Effects of Emergency Department Physical Design Elements on Security,Wayfinding,Visibility,Privacy,and Efficiency and Its Implications on Staff Satisfaction and Performance

Abstract

Objective:

The purpose of this study was to identify the role of emergency department (ED) design on ED staff satisfaction and performance.

Background:

High patient volume, surging workloads, and violent behaviors are expected pressures for ED staff. Literature suggests the substantial role of the physical environment in the delivery of care and its role in staff and patient experiences. Nevertheless, limited studies have explored simultaneous interactions between ED physical design elements, attributes (security, wayfinding, visibility, privacy, and efficiency), and staff satisfaction or performance.

Method:

Interviews, surveys, visibility graph analysis, and agent simulations were employed to understand the connection between ED physical design, attributes, performance, and staff satisfaction.

Results:

Enhanced security, effective wayfinding, team visibility, noise reduction, adequate privacy, and accessible supplies and equipment were significant predictors of staff satisfaction and performance. Unobstructed views in waiting and triage and controlled entrances were critical for improving security. To improve wayfinding, eye-level signage, reducing surveillance obstacles, and creating direct public routes were recommended. Rectangular units with multiple perpendicularly connected corridors and linear pod arrangements enhanced movement. Including team rooms and enclosed ERs were recommended for privacy improvements. Visibility was critical for team communication and improved by including short-distanced perpendicular corridors and eliminating columns. Enhancing access to supplies or equipment and reducing noise levels improved the perception of staff efficiency.

Conclusion:

The findings contribute to the general body of knowledge on the impact of ED physical design on attributes that potentially improve staff satisfaction and work performance.

Keywords

emergency department visibility efficiency staff performance staff satisfaction security wayfinding privacy healthcare design research space syntax agent analysis

The stressful and challenging work environment in emergency departments (EDs) is well recognized. The delivery of care is impacted by the construction of the surrounding environment. Despite the fundamental role of environmental qualities affecting staff satisfaction and performances, more recognition is needed for the pivotal role of the physical environment in EDs. Among the necessary suggested ED qualities, this article focuses on the following subtopics: (a) security, (b) wayfinding, (c) visibility, (d) privacy, and (e) efficiency.

Violence and aggressive behavior in the ED is prevalent and is linked to compromising staff job performance, productivity, depression, attention, and morale (Gates et al., 2011; Pati, Pati, & Harvey, 2016; Pich, Hazelton, Sundin, & Kable, 2010). Additionally, enhancing the feeling of safety in EDs leads to job satisfaction and less turnover (Gates et al., 2011). Many studies propose process and management interventions for enhancing security issues in EDs (Pich et al., 2010). Nevertheless, there has been little attention given to the role of the ED physical environment in security outcomes.

Studies have found that wayfinding in healthcare environments impacts nurses’ behaviors, comfort, stress, and performances (Mustikawati, Yatmo, & Atmodiwirjo, 2017; Pati, Harvey, Willis, & Pati, 2015). Yet, wayfinding studies that focus on ED layout configuration and spatial cues are rarely conducted. This comprehension is critical and current as hospital-based EDs are tackling wayfinding challenges for their complex appearance and growing connections to other departments.

Visibility is another substantial quality for the ED delivery of care. Higher visibility enhances staff awareness of patient conditions and prevents unsafe behaviors (Pati, Harvey, & Pati, 2014; Pati et al., 2016). Additionally, visibility impacts the quality of teamwork between clinical staff by supporting routine face-to-face communication (Gharaveis, Hamilton, Pati, & Shepley, 2017; Pati et al., 2014). Nevertheless, there is a lack of comprehensive understanding of the impacts of design consideration and improvement on visual connections in EDs and its relationship with staff performance and satisfaction.

Privacy in healthcare environments is an ethical concern and critical for patients’ physical and mental well-being (Lin et al., 2013; Pines & McCarthy, 2011). The ED department is unique as patients are usually in overcrowded conditions that infringements privacy and confidentiality (Calleja & Forrest, 2011; Lin et al., 2013; Pines & McCarthy, 2011). More research is needed to evaluate how the spatial layout and attribute of EDs can protect patient privacy and whether safeguarding patient or team privacy improves for staff performance or satisfaction.

The scarce body of literature focusing on the impact of physical design on efficiency outcomes suggests that exam room (ER) standardization, providing adequate space, and noise levels bear implications on efficiency outcomes (Adkins, Foran, Gill, Delatore, & Moseley, 2017; Fay, Carll White, & Real, 2018; Pati et al., 2014). Further, effective teamwork, visibility, and accessibility that are affected by the built environment bear positive implications for efficiency outcomes (Fay et al., 2018; Gharaveis et al., 2017; Pati et al., 2014). Whereas the limited previous research in the context of ED settings has separately explored security, wayfinding, visibility, privacy, and efficiency qualities, more research is needed on how these qualities interact with each other to support staff performance and satisfaction. Implications of this knowledge on ED buildings can contribute to a more pleasant and supportive workplace for ED staff.

Objective

The aim of this study was to study the relationship between ED spatial attributes linked to physical environment properties and its effects on staff satisfaction and performances. The research explored the following questions: (a) how does the ED physical quality facilitate or impede perceptions of security, wayfinding, visibility, privacy, and efficiency and (b) what is the nature of the relationship between perceptions of ED security, wayfinding, visibility, privacy, and efficiency on staff performance or satisfaction. By exploring the interaction of physical design elements and different parameters on staff performance and satisfaction, this study focuses on refining solutions from a physical design standpoint.

Method

Structured interviews and surveys of frontline staff were collected from two EDs, one featured centralized nursing units (Figure 1) and the other incorporated decentralized nursing units (Figure 2).

Figure 1.

Site 1 with centralized nursing units. As the image displays, medication rooms, physician station, nursing station, hospitalist work room, and tubing systems are positioned adjacent to each other in each pod. Source: Author.

Figure 2.

Site 2 with decentralized nursing units. The image displays the dispersed locations of clinical staff work areas (nursing stations, medication rooms, dictation areas, etc.). Image authorship: Author.

Departmental e-mail notifications were sent to recruit staff for interviews and surveys. Structured interviews explored significant barriers and bottlenecks, ways to improve, and necessary modifications from physicians, shift managers, and nurses (n = 8). Interviews were recorded, transcribed, and clustered into themes. To ensure the validity of themes, peer debriefing and external reviews were applied.

The surveys were designed to collect data on perceptions of spaces, delivery of care, services and operations, bottlenecks, visibility, communication and collaboration, satisfaction, and recommended improvements. Survey questions included items scored on a 5-point rating scale and were collected from 67 staff in both sites. Simple linear regression was used to determine the magnitude of the relationship between physical, staff performance, or satisfaction. Further, stepwise regression models were generated for understanding significant predictors of ease of access to equipment and supplies.

For analytical evaluation of spatial layouts, the study employed the Depthmap software to perform visibility graph analysis (VGA) and agent-based simulation (Turner & Penn, 2002). Global Integration illustrates how visually connected all paces are in the footprint and identifies barriers to the visual field (Turner, 2004). The agent-based simulation yields gate count values that represent the number of pedestrian flow per time unit in the environment (Al_Sayed & Turner, 2012). Tests of normality on the agent analysis data set indicated significant deviation from a normal distribution (p = .21, df = 45,928, p < .001). Therefore, nonparametric Mann–Whitney tests were employed to evaluate significant difference between gate count mean values in both sites. The data were analyzed using the SPSS software (Version 24.0).

Findings

To guide future architectural decisions, this study combined multiple methods that address spatial characteristics in EDs that impact staff satisfaction and work performance. The following section describes responses and spatial analytic outcomes concerning: security, wayfinding, visibility, privacy, and efficiency.

Security

Table 1 illustrates survey responses. The analysis indicated that security and safety upon arrival and when entering were an issue of consideration to respondents (M = 2.7, n = 64, SD = 1.05). Adequate visibility accounted for a 7% variance in the perception of safety, F(1, 61) = 4.65, p = .035, and 15.6% of variability in staff satisfaction, F(1, 60) = 11.11, p = .001. Additionally, the perception of safety explained 34% of variability in work satisfaction responses, F(1, 61) = 18.53, p < .001.

Table 1.

Descriptive Statistics on Staff Satisfaction Levels.

Themes	Measure	N	M	SD
Operational outcomes	Bottlenecks	54	2.19	1.12
	Door-to-admission times	54	4.02	1.97
	Door-to-discharge times	53	4.40	1.70
	Access to equipment	55	3.29	1.23
	Access to supplies	54	3.41	1.19
Security	Feeling safe and secure	64	2.70	1.05
Noise	Noise levels	63	2.76	0.89
	Interruption or distraction levels	63	2.70	0.98
	Ease of private interactions with team	64	3.31	1.18
	Private interactions with patients	64	3.66	1.28
Wayfinding	Wayfinding for patients	36	3.78	2.13
Physical environment change	Parking for patients	47	3.06	2.30
	Waiting area for patients	53	2.58	1.89
	Check-in area for patients	52	3.10	2.17
	Teamwork area	54	3.30	2.10
	Pod	50	3.14	1.87
Coordination and communication	Coordination with team members	64	2.84	0.76
	Finding team members	64	3.41	1.03
	Communicating with team members within pods	64	3.64	1.28
	Communicating with team members across pods	63	3.14	1.33
Visibility	Visibly of patients	63	3.60	1.20
	Visibly of team	61	3.69	0.99
	Visibility	64	3.66	0.93

Note. SD = standard deviation.

Ineffective wayfinding systems around the ED entrances and exit routes raised safety concerns. Staff believed multiple entrances, blind spots, and visitors walking behind the registration desk intruded security. For instance, one nurse indicated, “I wish we had better security as far as getting in and out of the triage doors. It is easy for someone to just enter and walk through our department.” Another respondent mentioned, “Outsiders have too much access to the ED and this is a safety concern.”

ED staff recommended micromodifications such as establishing mirrors, metal detectors, or bulletproof glassed nursing station areas as a means of enhancing security implications. For example, a respondent reflected on the need for protective barriers, “There is no protection for the staff up front if caught off guard. We may need a bulletproof glass or a more closed-in area, along with all nursing stations.” ED staff believed that providing separated waiting and triage areas for behavioral health (BH) patient promotes security. For example, a participant noted:

Homeless and psychiatric patients have nowhere to go. They sit and wait until we can get a social worker down to talk to them. If we had a separate room, like a sub-waiting room with some privacy, their needs could be better addressed.

Wayfinding

The agent analysis investigated how the ED spatial arrangement affected agent movements. Corridors with more obstacles and indirect connections produced more diversity of sightlines, as seen in Site 1 (Figure 3). Additionally, movement patterns in the waiting area were obstructed by columns or walls. Conversely, in Site 2, the rectangular unit shape with linear pod alignments and perpendicularly connected corridors enhanced movement and visibility (Figure 4). However, the T-shaped unit inhibited movement patterns from Pod 1 to other pods. In both sites, there were inadequate density of agent traces in many areas, such as the corridors linking the triage to exam rooms or the waiting areas, impacting wayfinding experiences. Average gate count values were higher in Site 2 than Site 1, M = 19.28, SD = 27.56, M = 18.64, SD = 22.58, respectively, and this difference was significant, U = 254,024,837, z = −6.53, p < 0.001.

Figure 3.

Site 1 agent analysis map. Unbalanced movement patterns due to irregular arrangement of corridors. Image authorship: Author.

Figure 4.

Site 2 agent analysis map. The rectangular unit shape with linear pod alignments and perpendicularly connected corridors enhanced movement and visibility. Image authorship: Author.

Exploring the survey responses, wayfinding improvement was cited as significant in reducing the occurrences of bottlenecks, and thus staff performance F(1, 31) = 5.44, p = .026. However, it was not a significant predictor of staff satisfaction. Confusing and indirect hospital circulation zones between public parking, the ED entrance, and hospital corridors elicited wayfinding issues for visitors. This situation imposed ED staff to personally guide patients to other departments, reducing operational outcomes. Including visual cues and landmarks, such as “colored arrows” to destinations, was recommended.

Visibility

The VGA maps illustrate poor visibility (higher density of blue) around the waiting room areas in both sites (Figures 5 and 6). As illustrated in the figures, columns impeded visibility, especially in the registration, waiting, and pod areas. In the central nursing units, support spaces restricted visibility toward patient rooms (site 1). Intersecting corridors at short intervals resulted in higher visibility saturations (red colors) around hallways and nursing stations in site 2 versus site 1.

Figure 5.

Site 1 visual graphic analysis map. Columns impeded visibility, especially in the registration, waiting, and pod areas. Image authorship: Author.

Figure 6.

Site 2 visual graphic analysis map intersecting corridors at short intervals resulted in higher visibility saturations (red colors) around hallways and nursing stations. Image authorship: Author.

Sufficient surveillance toward patients and having face-to-face communication with colleagues accounted for 15.6% of variability in staff satisfaction, F(1, 61) = 11.11, p = .001. Adequate visibility significantly predicted satisfaction with finding team members, F(1, 62) = 70.12, p < .001; communicating with team members within pods, F(1, 62) = 38.5, p < .001; communicating with team members across pods, F(1, 61) = 36.8, p < .001; and enhancing overall coordination with team members, F(1, 61) = 28.6, p < .001. Sufficient team visibility explained 16.3% of variability in staff satisfaction, F(1, 58) = 11.3, p = .001. Patient visibility accounted for 7.5% of variability in explaining the staff satisfaction outcome, F(1, 59) = 4.8, p = .033.

ED staff believed that decentralized pods increased proximity and access to patient rooms, allowing for more efficient and effective monitoring of patients. However, the enhanced patient proximity was countered by reduced team visibility and social isolation in decentralized pods. For instance, one nurse reported, “the pod setup makes it difficult for providers to communicate with each other and the focus on patients is lost.” The ED manager indicated, “There is no visual connection between pods. So, communication depends on the nurses. The lack of visibility is problematic for physicians too, as they prefer side-by-side communication.”

In centralized pods, staff recommended open, wall-less, column-less central areas that contributed to visual and auditory access for patient monitoring. The lack of visibility between pods was a barrier to communication that required additional tasks, as elaborated by a respondent, “it is hard to find team members but overall not too bad. To easily communicate with other pod members, I usually need to walk to the other pod or find a computer to locate their phone numbers.”

Staff perceived improved levels of nonverbal communication by reducing visual barriers. One of the nurses elaborated on this issue, “Our pivot nurse cannot see into the waiting room because there is a column blocking the view.” A physician noted:

The ideal ED to me is something that has no visual barriers, and that back-and forth non-verbal coordination happens between the physician and the team; so that no matter where you are, you can see your patients, techs, and patient nurses, secretary, and nurses.

Privacy

Ease of private interaction with patients accounted for 7.4% of variation in staff satisfaction, F(1, 60) = 4.8, p = .032. The ease of private conversations with team members explained 15% of variation in staff satisfaction, F(1, 60) = 10.6, p = .002, and 28% of variance in satisfactory communication with team members across pods, F(1, 61) = 23.21, p < .001. Satisfaction with pod configurations was affected by staff perception of not having satisfactory private conversations with team members, F(1, 47) = 5.2, p = .027.

In the check-in areas separated booths; and in triage and ERs doors were recommended changes to enhance acoustical privacy and protect patient confidentiality, especially during overcrowded periods. Users mentioned the need for sound-absorbent materials that support private conversation, as one respondent mentioned:

Having private conversations with patients can be difficult because there are no doors on the patient rooms and some people speak loudly. Having a private report can also be difficult unless we go to the med room with the computer as voices can easily be overheard, and the patients can walk by during report.

The need for spatial arrangements that support team discussions was discussed in some comments, for example, “There is no area of Care Station C that team members are able to have private interactions, whether discussing patient information or personal information.

Efficiency

Based on survey and interview responses, access to supplies and noise was two substantial environmental factors that correlated with ED efficiency. Ease of access to supplies accounted for 12.6% of variation in staff satisfaction, F(1, 50) = 7.2, p = .01. Further, ease of communication with team members across pods, β = .38, p = .002, and feeling part of a team, β = .414, p = .015, accounted for 38% of the variation in the perception of accessible supplies, F(2, 41) = 12.53, p < .001. That is, the more supplies were accessible and equally distributed, the more staff felt part of a team.

The analysis indicated that easily accessible equipment pertained to 13% of variation in staff satisfaction, F(1, 51) =7.53, p = .008. This outcome was positively predicted by ease of communication with team members across pods, β = .58, p < .001, and shorter door-to-admission or door-to-discharge times, β = .175, F(2, 41) = 31.6, p < .001, R² = .61.

Staff were disturbed by ED noise levels (M = 2.24, n = 63, SD = .89). Noisy environments accounted for a 34.2% of variance among those feeling distracted and unfocused, F(1, 60) = 31.15, p < .001. However, the perception of a noisy environment was not a significant predictor of staff satisfaction, communication within or across pods, or the need for pod modifications.

Standardization of equipment and supply location was emphasized to eliminate confusion or distraction from tasks, and enhance efficiency. A nurse described the need for standardized supply arrangements, “Supplies in the pods are not all the same, sometimes you have to go from pod to pod and sometimes to the storage room just to find what you need to do your job.” Another participant explained the effect of inaccessible supplies on throughput outcomes:

It would be great to have supplies in the patient’s room instead of walking in and out of the room every time a supply is needed. It would eliminate a lot of wasted footsteps, and reduce interruptions, distractions, and frustration for staff.

Participants complained about the difficulty to find equipment in an established place. For example, one of the shift managers noted, “Patient monitoring equipment is constantly missing. We have a hard time relocating it for the next patient because it has been all removed from rooms for the BH patients.” Another nurse reported, “Occasionally equipment and supplies are missing or broken in rooms, slowing down care and creating frustration while caring for patients.”

In many instances, clinical staff found that constant environmental noise correlated with physical and emotional exhaustion and amplified interruptions and distractions. Staff also noted the importance of visibility for face-to-face communication. Once visibility was impeded, clinicians “shouted” for communication purposes that escalated noise. To enhance attentiveness in the noisy EDs, staff suggested providing places to “dock away” or “hide.”

Discussion

Working in high pressure and demanding ED environments is overwhelming and challenging for ED staff. Therefore, research is needed to consistently assess and validate design interventions that enhance staff satisfaction and performances. As previously mentioned, there are a few studies that concurrently explore interactions between ED physical environment, attributes (security, wayfinding, visibility, privacy, and efficiency), and desired outcomes. This study found that explored attributes significantly correlated with ED staff performance and satisfaction. This finding suggests that the physical environment elements of EDs that impact different attributes can eventually enhance delivery of care.

Security

Supported by prior findings (Gates et al., 2011; Gharaveis et al., 2017; Pati et al., 2016), security and safety were critical for the ED staff for efficient delivery of care and satisfaction of the ED environment. Entrances and pathways with direct visibility elevated staff perceptions of safety and control. Having one controlled entrance to the ED department was perceived as a key element for amplified security outcomes. Participants believed that satisfactory visibility, especially around the arrival area, has the potential for enhancing staff perception of safety and satisfaction. This finding illustrates that visibility has a key role on the perception of safety that elevates ED staffs’ satisfaction levels.

In line with prior research (Broadbent, Moxham, & Dwyer, 2014; Gharaveis et al., 2017; Pati et al., 2016), micromodifications for safety enhancements included installing mirrors for greater visibility, metal detectors, or implementing high-impact and bulletproof glass in registration and nursing station areas.

Participants perceived the importance of providing an adequate number of security guards in areas with direct visibility to entrance doors who are trained to implement firearms in “code gray” situations (process for managing aggressive behaviors). In an attempt to modify the security of the medical patient waiting environment, providing a separate, quiet waiting space with sufficient visibility for BH patients was a design recommendation that is consistent with previous studies (Broadbent et al., 2014; Pati et al., 2016). These findings indicate the importance of enhanced visibility, controlled traffic, secluded waiting areas for BH patients, and micromodifications to enhance security outcomes in the ED environment.

These findings indicate the importance of enhanced visibility, controlled traffic, secluded waiting areas for BH patients, and micromodifications to enhance security outcomes in the ED environment.

Wayfinding

Ineffective wayfinding and signage causes inefficiency and workplace stress among healthcare providers. Without clear directional signage, patients may wander, become aggressive, fatigued, and abusive to providers (Jiang & Verderber, 2017; Pati, Harvey, Willis, et al., 2015). Nevertheless, there is a lack of empirical research on the impact of navigation and wayfinding qualities in hospital-based ED facilities.

The results found that irregular-shaped and distanced corridors intersections and physical obstructions were identified as structural aspects negatively impacting orientation and wayfinding experiences (Jiang & Verderber, 2017; Marquardt, 2011). Further, having linear arranged pod configuration is more supportive of movement flows, accessibility, and connectivity than perpendicular arrangements. Additionally, including waiting areas in direct visibility of registration spaces is recommended to encourage direct movement that facilitates wayfinding.

Enhanced waiting systems in the ED were perceived to have a substantial role in staff work processes and performance. In many hospitals, having dedicated or volunteer staff who escort patients is perceived as providing more personal attention that enhances patient satisfaction (Brown et al., 2015). This option was also suggested as a solution for enhancing wayfinding experiences in EDs. However, guiding patients’ families to destinations was perceived as a frustrating, distracting, and waste of time and steps (Buffoli et al., 2016). As suggested by previous research (Jiang & Verderber, 2017; Mustikawati et al., 2017; Pati, Harvey, Willis, et al., 2015), participants recommended implementing meaningful visual cues and eye-level signage to improve wayfinding experiences. These findings reflect the importance of spatial sequences and ER configurations that afford direct access to destinations enhances wayfinding and movement patterns.

… spatial sequences and ER configurations that afford direct access to destinations enhances wayfinding and movement patterns.

Visibility

In agreement with prior studies (Broadbent et al., 2014; Gharaveis et al., 2017; Lu, Ossmann, Leaf, & Factor, 2014; Pati et al., 2016), the findings show the importance of sufficient sightlines to improve visibility toward patients and opportunities for face-to-face communication that were imperative for staff satisfaction.

The VGA showed that columns, opaque support spaces, and indirect corridors restricted visibility. Team identification, verbal and nonverbal communication, and team coordination were critical factors to enhance perceptions of satisfactory team visibility and work environment. Therefore, participants suggested eliminating columns or walls at check-in, waiting, and pod areas to enhance visibility, safety, communication, and delivery of care. This implication has been also as suggested by previous research (Gharaveis et al., 2017; Pati et al., 2014; Pati et al., 2016).

The VGA showed that columns, opaque support spaces, and indirect corridors restricted visibility.

In line with prior research on nursing unit design (Bayramzadeh & Alkazemi, 2014; Gharaveis et al., 2017; Pati, Harvey, Redden, Summers, & Pati, 2015; Pati et al., 2016; Zborowsky, Bunker Hellmich, Morelli, & O’Neill, 2010), the enhanced visibility within centralized pods promoted team interaction, communication, a greater sense of cohesion, and interdisciplinary collaboration. In contrast to centralized pods and corroborating prior literature (Bayramzadeh & Alkazemi, 2014; Pati, Harvey, Redden, et al., 2015), the findings indicate the advantages of decentralized pods for private communication among team members. Supporting prior research (Pati, Harvey, Redden, et al., 2015; Seo, Choi, & Zimring, 2011; Zborowsky et al., 2010; Zhang, Soroken, Laccetti, De Castillero, & Konadu, 2015), ED staff perceived decentralized pods improved the performance by facilitating access and visibility to patient rooms, enhancing communication, and supporting ease of patient monitoring. The VGA also supported higher visual surveillance in decentralized pods due to the multiple short-distanced perpendicular corridors.

… the enhanced visibility within centralized pods promoted team interaction, communication, a greater sense of cohesion, and interdisciplinary collaboration.

Advancement in technology communication has relegated the need for proximate distances of care providers (Real, Fay, Isaacs, Carll White, & Schadler, 2018). However, research suggests providers need for face-to-face communication or information transmission and decision-making (Bayramzadeh & Alkazemi, 2014; Gharaveis et al., 2017; Varjoshani, Hosseini, Khankeh, & Ahmadi, 2015). The findings showed that in centralized pods, removing vertical nontransparent barriers was recommended to enhance verbal and nonverbal communication among team members. This is in line with prior literature (Gharaveis et al., 2017; Lu et al., 2014; Pati et al., 2016). In contrast, within decentralized pods, staff complained about the lack of visibility that impeded team communication and enhanced perceptions of social isolation, as noted in previous research (Parker, Eisen, & Bell, 2012; Real et al., 2018; Zhang et al., 2015). It can be concluded that the effects of spatial configuration on movement and visibility were consistent with individual perceptions of the spatial affordance.

… within decentralized pods, staff complained about the lack of visibility that impeded team communication and enhanced perceptions of social isolation.

Privacy

ED staff satisfaction was affected by the level of privacy affordances provided for patients (Broadbent et al., 2014; Gharaveis et al., 2017; Steinke, 2015). Prior studies on EDs suggest that perception of privacy is relegated when patient information is discussed in open treatment areas or workstations (Calleja & Forrest, 2011; Gharaveis et al., 2017; Lin et al., 2013). Supporting previous literature, staff recommended including allocated enclosed and transparent team spaces as a design intervention for enhancing patient privacy and effective communications that has been also recommended in prior studies.

… staff recommended including allocated enclosed and transparent team spaces as a design intervention for enhancing patient privacy and effective communications.

Literature exploring patient’s perceptions of ED environments suggests that patients in walled rooms perceive higher levels of privacy and satisfaction (Calleja & Forrest, 2011; Lin et al., 2013). Adding to the body of knowledge on staff perceptions of patient privacy (Calleja & Forrest, 2011; Gharaveis et al., 2017), the findings indicated substantial physical improvements for improving ED privacy were having solid walls with doors versus curtains in ERs or triage. Taking this into consideration would offer a more permanent solution for improving patient privacy and confidentiality.

Efficiency

Consistent with prior literature, operational improvement was frequently cited as a substantial factor for optimum care delivery and staff satisfaction (Beck, Okerblom, Kumar, Bandyopadhyay, & Scalzi, 2016). In line with prior studies (Fay et al., 2018; Seo et al., 2011; Steinke, 2015; Varjoshani et al., 2015), participants mentioned the need for the standardized location and replenishment of supplies and equipment within pods, patient rooms, and triage to enhance efficiency, reduce frustration, and improve care.

In line with prior studies, the stressful ambience of the ED inhibited inter-team communication and collaboration (Broadbent et al., 2014; Gharaveis et al., 2017; Varjoshani et al., 2015). High noise levels in the EDs amplified nurses’ and physicians’ distraction from tasks that was occasionally unsafe and nonpatient-centric, which is consistent with previous literature (Adkins et al., 2017; Broadbent et al., 2014; Gharaveis et al., 2017).

As described in prior studies (Bayramzadeh & Alkazemi, 2014; Parker et al., 2012; Zhang et al., 2015), centralized pods were information hubs for disseminating and communicating patient and team updates. Inherently, these spaces were exposed to noise from conversations, alarms, equipment, tubing, and mechanical systems. Obstructed visibility by support areas also resorted to shouting behaviors for communication. Contrary to centralized pods, decentralized team stations reduced distances and interruptions (Bayramzadeh & Alkazemi, 2014; Fay et al., 2018). These results have implications for increasing staff performance and satisfaction.

… centralized pods were information hubs for disseminating and communicating patient and team updates.

Conclusions

Findings from this study will serve healthcare facilities professionals, architects, and interior designers in understanding the current challenges of the ED workplace. This knowledge may lead to changes in design guidelines that enhance staff satisfaction and work performance. The findings indicated that higher levels of security, wayfinding, visibility, privacy, and efficiency impacted by physical environment attributes enhanced staff satisfaction and performances (Figure 7). Direct and short-distanced corridors, linear pod arrangements, and unobstructed surveillance toward teams and patients supported team communication, wayfinding, visibility, and security.

Figure 7.

Research conclusion. The findings established security, wayfinding, visibility, privacy, and efficiency as essential qualities for emergency departments to achieve safe, efficient, satisfactory, and high-quality outcomes. Image authorship: Author.

Controlled and limited entry points with high visual surveillance toward traffic areas were critical for perceptions of security. Privacy was enhanced by including partitions at registration, team rooms in pods, and ERs with doors. Reducing noise levels, especially in pods, enhanced concentration and team communication. Regarding centralized versus decentralized pod arrangements, each design concept exposed different pros and cons in terms of communication, visibility, and privacy. Therefore, stakeholders need to explore carefully each alternative and select the best option.

The primary limitation of the study is the convenience sampling and cross-sectional evaluations. Future studies are recommended to explore multiple EDs with greater spatial layout differences. Another limitation was distributing similar survey links to both sites, and participants having a choice in reporting their work site. Therefore, the survey response data were insufficient for statistical site comparisons. Further research is warranted to understand the aspects of the ED environment on other outcomes, such as measured performance outcome, waiting time, staff retention, patient satisfaction, and staff–patient interaction. While the mixed method application offsets some of the limitations, additional research is required to validate the results and expand the body of knowledge.

Implications for Practice

Key recommendations for ED space designs:

promote security through enhanced visibility, controlled traffic, and dividing medical and behavioral patient waiting and triage areas (during normal patient volumes);

enhance wayfinding from parking to entrances, provide adequate eye-level signage and navigation cues, limit entrances, and implement hierarchical pathways;

use a rectangular unit shape with linear pod alignments and multiple perpendicularly connected corridors to ease movement and enhance visibility;

limit columns, walls, or blind corners, while maximizing transparent vertical barriers between team spaces;

maximize privacy by including individual check-in booths, glassed exam rooms, and enclosed team or consult spaces;

facilitate workflow by enhancing access to supplies and equipment through standardization, movability, and modularity of support core elements; and

enhance efficiency and reduce distraction by controlling and relegating noise levels produced by equipment, voices, and interruptions.

Footnotes

Acknowledgments

The author thanks Esperanza Harper, Alice Gittler, Hilke Schoonvliet, and Nicholas Watkins for their contributions.

Declaration of Conflicting Interests

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

Funding

The author appreciates Novant Health and EwingCole for funding this research article.

ORCID iD

Zahra Zamani, PhD

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