Coping and Caregiving: Leveraging Environmental Design to Moderate Stress Among Healthcare Workers in the Emergency Department Setting

Questionnaire

The online questionnaire was developed around study objectives by the research team that included design researchers and an emergency medicine physician, then pilot tested by two additional providers before being distributed. It was distributed, using Qualtrics, to physicians, residents, nurse practitioners, and nurses working in the three EDs. The self-administered questionnaire, accessed using a link to the online survey, collected descriptive information about caregivers’ job-related stress, coping behaviors, and perceived environmental qualities that may facilitate those behaviors. The questionnaire included the following: (1) five multiple-choice demographic questions asking about participants’ roles, length of experience, typical shifts, work location, and workload; (2) four matrix table job-related stress questions asking about sources of stress, frequency of feeling stressed at work, coping activities, and spaces used to destress; and (3) a combination of multiple-choice and matrix table questions regarding possible reasons for not being able to physically step away from work demands, helpful environmental attributes in supporting coping behaviors, existing supportive environmental attributes in their work environment, and changes that they would like to see made to their physical work environment to help them cope with stress while at work. In the last part, participants were asked about their perceptions regarding their safety at work, their satisfaction with patient/family access to their immediate work area, and environmental attributes that may compromise their safety. This part included Likert-type scale and open comment text box questions.

Interviews

Face-to-face interviews were conducted to gain deeper insights into healthcare workers’ coping behaviors and to understand how environmental attributes may influence those behaviors. Participants who completed the survey received contact information to reach out to one of the researchers if they were willing to participate in an interview. Additionally, participants were recruited from a regularly scheduled medical education meeting. We interviewed participants in their workplace, and each session lasted between 15 and 25 min. After collecting basic demographic information, interviewees were asked about job-related stress (e.g., frequency and sources of stress), behaviors around destressing, and to describe an ideal place where they might go to destress.

Culture of acceptance

Participating ED clinicians seemed resigned to the fact that the ED will be short-staffed, there is a high probability that they will feel threated, and they will not have time to take breaks, even for lunch or dinner. Two recurring subthemes were identified: “We don’t take breaks” and “We often feel threatened.”

Physician centricity versus staff integration

Participants talked about an existing debate over whether there should be a physical barrier between doctors and nurses. In the hospital-based ED, there is a separate glassed-in space, sometimes referred to as the “doc box,” for physicians, physician assistants, and nurse practitioners only. The physical barrier was perceived as a hindrance to physician–nurse communication by nurses, who would prefer that it be removed. Most physicians, however, strongly advocated for having a separate space for themselves to reduce interruptions and unwanted noise when they need to concentrate. One physician stated that doctors and nurses are undergoing different types of stress and expressed their opinion that ultimately doctors are responsible for patients’ conditions, incidents, and so on. Therefore, having a separate space should be understandable. However, some physicians stated that having a shared space for physicians and nurses might foster communication flow and ultimately improve patient care quality. One physician said she wished the fourth wall of the “doc box” (a four-walled glass room) was removed and integrated a bit more into the nursing station, because overhearing nurses often draws doctors’ attention to important issues about patients that might seem unimportant to nurses and therefore not shared with physicians. She also noted that she was definitely in the minority, having this opinion.

I think that communication with the nurses is nice to have a little more clearly and it’s very exclusive and very fancy to have the docs all in their own box but you don’t get to overhear the nurses saying stuff that’s really important. The nurse will casually mention something that turns out to be really important and they didn’t think it was important enough to tell you because they don’t know.

Another physician noted although she supports having a separate space for doctors, there are advantages of sitting close to nurses in terms of overhearing issues and avoiding incorrect orders and miscommunication, commenting, “Well, one of my favorite things about that space out there is the fact that we sit so close to the nurses that we can easily identify issues, wrong orders, miscommunications.”

The discussions on whether physicians should have their own workspace, separate from nurses, revealed a power dynamic that has existed for decades. Physicians perceived their roles as being different enough from nurses to warrant greater privacy and less accessibility to others, to enhance their ability to concentrate. Nurses were described, at times, as being noisy and engaging in a lot of “social talk.” This finding raises the question as to whether designing integrated staff teamwork areas, which the literature recommends, will result in the desired outcomes as long as these perceptions, which may or may not be accurate, persist. Perhaps physicians will find a way to segregate themselves anyhow. The first author has observed, during postoccupancy evaluations, labeling of several computers in a shared workspace as being “for physician use only.”

Whether or not clinicians work in separate areas based on their role, participants noted that adequately sized care team stations would help reduce stress. Care team stations are often crowded because they are too small to accommodate all staff members who need to use them at the same time (e.g., nurses, physicians, scribes). Some staff areas, like offices, have been converted to storage spaces. In fact, any space that is viewed as superfluous is turned into a storage area for equipment and supplies. Participants mentioned needing additional touchdown spaces, such as small offices, to focus on work with minimum distractions and to communicate with others.

Privacy please

Statements around the issue of privacy, including visual, acoustic, and physical accessibility were pervasive. Some participants noted that patients and their companions have too much access to staff. One physician stated that it is difficult to provide corrective instruction to colleagues for fear of being overheard. For example, one physician stated:

There is no barrier for us to discuss patients or difficult parents without wondering if they [family members] are standing on the other side of the wall listening. So, some of those conversations that you would like to have with the residents maybe don’t occur because you don’t know who’s right around the corner.

Another clinician noted that they find themselves pulling residents into a makeshift storage area in a staff-only corridor to let them know how they could have handled a situation better.

Clinicians need visual as well as auditory privacy. One participant noted, “I’d appreciate if patients couldn’t see me and bang on the window for my attention, like I’m a zoo animal.” Healthcare workers in the ED setting spend most of their shift “on-stage” with limited visual and acoustical privacy. Not only can this cause stress among staff members, but they also perceived that constant visibility by patients and companions hinders vital staff-to-staff communication. Participants noted that open layouts provide high visibility to patients and perceived control over the care environment, too much openness may make physicians too accessible to patients or visitors. One participant stated that nurses prefer to sit where they have good visibility of the “sick kid room” but “We’re the first ones people see when they come around the corner. So…angry parents come and are like ‘Why am I still here? What are we doing? You’re not doing your job.’”

Many respondents noted that constant interruptions and distractions caused stress, citing numerous examples. This was most obviously expressed by physicians who worked in the hospital-based ED. When asked what they needed to help them cope with job-related stress, one participant commented, “The biggest thing would be to be interrupted less. Interruptions are the biggest stressor.” Several doctors stated that being able to concentrate without interruption is a necessary component of optimum care delivery, but it is lacking in their work environment. Nurses also complained of distractions. One commented, “There is nowhere for nurses to document in quiet without interruption,” and another mentioned the need for “a private area where nurse charting can be uninterrupted by patients and families.”

Other staff members are a source of interruptions and distractions. Although some distractions are helpful, like overhearing important patient information, frequent interruptions can be detrimental to both job performance and patient well-being (Coiera et al., 2002; Weigl et al., 2020; Westbrook et al., 2018). One participant stated:

It’s a very small space that we all are jammed up in, working. There’s a lot of noise, distraction, patients coming through, nurses constantly interrupting. We cannot even talk to a doctor without being interrupted every few seconds, and when we work, the noise distraction just from social talk and laughing…it’s just distracting. I actually put ear plugs in my ears.

Some participants blamed having an open layout for the barrage of distractions and interruptions. Although noted as enhancing communication between physicians and nurses, it can also contribute to the amount they, specifically physicians, get interrupted, minimizing their attentiveness. Regarding interruptions, one physician stated, “You might have to go back like hours later and be like, ‘I totally missed something. Now I have to redo everything that I just did because I got interrupted at the critical time when I was putting in orders.’”

No place of refuge

Although the clinicians who were interviewed seemed to accept the fact that they do not have time to take a break, they also acknowledged that sometimes it is imperative to momentarily step away from work demands. One participant noted, “There is nowhere for us to retreat to.” At one of the free-standing EDs, a physician stated, “We’ll do a lap, walk around, especially if there’s tension among staff. I’m like, ‘You need to go outside and go do a lap.’ Our building is so small. We don’t have a lot of places to go that are private.” This comment about taking a walk supports findings from the questionnaire indicating that taking a walk was selected by approximately half of all participants as an activity in which they engage to destress.

Some participants described work environment attributes that would make it easier for them to cope with job-related stress. For example, staff members frequently mentioned that they often seek a quiet moment to decompress in the restroom, yet several interviewees in the hospital-based ED stated that there are simply not enough staff restrooms available to them that are proximal to their work areas. Often, they step inside, lock the door, and seconds later someone else is there needing to use the restroom. Restrooms should be sufficient in number, conveniently located and provide olfactory, auditory, and visual privacy from patients, visitors, and other staff members.

Staff areas (e.g., break rooms, cafeteria, and EMS room) located outside the unit were considered too far away because staff cannot be far from their patients. There was a common perception among staff that they are viewed as “slackers” if they spend time in a “break room.” One participant stated, “Many times we end up eating at the nurse station, and while doing so family/patients/staff are constantly coming up to us.” However, taking a short walk to a coffee shop in the lobby was perceived as an effective way to step away from work demands momentarily. Physicians and nurses noted a lack of private spaces to take quick pauses throughout the day and places to compose themselves after losing a patient. Many participants expressed that there is a need for a dedicated and accessible space inside the ED where staff can go to unwind when they are experiencing job-related stress. Having a welcoming, safe, quiet place where staff can pop in for at least a couple of minutes was perceived as being helpful. Break rooms are often considered to be too far away from workstations for a momentary pause. A few participants noted that there is some sort of a secret place in the hospital where staff sometimes go when they need to cry, but the location of that place, which is not a designated respite space, was undisclosed.

Participants clearly articulated how one might design a respite space where they could step away from job-related stress. They often noted the importance of visual and auditory privacy, easy access (adjacency to ED), noise control, lockable doors, and access to and ability to control natural light. Some mentioned that it would be nice to have a massaging chair available to them. Several participants commented on the benefits of having an outdoor place to take a few minutes to relax, eat, drink, or put their feet up. They talked about how such a place, close to the ED and with comfortable seating, could help them destress by changing the scenery and allowing them to get some fresh air.