has a view of patient’s bed has the larger area of vision (272 sf). Of note is that the distances between the NS and the door of the PR are nearly equal (the width of the corridor). The difference between the corner and the island configuration is the visual field between this station and other NSs, which does not correlate with the distance. In NS 9, other NSs (9B and 9C) are visible, but in NS 8, no other NSs are visible.

On a smaller scale, challenges to visibility were observed when the doors to PRs were closed and the window shades drawn. Bedside nurses could not see people going by and other interprofessional team members could not see into the room. Interprofessional team members were observed poking their head in or out of the PRs looking for help, which was described to be done at the risk of micromanaging. A therapeutic interprofessional team member was observed to poke her head out of a room and say to the nurse, “I heard that. Sorry I’m nosy.”

When challenges to visibility occur, interprofessional team members actively searched for other interprofessional team members. As described by a therapeutic interprofessional team, “If I have a question, say about transport, and I’m not busy, I will walk over and see if someone is in the transport alcove [behind NS 1E on Figure 1] and just ask them.”

When describing the smaller size of the old unit, many interprofessional team members’ referred to ‘eyes on the patient’: “There were lots of people to watch that child…so that they didn’t wake up and maybe pull out their ET tube.”

Influence of the HCBE Space Syntax Constructs on Macrocognition

As noted, the intersecting relationship between macrocognition and the space syntax constructs was evident throughout the study and can be summarized in an overarching theme called the “neighborhood.” This theme emerged through deeper analysis and interpretation of the data, particularly the way that team members described the spatial functioning of the unit. Within this larger theme of neighborhood, three subthemes emerged: “corners and islands,” “neighbors and buddies,” and “eyes on the patient.”

Thematic analysis: The neighborhood

The term neighborhood first appeared when the notice for “neighborhood huddle” was sent through the electronic phone system. Further clarification of the term was explained by the team members as “little areas” or “places to get answers.” An operational team member described neighborhood as originally used to help with the transition from a prior PICU, where all PRs and services were visible and staff interacted informally, to one that was linear and separated by individual PRs, and nearly 3 times the size. The idea was to create groups of adjacent spaces to make a neighborhood.

Corners and islands

The interprofessional team members used the term “corner” as a way of pointing to an actual place on the floor plan or showing these areas within the physical layout. They categorized (and annotated on a blank floor plan) these corners as “great” (NS 9); “good, lovely, and big” (NS 1B-D); or simply as “a smaller scaled corner” (NS 3A, B, C; Figure 1). As described by an operational interprofessional team member:

I think a lot of the straighter ways where…kind of in between nurses’ stations and not necessarily around a team room, because the corners, since there’s enough patients on both sides at one nurses’ station, they tend to have more people, the corners are pretty good.

The three corners on the unit are connected by corridors (streets) also help configure the islands. Islands are NSs that participants described as having poor visibility into PRs or were isolated architecturally from other NSs. This is exemplified by NS 6, named and referred to by study participants as “respiratory therapy island.” The respiratory therapists explained that this name started because they had no other space of their own (their office and mailboxes are in another building), and they claimed NS 6 as their own. The nurses added it was so named because it was directly across from the rooms which the sickest patients are assigned (PR 25, 26, 27, and 28) requiring 24-hr vigilance by nurses and respiratory therapists.

Other examples of island neighborhoods include NS 2, 4, 7, and 8. Although NS 8 is adjacent to a team room, it is considered an island when no other nurse buddies are available, such as if an assignment pairing of PR 31 and 32 occurs with rooms facing both NS 7 and 8. Nurses describe walking to other neighborhoods from these island locations not only for help but simply to see others.

Neighbors and buddies

The PICU HCBE appeared to facilitate the formation of clinically and socially supportive relationships, which the nurse study participants referred to as neighbors or “buddies.” Buddies are nurses with near or adjacent patient assignments, who are visible to each other, and on the same team. These buddies were identified as team mates for neighborhood patient care. To facilitate this relationship, they created a “neighborhood report” or “mini-huddle” following formal changeover report to understand their adjacent team member’s assignment. This huddle was performed to provide coverage and to increase the safety of their collective patient care activities by understanding their neighborhood’s events. As explained by a clinical interprofessional team member in a focus group, “sometimes, they’re just there for an extra pair of hands like when you get an admission, your buddy, your nurse next to you, always comes and helps you settle the kid.”

Eyes on the patients

The theme of “eyes on the patient” emerged from analysis of observations and focus group data. A clinical interprofessional team member described the difficulty of having eyes on the patient due to island configurations: “Very, very unideal such as we have a couple of rooms that are sort of on an island or in between NSs, where it is hard to have eyes on the patient because it looks out onto a hallway.”

Summary of Key Findings

Well-designed neighborhoods of the PICU are those in which all three of the space syntax constructs (openness, connectivity, and visibility) are present, facilitating both formal and informal SMIs. If the neighborhood limits or inhibits macrocognitive processing or lacks the space syntax components, it is considered an island.

Well-designed neighborhoods of the PICU are those in which all three of the space syntax constructs (openness, connectivity, and visibility) are present, facilitating both formal and informal SMIs

Discussion

Neighborhoods are a place that includes the key functions of a group of residents. The importance of having “streets” or corridors that allow for interprofessional team member interactions and visibility is reminiscent of Jacobs’s (1961) view of neighborhoods:

A city street…as the streets of successful city neighborhoods always do, must have…: a clear demarcation between public and private space; eyes upon the street, eyes belonging to those we might call the natural proprietors of the street. The building on a street…must be oriented to the street. They cannot turn their backs or blank sides on and leave it blind. (p. 35)

It has traditionally been thought that the shortest distance between key spaces on the unit improved the efficiency and safety of care delivery (Thompson et al., 2012). However, the current study suggests that visibility of essential elements, such as the head of the patient’s bed, reduces the need to walk to the room, while increasing the opportunity to safely leave the patient’s room. This is explained through deeper analysis of this PICU’s distance matrices from the NSs (origin) to team rooms, medication rooms, linen/nutritional supplies, and the break room (Table 2). These results demonstrated that distances between the SSs were not indicative of the corner or island configuration. Some of the shortest distances were in the island configuration; the longest distances were in the corners. Interprofessional team members’ preferred caregiving locations were not associated with locations having shortest distance measures, but rather the improved connectivity and visibility found in “good corners.”

Interprofessional team members’ preferred caregiving locations were not associated with locations having shortest distance measures, but rather the improved connectivity and visibility found in “good corners.”

In this PICU, visibility (line of sight) is a major factor for design. The findings suggest that visibility is determined more by field of vision than distance. Findings are consistent with studies linking visibility with patient safety and quality care outcomes (Apple, 2014; Ball & McElligot, 2003). Findings also support the analysis of reduced team collaboration by Zborowsky et al.(2010) and add to the literature with isovist (field view) analysis demonstrating decreased field of vision between NSs. The only two alcove-style NSs in the hallway outside of PRs 25/26 and 27/27 (highlighted in red on Figure 1) help to mitigate the island configurations with increased visibility to these rooms and were a well-populated interprofessional team member location for sharing information.

These findings highlight the interrelated nature of the space syntax constructs and that modification of openness, while sometimes desirable for privacy, has an impact on visibility. Additionally, participants’ responses suggest visibility may enhance clinical and operational interprofessional team member development.

Macrocognitive Adaptation to Challenges

Interprofessional team members sometimes adapted or repurposed the space to meet their needs. When openness created a limitation, the interprofessional team member sought out any enclosed space, even an empty PR or medication room for privacy.

Implications for Practice

The implications for practice, based on this research, are centered on creating neighborhoods comprised of PRs, SSs, CSs, and teams. This supports improving the process of patient rounding to one that is neighborhood-based instead of geographically based. Long-term changes which support creating neighborhood’ configurations include reconfiguring NSs to team stations improving visibility within and between stations as well as standardizing PR sizes.

Recommendations for Healthcare Design and SMIs

The findings of this study suggest that macrocognition is enhanced by certain features of the HCBE that facilitate successful neighborhoods, particularly the dimensions of a “good corner” depicted in observation, participant responses, and isovist views. These features include NSs with visibility within and between other NSs or nurse alcoves and short and straight corridors without columns or walls blocking views (or design layout to increase number of corners and maximize views). Recommendations based on this study include designing and testing new or reconfigured HCBE spaces that maximize these features. Additionally, cost-effective adaptations of interprofessional team practice may also be developed for existing designs. For example, to reduce the number of persons in the corridor during patient care rounding, virtual interactions could be implemented from team rooms. Other uses of islands could be explored, such as multidisciplinary seating/monitoring to facilitate SMIs.

Architectural and computer simulation modeling methods and analyses could be used together to find the right balance between space syntax constructs, clinical care, and interprofessional team member SMIs (Cai & Zimring, 2012; O’Hara, 2014; Shaikh, 2015). The intersection of these fields is in its early stages; however, this could be a beneficial topic for interprofessional practice and education. Future studies could explore the SMIs in other settings as well as provide quantification of the situated SMI occurrences and examine the link between SMIs and patient outcomes.

Limitations and Strengths

The study was performed in one pediatric ICU over a period of 11 days (on day shift) which limits the generalizability of the findings to other shifts or ICUs. However, the use of thick description, as advocated by Lincoln and Guba (1985), was utilized to enhance transferability of findings. We recommend validating our recommendations with members of night shift and the particular hospital staff before implementing.

Strengths of the study include the data triangulation between ethnographic and architectural data components; an interdisciplinary approach to understand the intersection of nursing, human factors engineering, and architecture; and a deeper understanding between the intended use of space and the adaptation and meaning of space.

Conclusion

Results from this study support the intricate link between macrocognitive interactions and space syntax constructs within the HCBE. These findings help increase understanding of how to use the framework of mHCBE to improve design of new spaces or refine existing spaces or adapt interprofessional team practices to maximize formal and informal SMI opportunities. The findings lay the foundation to replicate this research to develop the mHCBE framework into a theory for future research to improve safety and quality for patient and family care and interprofessional teams.

Implications for Practice

Improve preplanning for space design to include all interprofessional team members, identifying corners, and potential islands.

Support likely places where informal interactions among interprofessional team members (clinical, therapeutic, and operational) will occur, including in corridors, in front of PRs and near team rooms.

Improve patient rounds by having colocated rooms with dedicated interprofessional team members.

Use smaller neighborhoods to allow “eyes” on the patients and each other for better team work and detection of subtle changes in patients’ condition to improve patient care.

Footnotes

Acknowledgments

The authors would like to acknowledge Steven Langston, AIA, ACHA, EDAC, LEED BD+C, design director, Rogers, Lovelock, and Fritz, Inc., Orlando, FL; Judy Nordberg, education and clinical services librarian, University of Massachusetts Medical Center, Worcester, MA; Stuart Roberston, Ed.D. Robertson Educational Resources, NVivo specialist; Joshua F. Kilbridge, President Creative Director, Kilbridge Associates, for editorial assistance; and to all the Interprofessional Team Members working in this PICU.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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