A room designed for caring Experiences from an evidence-based designed intensive care environment

Fredrika Sundberg

SVANENMÄRKET

Trycksak3041 0234

A room designed for caring Experiences from an evidence-based designed intensive care environment

Copyright © Fredrika Sundberg, 2020

Faculty of Caring Science, Work Life and Social Welfare

University of Borås

SE-501 90 Borås, Sweden

This dissertation is available at:

ISBN 978-91-88838-74-2 (printed)

ISBN 978-91-88838-75-9 (pdf)

ISSN 0280-381X, Skrifter från Högskolan i Borås, nr. 106

Electronic version http://urn.kb.se/resolve?urn=urn:nbn:se:hb:diva-23183

Cover Design:

Illustration front page: Ida Brogren

Portrait photographer: Örjan Jakobsson

Printed in Sweden by STEMA

Borås 2020

Abstract

Aim: The overall aim of this doctoral thesis was to examine and evaluate if and how an intensive care unit (ICU) room, which had been designed using the principles of evidence-based design (EBD), impacted the safety, wellbeing and caring for patients, their family members and staff. Methods: Paper I explored the nursing staff experiences of working in an EBD intensive care patient room through 13 interviews that were analysed by qualitative content analysis. Paper II focussed on the meaning of caring and nursing activities performed in two patient rooms—one EBD refurbished and one standard. Ten non-participant observations were conducted, which were followed by interviews. The data were analysed using a phenomenological hermeneutical approach. Paper III evaluated the relationship between a refurbished intensive care room and adverse events (AE) in critically ill patients. A total of 1,938 patients’ records were included in the analysis. Descriptive statistics and binary logistic regressions were conducted. Paper IV studied visitors’ (N = 99) experiences of different healthcare environmental designs of intensive care patient rooms through questionnaires. Descriptive statistics and linear regressions were conducted for the analysis. Main results: The refurbished intervention room was reported as a positive experience for the working nursing staff and the visiting family members. The nursing staff additionally indicated the intervention room strengthened their own wellbeing as well as their caring activities. Although there were no observed, objective differences regarding the caring and nursing activities due to the different environments, the differences were instead interpreted as being due to different developed nursing competencies. The visitors reported the enriched healthcare environment to have a higher everydayness and a feeling that it was a safer place compared to the control rooms. The findings revealed a low incident of AEs in both the intervention room as well as in the control rooms, lower than previous described in literature. The likelihood for adverse events were not significantly lower in the intervention room compared to the control rooms. Conclusion: This dissertation contributed to the existing knowledge on how a refurbished patient room in the ICU was experienced by nursing staff and visiting family members. The dissertation also showed the complexity of conducting interventional research in high-tech environments. The new knowledge on the importance of the healthcare environment on wellbeing, safety and caring must be considered by stakeholders and decision-makers and implemented to reduce suffering and increase health and wellbeing among patients, their families and staff. Key words: intensive care units, critical care, caring, hospital design and construction, evidence-based facility design, built environment, health facility environment, patient rooms, critical illness, patients, family, nurses

Original papers

Paper I Sundberg, F., Olausson, S., Fridh, I. & Lindahl, B. (2017) Nursing staff's experiences of working in an evidence-based designed ICU patient room-An interview study. Intensive Critical Care Nursing, 43, 75-80. Paper II Sundberg, F., Fridh, I., Olausson, S. & Lindahl, B. (2019) Room Design-A Phenomenological-Hermeneutical Study: A Factor in Creating a Caring Environment. Critical Care Nursing Quarterly, 42, 265-277. Paper III Sundberg, F., Fridh, I., Lindahl, B. & Kåreholt, I. (In Press) Associations between healthcare environment design and adverse events in intensive care unit. Accepted for publication in Nursing in Critical Care. DOI: 10.1002/NICC.12513 Paper IV Sundberg, F., Fridh, I., Lindahl, B. & Kåreholt, I. Visitor’s Experiences of an Evidence-Based Designed Healthcare Environment in an ICU Submitted

Contents

INTRODUCTION......................................................................................... 8

BACKGROUND........................................................................................... 9

Environment – a core concept embedded in caring sciences ..................... 9

Healthcare environment....................................................................... 10

Intensive care environment .................................................................. 10

Being cared for in the intensive care environment ............................... 11

Visiting the intensive care environment .............................................. 12

Working in the intensive care environment ......................................... 12

Swedish intensive care settings ........................................................... 12

Safety in the intensive care environment ............................................. 13

Complex intervention research ............................................................ 14

Evidence-based design ........................................................................ 14

THEORETICAL PERSPECTIVE ............................................................... 14

Lived space and place - a geographical approach .................................... 15

Caring and nursing .................................................................................. 16

Caring in intensive care settings .......................................................... 17

RATIONALE .............................................................................................. 17

AIM ............................................................................................................. 19

Overall aim .............................................................................................. 19

Specific aims of the included studies ....................................................... 19

METHODS ................................................................................................. 19

Methodological approaches ..................................................................... 20

Qualitative Research Interviews .......................................................... 20

Qualitative Research Observations ...................................................... 21

Questionnaires ..................................................................................... 21

Qualitative content analysis ................................................................. 22

Phenomenological hermeneutical method ........................................... 22

Regression ........................................................................................... 23

Setting ..................................................................................................... 24

Design ..................................................................................................... 26

Study I ..................................................................................................... 27

Participants .......................................................................................... 27

Data collection..................................................................................... 27

Data analysis ....................................................................................... 27

Study II.................................................................................................... 27

Participants .......................................................................................... 27

Data collection..................................................................................... 28

Data analysis ....................................................................................... 28

Study III .................................................................................................. 28

Participants .......................................................................................... 28

Data collection..................................................................................... 29

Data analysis ....................................................................................... 29

Study IV .................................................................................................. 30

Participants .......................................................................................... 30

Data collection..................................................................................... 30

Data analysis ....................................................................................... 30

Ethical considerations.............................................................................. 31

RESULTS ................................................................................................... 33

Study I ................................................................................................. 33

Study II ................................................................................................ 33

Study III .............................................................................................. 34

Study IV .............................................................................................. 34

DISCUSSION ............................................................................................. 35

Discussion of the findings ....................................................................... 35

Dwelling in the intensive care unit ...................................................... 36

Making the unfamiliar familiar ............................................................ 36

Sustainable work environment in the ICU ........................................... 37

Methodological considerations ................................................................ 38

CONCLUSION ........................................................................................... 42

Clinical implications ............................................................................... 42

FUTURE RESEARCH ............................................................................... 43

SWEDISH SUMMARY.............................................................................. 44

ACKNOWLEDGEMENT........................................................................... 46

REFERENCES ............................................................................................ 49

PAPER I-IV ................................................................................................ 61

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INTRODUCTION

The healthcare environment can promote health and wellbeing, but it can also prolong illnesses and even cause other healthcare-related illnesses. Intensive care is a level of care where the most critically ill patients require care in order to survive. The medical and technical advancement in the intensive care units (ICUs) has had an enormous impact on saving more lives and has led to what the intensive care is today. However, the main focus has been on saving as many lives as possible rather than the overall environment within these highly technological settings. As the development in the medical technological field advances and gains ground, it is also important to study the impact the physical healthcare environment can have on the people—patients, visiting family members and staff—who inhabits this arena. Patients in the ICUs are already in an extremely delicate state and facing life-threatening illnesses or conditions, and family members are facing a frightening situation filled with feelings of uncertainty. Critical care nurses (CCNs) are specifically trained to manage the high-technological work environment, which is filled with stressors.

In 2010, an intensive care room was refurbished with cyclic lightning, sound absorbents and unique interior and exterior design, aiming to promote health. This dissertation studied how this refurbished two-bed intensive care room affected safety, wellbeing and caring for patients and their family members and staff.

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BACKGROUND

Environment – a core concept embedded in caring sciences

The core foundations in caring sciences are the four metaparadigm concepts: nursing, person, health and environment (Fawcett & Desanto-Madeya, 2013); however, the concept of the environment has been overshadowed by the other concepts in the research (Dahlborg Lyckhage et al., 2018; Ylikangas, 2017). The environment, which surrounds us, is fundamental to all living creatures. The environment can be measured (e.g., sound levels and visibility, such as solid buildings versus green spaces) with the aim to provide healthy shelters and housing. The environment can also be the fresh air that we breathe. In other words, the environment can be experienced through our senses known better as milieu. Both concepts (environment and milieu) are frequently operationalised in the same way, making it difficult to separate them from one another. In a semantic concept analysis of milieu, Ylikangas (2002) found milieu had a deeper meaning through five dimensions: atmosphere, surroundings, relationship, environment and centre.

The importance of the environment for human and humankind is acknowledged by several nursing theorists, such as Florence Nightingale, Jean Watson and Rosemarie Rizzo Parse. Parse viewed the concepts of human and the universe as inseparable and irreducible (Bournes & Schmidt Bunkers, 2018). The nursing paradigm identifies the unitary being as one who co-participates with the environment in creating and becoming (Parse, 1981). The fundamental focus in nursing is promoting or restoring health, preventing illness or caring for the sick, all of which require provisions for a supportive, protective and/or corrective mental, physical, sociocultural and spiritual environment (Watson, 2008). The environment can also be viewed as the external and internal stimuli or factors that are surrounding humans (Hickman, 1995; Watson, 2008). The internal environment consists of various components, such as biophysical, mental, spiritual and sociocultural. The external environment consists of such factors as stress-change, comfort, privacy, safety and clean-aesthetic surroundings (Watson, 2008). Humans interact with and adapt to their environment to maintain equilibrium and to achieve goals (Hickman, 1995).

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Healthcare environment

The importance of the healthcare environment has been known for centuries. Already in the nineteenth century, Florence Nightingale (1859) described the impact of the healthcare environment upon health and wellbeing. She stated that it was crucial to have an optimal healthcare environment, as she detected that patients had a faster recovery if they were cared for in optimal hospital rooms. She recognised the healing significance of aspects in the environment, such as noise, light, ventilation and cleanliness. Instead of establishing Nightingale’s philosophy, hospitals and ICUs today are full of elements of crowding, noise, too much or too little light and mazes, which all have been found to increase stress in patients, visitors and staff (Norlyk et al., 2013; Sternberg, 2009). The healthcare environment is complex and has been shown to promote health and wellbeing, sustain illness and even increase the risk of causing healthcare related illnesses (Ulrich, 2006; Ulrich et al., 2019; Ulrich et al., 2008).

Intensive care environment

Critically ill patients with life-threatening conditions are cared for in ICUs. Intensive care, whereby the patients are treated and monitored, requires access to advanced technical medical equipment. Therefore, the environment of ICUs is filled and dominated by sophisticated technology (Andersson et al., 2019; Meriläinen et al., 2013; Stayt et al., 2015; Tunlind et al., 2015). The machinery is continuously running at the patients’ bedside, often very close to the patients’ heads. The machinery is something that often generates sound through operating noise and alarms, which do not create the most conducive peaceful environment that critically ill patients need to recover (Darbyshire et al., 2019; Delaney et al., 2017; Engwall et al., 2014; Engwall et al., 2017; Johansson et al., 2016).

Due to rapid changes in the patients’ conditions, different technical equipment is brought into the patient rooms. This implies that the bed spaces constantly change due to the presence or absence of machinery and, therefore, the patient rooms take different forms (Olausson et al., 2014). Over the decades, advances in intensive care, medicine and technology have been impressive. This has not, however, been matched by adjustments to the buildings. New equipment is often placed in the patient rooms wherever there is free space rather than being integrated into the design of the patient rooms. This then places new demands for proper design of the ICU and demonstrates the current need for quality development and research in the area of the ICU design (Denham et al., 2018; Rashid, 2011).

The wellbeing, or illbeing, of patients, their family members and staff are strongly connected to the environment, both the physical and psychological

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environment (Delaney et al., 2017; Hill et al., 2019; Olausson et al., 2019; Siffleet et al., 2015; Wung et al., 2018). The importance of wellbeing was already acknowledged in 1946 by the World Health Organization (WHO, where wellbeing and the three dimensions, physical, mental and social, were recognised as crucial components of health, defining that health was not simply the absence of disease (WHO, 1946).

Being cared for in the intensive care environment

Intensive care is a level of care and not a specific place. The Swedish Intensive Care Registry (SIR) definition of intensive care is ‘advanced monitoring, diagnostic or treatments provided for patients with threatening or manifest failure within vital functions’ (SIR, 2018). To provide care for the critically ill patients, the ICUs are filled with sophisticated technology, and the patients are cared for by specially trained and educated staff (Morton & Fontaine, 2018). Nonetheless, the technology not only creates safety and security for the patients but it also demands time and attention from the staff, which decrease the time spent with the patients. (Tunlind et al., 2015). Another shortcoming of the sophisticated technological equipment is it creates sound and noise. Sound, noise and other factors, such as incorrect lighting, that are generated in the intensive care patients’ surroundings has been shown to affect the patients negatively (Darbyshire et al., 2019; Delaney et al., 2017; Korompeli et al., 2019). Stimuli from the equipment could increase the levels of stress, often affecting the patients’ sleep and circadian rhythm, which could then lead to ICU-delirium or other medical illnesses (Brummel & Girard, 2013; Lu et al., 2019; Madrid-Navarro et al., 2015). Former intensive care patients carry memories from their stay in the ICU. Most of the patients have had positive experiences after the discharge with feelings of security and satisfaction (Kelepouri et al., 2019). Unfortunately, this is not true for all. Some patients reported strange and scary memories, either real or delusional (Kelepouri et al., 2019; Svenningsen et al., 2016; Zetterlund et al., 2012). During treatment in the ICU, patients are often connected to tubes, lines and wires that immobilise and confine them to bed. The majority of patients have lost their verbal function, as they are intubated for ventilator treatments. Patients often experience existential fear, as their lives themselves are threatened (Egerod et al., 2015; Johansson et al., 2012). Intensive care patients are very frail (Brummel et al., 2017).

Patients are dependent on the critical care staff, their family members and the technology to endure and survive their conditions (Olausson et al., 2013). The knowledge that their family members were bedside was reported to be extremely important to the patients. In one study, patients expressed that they wanted to show their progress and that they were on their way back to life (i.e. retained hope) to their loved ones (Eriksson et al., 2011).

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Visiting the intensive care environment

Family members of critically ill patients experience high levels of stress due primarily to the life-threatening conditions of their loved ones but also due to the unfamiliar environment (Ruckholdt et al., 2019; Turner-Cobb et al., 2016). Many described their first visit to their critically ill loved one in the ICU as a shock. Seeing their loved one as the patient with tubes and wires connected to their body created feelings of unreality and confusion (McKiernan & McCarthy, 2010). The experience of distress has been shown sometimes to develop into post-traumatic stress disorder (Petrinec & Daly, 2016). Over the past 40 years, having information and being able to visit the patient have ranked as the most important needs of family members of critically ill patients (Jacob et al., 2016). Despite this, visiting hours are often harshly restricted. However, several ICUs have been converting to having more flexible and extended visiting hours (Chapman et al., 2016), resulting in more satisfied family members. There are many factors that can increase distress in the ICUs; however, one factor, hospital gardens for family members, has been found to decrease stress levels (Ulrich et al., 2019).

Working in the intensive care environment

The nursing workload in ICUs is often high, and the work is stressful because the severity of the patients’ illnesses and the acute events that often arise and demand immediate action (Papathanassoglou & Karanikola, 2018). Technical equipment is needed when providing care for critically ill patients, and this is a distinguishing feature of the work environment for the staff. On one hand, nursing activities are facilitated by technology. But on the other hand, the technology can create stress for the staff and take the focus away from the patients (Olausson et al., 2014; Price, 2013; Tunlind et al., 2015). Studies have shown that CCNs are vulnerable to developing burnout due to the occupational stressors (Epp, 2012). Olausson et al. (2014) have depicted the technology as something that gradually becomes nurses’ extended arm in their efforts to create security and safety for the patients.

Swedish intensive care settings

In ICUs in Sweden, the core team around the patients consists of physicians (anaesthesiologists/intensivists), CCNs and assistant nurses (ANs), where the physicians are in charge of the medical care, and the CCNs are responsible for planning and implementing the caring activities. In Swedish ICUs, unlike some other countries (Freeman et al., 2016; Suliman, 2018), any form of physical restraints are not allowed. Consequently, there is always staff present in the patient rooms at the ICUs. The Swedish Society of Nursing (2012)

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published a text regarding the skills and competencies of CCNs. Three major areas the Swedish Society of Nursing has stated CCNs should have competency and expertise in high technological settings, such as the ICU, are: (1) theory and practice of caring; (2) research, development and education; and (3) leadership. These three areas ought to be imbued from a holistic approach, an ethical approach and with a patient safety focus (Svensk sjuksköterskeförening, 2012). In Sweden to become a CCN, registered nurses (RNs) complete a specialist university nursing programme in intensive care, which is equivalent to a one-year master level degree, with clinical practice in an ICU. The ANs require a degree from upper secondary school. It is the CCNs and the ANs that perform the caring and nursing activities around the patient, and the CCNs lead those activities.

Safety in the intensive care environment

Safety is a broad concept that in this dissertation includes both patient safety and a safe work environment for staff. Patient safety is, and should always be, an important topic within healthcare. In Sweden, the Patient Safety Act defines iatrogenic injury as suffering, a somatic or mental injury or illness and death that could have been avoided if adequate measures had been taken during the patient’s contact with health services (SFS, 2010:659). The first chapter in the Health and Medical Services Act (SFS, 2017:30) states that healthcare and medical care professionals are supposed to take action to prevent illness and injuries. The National Board of Health and Welfare estimates that 100,000 iatrogenic injuries occur in Sweden each year (Socialstyrelsen, 2019).

ICU patients are at greater risk for adverse events (AE) and iatrogenic injuries due to their greater need for medications, invasive procedures and devices (Ortega et al., 2017; Rothschild et al., 2005). Preventable AEs among ICU patients are relatively common and have serious consequences since this category of patients is already in an extremely vulnerable situation, balancing on the edge of life and death (Latif et al., 2015; Latif et al., 2013; Ortega et al., 2017; Rashid, 2011; Rothschild et al., 2005). Iatrogenic injuries can lead to prolonged length of stay (Codinhoto et al., 2009) in the hospital and increase the mortality rate (Codinhoto et al., 2009; Roque et al., 2016). Prolonged LoS additionally increases the costs on society, and, for the patients and their family members, suffering can be prolonged.

The work environment is regulated in Sweden through the Work Environment Act (SFS 1977:1160) to ensure a safe working environment. The Act aims to prevent illnesses and accidents at work. Critical care nurses work in high technological settings with high acuity of the work. Today, there is both a national and international shortage of CCNs. This shortage creates an

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unhealthy work environment, resulting in higher workload for those CCNs who do work in the ICU (Keys & Stichler, 2018; Ulrich et al., 2019).

Complex intervention research

Complex interventions comprise multiple interacting components where the complexity increases by an additional component but also by targeted groups (Craig et al., 2008). Complex interventions aim to improve the wellbeing of people with health- or social-care needs (Richards & Rahm Hallberg, 2015). The intervention in this thesis also aims to promote health in patients, family members and staff (Lindahl and Bergbom, 2015). After developing a complex intervention, the changes needed to be evaluated, so if successful, these changes could be implemented elsewhere (Craig et al., 2008; Richards and Rahm Hallberg, 2015). The evaluation process consisted of the key functions: implementation, mechanisms of impact and context. Context is a key component when evaluating an intervention, as the context might promote or suppress the intervention’s effects (Moore et al., 2015).

Evidence-based design

In a classical study from 1984, Ulrich demonstrated that patients assigned to beds with windows that faced the natural scenery had shorter postoperative hospital stays and needed less potent analgesics than patients with beds that faced a brick wall. This research led to the development of the evidence-based design (EBD) concept. EBD has evolved as a new research field focusing on the impact of the architecture on health environments. The conceptual framework of EBD includes (1) audio and visual environments; (2) safety enhancements: (3) a wayfinding system; (4) sustainability; (5) the patient room and (6) support spaces for family, staff and physicians (Ulrich et al., 2010). EBD integrates knowledge from various research disciplines in order to improve decision-making about healthcare surroundings and architecture based on the best available evidence (Hamilton & Watkins, 2009; Ulrich, 2012).

THEORETICAL PERSPECTIVE

This dissertation is grounded within caring sciences. Caring sciences is a human science (Arman et al., 2015; Eriksson, 2018; Martinsen & Eriksson, 2009). Caring sciences is not bound to a specific profession; rather it is a way or an approach of being in the world, interacting with other human beings. A caring science perspective means a holistic view with regards to others. This

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holistic view places the patient at the centre of the focus, where the patient is viewed as a suffering and vulnerable human being regardless of the diagnosis. Instead, the essential focus is on the patients’ problems, needs and desires. The understanding of what is good for the patient is always at the centre of caring science research (Arman et al., 2015; Eriksson, 2018).

Lived space and place - a geographical approach

Caring is about more than executing technical tasks, and the places where caring occurs involve human intentions instead of being simply physical sites. Places are a combination of personal attachments, emotions and feelings that nurses bring to a variety of care settings (Andrews, 2003, 2016). When caring for critically ill patients, it is vital for nurses to provide comfort (Cypress, 2011). Facilitating comfort, for patients and their family members, requires attention to be given to the environment (Olausson et al., 2019). The fundamental atmosphere in a dwelling is having a foothold in existence, and dwelling may be described as belonging, being safe and feeling at home (Martinsen, 2006). Hospitals and sickrooms can either provide the shape and boundaries that are experienced as protective, secure and dignified to the ill, but they can also be experienced as shameful, violating and invasive through their architecture and design (Martinsen, 2006). For instance, the same space can be experienced differently, depending if you are sick or healthy (Van Manen, 2014). The feelings hospitals can elicit also differs depending if you are a patient, visitor or nurse.

As a helpful guide for reflection on meanings within the lifeworld concept in terms of the research process, Van Manen (2014) suggests investigating the existentials of lived relation (relationality), lived body (corporeality), lived space (spatiality), lived time (temporality) and lived things and technology (materials) when describing the concept lifeworld in research. These concepts are considered existentials in the sense that they belong to everyone’s lifeworld (i.e. they are universal themes of life; (Van Manen, 2014). These existentials can be differentiated but not separated.

The idea of the lifeworld guided the reflection in the research process in this dissertation, where the lived experiences were an important starting point. In order to create new knowledge about the caring environment within intensive care, this dissertation focused on space and place as lived. This does not mean to exclude the other lifeworld existentials that van Manen discussed, but the current research aims were to help gain knowledge about how space and place are connected and affect the other lifeworld existentials.

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Caring and nursing

Caring is rooted in beliefs and perceptions about what it means to be a human being, and it is the most authentic criterion of humanity. Caring is about loving, and while it is common to all humanity, it is uniquely communicated through nursing (Arman et al., 2015; Roach, 2002). Caring has a starting point in existence itself since it is characterised as a human scientific discipline. The intention of caring is to relieve suffering and promote health and wellbeing (Arman et al., 2015). Caring cannot take place without a relationship between the caregiver and the patient. The relationship is essential, and it can be created through attunement and an active listening dialogue (Arman et al., 2015; Eriksson, 2018; Martinsen, 2006). Caring is originated from mutuality and an interactive process. The opposite of caring means seeing the patient as a passive receiver and as an object (Eriksson, 2015). Martinsen (2006) used the metaphor about seeing with a heartily participating eye and claimed that it meant that the nurses had to put themselves into a position where they may become worthy of the trust of another. Being vigilant is, therefore, a crucial criterion for the caring relationship, and caring is actualised through watchfulness (Meyer & Lavin, 2005). Caring cannot exist without a vigilant approach.

Professional caring is far more complex than, for instance, simply being kind. Roach (2002) theorised that the attribute of caring consists of six Cs: compassion, competence, confidence, conscience, commitment and comportment. Other nursing theorists also ascribed caring some of these attributes, both Eriksson and Martinsen, discussed compassion and courage, respectively (Eriksson; ethos, Martinsen; ethical demand), as important foundations of caring.

There is a difference between taking care of patients and caring for patients. The first approach is an objective process, focusing on the medical-surgical needs of the patients, while the latter is a subjective process rooted in nurses’ humanness (Paulson, 2004). There are different views on nursing. One view is that nursing is a profession whereas caring is a theoretical foundation. Another approach is that nursing is commonly regarded as containing nursing skills and executing techniques to promote health and prevent illness, whereas caring is regarded to be the essence of nursing. Nursing and caring are intertwined in the way that caring cannot exist without nursing and nursing should not exist without caring.

Courage is needed to resist external pressure that has other aims/scopes than prioritising caring, such as costing. At a time when the market/marketplace with the introduction of New Public Management along with hospital organisations are gaining ground, nursing seems to be taking priority over caring (Dahlborg Lyckhage et al., 2018). The concept of caring seems to be diluted and reduced to ticking checklists of performed care (i.e.

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nursing without the caring aspect). Some stakeholders seem to hold this mechanical approach to nursing as superior to caring, as it may seem efficient and money saving. When values of efficiency and financial and organisational resources take priority, it puts a global pressure to de-professionalise caring and to diminish the personal and common good aspects of caring. It is then crucial for nursing staff to have the courage to choose differently and to stand up for the ethos/common good and for the caring aspect in nursing (Arman et al., 2015; Eriksson, 2018; Hoeck & Delmar, 2018; Roach, 2002).

Martinsen, inspired by the thoughts and ideas of Foucault, stated that the development of medicine, sometimes to measure the human body in an unnatural way, is one of society’s ways of controlling people. The dichotomising of sick/healthy and normal/abnormal differs from the caring perspective of the patient. Human beings live and experience wholeness. This view leads to the more caring questions about what patients need or what hinders their recovery (Arman et al., 2015).

Caring in intensive care settings

Medical technology is a fundamental part of the treatment when providing care for patients in intensive care settings. CCNs are specially educated and trained in mastering the technology around the patients (Morton & Fontaine, 2018). Nonetheless, technical skills on their own are not enough when caring for critically ill patients. CCNs also need competence in caring, and they are perceived as both caring and technical experts, meaning they understand, interpret and act upon the physical data that are crucial for the good of the patient (Beeby, 2000a, 2000b). Caring for patients with life-threatening conditions includes treating the physical symptoms as well as supporting psychological wellbeing. It is about seeing the patient as a whole (Martinsen, 2006; Meyer & Lavin, 2005). Caring in intensive care settings means, as in other settings and contexts, acknowledging the patient as a human being rather than a body or a diagnosis (Beeby, 2000a; Martinsen, 2006).

RATIONALE

The environment is a metaparadigm concept within caring sciences. Although the environmental concept is of importance, it has often been overshadowed by the other concepts and consequently less research has been done on it. However, research has shown that the healthcare environment can promote health and wellbeing but also cause healthcare related problems and illnesses.

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ICUs are filled with advanced and sophisticated technology, and the unfamiliar environment may feel unfriendly and unwelcoming for those visiting and being taken care of in such settings. Critically ill patients, with life-threatening conditions being cared for in the ICUs, are vulnerable. Sounds and lights often disturb patients and their family members and staff around the clock, causing increased stress levels. Intensive care has been shown to cause patients discomfort and change their circadian rhythm, something that can lead to the development of ICU-delirium. Intensive care patients are also at a higher risk for iatrogenic injuries and AEs due to the high acuity and invasive procedures as well as the healthcare environment in the ICUs.

Intensive care is a complex area with several factors that interact that require both advanced technical and caring skills. The staff are often forced to work in very narrow spaces and are expected to interact with machines often without being able to influence their functionality, for instance mobility. The nursing staff in the ICUs are at high risk for burnout due to their stressful work environment.

EBD has evolved as a new research field, focusing on the impact of architecture on health environments on all who interact with it. For any hospital that is in the planning stages of building new ICUs or reconstructing existing ones, it is pertinent that there are guidelines on ways to build and design an optimal care environment for patients, family members and staff (Rashid, 2014). Rashid (2011) argued that despite experience and expertise in design and construction, architects alone cannot create the ultimate ICU room. Consequently, when designing an ICU, it is of utmost importance to take into account the experience and knowledge from caring personnel. That integration and multi-disciplinary collaboration is often missing from today’s research and implementation.

Developments of intensive care medicine, as well as technology, have evolved tremendously over the past 50 years; however, the buildings have not been adjusted accordingly. Today, new technical equipment is often placed in the intensive care room wherever there is free space rather than being integrated into the patients’ rooms. This causes limitations in the current design of ICUs. Patients in need of intensive care are still at risk and are less safe despite the advanced technological progress. The quality in designing intensive care environments is still in great need of development (Rashid, 2011). Suffering a serious and life-threatening illness or injury is extremely traumatic both for the patient and their family members. Patients’ vulnerability increases in a care environment that appears to be too technical and scary. By designing and decorating an ICU-room according to EBD ideology, the intention is that many of these problems can be eliminated or at least reduced. These factors raise the question of could an EBD patient room contribute and strengthen healing processes (i.e. promote health)?

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AIM

Overall aim

The overall aim of this doctoral thesis was to examine and evaluate if and how an ICU-room, which had been designed using EBD principles, affects safety, wellbeing and caring for patients, their family members and staff.

Specific aims of the included studies

Study I - to explore the experiences of nursing staff of working in an Evidence-based designed ICU patient room. Study II - to illuminate the meanings of caring and nursing activities performed in two patient rooms where one had been rebuilt according to EBD. Study III - to evaluate the differences between a regular and a refurbished intensive care room in risk for AEs among critically ill patients. Study IV - to study visitors’ experiences of different healthcare environment designs of ICU patient rooms.

METHODS

This dissertation consists of four separate studies that were based on empirical data. All conducted studies examined and evaluated how an ICU-room, which had been designed with EBD principles, affected safety, wellbeing and caring. This was examined from different angles and perspectives: the staff’s and family members’ experiences and the reports of patients’ AEs. To achieve the aims of this dissertation and the four different studies, different angles and, thus, various methodological approaches were needed.

The epistemological view in this dissertation was that human beings are searching for meaning through description and interpretation. The methodological starting point was, therefore, that the research questions dictated the methods, meaning both qualitative (Study I and II) and quantitative methods (Study III and IV) were necessary to answer the aims and research questions. The studies’ different results have led to a deeper

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understanding and new knowledge about the meaning of the healthcare environment within the ICU. There has been a movement between preunderstanding and understanding of the studies’ various findings.

My personal preunderstanding originates from several years as a CCN who cared for critically ill patients and almost daily encounters with the family members and seeing the impact of the professional obligations on colleagues. This has led to an understanding when approaching the research participants. Although I had never been employed in an ICU where research was conducted, my experience has led to an open mind and curiosity to take part of the lived experiences of the participants. It is crucial not to let my personal preunderstanding influence the results, but to use the experience to conduct the studies in new ways that would result in high ecological validity. I have also participated in planning a new and refurbished ICU and know from this experience the importance of a multidisciplinary team when designing a well-structured healthcare environment.

Methodological approaches

Qualitative research is a systematic, interactive and inter/subjective approach used to describe life experiences and give them meaning (Burns and Grove, 2005). Since human emotions are difficult to quantify (assign a numerical value), qualitative research provides a more effective method to investigate emotional and experienced responses. In addition, qualitative research focuses on the discovery and understanding of the whole, an approach that is consistent with the holistic philosophy of nursing (Burns and Grove, 2005). Quantitative research is formal, objective and systematic in which numerical data are used to obtain information about the world. This research method was used to describe variables, examine relationships among variables. Statistical analyses enable researchers to organise, interpret and communicate numeric information (Burns & Grove, 2005; Polit & Beck, 2016).

Qualitative Research Interviews

During qualitative research interviews (Brinkmann & Kvale, 2015), participants get the opportunity to express themselves about their lived world and experiences. However, the interviewer needs to craft the questions careful to allow these expressions (Polit & Beck, 2016). Interviewing is a process where the interviewer acquires interview skills over time. Qualitative research interviews are not conversations between equal partners; the researcher has an agenda and a purpose with the interview and guides the conversation towards the aim of the study (Brinkmann & Kvale, 2015). It is crucial that the

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transcriptions from the interview interaction are done with rigor (Polit & Beck, 2016).

Qualitative Research Observations

The human capacity to observe our surroundings gives us the skills to make judgments about our observations. In the context of research, however, observation needs to be substantially more systematic than the observation that characterises everyday life. Observation is the act of perceiving a phenomenon and recording it for scientific purposes (Angrosino & Flick, 2007). Observation is performed not only via vision but by using all senses when perceiving a phenomenon. The aim of observation is to collect data about the lived human experience in order to discover predictable patterns.

There are different kinds of observational research. In non-participatory observations, the researcher conducts observations for brief periods, which contrasts the ethnographer style that can require living with the research participant(s) for years. This kind of observation has the advantage that the researcher is known and established, but relates to the ‘subjects’ of study solely as a researcher. There is no risk of blurring the lines between researcher and friend for the research participants in this method as well. The observations can be both structured, semi-structured and unstructured (Mulhall, 2003; Salmon, 2015). The non-participatory, unstructured type of observational research was used in this dissertation (Study II).

To conduct quality research observations, the observer has to have language skills, explicit awareness, a good memory, cultivated naïveté and writing skills. Language skills are not simply speaking the same language. Having language skills also means having the ability to be flexible and adjust one’s way of speaking to be understood in different contexts. Explicit awareness is noticing the details that are easy to filter out in everyday life. A good memory helps fill in the gaps and reduce missing information in situations where not everything can be recorded. Cultivated naïveté is needed to question what could be considered as obvious or taken for granted. Lastly, good writing skills are required when turning the observational data into some type of narrative context for analysis (Angrosino & Flick, 2007).

Questionnaires

The semantic environment description (SMB) is a structured method used for evaluating the impression of an architectural environment. The SMB-method measures the impression with eight factors: pleasantness, complexity, unity, potency, social status, enclosedness, affection and originality (Kuller et al., 1991). It is used in research in varieties of research disciplines from car interior (Karlsson et al., 2003) to outdoor environments at different nursing

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homes (Bengtsson & Carlsson, 2006). The SMB was developed in the seventies and may be somewhat outdated today, or the meanings of words has changed with time. Despite this, there are not many available tools for testing the perceiving of the built environment.

The Person-centred Climate Questionnaire family version (PCQ-F) was developed and validated in acute care settings to record how family members perceive the psychosocial climate (Lindahl et al., 2015). The PCQ-F evaluates the dimensions safety, everydayness and hospitality of the psychosocial care. In study IV, the dimension of safety was divided into ward climate, safety and safety, staff. This was done to distinguish the perception of the built environment from the perception of the staff. The instrument investigates to what degree family members of hospitalised loved ones perceive settings as being person-centred, safe, welcoming and hospitable within an everyday and decorated physical environment. The PCQ has versions for patients (Edvardsson et al., 2008) as well as for staff (Edvardsson et al., 2009). This family member version enables further comparison of care settings by different stakeholders.

Qualitative content analysis

Content analysis is a scientific method that can be used both with a quantitative or qualitative approach (Hsieh & Shannon, 2005; Krippendorff, 2013). Qualitative content analysis aims to describe the researched phenomena in a conceptual form by following three steps: preparation, organising and reporting (Elo & Kyngäs, 2008). There are several models described in the literature, but two main different types of the qualitative content analysis can be identified—inductive and deductive. Inductive content analysis is used when there is no previous research done on the phenomenon. Deductive content analysis, on the other hand, is used when existing theories are being tested in new contexts or are being compared (e.g. longitudinal studies). In this thesis, the inductive content analysis was used (Study I) (Elo & Kyngäs, 2008).

Phenomenological hermeneutical method

The phenomenological hermeneutical method was developed by Lindseth and Norberg (2004) for human studies and healthcare research. This method originates and combines the hermeneutical traditions of interpretation and the phenomenological tradition to capture the essence of meaning derived from lived experiences. The work of the French philosopher Paul Ricoeur (1913-2005), inspired Lindseth and Norberg to develop the method. The phenomenological hermeneutical method has an approach rooted in a life-world perspective and uses narratives as data (Lindseth & Norberg, 2004;

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Ricœur & Thompson, 2016). When collected data for instance, observations and interviews can be transcribed into texts, and the texts assume an autonomous status where the meaning it mediates uncover an understanding of a possible being in the world (Lindseth & Norberg, 2004). The phenomenological hermeneutical analysis process moves between the phases of naïve understanding, thematic structural analysis, and comprehensive understanding. The analysis contains a movement between a subjective and an objective approach, between the revealed events and meaning as well as close and distances to the text. There is no true interpretation, but the most trustworthy (Ricœur, 1976).

Regression

The British scientist, Sir Francis Galton (1822-1911), developed statistical calculations known as regressions, which were needed for his research (Galton, 1886). Regression analysis is a group of statistical procedures used to assess the relationships among variables. It comprises several techniques for modelling and analysing numerous variables to explain the variance in the model. The focus is on the relationship between one or more dependent variables and one or more independent variables.

In statistical analyses there is always a risk that associations are influenced by external variables, what is commonly called omitted variable bias (Nizalova & Murtazashvili, 2016; Scheffler et al., 2007). To minimize the risk for this bias other variables must be held constant. The variables that are made to remain constant are referred to as the control variables. Extraneous variables can be controlled for by using multiple regression. Controlling for implies that the associations of interest are shown as if there are no associations between the variables included in the association of interest and the control variables (Scheffler et al., 2007).

P-values are used for both descriptive statistics and regressions. The p-value shows the likelihood that you obtained a specific result not by chance (Cohen, 1995).

Linear regression Linear regressions are a method to demonstrate the linear relationship

between a numerical dependent variable, normally on an interval or ratio scale, and one or more explanatory variables – a statistical technique for estimating the value of a dependent variable from one or more independent variable. A regression with one explanatory variable is called a simple linear regression or bivariate linear regression. A multiple linear regression is when there is more than one explanatory variable. Linear regressions are a statistical technique for estimating the value of a dependent variable from one or more

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independent variables. Linear regression is one of the most widely used of all statistical techniques (Kumari & Yadav, 2018).

Binary logistic regression Binary logistic regressions are used to analyse dichotomous outcomes in

relation to one or more independent variables (i.e. the predictors). The results are calculated as the odds of an outcome rather than the other, and these are presented as odds ratios. The independent variables can either be categorical or continuous, or a mix of both, in one model. The technique is similar to multiple linear regression with one difference being that the dependent variable is dichotomous (e.g. pass/fail) and another being the results are presented as odds ratios (Brace et al., 2016; Pallant, 2016; Sperandei, 2014). The impact of each variable on the odds of the observed variable of interest is the result. By analysing the association of all the variables together, it limits confounding effects, which is the major advantage of using this analysis (Sperandei, 2014).

Setting

The intervention room A patient room was refurbished in 2010 (Lindahl and Bergbom, 2015)

according to the principles of EBD and the available guidelines for complex intervention research (Craig et al., 2008). The room was designed to have two beds, acoustic panels on the walls and ceiling and new flooring. In addition, prototype pendulums equipped with lights, electrical sockets and medical gas supplies were installed. Cyclic light was installed and the medical and technical devices were placed beside the patients and not, as typical, behind the headboard. The walls were painted in soothing shades, and all furnishings were covered with ecological materials, such as textiles, and comfortable furniture was placed in the room for visitors (see Figure 1 and 2). The room had a window and door leading onto a patio where furniture and seasonal plants were accessible to the patients and their relatives (Lindahl and Bergbom, 2015). Within the research project, there were rooms that were identical to how the intervention room was prior to the modifications, and these rooms were used as control-rooms.

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Figure 1 Differences in design between the intervention (on the right) and the control room (on the left)

Figure 2. The patio with furniture and flowers outside the intervention room.

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Design

Table 1 shows an overview of the four studies. Study I and II had a qualitative approach, and Study III and IV were carried out using quantitative methodologies.

Table 1. Overview over the Dissertation’s Included Studies

Aim Participants Data collection Method of analysis

I To explore the experiences of nursing staff of working in an EBD ICU patient room

Eight CCNs and five ANs (N = 13)

Qualitative research interviews

Qualitative content analysis

II To illuminate the meanings of caring and nursing activities performed in two patient rooms where one had been rebuilt according to EBD

The participants consisted of 7 CCNs, 1 student, and 7 ANs (N = 15)

Non-participatory observations followed by qualitative research interviews

Phenomenological hermeneutical method

III To evaluate the differences between a regular and a refurbished intensive care room in risk for AEs among critically ill patients.

There were 1,938 patients (1,382 in the control rooms; 556 in the intervention room).

Data from patients’ medical records.

Descriptive statistics and binary logistic regressions.

IV To study visitors’ experiences of different healthcare environment designs of ICU patient rooms

Visiting family members, (N = 99)

Questionnaires: PCQ-F and SMB

Descriptive statistics and linear regressions.

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Study I

Participants

The 13 participants were recruited through a purposive sampling (Polit and Beck, 2016). In order to reflect the constitution of the unit’s staff, 8 CCNs and 5 ANs were interviewed. Their ages ranged from 39 to 59, and their years of experience in the same ICU ranged 4 to 38 years. All the CCNs worked all shifts (day, evening and night) as did the ANs except two who did not work night shifts. Both CCNs and ANs worked in all rooms in the unit, and no one on staff was allocated solely to the refurbished room.

Data collection

In order to explore the intensive care staff's experiences of the intervention room, a qualitative research interview was used. The qualitative research interview approach was used to gain an understanding of the ICU through the participants’ perspectives and allow them to express their feelings and insights into the current phenomenon under investigation (Brinkmann & Kvale, 2015).

Data analysis

The collected material was analysed using qualitative content analysis with an inductive approach (Elo & Kyngäs, 2008). This approach aimed to achieve a condensed yet broad description of the actual phenomenon under examination, and the outcome of the analysis was in the form of concepts or categories that described the phenomenon (Elo and Kyngäs, 2008, Polit and Beck, 2016).

Study II

Participants

Both CCNs and ANs participated in this study. There were a total of 15 participants: 7 CCNs, 1 student (one week from graduating as a CCN), and 7 ANs. The participants ranged in age from 22 to 55, and their work experience ranged from 3 weeks to 12 years in the actual ICU.

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Data collection

Non-participatory observations were conducted and combined with follow-up interviews. In total, 10 non-participatory observations were conducted. They totalled 47 h 31 min, lasting an average of 4-6 h per session. Of the non-participatory observations, six were conducted in the control room and four were conducted in the refurbished patient room. Field notes were taken during the observations. Participants, who had been active during the observation session, were asked to reflect and share their experience of performing the caring activities. The interviews were conducted individually or in pairs (CCN/student and AN), according to the wishes of the participants.

Data analysis

The data were analysed using a phenomenological hermeneutical method (Lindseth and Norberg, 2004). The observation notes and the interview texts were transcribed verbatim and analysed as a whole. This type of analysis means working with interpretation back and forth between the phases: naïve reading, structural analyses and comprehension of the whole. Naive reading, or understanding, was derived from several readings to perceive the meaning of the entire text. The next step was using a thematic structural analysis to identify and formulate themes where the whole text was read in a more objective mode and divided into meaning units. Then, the meaning units were condensed into subthemes and themes. In this study the thematic structural analysis was presented as two composite narratives, based on all the collected data during the observations and interviews. Narratives is one of the aspects concerning the disclosure of meaning (Polkinghorne, 1988). There are different ways if conducting narrative research. Most common is analyzing narratives but it can also be used as composite narratives to present interviews and visual data (Polkinghorne, 1988; Riessman, 2008; Wertz et al., 2011; Willis, 2018). Comprehensive understanding included reflection on the subthemes and themes.

Study III

Participants

The study sample consisted of all the patients assigned to the refurbished intervention room and two control rooms in an ICU between 2011 and 2018 (N = 2,337). Patients who were admitted to the ICU only for observation and those who did not meet the criteria for intensive care were excluded from

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further analysis (n = 399). Ultimately, 1,938 patients were included in this study (1,382 in the control rooms and 556 in the intervention room).

Data collection

Data were retrospectively collected for the critically ill patients admitted to the multidisciplinary ICU between 2011 and 2018. Since the researchers had no access to any medical records, data were collected from the administration office of the clinic. Data were anonymised prior being given to the authors, to preserve confidentiality.

Patients admitted to the intervention room and two control rooms were eligible for inclusion of the study. When all the rooms were empty, the nurse in charge randomly assigned to one of the rooms. To conserve staffing resources, the adjacent bed space was filled, before assigning a patient to an empty room, if any room contained a patient. The study sample consisted of all the admitted patients to the intervention room and control rooms (N = 2,337). Patients who were only admitted for observation and those who did not meet the criteria for intensive care were excluded from further analysis (n = 399). Finally, 1,938 patients were included in this study (1,382 in the control rooms and 556 in the intervention room).

All the reported AEs were included in the study, however, those with extremely low occurrence, were not analysed further than being included in the totals for ‘Any AEs’ and the number of AEs.

Data analysis

All analyses were performed using SPSS Statistics version 25 by IBM. Descriptive statistics were used to present descriptive data on the AEs in the patients assigned to the intervention room and the control rooms. Binary logistic regressions were used to estimate the relationship between the intervention/control rooms and AEs and complications. As this was a binary regression, all AEs were coded into dichotomous variables as 0 =”none”, and 1 =included one, two and three AEs) Three different models were executed by regressions. Model 1 was controlled for the type of room (intervention versus control room), window bed versus non-window bed, LoS, and deceased versus not deceased. Model 2 was additionally controlled for age and sex. Model 3, the fully adjusted model, was additionally controlled for trauma versus no trauma, reasons for admittance. The statistical significance was set at p  <  0.05.

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Study IV

Participants

Patients’ visitors were asked to answer questionnaires; PCQ-F and SMB. Visitors, such as family members and close friends during their visit of the critically ill patients being cared for in the ICU, were asked to participate. The questionnaires were distributed by the staff or the researcher. The questionnaires were answered while the visitors were in the patient rooms—intervention room or control rooms.

Data collection

The data collection took place between November 2015 - April 2019, and a total of 104 questionnaires were collected. However, five questionnaires were excluded because the room the visitors were in was not indicated. Therefore, 99 questionnaires (69 from visitors in the control rooms and 30 from those in the intervention room) were used in the analysis.

Data analysis

All analyses were performed using SPSS Statistics version 25 by IBM. Descriptive statistics were used to present the descriptive data of the visitors visiting loved ones in the intervention room or the control rooms. Linear regressions were used to estimate the relationships between the intervention/control rooms and the PCQ-F and the SMB.

When analysing the PCQ-F, the dimension of Safety was divided into Ward climate, safety and Safety, staff to distinguish the perception of the built environment from the perception of the staff. The Ward climate, safety and the dimension of Everydayness, was also grouped together and analysed under name of Ward climate, general, and the dimensions of Safety, staff and Hospitality were grouped together and analysed under the name of Ward climate, Staff.

The PCQ-F was analysed in three different models that were executed by linear regressions. In model 1, no control variables were included, merely crude differences between intervention room and control rooms. Model 2 was controlled for age, sex, and relationship to the patient. The fully adjusted model (Model 3) was controlled for age, sex, relationship, number of visits, and whether the patient had changed rooms during the ICU stay.

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Ethical considerations

In this dissertation, ethical considerations were paramount throughout the entire research process. All studies followed Swedish legislation and the World Medical Association’s Declaration of Helsinki (WMA, 2013), which guided the methodology for each research project. There are four basic ethical principles: autonomy, beneficence (doing good), non-maleficence (causing no harm) and justice (Beauchamp & Childress, 2013), which guided this dissertation.

When doing research in intensive care settings, several aspects must be taken into considerations. Since some of the data were collected through qualitative empirical research methods, interviews with people in an extreme situation must be carried out with the understanding and preparedness for how the participants may react and respond to the situation. The research questions must be well designed before they are asked, and ethical considerations are embedded into all stages of an interview (Brinkmann & Kvale, 2015).

Conducting research within the context of intensive care is challenging as critically ill patients with life-threatening conditions are involved (Silverman & Lemaire, 2006). Patients, as well as their next of kin, are in a delicate situation and must be treated with extra care. Critically ill patients are considered a vulnerable group (Polit and Beck, 2016). Also, their next of kin are in a vulnerable state, not knowing if their loved one is going to survive or suffer life-altering injuries. Family members’ experiences are described as a period of chaos with difficulties absorbing what has happened, feelings of fear and waiting in uncertainty and pain of seeing a seriously ill relative (Larsson et al., 2013). But in order to gain knowledge to improve the care and support for both critically ill patients and their next of kin, it is crucial to conduct research. The research must be carefully planned, and ethical guidelines must be strictly adhered to. Therefore, extra consideration was taken prior conducting the studies in this dissertation

I never worked in the ICU where the studies were conducted, but I have experience of working as a CCN in a similarly designed and run ICU. Therefore, I was familiar with the ICU environment without having any prior relationship with the participants, thus limiting ethical concerns and influence. I am also used to meeting patients’ next of kin and could deal with their feelings and concerns with some experience. The lesson to learn from moral phenomenology is that by describing the world adequately, by getting close enough to the phenomena and by being objective regarding particular situations leads to us knowing what to do, taking us beyond ethical theories and abstract principles (Brinkmann & Kvale, 2015).

In Studies I and II, the focus was on the staff working in the intervention room. These participants were not considered as vulnerable in the same way as patients and their loved ones were. For Study I, the participants received

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both written and oral information about the study before they signed a consent form. But in Study II, in order to eliminate biasing the results, no consent form was handed to the participants in advance of the observations. Instead, the staff received general information verbally about the planned observations at staff-meetings, but they were not informed what was going to be observed and instead were given the choice not to work in the intervention room during the observation times. However, the participants did receive both written and oral information about the study and signed a consent form at the time of the interviews instead.

In Study III, data were collected through medical registers in order to answer the research question. Although intensive care patients are considered a vulnerable group to conduct research on, the patients in this study were not patients at the time of the data collection, and the study was with their data and no direct contact. They were not informed about this specific study but were to be given information from the clinic about volunteering in SIR.

In Study IV, the patients’ visitors were asked to fill out a questionnaire distributed by the researcher or staff who were working in the control or intervention rooms. The staff were used to meeting, supporting and taking care of their patients’ next of kin, therefore, they had the experience to choose when they felt the timing was right to distribute the questionnaires. The questionnaires were answered when the next of kin were in one of the patient rooms; therefore, no time was missed from their loved ones to participate in the study.

Informed consent was obtained from the participants before they were interviewed. The participants also received written and oral information about how the data would be processed and stored. The information letter contained information about how the text would potentially be published. For instance, participants received a letter guaranteeing that any text that would be published in such a way that the participants could not be identified. The letter also stated that data would only be handled by authorised personnel directly associated with the research project. If participants were interested in the results of the study, they were told how they could get access to it. The participants were additionally informed orally and in writing that they had the right to withdraw from participation at any time without any consequences to them or their relatives. Written consent for the project was obtained from the chief clinicians who were responsible for the ICU at the hospital where the study was conducted. The project was authorised by the Regional Ethical Review Board, Gothenburg (Reg. 695-10) before data collection commenced.

The research and the four studies were conducted in collaboration with the research group, High-tech health care environments, at the University of Borås, the hospital with the refurbished and control rooms and private companies. However, there are no conflicts of interest, as none of the researchers has been financially compensated for working on this project.

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RESULTS

This doctoral thesis aimed to examine and evaluate if and how an ICU-room, which had been designed according to EBD principles, affected safety, wellbeing and caring for patients, their family members and staff. The four included studies examined this through various methodology. The findings revealed that in some studies the refurbished patient room had an impact and affected those who inhabit the room, the nursing staff and the visiting family members. However was this not visible in the study of patients and AEs.

Study I

The findings revealed that the nursing staff experienced the refurbished patient room as a room that was something completely different than they were used to. The analysis resulted in four categories with seven subcategories. (1) “A room that stimulates alertness” described the effects of the sound and light improvements as giving a feeling of alertness to the participants. The different sound environment in the refurbished ICU room made it easier for staff to stay focused on their work and, therefore, they felt more alert. Instead of working in dimmed surroundings, they felt assured that the light was always the best for the patients, which gave them with one less aspect to worry about. (2) “A room that promotes wellbeing” described how the participants experienced the refurbished room as having a different atmosphere than the rest of the unit. The atmosphere of the room made them feel more relaxed and calm, feelings that they reported lingered even after their shift. (3) “A room that fosters caring behaviours” described how the fact that nature was included into the design of the room that gave them a homey atmosphere and less sterile like most hospitals. They stated this inspired them in their nursing care. (4) “A room that challenges nursing activities” was about the room being different in relation to the other patient rooms and sometimes confused them where the necessary medical materials were stored. The participants also indicated that the prototype pendulums limited their access to their patients, as they were not manoeuvrable enough.

Study II

There were no observable differences in the caring activities performed in the differently designed patient rooms. However, the meanings of caring that were demonstrated during the nursing activities were interpreted as dissimilarities in performing care.

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The analysis resulted in two themes and the result was presented as composite narratives. The first composite narrative was named “Being a cog in a bigger wheel”. The subthemes (a) medical charts control my nursing actions, (b) room storage occupies my day and (c) being in a hierarchal system built the theme. The other composite story was named “Being attuned to caring”, where (d) being vigilant and attentive, (e) being part of a team and (f) being experienced eases my workload were subthemes to being attuned to caring.

In the comprehensive understanding the theme of “Being a cog in a bigger wheel” with subsequent subthemes underpinned the interpretation of “Caring with an instrumental gaze”. Some of the nursing staff had an instrumental gaze, interpreted as caring with a task-orientated approach. The theme of “Being attuned to caring” with subsequent subthemes underpinned the interpretation of Caring with an attentive and attuned gaze, where the needs of the patients structured the working shift.

The study findings indicated that caring could be lost when nurses used a task-oriented approach rather than a person-centred one. However, when nurses did practice the person-centred approach, caring was conveyed by using an attentive and attuned gaze.

Study III

The findings revealed that there were no significant differences in baseline characteristics of the patients. The majority of the patients did not suffer any AE (n=1,727, 89%), which was higher than previous described in the literature. Nevertheless, 211 patients (11%) had at least one AE, whereof 11 % (n= 152) of the patients in the control rooms patients and 10.6 % (n= 59) of the patients in the intervention room (p > .805). The result did not find any decreases in the AEs due to the design of the rooms.

Of the examined AEs, the result showed that in year 2015, patients who were assigned to the intervention room, had a significantly higher odds of getting ventilator-associated pneumonia (VAP).

Study IV

The descriptive statistics showed no significant differences between the characteristics of the visitors in the control rooms and the intervention room regarding sex, age, number of visits, and relationship to the patient; likewise, there was no difference in whether the patient had changed patient room during the stay at the ICU.

The Semantic environment description (SMB). Each dimension was controlled for age, sex, relationship to the patient, number of visits, whether the patient changed rooms during the ICU stay in the regression analysis. No

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significant differences between either of the dimensions in the intervention room and in the control rooms were found. The p-values were all > 0.1, except for the Potency dimension, where p = 0.085.

The Person-Centred Climate Questionnaire family version (PCQ-F). The results showed that the visitors perceived the intervention room as significantly having greater “Everydayness”, in Model 2 (p < 0.045) and 3 (p< 0.021). The “Ward Climate, safety” was significantly perceived as safer in the intervention room than in the control rooms in Model 1 (p < 0.048). These combined (“Ward Climate, general”) were also significantly scored higher in the intervention room as in the control rooms (Model 1; p < 006, Model 2; p < 0.005, Model 3; p < 0.013). The dimensions concerning the perception of the staff, “Safety, staff” and “Hospitality” was not perceived as significantly different between the intervention room and the control rooms, not even combined as “Ward Climate, Staff”.

DISCUSSION

Discussion of the findings

The new knowledge acquired in this dissertation developed on and supports the existing literature and research that has shown that despite the presence of life-threatening conditions and being in a high technological environment, it is possible to experience a sense of at-homeness in an ICU. This feeling of at-homeness goes beyond just how the patients feel and can be expanded to the medical staff, such as CCNs and ANs, and visiting family members when the healthcare environment is designed with this in mind and enables dwelling. Ill patients deserve a healthy environment for their recovery or end of life. Florence Nightingale (1859) acknowledged and demanded better healthcare environments for her patients, as she found both the physiological and psychological aspects of healthcare affected them. Intensive care prioritises saving lives. Nevertheless, the atmosphere in the healthcare environment should not be neglected. Critically ill patients and their families need to be cared for in as optimal surroundings as possible, as this has been shown to affect their health outcomes. The nursing staff always prioritises the comfort of the patient before their own. This may lead to an unhealthy work environment with working in the dark and crawling on the floors to reach cables and wires to the technology.

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Dwelling in the intensive care unit

ICUs are special places. For those who enter an ICU for the first time, a feeling of being overwhelmed often arises. There is machinery in almost every space in the room, and there are unfamiliar and piercing sounds and lights that make one think of a spaceship. This alien environment provides shelter for the most critically ill patients and vulnerable patients admitted to the hospital. The patient care in intensive care settings ranges from high technological interventions to the very basic care a person needs. CCNs are on the frontline and responsible for providing the care the medical team deems necessary. CCNs are often the first and last person the patients and their family members see when being admitted and discharged from the ICU.

The results of the different included studies showed that caring can and should be supported by the healthcare environment. The improved healthcare environment enabled the persons in intensive care units to reduce the feelings of stress and the high technological environment was not perceived as alien rather as an acquainted place with familiar distractions from the critical situation.

The physical environment of the ICU can be measured and quantified as well as experienced and lived. Often when talking about lived places and spaces, people use the term atmosphere. The various attunements or ambience of the room, such as sorrow and relief, are examples of different atmospheres (Martinsen, 2006; Van Manen, 2014). People need to feel a sense of belonging and security to be able to dwell in their shelters. Being safe is a crucial component of being at ease and comfortable in one’s atmosphere, and the physical environment is one aspect to this (Edvardsson et al., 2005; Olausson et al., 2019; Rasmussen & Edvardsson, 2007). Feeling secure is also an aspect of feeling at home, at-homeness. To be able to feel at-homeness, people need being able to feel safe, connected and centred. These feelings are threatened when being ill or in technology‐dense environments, but it is still possible to overcome these threats by developing welcoming atmospheres in ICUs (Andersson et al., 2019; Edvardsson et al., 2012; Ohlen et al., 2014; Rasmussen & Edvardsson, 2007; Saarnio et al., 2018; Saarnio et al., 2019).

Making the unfamiliar familiar

ICUs are closed areas, and several studies have investigated the advantages and disadvantages of opening up the units for family to visit and being less restricted solely to medical staff (Akbari et al., 2020; Mitchell & Aitken, 2017; Nassar Junior et al., 2018). The closed environment, in terms of the ICU, refers both to being unknown to the general public and also for actually being physically closed and locked. Visitors need to ring a door bell and state their reason for accessing the units in Sweden, and this lack of

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accessibility is why the ICU environment is unfamiliar to many (Lindahl & Bergbom, 2015). This unfamiliarity then becomes especially challenging and overwhelming for the visitors during their first visits since they are forced to deal with both a new environment and face the fact a loved one is in a life-threatening condition, creating a combination of stressors. Family members have been shown to be at a higher risk for psychological distress, such as anxiety, fatigue and even post-traumatic stress syndrome, in this situation (Imanipour et al., 2019; Stayt & Venes, 2019; Wintermann et al., 2016).

In Study IV, the visiting family members experienced the refurbished intervention room that was designed to have more everydayness. The intervention room offered something beautiful to look at and could be a distraction from the serious circumstances they were in. By having an everydayness feel to ICU rooms, it could be a way of making the unfamiliar familiar and a way of making an alien environment habitable to decrease the anxiety and fatigue often reported by family members. Then the hospital could become more habitable and the body can adapt more to the room in a good way (Martinsen, 2006).

Sustainable work environment in the ICU

There is an international shortage of CCNs. This creates an additional stressor on top of an already stressful work environment that deals with life and death on a daily basis. This fact coupled with a high workload results in high turnover from burnout and other stress syndromes for the CCNs and other personnel categories in the ICU (Al Ma'mari et al., 2020; Chuang et al., 2016; Moss et al., 2016; Papathanassoglou & Karanikola, 2018). Sustainable means “of, relating to, or being a method of harvesting or using a resource so that the resource is not depleted or permanently damaged” (Merriam-Webster, 2020). If the work environment and working conditions for CCNs do not improve, it will continue to be difficult to recruit these essential healthcare workers, which will add even more stress to the current CCNs. The high technological environment with constantly piercing noise and alarms is draining for the nurses. This dissertation showed that when improving the work environment for the nursing staff their own subjective wellbeing increased both at work and their life outside of work (Study I). The improved environment was also reported to strengthen their perceived ability to care for the critically ill patients. An improved healthcare environment in high technological settings, like the ICU, could physically and psychologically benefit several stakeholders who work in the ICUs based on the findings in Study I.

The concept of sustainability in nursing needs further development, and in order to do so, the field of caring sciences needs to conduct research using multidisciplinary approaches (Goodman, 2016). The complex intervention

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carried out on the refurbishment of the intervention room was an example of such multidisciplinary teamwork (Lindahl & Bergbom, 2015). When creating healing environments, architects, designers and those who inhabits the areas, in this case, staff, patients and family members, ought to participate in all stages of planning, executing and evaluating the process. In this case, the multidisciplinary team was a good start; however, more members of the team could/should have been included. While ICU staff (CCNs and ANs) were involved, none that actually worked at that specific ICU were included on the research team. Every ICU has its own tone, and it is crucial that those who will be working in that particular refurbished ICU are involved in the different phases of refurbishment. The patients and family members also need a spokesperson who will represent their views and opinions, which were missing from this planning committee. It is, of course, impossible to include future patients, but those who have had experience of being admitted to this specific ICU could offer their opinion on what would benefit future patients. Patient and public involvement or co-production is growing rapidly in the research community, and future research projects will already consider this at the planning stages.

Methodological considerations

Aspects of the healthcare environment as well as the design of the ICUs can be measured and quantified. However, they can also be lived. Therefore, given the complexity of the healthcare environment, different methodological approaches were used to gain knowledge from different perspectives about this research area. Both qualitative (Study I and II) and quantitative (Study III and IV) methods were applied to fulfil the overall aim of this dissertation. Qualitative and quantitative research are not dichotomous but rather the opposing ends of the same rope (Creswell & Creswell, 2018). These methods, as well as the paradigms, have both strengths and limitations.

Justifications for research methods choices When planning research, three elements are specifically crucial in the

framework and require thoughtful consideration: the research approach, research design and research methods (Creswell & Creswell, 2018). The three components of research for each study used in this dissertation were decided after careful consideration. The key component in the scaffolding is the specific research methods that are undertaken for data collection, analysis and interpretation that researchers propose for their studies (Creswell & Creswell, 2018). The different research method choices were based on the research problem and the aim of each study.

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In Study I, the research problem arose from a gap in the knowledge on the impact of the physical environment on the nursing staff in the ICU. When something is unknown, exploring is a possible away to go. The aim was, therefore, to explore. The methodological approach was research interviews with qualitative content analysis, and the findings were interpreted through categories with subcategories. As this was my first study, interviewing felt natural to start out with. The qualitative content analysis is a well-structured method (Elo & Kyngäs, 2008; Graneheim & Lundman, 2004), not implying that it is an effortless method but the structure can be appropriate for a doctoral student.

The results of Study I inspired Study II by wanting to know more of this phenomenon of experiencing improved care ability based on the physical environment in the ICU. Therefore, the aim of the second study was to illuminate meanings. The data collection was non-participant observations and interviews. The data were then analysed with a phenomenological hermeneutical method (Lindseth & Norberg, 2004). This method describes and interprets the data, leading to a deeper understanding, illuminating the meaning of a phenomenon with different stages.

In Study III, data from patient records reported to SIR were collected. The data were analysed with binary logistic regressions to investigate the odds ratio for AEs in patients who were cared for in the intervention room vs in the control rooms. As binary logistic regression is used to predicting odds for an event to occur (Brace et al., 2016), this statistical analysis seemed suitable to the research question.

In study IV, questionnaires were collected and analysed with linear regressions to distinguish experienced differences by visitors to the refurbished room and control rooms. The questionnaires contained Likert-type scales that was combined into normally distributed indexes; therefore, linear regressions were suitable analysis. Descriptive analyses were used for baseline characteristics in the patients (Study III) and in the visitors (Study IV) to detect if the two groups were comparable.

Trustworthiness in qualitative research When it comes to qualitative research, the accuracy of the findings must

be established, and to do so, trustworthiness, also known as rigor, needs to be considered (Cypress, 2017; Whittemore et al., 2001). Trustworthiness is obtained from the standpoint of the researcher, the participant or the consumer of the research in question (Creswell & Creswell, 2018). Lincoln and Guba (1985) as well as Elo et al. (2014) argued that there were different criteria to achieve trustworthiness as a researcher: credibility, dependability, confirmability and transferability. To fully grasp the importance these criteria

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have on qualitative research in this dissertation, it is crucial to understand and operationalise them fully.

Credibility concerns assurance in the truth of the data and the interpretations made from them (Polit & Beck, 2016). To enhance credibility in the qualitative studies in this dissertation (Study I and II), quotations were presented in the findings of the both studies to allow the voice of the participants to be visible to the reader and create credibility through transparency. The methods used, qualitative content analysis (Study I) and phenomenological hermeneutical method (Study II), have been thoroughly described, and examples of the analysis processes were presented in a table (Study II). However, this was not done in Study I, which may be seen as a limitation, as the reader cannot trace and follow the interpretations.

Prolonged engagement with participants is another way of enhancing credibility. Spending more time with participants allows the researcher to study the “culture”, which can reduce or prevent misunderstandings, thus building trust (Lincoln & Guba, 1985). The gained trust can lead to a richer data. Before the observations in Study II, the nursing staff were shadowed. In this way, the researcher and the nursing staff could build rapport while the researcher got accustomed to their routines and the surroundings at the ICU.

Dependability is to credibility, as reliability is to validity within the quantitative paradigm, and thus dependability means the constancy of data over time and conditions (Polit & Beck, 2016). Dependability is obtained if the data are reliable and have stability (Creswell & Creswell, 2018). The author of this dissertation gathered and transcribed all the data for Study I and II. The transcripts were checked thoroughly to detect and eliminate mistakes. Data were discussed and evaluated by the other co-authors, experienced researchers, to eliminate any biases and improve techniques for conducting interviews and research observations. The analyses were performed until consensus was reached among the co-authors. This was all made to enhance the possibility for the studies to be repeatable.

Confirmability represents objectivity in the sense that the findings accurately represent the participants’ voices (Polit & Beck, 2016). The research programme concerning the refurbished intensive care room was funded by the Swedish Research Council; however, they had no involvement in the research process. None of the authors of the qualitative studies stood to gain personally from the research. However, there might have been subconscious biases that could have affected the findings, but having to have a consensus among the authors minimised that risk.

Transferability refers to the extent of applicability of the findings (Polit & Beck, 2016), and it is not decided by the researcher. Instead distinct and rich descriptions were provided for potential appliers (Creswell & Creswell, 2018; Lincoln & Guba, 1985). Clear descriptions were provided, and terms were operationalised with detailed information about the study setting and the

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participants in Study I and II. So the readers can make the judgement for themselves.

Reliability and validity in quantitative research Reliability concerns consistency or repeatability of an instrument

(Creswell & Creswell, 2018; Polit & Beck, 2016). Validity is the extent to which an instrument is measuring the construct it aims to measure (Polit & Beck, 2016).

The instruments used in Study IV, the PCQ-F and SMB, were previously developed and tested by other researchers (Kuller et al., 1991; Lindahl et al., 2015). This increases the reliability and validity of Study IV. However, they were not, to the best of our knowledge, previously tested in intensive care settings, which may be seen as a weakness. The low response rate (n = 99) is another threat to the reliability of Study IV.

It is questionable if the PCQ-F measured what it was intended to. The instrument is grounded in person-centred care and divided into three dimensions: safety, everydayness and hospitality. Many of the items were related to perception of the staff. Therefore, the dimension of safety was subdivided into two parts in Study IV, safety staff and safety ward climate. The ward climate is complex to measure. What is causing the ward climate, is it the staff, the built environment or something else? It is probably a combination of everything, where all aspects need to be accounted for. However, in study IV, the instrument was used at the same ICU, therefore the same staff and guidelines, i.e. the same care. The only different aspect was the built environment. The findings indicated that there were significant differences experienced by the visiting family members between the intervention and control rooms.

Another threat to the validity of Study IV was the age of the SMB. Semantics are examining the study of meanings (Merriam- Webster) and, therefore, the instrument used, the SMB, ought to be evaluated and if needed, the language should be updated. The language usage might be the same today as it was then, but it could also have changed since the instrument was constructed.

The variables of AEs that were used in Study III were chosen due to them being reported to a national quality register, the Swedish Intensive Care Registry. They were considered as both nationally and internationally important to study. Not being in control of how data are collected can be problematic. In Study III, there was no access to the patients’ medical records. Data were collected and stored successively by the hospital from 2011 to 2018. The data were accessed in 2019 through the administration office at the clinic. This means that it was impossible to gain all the necessary information, such as Simplified Acute Physiology Score III (SAPS III), for the study. The

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AEs in Study III were the events that were reported by the staff who were working in the ward, and there is a possibility this might not reflect the true number of AEs as all AEs may not be reported due to different reasons such as they have not been diagnosed or not enough time for staff to register.

Data for Study IV were collected over quite a long period, November 2015 to April 2019. Despite this, only 99 questionnaires were included in the study. Intensive care is a challenging research area with the biggest issue being recruitment (Pattison et al., 2017). In this case, it could have been that an extra challenging aspect was approaching visiting family members of critical ill patients by nursing staff with an already high workload. As the refurbished intensive care patient room was studied by many researchers over a long period of time, it could be the staff were less motivated to assist. Another concern is there is no way to know what the exact response rate was, as no information was collected on how many visitors were approached to participate.

CONCLUSION

This dissertation contributed to the existing knowledge on how a refurbished patient room in the ICU was experienced by nursing staff and visiting family members. The intervention room was reported as having a more homey atmosphere both for the staff and for the visitors. This nicer atmosphere led the nursing staff to feel they subjectively provided better care. The findings discovered much lower incidents of AEs in both the refurbished patient room and the control rooms compared to previous research. However, no significant differences between the different designed rooms were found in regards to the AEs. This dissertation also demonstrated the complexity of conducting interventional research in high-technological environments. The new knowledge on the importance of the healthcare environment on wellbeing, safety and caring must be considered by stakeholders and decision-makers and implemented to reduce suffering and increase health and wellbeing among patients, their families and staff.

Clinical implications

The healthcare environment, especially within intensive care, is multifaceted, requiring several components to be taken under consideration to make improvements. However, an improved and enriched healthcare environment that was described in this dissertation provides opportunities for improvement. When the environment is experienced as homey and dwelling

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is possible, it is possible to see that caring is facilitated. When the environment is not perceived as alien and unfamiliar, visiting family members rather feels acquainted to the surroundings and the surroundings offers positive distractions which distract their thoughts from illness and treatment. This comfortable atmosphere could minimise the risk of negative psychological effects for the family, patients and medical staff alike. Further research on this subject is needed. Patient safety is multifaceted and several aspects need to be investigated further, such as medication errors and pressure ulcers, due to the design of the patient rooms.

FUTURE RESEARCH

Future research ought to be performed through co-operation and patients and public involvement (PPI) throughout the research process. The findings in this dissertation answered several research questions and filled gaps in the knowledge, but they also revealed other knowledge gaps that need to be considered in future research.

• To illuminate the meaning of the refurbished room for patients assigned to that patient room.

• To perform a longitudinal RCT-study of patients assigned to the intervention room and to study their recovery process compared to those assigned to the control rooms.

• To study other aspects of patient safety, such as medication errors and pressure ulcers etcetera.

• To examine the interaction between the patient and their visiting family members.

• To elucidate the meaning of family members’ visits to the refurbished patient room.

• To investigate the psychological consequences to compare the health of visiting family members in the intervention room with the control rooms as a longitudinal study,

• To involve CCNs and ANs in the research process from the planning to evaluation phases to be able to study and improve their work environment.

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SWEDISH SUMMARY

Bakgrund Vårdmiljö kan främja hälsa och välbefinnande men det kan också förlänga

sjukdomstillstånd och till och med skapa andra sjukdomar och ohälsa. Intensivvård är en vårdnivå där de mest kritiskt sjuka patienter behöver vårdas för att kunna överleva.

Den medicinska och tekniska utvecklingen inom intensivvårdsavdelningar (IVA) har gjort enorma framsteg i att rädda alltfler liv, vilket har lett fram till vad intensivvården är idag. Huvudsyftet har varit att rädda så många liv som möjligt och vårdmiljön har kommit i skymundan i dessa högteknologiska miljöer. Allt eftersom de medicinsktekniska framstegen görs, är det även av vikt att studera den byggda miljöns betydelse för människor som bebor denna arena – patienter, besökande familjemedlemmar samt personal Då intensivvårdspatienter redan befinner sig i ett extremt känsligt skede med livshotande sjukdom eller tillstånd utgör en ohälsosam miljö ett ytterligare hot mot hälsan. Även deras besökande familjemedlemmar befinner sig i en skrämmande situation med många känslor av osäkerhet och rädsla. Specialistsjuksköterskor inom intensivvård har speciell utbildning för att klara av den högteknologiska arbetsmiljön, som är fylld av stressande inslag.

År 2010, blev ett intensivvårdsrum med två patientplatser totalrenoverat med syftet att främja hälsa. Rummet renoverades enligt evidensbaserad design som syftar till att skapa helande och berikande miljöer. Cyklisk belysning installerades, och ljudabsorbenter sattes in i väggar och tak. En unik inredningsdesign med lugnande färger på väggar samt textilier skapades. Även en uteplats för patienter och deras närstående inreddes med möbler och blommor efter säsong. Syfte

Avhandlingens övergripande syfte var att undersöka och utvärdera om och hur ett intensivvårdsrum som renoverats enligt evidensbaserad design (EBD), påverkade säkerheten, välbefinnandet och vårdandet för patienter, deras familjemedlemmar samt för personal. Metod

Syftet i studie I var att utforska personalens erfarenheter av att arbeta i ett EBD-patientrum. Intervjuer genomfördes med åtta specialistsjuksköterskor inom intensivvård och fem undersköterskor, totalt 13 intervjuer. Data analyserades med kvalitativ innehållsanalys med induktiv ansats enligt Elo and Kyngäs (2008). Delstudie II fokuserade på att belysa innebörden av vårdande och omvårdnadshandlingar som genomfördes i två patientrum på intensivvårdsavdelning, varav ett var renoverat enligt EBD. Tio icke-deltagande observationer, varav sex genomfördes i interventionsrummet och

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fyra i kontrollrummet, med uppföljande intervjuer genomfördes. Fenomenologisk hermeneutik användes som analysmetod (Lindseth & Norberg, 2004). I delstudie III utvärderades skillnaderna mellan ett standardrum och ett interventionsrum på intensivvårdsavdelning gällande risk för komplikationer och negativa händelser hos intensivvårdspatienter. Data från 1938 patienters journaler inkluderades i studien. Deskriptiv statistik och binära logistiska regressioner utfördes. I studie IV undersöktes besökande familjemedlemmar och vänners uppfattningar om vårdmiljön gällande utformning och atmosfär i olika designade intensivvårdsrum. Enkäter samlades in under besökarna tid i patientrummen och totalt inkluderades 99 enkäter. Deskriptiv statistik och linjära regressioner utfördes. Resultat

Interventionsrummet beskrevs som en positiv erfarenhet av intensivvårdssjuksköterskorna och undersköterskorna samt av besökande familjemedlemmar. Personalen indikerade även att interventionsrummet stärkte deras eget välbefinnande och vårdande handlingar. Den upplevelsen kunde inte bekräftas i observationerna. Däremot identifierades det skillnader i personalens vårdande och omvårdnadshandlingar vilket tolkades bero på olika utvecklade vårdande kompetenser. Besökarna rapporterade att den berikade vårdmiljön i interventionsrummet hade större vardaglighet och upplevdes som en tryggare plats än kontrollrummen. Resultatet i studie III visade på färre rapporterade komplikationer i såväl interventionsrum som i kontrollrum, än vad som tidigare beskrivits i forskning. Det förelåg inte signifikant lägre sannolikhet för färre komplikationer i interventionsrummet än i kontrollrummen. Slutsats

Denna avhandling bidrog till det existerande kunskapsläget om hur ett renoverat intensivvårdsrum upplevdes av personal och besökande familjemedlemmar. Avhandlingen visade också på den komplexitet som finns i att genomföra interventionsforskning i högteknologiska miljöer. Den nya genererade kunskapen om vikten av vårdmiljöns betydelse för välbefinnande, säkerhet och vårdande bör beaktas av beslutsfattare och implementeras i den kliniska verksamheten samt i undervisning för att reducera lidandet och främja hälsa och välbefinnande för patienter, deras familjer samt för personal.

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ACKNOWLEDGEMENT

Undertaking a PhD degree is not a one-woman-show. This dissertation would not have been if there had not been these wonderful people around me who have in many diverse ways helped, guided, encouraged and persuaded me through the process of completing the education and the fulfilment of this dissertation. I would like to express my deepest and most sincere gratitude to all of you.

The Faculty of Caring Science, Work Life and Social Welfare and the

Department of Caring Science at University of Borås for giving me the opportunity to become a doctoral student and providing me with a workplace.

The Research School of Health and Welfare at Jönköping University where I was first enrolled as a PhD student and where my first seminars and courses were completed. A special appreciation to Bengt Fridlund and Kajsa Linnarsson for all their support, and to the doctoral student group, where I felt at home.

I have had the most supportive group of supervisors. I have always felt

welcomed and no question has ever been considered stupid. You have all supported me and pushed me to grow as a researcher. This dissertation would not exist without you!

Berit Lindahl, my main supervisor. Where should I start? The ink on the

hiring contract had barely dried when you sent me to Brighton. You have shown me the importance of international contacts several times, and we both share the same interest in travelling. You have been supportive from the beginning and available when I have needed you the most. Having 11-kaffe was and still is an excellent tradition, and the importance of self-rewarding after tasks were crucial for surviving academia.

Pingo, Ingemar Kåreholt, you have opened your office and even shared your mobile data with me. I have really appreciated our days in Jönköping, constructing dummy variables and me going from not understanding anything to at least understand something.

Isabell Fridh, the unique capability of really seeing what was missing or was unclear in texts is your superpower. Thank you for sharing and your efforts to really put patient and intensive care in focus.

Sepideh Olausson, you have thoughtfully and wisely commented on texts and been supportive and cheerful.

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Birgitta Wireklint Sundström, you have been supportive and really enthusiastic in the roll as examiner, which I have really valued.

To all of you who had read and commented on my texts and drafts throughout this research education, at seminars and other occasions, thank you. It has been really cherished. A special thanks to you, Christie Tetreault, for the thorough editing. Signe Wulund, at the library at University of Borås, thank you for all valuable help.

My fellow doctoral students at the University of Borås, thank you all for

everything, for friendship, joy and madness. We have shared rejections and acceptances, tears and joy. Without you, this experience would not have been the same. Åsa Israelsson-Skogsberg, my partner in crime. What would I have done without you? Our friendship is very dear to me, and you are so special and gifted. It has been a true pleasure to have shared this experience with you. We have travelled almost over the whole world together, and it is you who makes me feel at home in this crazy academic world.

Jonas Karlsson, you were the unofficial supervisor when Åsa Lundgren and I wrote our Master thesis and we never thanked you for that - Thank you! You made me wanting to go back to the University of Borås.

Marie, Matilda and Susanna, thank you for sharing the lunch room and

much more at KTC. All colleagues at the University of Borås, you are so encouraging and

supportive. All friends and former colleagues at KAVA and IVA, Skövde for cheering

for me and believing in me. My friends outside of academia who really kept me grounded. You all have

made the completion of this dissertation through your friendship and companionship.

Anna and Lisa, you have always been a part of my life and I wish it to always stay the same.

My childhood friends, Linda, Linn, Maria, Louise, Stina, Hanna, thank you for always believing in me, you are so supportive and loving and meeting you really recharges my batteries.

My friends at the tennis court, Angelika, Koutaiba and Stina, I had so much fun, and hitting all my frustrations in each stroke made me feel less stressed and gave me such joy. Looking forward a summer full of tennis.

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My friends in Broddetorp, Eva Westin, our walks and talks were the best therapy and when that was not enough, we had our Prosecco-nights. Åsa Paulsson, my dear friend, I envy your positivity and appreciate your friendship. Maria Willebrand, thank you and Kristoffer for signing all those documents five years ago, making it possible for me to be enrolled as doctoral student. Maria, you are amazing, cannot wait until next shopping trip with you.

My nearest and dearest, my family, Mamma, tack för att du alltid är min

ringhörna och stöttar mig när det behövs och pushar mig när det behövs, jag älskar dig!

To whom who is not here today, Pappa, du trodde alltid på mig och jag är övertygad om att du hade varit stolt idag!

Finally, my husband Bengt, thank you for all the technical support, you have saved me so many times, what would I have done without you? My marvelous sons, Arvid and Axel, my beloved boys who really put things into perspective and constantly reminded me what were the most important things in life – it is always you two. Jag älskar er!

This work was supported by grants from the Swedish Research Council (Vetenskapsrådet), Astrid Janzons stiftelse, Uppsala sjuksköterskehem, Vårdförbundet, Riksföreningen för anestesi och intensivvård (ANIVA)

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My friends in Broddetorp, Eva Westin, our walks and talks were the best therapy and when that was not enough, we had our Prosecco-nights. Åsa Paulsson, my dear friend, I envy your positivity and appreciate your friendship. Maria Willebrand, thank you and Kristoffer for signing all those documents five years ago, making it possible for me to be enrolled as doctoral student. Maria, you are amazing, cannot wait until next shopping trip with you.

My nearest and dearest, my family, Mamma, tack för att du alltid är min

ringhörna och stöttar mig när det behövs och pushar mig när det behövs, jag älskar dig!

To whom who is not here today, Pappa, du trodde alltid på mig och jag är övertygad om att du hade varit stolt idag!

Finally, my husband Bengt, thank you for all the technical support, you have saved me so many times, what would I have done without you? My marvelous sons, Arvid and Axel, my beloved boys who really put things into perspective and constantly reminded me what were the most important things in life – it is always you two. Jag älskar er!

This work was supported by grants from the Swedish Research Council (Vetenskapsrådet), Astrid Janzons stiftelse, Uppsala sjuksköterskehem, Vårdförbundet, Riksföreningen för anestesi och intensivvård (ANIVA)

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PAPER I-IV

Paper I

Intensive and Critical Care Nursing 43 (2017) 75–80

Contents lists available at ScienceDirect

Intensive and Critical Care Nursing

journa l homepage: www.e lsev ier .com/ iccn

Nursing staff’s experiences of working in an evidence-based designedICU patient room—An interview study

Fredrika Sundberga,b,∗, Sepideh Olaussonc, Isabell Fridhb, Berit Lindahlb

a The Research School of Health and Welfare, The School of Health and Welfare, Jönköping University, Swedenb Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Swedenc Institute of Health and Care Sciences, University of Gothenburg, Sweden

a r t i c l e i n f o

Article history:Received 10 February 2017Received in revised form 3 May 2017Accepted 15 May 2017

Keywords:Hospital design and constructionIntensive care unitsInterior design and furnishingsNursing staffQualitative research

a b s t r a c t

Introduction: It has been known for centuries that environment in healthcare has an impact, but despitethis, environment has been overshadowed by technological and medical progress, especially in inten-sive care. Evidence-based design is a concept concerning integrating knowledge from various researchdisciplines and its application to healing environments.Objective: The aim was to explore the experiences of nursing staff of working in an evidence-baseddesigned ICU patient room.Method: Interviews were carried out with eight critical care nurses and five assistant nurses and thensubjected to qualitative content analysis.Findings: The experience of working in an evidence-based designed intensive care unit patient room wasthat the room stimulates alertness and promotes wellbeing in the nursing staff, fostering their caringactivities but also that the interior design of the medical and technical equipment challenges nursingactions.Conclusions: The room explored in this study had been rebuilt in order to create and evaluate a healingenvironment. This study showed that the new environment had a great impact on the caring staffs’wellbeing and their caring behaviour. At a time when turnover in nurses is high and sick leave is increasing,these findings show the importance of interior design ofintensive care units.

© 2017 Elsevier Ltd. All rights reserved.

Implications for clinical practice

• Nursing staff need to be included in the process of designing intensive care units.• Improve sound environment with sound absorbents when building or refurbishing and install cyclic lighting in intensive care units

patient rooms.• Include nature in the process of designing intensive care units.• Offer adjustable mobile solutions for technical equipment and provide space around the patient bed.

Background

The intensive care unit environment

It is known that health care environment and lived space areimportant aspects of care. As early as in the nineteenth cen-tury Nightingale (1859) described the importance of the health

∗ Corresponding author at: University of Borås, Allégatan 1, 501 90 Borås, Sweden.E-mail address: fredrika.sundberg@hb.se (F. Sundberg).

care environment on health and wellbeing. She acknowledgedthe importance of aspects in the patients’ environment such asnoise, light, ventilation and cleanliness as assisting the healing. Butinstead of embracing Nightingale’s philosophy, hospitals and inten-sive care units (ICUs) were built like industries with production astheir goal. Hospitals today are full of elements of crowding, noise,too much or too little light, odours and mazes; all these elementsincrease stress in patients, visitors and staff (Norlyk et al., 2013;Sternberg, 2009).

The working environment of the staff is defined by the tech-nical equipment that is needed when providing patient care. The

http://dx.doi.org/10.1016/j.iccn.2017.05.0040964-3397/© 2017 Elsevier Ltd. All rights reserved.

76 F. Sundberg et al. / Intensive and Critical Care Nursing 43 (2017) 75–80

technology facilitates nursing activities and creates safety but isalso seen as taking too much time away from the patient andcreating stress as it restricts the patient care because the nursesfeel hindered in their work (Olausson et al., 2014; Price, 2013;Tunlind et al., 2015). The work environment for critical care nurses(CCNs) is reported to be unhealthy (Breau and RhÉAume, 2014).Epp (2012) found that CCNs are particularly vulnerable to devel-oping burnout due to the chronic occupational stressors, whichinclude high patient acuity, high levels of responsibility, workingwith advanced technology and caring for families in crisis. The workin ICUs is carried on around the clock and the staff are often forcedto work in narrow spaces and expected to interact with machinesfrequently without being able to influence their functions. There isa lack of evidence regarding the comfort issue in relation to staff.Previous research claims that further research is needed to deter-mine what staff require of their work environment (Huisman et al.,2012).

Design and architecture of intensive care units

The role of healthcare facilities is to provide stable environmen-tal conditions that avoid disturbing the patients’ healing process(Codinhoto et al., 2009). Over the decades advances in intensivecare medicine and technology have been impressive, this has not,however, been matched by adjustments to the buildings. Sophisti-cated technology are characterising for ICUs (Almerud et al., 2007;Meriläinen et al., 2013). New equipment is often placed in thepatient room where there is a free space rather than being inte-grated into the design of the patient’s room. Obviously this placesnew demands on the design of the ICU and shows the current needfor quality development (Rashid, 2011). Ulrich (1984) reported thatpatients cared for in surgical wards and assigned to rooms withwindows looking out on a natural scene had shorter postoperativehospital stays and needed fewer potent analgesics than the patientsassigned to rooms with windows facing a brick building. This studyled to the development of the evidence-based design (EBD) con-cept. By designing and decorating the ICU room according to EBDframework many of these problems may be eliminated or moder-ated. The conceptual framework of EBD includes audio and visualenvironments; safety enhancement: a wayfinding system; sustain-ability; the patient room; and support spaces for family, staff andphysicians (Ulrich et al., 2010). With focus on the impact of archi-tecture on health environments, EBD has evolved as a new researchfield. It offers a guide to healing environments and a way in which tointegrate knowledge from various research disciplines, in order toimprove decision-making about health surroundings and architec-ture based on the best available knowledge (Hamilton and Watkins,2009; Ulrich, 2012). Any country or hospital that is in the plan-ning stages of building new, or reconstructing existing ICUs, needa well-tested basis on which to build and design an optimal careenvironment for patients, their loved ones and staff (Rashid, 2014).Despite their expertise in design and construction, architects alonecannot create the ultimate ICU room (Rashid, 2011; Redden andEvans, 2014; Thompson et al., 2012). In the process of designing anICU it is necessary to take into account the experience and knowl-edge of healthcare professionals (Hamilton and Watkins, 2009;Redden and Evans, 2014). Such integration and multi-disciplinarycollaboration is often missing today. The healthcare environmentis an important but a recognized aspect of healing in ICU care. Thedevelopment of medicine and technology has led to ICU patientsbeing more aware of their surroundings and the increased stress-ors in their already critical state. The work environment is full ofstressors for the staff, resulting in a high turnover and burnout syn-drome in CCN. This leads to the question, could an EBD-designedpatient room be a way to reduce these problems?

Aim

The aim of this paper was to explore the experiences of nursingstaff working in an Evidence-based designed ICU patient room.

Method

This study is explorative and data were collected through qual-itative research interviews and analysed using inductive contentanalysis (Elo and Kyngäs, 2008). The method aims to achieve acondensed but broad description of the actual phenomenon underscrutiny and the outcome of the analysis is in form of concepts orcategories that describe the phenomenon (Elo and Kyngäs, 2008;Polit and Beck, 2016).

Setting – a refurbished intensive care unit patient room

The study was carried out in an eight-bed general ICU in Swedencaring for about 800 patients each year. One patient room wasrenovated and furnished in 2010 (Lindahl and Bergbom, 2015),according to the principles of EBD and the guidance available forcomplex intervention research (Craig et al., 2008). The room wasdesigned for two beds, equipped with acoustic panels on the wallsand ceiling and new flooring. In addition prototype pendulumswere installed, equipped with lights, electrical sockets and medicalgas supplies. Cyclic light was installed (Engwall et al., 2014) andthe medical and technical devices were placed where the patientscould see them and not, as is usual, behind the headboard. The wallswere painted in soothing shades, organic textiles and decorationsand comfortable furniture for visitors placed in the room. The roomhas a window and door leading onto a patio with furniture and sea-sonal plants outside the room which is accessible to patients andtheir relatives (Lindahl and Bergbom, 2015).

The unit is located on the ground floor with windows in allrooms, half of the patient rooms have doors leading directly tothe outside. The unit uses light sedation regimens, which meansthat the estimated level for the Motor Activity Assessment Scale(MAAS) is 2–3 (Devlin et al., 1999). Staff are always present at thebedside. The nursing staff comprises CCNs (60%) with further qual-ifications in intensive care and assistant nurses (ANs) (40%). Thenurse-patient ratio is 1:1 or 1:2 and generally a CCN and an ANwork together on each shift.

Participants

The interviewees of comprised eight CCNs and five ANs (n = 13)and were recruited using purposive sampling (Polit and Beck,2016). The study was introduced at a staff meeting where infor-mation was given that we wanted participants with various viewsand perspectives. As the aim was to reflect the constitution of thestaff, more CCNs were interviewed than ANs. The participants wereaged from 39 to 59 and had been working in the ICU for 4–38 years.All the CCNs worked all shifts (day, evening and night) as did ANsexcept two (who did not work night shifts). Both CCNs and ANsworked in all rooms in the unit and no staff was allocated solely tothe refurbished room.

Data collection

Data were collected between April and September 2015. Gen-eral information about the study was given on two occasions duringstaff meetings. All CCNs and ANs then received a letter invitingthem to participate in their workplace mailboxes. Those who indi-cated that they were interested in participating were contacted tocheck that they met the inclusion criteria. The participants chosethe time and place for the interview. Open-ended interviews were

F. Sundberg et al. / Intensive and Critical Care Nursing 43 (2017) 75–80 77

Table 1Description and summary of categories and subcategories.

Category Subcategory

A room that stimulates alertness Light as a support for caringA sound formation that offersharmony

A room that promotes wellbeing A comfortable environmentA room that fosters caring behaviours Homely atmosphere

Facilitates communicationA room that challenges nursing

activitiesA different roomLimited accessibility

conducted in order to obtain data that had greater depth and moredetails. All interviews started with the same introductory ques-tion; “What is it like to work in the refurbished patient room?” Theinterviews lasted for 30–60 minutes and were digitally recorded.

Ethical considerations

Before signing a consent form the participants received bothwritten and oral information about the study and their right towithdraw at any time without giving any explanation. Written con-sent was obtained from the chief clinicians responsible for the ICU.The project was fully authorized by the Regional Ethical VettingBoard (695-10).

Data analysis

Qualitative content analysis (Elo and Kyngäs, 2008) with aninductive approach was used since the topic was considered tobelong to an unknown research field. The interviews were tran-scribed verbatim and read through several times so that theresearchers could familiarise themselves thoroughly with the data(Elo and Kyngäs, 2008). The analytical process then began withrepeatedly identifying codes and subcategories, to ensure thatnothing was omitted. Subcategories were grouped together accord-ing to common content and then abstracted to form categories.Finally the material was read once again as a whole in order tocheck the trustworthiness and the accuracy of the abstraction ofcontent and meaning and presented in the categories.

Findings

Four categories with subcategories emerged from the analy-sis (Table 1). The findings are presented below and illustrated byquotations from the interviewees.

A room that stimulates alertness

All the participants were positive towards the sound and lightin the room and wished the entire unit had been refurbished in thesame way. They stated that the effects of the sound and light gavethem a feeling of alertness.

Light as a support for caringBefore the refurbishment project nursing staff used to work in

dim surroundings. As the lights in the other patient rooms shonedirectly into the eyes of the patient, in order to protect them, nursesdid not always turn the lights on, meaning they worked in shadow.On occasions they forgot to turn the light on as they were too busy.The participants really appreciated that the light in the refurbishedroom was automatic and came from floor level, headboard andthe pendulums. They explained that the cyclic light made themfeel they could more easily focus on their patients and the caringactivities due to the change of light during the day.

“Otherwise you step into fatigue, entering a dark room. [The light]Invites you to be alert the whole time somehow. (CCN 2).”

The cyclic light was reassuring for the participants in that it wasalways the best light for the patients and not needing to adjust thelight, gave them one thing less to worry about.

“So it affects you, because you know that when I enter the refur-bished room, I know that there is a current lighting that will beadapted throughout the day. So I feel better, entering the room(CCN 2)”

The staff in the ICU normally switched off the lights in thepatient rooms during the lunch hour and also tried to pause patientactivities in order to allow patients to get some rest. Some of theparticipants said that after their lunchbreak, they usually felt verytired in the dark rooms (the other patient rooms) and it was diffi-cult to stay focused on the patients but the light in the refurbishedroom helped them to stay alert and focused because it was brighterthan in the other rooms.

A sound formation that offers harmonyAlthough the technical equipment in the refurbished room was

identical with that in the other patient rooms, the staff experi-enced the sound environment as much better. Normally the nursesworked in a noisy environment where the sounds were harsh andalarms from technical devices produced echoes. In the refurbishedroom, they felt the sound was softer, lower but distinct and not astiring as in the ordinary rooms.

“Even if there are alarms and beeps from the neighboring patient,there is not the same intensity in the sound. It is more harmonic, ifone can say that a beep can be like that (giggle). . .(AN 10)”

The participants felt that sound and noise were absorbed whichmade them more aware of noise in general leading in turn to themtalking in a lower tone to each other and to the patients and tothink more about how they performed their daily duties. One exam-ple mentioned was opening sealed packages outside the room toavoid disturbing the soft and comfortable sound environment forthe patients and for themselves.

“a completely different way than it does in the other patient rooms. . . in there, it’s like the sound is just eaten up, it is sucked intosomething so that is not at all a harsh sound . . . it is like entering adifferent atmosphere, somehow (CCN 7)”

The feeling that sound was being absorbed was experiencedimmediately on entering the refurbished room and this differentsound environment made it easier to concentrate on their workand stay alert. With fewer noise stressors they felt more energizedand ready for work.

A room that promotes wellbeing

The refurbished room with its different colours, textiles, the spe-cial light and sound created a different environment which wasvery appealing. Entering the room almost immediately made theparticipants feel more relaxed and calm. This feeling lingered evenafter they ended their shift and were heading home. But not onlydid the room prevent them from feeling stressed, it calmed themdown if they felt stressed when they entered it. The atmospherein the room made them feel as if they could endure more setbacksand difficult situations were perceived less serious than in the otherpatient rooms and they could instead focus all their attention andenergy on the patient.

“It’s like coming, yes; it’s a whole different world when you go inthere (CCN 4)”

78 F. Sundberg et al. / Intensive and Critical Care Nursing 43 (2017) 75–80

A comfortable environmentThe sound level and the different sound environment, softer

than in the other patient rooms, made it appear as if the refur-bished room was enclosing them. They all felt more at peace andthat the environment there helped them to prevent their level ofstress rising as it usually did in their work situations. The partici-pants stated that if they felt stressed on entering the refurbishedroom, it helped them to calm down and reduced their adrenalineproduction when faced with serious situations.

“Actually I am more, you are happier and calmer and harmoniousand you are a bit like; now we are in this room. . . It is different. Yesa different calm and different, you feel that you are a completelydifferent person (laughter) when you are working in there (CCN 4)”

After a shift they were not as tired as they usually were whenworking in the ordinary patient rooms. The participants said thatthey felt more relaxed both while they were present in the refur-bished room and also after they had finished their shift. They feltthat they had more energy than they used to have working in theother patient rooms.

“yes, it is a different atmosphere in there somehow . . . it’s likesomething completely different, it’s difficult to explain. I feel morerelaxed, perhaps, that you, I do not think you really have the samepace, in the same way, that everything is so, yes you are a bit calmerand therefore quieter and can take it at a different tempo, like. . . .(CCN 7)”

When leaving the refurbished room on errands to other areas inthe ICU, they could be almost surprised by the activity, both phys-ical and emotional, on the ward. Then it felt good to return to therefurbished room again.

“Then you put on some music in there, some soft music, and it’senjoyable. It’s a bit like, well going into a spa, almost. It is so quietthere (CCN 7)”

A room that fosters caring behaviours

The environment in the intervention room, especially with viewto nature outdoors so accessible and nearby made the room feel lesslike a hospital and more like a home environment. The atmospherein the room created by the different colours, light and sound madethe nursing staff feel they had more energy to care for their patients.

Homely atmosphereThe atmosphere made it easier to see the patient as a person

rather than a diagnosis. The natural scenery helped the participantsconnect better with the outer world and reminded them, and theybelieved that it also reminded the patients and their next of kin, thatthere was still a world beyond the room. The participants hopedthat the natural view would encourage the patients to struggle lit-tle harder to recover so they could return home. When caring forpatients in the palliative phase, the participants said that they feltthat they could offer something more; not just an ordinary room,but rather an experience. The participants stated that they felt thatthe atmosphere of the room gave dignity to their patients.

“I experience a more home-like environment inside, [the refur-bished room] so what’s it called, I reflect it, I think that feeling iscontagious [to the others] (CCN 2).”

With nature so close by and accessible, the interviewees hopedthat not only would the patient struggle harder, but would also beled to think about recovery a little bit sooner than patients in theother patient rooms.

“you feel healthier when you see the other life, I think so. . .. it affectsso much, when you see the nature; home is not as far away, and Iactually think that you think so. If you only look into a brick wall,then you are so isolated, you are in another world, and then, perhapsyou do not have the strength or the will to move forward. (CCN 6)”

Nature and life going on outside inspired them to get the patientmobilized a little earlier than usual, and also to get them eating anddrinking again.

“I think that you move forward a little faster and think about mobi-lizing them and starting − would you like something to drink, andyou, it sounds strange, but you are so different in that room, Iactually think so (CCN 4)”

Facilitates communicationSeveral participants spoke about how the improved sound envi-

ronment made communication with both patients and colleagueseasier. Communication with patients in the ICU is often difficultdue to intubation and the staff has to lip-read. In situations whenpatients do have a voice, it is often weak and faltering. However,the refurbished room reduced disturbing noise and led some of theinterviewees to feel that communication was facilitated.

“There were a lot of people in there, and yet you were able to talk toeach other, if you think about the sound here (the interview room),here you have it in the background all the time, disturbing and irri-tating, you have a small echo all the time. But not in there. . .Andthen you don’t have all the beeps and strange noises from our equip-ment. So it also means that there is, uh, a more pleasing sound. (CCN8).”

A room that challenges nursing activities

The patient room was refurbished using existing premises; nowalls were moved so the room area was unchanged. Despite thisthe participants felt that the room, like the ordinary patient rooms,was too small. The new design of the refurbished room confusedthem sometimes as they had to orientate themselves differentlyand they felt that access to patients and equipment was sometimeslimited.

A different roomThe participants thought that the refurbished room was dif-

ferent from the other patient rooms, not necessarily in a good orbad way − just different and this difference was challenging whenentering the room. This was a problem especially at the beginningas equipment was not in the same place as in all the other patientrooms in the unit. There was an overall wish among the inter-viewees that all rooms had been designed in the same way; theydid not prefer one room over the other, but wanted the placing ofequipment and the furnishing to be the same.

“Everything is in completely different places, yes, the storage. . ., onthe shelves in the cupboards and so on, they are not the same, soyou have to think: Right, today I am in this room, (CCN 1)”

Limited accessibilityThe refurbished patient room was equipped with some medical

technical prototypes e.g. the pendulums that were to be clinicallytested and evaluated. All the nursing staff wanted the pendulumsto be moveable. As they were, the pendulums sometimes hin-dered direct access to patients. Instead, staff had to go around thependulums or crouch, which irritated and frustrated them. Thependulums were also placed at a difficult height where shortermembers of staff could not reach them easily and the tall onessometimes hit their heads while caring for the patients. This was

F. Sundberg et al. / Intensive and Critical Care Nursing 43 (2017) 75–80 79

never mentioned as a hazard for the patients but was rather seenas a work environment problem.

“It is much more complicated in there. To get close, and there’s alot of stuff hanging from the ceiling, along the patient bed, it is notjust behind or just next to the head of the bed but also, yeah, thereare lamps hanging down and a lot of tubes. (CCN 7)”

Discussion

This study indicates that the ICU environment itself can beexperienced as a healing atmosphere for both patients and staffby building or refurbishing ICUs following the principles of EBD.Improving the healthcare environment led to the nursing staffexperiencing a personal alertness and wellbeing that fosteredtheir caring activities vis-á-vis the patients. Moreover, the findingsrevealed that an ICU patient room needs to be spacious in order tofunction well.

One of the most important roles for the nurses when caring forcritically ill patients is to provide comfort (Cypress, 2011). Facilitat-ing comfort, for both patients and staff, requires consideration tobe given to the environment. The participants in this study statedthat if they feel better they deliver better care. Norlyk et al. (2013)showed that patients see professionals as the ones who create anatmosphere in which they feel supported and cared for. Our argu-ment is that if the ICU environment is improved it helps the staffto create a more supportive and caring atmosphere, which is whatpatients want and need in order to recover. Nursing is much morethan carrying out technical tasks and the places where nursingoccurs are not just physical sites but also involve human intentions.Places are combinations of the personal attachments, emotions andfeelings that nurses bring to a variety of care settings (Andrews,2016, 2003).

Lived space refers to “the more” of the physical space, in otherwords, felt experiential space (Norlyk et al., 2013; Van Manen,1997). In this study “the more” was experienced in the refurbishedroom, as an atmosphere more like home. At-homeness representsfeelings of belonging and tranquility as well as a close personal rela-tionship; home is a lived space where we feel protected, hidden andsafe (Norlyk et al., 2013; Van Manen, 1997). According to the Nor-wegian philosopher Martinsen (2006) houses can metaphoricallyeither sing or scream. And where ICUs normally scream, nursingstaff perceived this refurbished room to sing, hopefully not only forthemselves but also for patients and their next of kin allowing themall to dwell in the room. The fundamental atmosphere in dwellingis having a foothold in existence, and this may be described asbelonging, being safe and feeling at home (Martinsen, 2006).

An improved work environment may reduce burnout amongnursing staff, increase job satisfaction, minimise the risk ofturnover, and keep experienced and skilled professionals in place.This will result in patients being cared for by skilled nurses whostay in the profession and who feel good in their jobs; it con-stitutes a way of conducting social sustainability. Tummers et al.(2013) found that a negative work atmosphere had a strong influ-ence on nurses’ intentions to leave their organisations and thatthe impact of the work atmosphere is not often the subject ofresearch. Other studies show similar findings where noise and feel-ing of stress are linked (Applebaum et al., 2010; Ryherd et al., 2008)and where improvements in the work environment in general andthe sound environment in particular have been correlated withimprovements in mental health, wellbeing, resilience, and the cop-ing strategies of healthcare professionals (Schreuder et al., 2012;Wang et al., 2013). Johansson et al. (2016) showed that staff reallywants to improve the environment in the ICU and that they try toachieve this with the tools available to them. They adjust lights andcurtains in order to change the environment for the better although

they feel powerless to influence decision making about design andrefurbishing.

The participants stated that, when working in the refurbishedroom, they felt more alert and relaxed both while they were actu-ally in the patient room and after finishing their shift. Having moreenergy after working a shift meant that the staff was more ableto engage with their families and friends and pursue their hobbiesin their leisure hours. We argue that this promotes wellbeing andfacilitates satisfaction among employees thus minimising the riskof high turnover among the nursing staff.

Previous research has focused on only one aspect at a time ofthe healthcare environment, e.g. light or noise, or view of nature(Ulrich, 2012). This study has a holistic perspective as it includesall those aspects and in this it is unique. The participants spokeof the refurbished room and the atmosphere within it and that itwas this atmosphere which inspired them to improve their caringactivities.

ICUs are in great need of flexible bed spaces as technical equip-ment is brought into the rooms according to patients’ needs. Thatmeans that the bed space varies in accordance with the phys-ical condition of the critically ill patients, in that it constantlychanges due to the presence of machinery and therefore takes dif-ferent forms (Olausson et al., 2014). This study also confirms theimportance of consistency of room layout as uniformity designcan support nursing staff in their work. The prototypes of thependulums lacked this flexibility meaning that they need furtherdevelopment before being put on the market.

Limitations

The findings in this study provide a rich description of the expe-riences of nursing staff working in an evidence-based designedICU patient room. Both CCNs and ANs were invited to partici-pate but not physicians because, unlike CCNs and ANs, they arenot at the bedside around the clock and they can therefore beseen as visitors to the patient room (Halford and Leonard, 2003).The open-ended interviews allowed the participants to talk freely,producing detailed descriptions concerning the subject in focus.Authentic quotations are presented to enhance credibility, enablingthe reader to decide whether or not our interpretations are reason-able (Elo and Kyngäs, 2008).

Since all the authors, apart from being researchers, are CCNs,we have a contextual understanding of the research field. Theinterviewer had never worked at the ICU where the partici-pants were employed and therefore had to question personalpre-understanding.

To achieve trustworthiness, prolonged engagement (Creswell,2007) was used. After 11 interviews, even if the collected data wasdeemed rich and detailed, two more interviews were conductedin order to provide a comprehensive dataset. As Elo et al. (2014)suggest for conducting inductive content analysis, the first author(FS) was responsible for the analysis and the other co-authorsthoroughly followed up the whole process of analysis and cate-gorisation. Since all the interviews were transcribed verbatim, theco-authors had access to the whole of the material and consensuswas reached after discussion of what the content was all about.Transferability is limited due to the uniqueness of this study. Asthis kind of research, i.e. evaluation of a complex intervention con-cerning interior design in an ICU patient room, is in the early stages,further development of a methodology adjusted to an ICU contextis required.

In conclusion the room explored in this study was rebuilt withthe aim of creating and evaluating a healing environment for themost seriously ill patient group in hospitals. This study shows thatimproved sound environment, cyclic lightning, interior design and

80 F. Sundberg et al. / Intensive and Critical Care Nursing 43 (2017) 75–80

view to nature had a great impact on the wellbeing and caringbehavior of the nursing staff. In times when the turnover in nursingstaff is high and the incidence of sick leave is increasing, the interiordesign of ICUs assumes a great importance.

Funding sources

This work was supported by the Swedish Research Council,Stockholm, Sweden (grant number 521-2013-969). They had noinvolvement in any part of the research process.

Conflict of interest

There are no conflict of interest.

Appendix A. Supplementary data

Supplementary data associated with this article can be found, inthe online version, at http://dx.doi.org/10.1016/j.iccn.2017.05.004.

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Crit Care Nurs QVol. 42, No. 3, pp. 265–277Copyright c© 2019 Wolters Kluwer Health, Inc. All rights reserved.

Room Design—APhenomenological-HermeneuticalStudyA Factor in Creating a CaringEnvironment

Fredrika Sundberg, CCRN; Isabell Fridh, PhD, CCRN;Sepideh Olausson, PhD, CCRN; Berit Lindahl, PhD, CCRN

Medical technology has progressed tremendously over the last few decades, but the same devel-opment cannot be seen in the design of these intensive care unit environments. Authors reportresults of a study of evidence-based room design, emphasizing the impact on conveying a car-ing attitude to patients. Ten nonparticipant observations were conducted in patient rooms with2 different designs, followed by interviews. The data were analyzed using a phenomenological-hermeneutical approach. The results did not reveal that it was obvious that redesigned spacesresulted in a more caring attitude. The meanings of caring displayed during nursing activitieswere interpreted by interpreting gazes. Some of the nursing staff had an instrumental gaze, in-terpreted as caring with a task-orientated approach, while others communicated their caring withan attentive and attuned gaze, where the needs of the patients regulated the working shift.The study findings indicated that caring may not be perceived when nurses use a task-orientedapproach. However, when nurses practice a person-centered approach, using an attentive andattuned gaze, caring is conveyed. Caring in intensive care contexts needs to be assisted by a sup-portive environment design that cultivates the caring approach. Key words: caring, critical carenursing, evidence-based design, intensive care units, qualitative research

I NTENSIVE CARE NURSING takes place ina high-tech environment that is designed

for saving lives and implies a context where

Author Affiliations: Department of Caring Science,Faculty of Caring Science, Work Life and SocialWelfare, University of Boras, Boras, Sweden(Ms Sundberg and Drs Fridh and Lindahl);Department of Anesthesiology and Intensive Care,Sahlgrenska University Hospital, Gothenburg,Sweden (Dr Fridh); and Institute of Health and CareSciences, Sahlgrenska Academy, University ofGothenburg, Gothenburg, Sweden (Dr Olausson).

This work was supported by the Swedish ResearchCouncil, Stockholm, Sweden (grant number 521-2013-969). They had no involvement in any part of the re-search process.

The authors have disclosed that they have no signif-icant relationships with, or financial interest in, anycommercial companies pertaining to this article.

Correspondence: Fredrika Sundberg, CCRN, Depart-ment of Caring Science, Faculty of Caring Science, Work

care is given to patients experiencing life-threatening conditions. To provide care forcritically ill patients, the intensive care unit(ICU) is filled with and characterized by so-phisticated technology.1,2 Intensive care isconducted around the clock, and there arealways sound and light diversions.3-5 Medicaltechnology has evolved tremendously in thelast few decades; however, the same develop-ment cannot be seen in the design of ICU en-vironments, where the most ill and vulnerablepatients receive care. The current study illu-minates the meaning of caring and nursing ac-tivities performed in an ICU, with 1 room hav-ing been rebuilt according to evidence-based

Life and Social Welfare, University of Boras, Allegatan1, 501 90 Boras, Sweden (fredrika.sundberg@hb.se).

DOI: 10.1097/CNQ.0000000000000267

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265

266 CRITICAL CARE NURSING QUARTERLY/JULY–SEPTEMBER 2019

design (EBD). Evidence-based design is aconcept of integrating knowledge from vari-ous research disciplines into healing environ-ments for patients and their families, as wellas for staff.6,7 The study takes a nursing ge-ographical approach,8 and we argue that theknowledge collected through this study canbe transferred to other nursing contexts. Westart with a contextual description of what itis like to work in an ICU.

Caring and nursing activities have differentlevels of intensity. There are times when only1 staff member is in the patient room, mon-itoring patients in stable condition and evenoffering patients lunch. However, then some-thing occurs, such as a patient being newlyadmitted or undergoing sudden deterioration.Then, there is a shift from being alone indim surroundings to, out of nowhere, havingthe room filled with nurses, assistant nurses(ANs), and physicians. Sometimes, up to 10people come from different locations and in-vade the patient’s room; now, the room isflooded in sharp and piercing light. Althoughthere are many more people in the room,the sound level does not necessarily increase.The staff start working like bees in a beehiveand know exactly what the patient needs andwhat their responsibility is; they work imme-diately, sometimes alone with different tasksand sometimes together. The team leader su-pervises all the activities that are occurringand to whom the team communicates the ac-complishment of activities. When a leader isabsent, important activities risk being left un-executed. The room can even turn into an op-erating theater if this fits the condition andneeds of the patient. Then, just as suddenly asit rose, the intensity drops, and there is only1 staff member in dim surroundings, who re-turns to offering patients supper.

BACKGROUND

Caring and nursing

According to Roach,9 caring is the mostcommon, authentic criterion of humanness.Roach claimed that caring is a purely “human

mode of being” that is common to all hu-manity but uniquely expressed through nurs-ing. Caring is a complete way of engagingwith another person that entails the authen-tic expression of the self. The work of pro-viding excellent nursing care is focused onhumans’ relational and unique nature. Profes-sional caring is more complicated than, for in-stance, being nice, and Roach9 theorizes thatthe attribute of caring consists of 6 Cs, as fol-lows: compassion, competence, confidence,conscience, commitment, and comportment.Nursing is often considered to comprise us-ing nursing skills and executing techniques topromote health and prevent illness, whereascaring is considered to be the essence of nurs-ing. Therefore, there may be a difference be-tween “taking care of” patients and “caringfor” patients.10 Taking care of patients is anobjective process centered on the patients’medical-surgical needs, while caring for pa-tients is a subjective process grounded innurses’ humanness. The focus in this study iscaring for patients.

Caring in ICUs

When providing care for critically ill pa-tients, medical technology is an essential partof the treatment. The patients in ICUs are gen-erally immobilized because of the technicalequipment needed for monitoring and caringfor them.11 However, technical skills are notsufficient when caring for patients in the ICU,both technical mastery of the technology andcaring skills are required from nurses in ICUs.Critical care nurses (CCNs) are seen as bothcaring and technical experts, which meansthat they must understand, interpret, and acton physiological data that are essential for thebenefit of the patient.12 Patients are undera tremendous amount of stress,13 and caringfor patients in the ICU should focus not onlyon how to treat their physical symptomsbut also how to identify and support theirpsychological well-being.14,15 Caring in thecontext of intensive care means havingemotional skills, where being involved withthe patient and being there means acknowl-edging the patient as a person rather than a

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Room Design for Caring Environment 267

body.12 This is also a part of person-centeredcare. Cederwall et al16 found that, for person-centered care, CCNs strive to find the personbehind the patient with the intention ofunderstanding the patient’s perspective andhis or her current situation as a starting pointfor initiating a partnership with him or her.

The health care environment

The built environment influences healthoutcomes, both in society in general andin hospitals17-19; thus, the health care en-vironment can promote health and well-being. However, the built environment canalso cause health care–related problems andillness.20,21 The concept of EBD has evolvedas an attempt to integrate knowledge fromdifferent research disciplines into design-ing healing environments.6,22 Increasingly, re-search from various disciplines has shown theneed for an environment in hospitals that aidsin healing.23 There is growing evidence thatthe ICU environment affects nurses’ ability toprovide safe patient care.23 The care environ-ment is one of the linchpins in the person-centered nursing conceptual model,24 whichaims to individualize patient care.

An important question is whether the de-sign and environment affect nursing staff’scaring activities. In an earlier study focus-ing on nursing staff’s experiences of work-ing in an ICU patient room designed usingthe EBD principles, the nurses stated thatthe redesigned room fostered their caringactivities.25 These findings raised the ques-tion of whether an enriched environmentcontributes to nurses’ caring activities. If so,is it visible in the nurses’ caring activities? Itis also of interest to gain knowledge abouthow ICU nursing staff members reflect ontheir activities in relation to the enriched en-vironment. How do they express their caringresponsibilities and the nursing attributes ofcaring?

AIM

The aim of the current study was illuminat-ing the meanings of caring and nursing activ-

ities performed in 2 patient rooms, where 1had been rebuilt according to EBD.

METHODS

A phenomenological hermeneutical met-hod,26 inspired by Ricoeur’s27 philosophy,with nonparticipant observations in combi-nation with interviews was used to describeand interpret nursing staff’s everyday activi-ties. The design was phenomenological (de-scriptive) because the study focused on howthe phenomenon of caring activities appears.Moreover, the study was hermeneutical (in-terpretive) because a text—in this case, fieldnotes and interview transcripts—is always in-terpreted by the reader.27

Participants and settings

The present study was conducted in a gen-eral ICU in Sweden that cares for about 800patients each year. The nurse-patient ratio is1:1 or 1:2, and there are always staff presentat the bedside. Generally, a CCN and anAN work together each shift. According toSwedish law, CCNs are responsible for nurs-ing care; they have a professional certifica-tion and have completed a 4-year educationprogram at the university level, whereas ANshave a college diploma. Both CCNs and ANsparticipated in the current study; a CCN stu-dent also participated. The latter was a regis-tered nurse pursuing her master’s degree inintensive care science; she was 1 week awayfrom graduating as a CCN. The participantswere aged 22 to 55 years, and their work ex-perience ranged from 3 weeks to 12 years inthe specific ICU. The participants consistedof 7 CCNs, 1 student, and 7 ANs, or 15 partic-ipants in total.

The nonparticipant observations wereconducted in 2 different 2-bed patient roomsin the ICU. The patient rooms were situatednext to each other. One of the rooms hadbeen redesigned, whereas the other had keptits original design. The redesigned patientroom had been refurbished in 2010,28

guided by the idea of complex interventionresearch29 and principles of EBD.7 Acoustic

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268 CRITICAL CARE NURSING QUARTERLY/JULY–SEPTEMBER 2019

panels had been built into the walls andceiling, and new flooring had been installed.In addition, prototype pendulums had beeninstalled, equipped with lights, electricalsockets, and medical gas supplies. Cycliclights, with automatic dusk and dawn, hadbeen installed. The walls had been paintedin soothing shades, with organic textiles anddecorations, and comfortable furniture forvisitors had been placed in the room. Theroom had a window and a door leading ontoa patio with furniture and seasonal plantsoutside, which was accessible to patients andtheir relatives (Figure 1a and b).28

Data collection

The data were collected through a com-bination of nonparticipant observation30 andfollow-up interviews. General informationabout the study was given at 2 occasions dur-ing staff meetings.

Nonparticipant observations

Observation is the act of noting a phe-nomenon and recording it for scientificpurposes, and it is characterized by a moresystematic and formal process than the ob-servation that characterizes everyday life.30

In nonparticipant observations, the peoplebeing observed are informed that their be-havior is being recorded and the researcherwill not participate in any events that occur.The nonparticipant observations performedin the present study were conducted during

both day and evening shifts. In total, 10 non-participant observations were conducted,totaling 47.5 hours (an average of 4-6 h/d).The observer, who was an experienced CCNbut had never been employed in the ICU un-der study, refrained from participating in thenursing care with a view to obtaining moreaccurate observations of the caring activities.The observer wore staffing scrubs. First, 6nonparticipant observations were conductedin the room with the original design, andafter those sessions, 4 were conducted inthe redesigned room. Field notes were takenduring the observations.

Interviews

The nursing staff members were in-terviewed after the observation sessionsregarding their lived experiences of thecaring activities they had carried out duringthe working shifts (Table 1). The participantschose the time and place of the interview.Most of the interviews were completed di-rectly after the shifts but 2 were scheduled upto a few weeks later. Some of the interviewswere conducted with both the CCN and theAN at the same time, and sometimes, theseinterviews were conducted separately. In to-tal, 11 interviews were conducted, including3 pair interviews and 8 individual interviews(Table 1). All the interviews were conductedaccording to the preferences of the researchparticipants. Five of the observed researchparticipants declined to participate in the

Figure 1. (a) Original design of the room. Used with permission. Copyright Lindahl. (b) Redesigned room.Copyright Lindahl. Used with permission.

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Room Design for Caring Environment 269

Table 1. Overview: Data Collectiona

Room Observation Shift CCN + ANIndividualInterview

PairInterview

1 Day A2 Day B + a X

Ordinary room 3 Day C + a X4 Day B + b X5 Day D + c X6 Evening E + d

7 Day Student + e XRedesigned room 8 Day Student + e X

9 Evening F + f X10 Day G + g

Abbreviations: AN, assistant nurse; CCN, critical care nurse.aCritical care nurses are denoted in uppercase letters and assistant nurses are denoted in lowercase letters.

interviews. Open-ended interviews wereconducted for obtaining material that hadgreater depth and more detail.31 The fieldnotes guided the interviews individually toadd a more comprehensive understandingof them. All the interviews started with thesame introductory question: “How did youexperience this shift?” They were digitallyrecorded and transcribed verbatim.

Data analysis

The field notes from the observationsand the transcribed interviews were readand reread repeatedly as a whole andthen as parts that were subjected to anal-yses according to the phenomenological-hermeneutical method described by Lindsethand Norberg.26 The steps of these analysesare naive reading, structural analyses, and

comprehension of the whole. Naive read-ing, or understanding, is derived from severalreadings to perceive the meaning of the en-tire text. The next step is a thematic struc-tural analysis used to identify and formulatethemes. The whole text is read in a more ob-jective mode and divided into meaning units.Then, the meaning units are condensed intosubthemes and themes (Table 2).

The themes were read and reflected onto validate the naive understanding. Theresults from the thematic structural analy-sis are presented in the form of 2 fictivecomposite stories.32,33 These stories are de-rived from the subthemes and themes thatemerged in the thematic structural analyses(Table 2), and they are presented in fictivevoices. Quotations from the research partici-pants are inserted to validate and illustrate the

Table 2. Thematic Structural Analysis

Subtheme Theme

Being vigilant and attentiveBeing part of a team Being attuned to caringBeing experienced eases my workload

Medical charts control my nursing actionsRoom storage occupies my day Being a cog in a bigger wheelBeing in a hierarchal system

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270 CRITICAL CARE NURSING QUARTERLY/JULY–SEPTEMBER 2019

interpretation of the text. The last step in thephenomenological hermeneutical analysis isobtaining a comprehensive understanding.This phase aimed to summarize and reflecton the subthemes and themes in relation tothe research question and context of the cur-rent study. The text was critically reflectedon with an open mind, considering the naiveunderstanding and the validated themes andthe researchers’ preunderstanding. This stepled to an interpretation and mediated anew and deeper understanding of the phe-nomenon.

Ethical considerations

Written consent was obtained from the re-sponsible department manager at the ICU.The project was fully authorized by the Re-gional Ethical Review Board in Gothenburg(No. 695-10). The staff received general in-formation verbally at staff meetings aboutthe planned observations, but they were nottold exactly what would be observed; instead,they were given the choice not to work inthe relevant patient rooms during the obser-vations. The participants received both writ-ten and oral information about the study afterthe observations and signed a consent format the time of the interviews. Those who de-clined being interviewed signed the consentform after the observations had taken place.

RESULTS

Naive understanding: An initialinterpretation of the whole

The naive understanding can be expressedas follows: The caring and nursing activitiesin the 2 rooms did not appear to differ. How-ever, it seemed that caring activities were con-ducted in 2 opposing manners. In some cases,the caring activities appeared to be ruled bylists expressed in the patients’ records/charts.Here, a caring approach seemed to be lost. Inthe other approach, it appeared as though thepatients’ needs were guided by the caring ac-tivities and the patient was met as a person;

caring activities could involve leaving the pa-tient in peace to rest. Managing care in theICU room means running in and out, whichis often done by a lot of people, and restock-ing the cupboards. Caring in the originally de-signed room involved performing caring ac-tivities in dim surroundings because the lightswitch was hard to reach and often forgotten.Inhabitants in both patient rooms had accessto a patio, a view of nature, and fresh air blow-ing in. Birdsongs could be heard and flowerscould be seen.

Thematic structural analysis

The next step in the process of the analy-sis was further examining and validating thenaive understanding. In the structural analy-sis, we examined the text regarding meaningsin caring and nursing activities in both theredesigned and ordinary patient rooms. Thiswas done by dividing the text into meaningunits. A meaning unit could be some words,sentences, or a paragraph relating to the samemeaning. The meaning units were then con-densed and abstracted into subthemes andthemes (Tables 2 and 3).

The nursing care given in the 2 differentlydesigned patient rooms appeared to be sim-ilar. It was the approaches and attunementperformed by the studied nursing staff thatdiffered, and such differences were reflectedin their way of caring for the patients. Someof the nursing staff’s performances were in-terpreted as being ruled by an industrial wayof thinking; therefore, the atmosphere wasexperienced as hierarchical and the work-ing shift appeared to function like clock-work, with various preset tasks to be com-pleted. The other approach showed disregardof the industrial structure, and instead, meantpracticing a more person-centered approach,where the needs of the patients regulated theworking shift.

The 2 interpreted approaches are pre-sented and illustrated via 2 fictive compos-ite stories,32 which were generated on thebasis of all the collected data from the ob-servations and the interviews and are related

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Room Design for Caring Environment 271

Table 3. Example of the Thematic Structural Analysis

Meaning Unit Condensation Subtheme Theme

The nurse walks toward theworkbench, then toward theroom storage (searching forsomething). Then she goes tothe door facing the hallway andwaits, when somebody passesby, she asks for syringes for thefeeding tube.

The room storagecontrols thenurses’ actions

The room storageoccupies myday

Being a cog in abigger wheel

The nurse needs to pause heractivities around the patientbed, she takes off her glovesand goes to the bathroom to getan underpad for the bed.

The room storagecontrols thenurses’ actions

The room storageoccupies myday

Being a cog in abigger wheel

in a first-person fictive voice, originating fromthe themes and subthemes that emerged inthe thematic structural analysis (Table 2).The quotations represent the various partic-ipants’ statements and are inserted to vali-date and illustrate the interpretation of thetext.

Story of Nurse Maggie: Being attuned tocaring

Being vigilant and attentive

When I enter the patient room, I look at thepatients individually to see and plan my car-ing activities. However, I also take the medi-cal charts and records into account and createmy daily plan to assess how to best care forthe patients. When the charts say that the pa-tients need to be mobilized, I know which pa-tient I will start getting out of bed and whichI will let rest. I know what planned proce-dure during the day is going to be too tough.The patients sometimes need to rest so thatthey are not pushed too much and deterio-rate even more in their critical condition. It ismy responsibility to make sure that this willnot happen. During my shift, I pay attentionto the mimic of the patient to obtain the nec-essary information; it can be that the patientis in pain or worried or maybe wants to com-municate something to us. When I am not incharge of the patient, but I am helping out

where help is needed on the ward, I do notback down from suggesting time-consumingcare activities, such as taking the patient for ashower.

The patient is smiling, and the AN who just en-tered the room sees this and laughs. She strokesthe patient’s cheek.

Being part of a team

Almost every day at work, I feel like theteam is a unit. It does not matter whetheryou are a physician, nurse, AN, or physio-therapist. We are all in this together, and weaim to deliver the best care for the patients. Ifeel safe and warm when I see my cowork-ers, doctors, and ANs, and we thank eachother for a well-executed job when we havedone something extra for the patient. At thisICU, we laugh and stick together. When stafffrom other units visit as consults, we prior-itize each other first and ignore hierarchicalorders.

Some physicians are more communicative, and Ican say, “I’ve seen this,” and then, they can ex-plain something to me, and you can ask stuff. Thatmakes it so much easier to be part of the team andI can initiate some plans for the patient.

When we have students or new staffingat the unit, we all try to instruct and guidethem in the right direction. I do my best

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272 CRITICAL CARE NURSING QUARTERLY/JULY–SEPTEMBER 2019

to make them feel welcome. I am also verycareful and try to give them responsibili-ties that they are capable of handling. It isimportant—but not always easy—to balanceensuring that they feel independent and keep-ing them from feeling alone or deserted. I tryto make them feel like equal colleagues in thisICU team.

Being experienced eases my workload

When I was new at work, my shifts weretiring, and I was exhausted at the end ofthe day. I became nervous quickly, andwhen a physician or a colleague told me todo something, it felt like a command andvery important. I took it very seriously. Butnow, I feel more relaxed and not as stressedover things that used to give me chills. Myexperience makes me know what caring ornursing activity to do directly and what I canpostpone until I have the time to do it prop-erly. Today, I can laugh at the younger, moreinexperienced me and feel that I have comea long way in my growth and progress as anurse.

Everything that you do that is for the first time,and like that; it kind of feels like a mountain toclimb, but everything gets easier and easier withtime . . . .

Story of Nurse Hannah: Being a cog in abigger wheel

Medical charts control my nursingactions

When my shift starts and I enter the patientroom, the first thing I do is look at the chartsand medical records to see and plan the nurs-ing activities that the patients need. I priori-tize the nursing activities that are on the listfor the day, and then, I execute them in mygiven order. It does not matter what room Iam working in; I always check the patient’slists and charts first. When I give the reportto the next shift, it feels good to know thatI can tick all the boxes, knowing that I havenot missed a thing in caring for the patients.At the end of the day, I can say I did well, I did

all my chores, and the patients are well takencare of.

It is good to know that you have done everythingthat you should, what you had eh on the list in yourhead. You surely have a plan and think about thisand this and this, the project list, and I think thatit feels good that we have been doing well. Well, Ido not know; there was not much extra to do.

Room storage occupies my day

During my shift, I sometimes crawl acrossthe floor to put the medical cords in the rightpositions. I run in and out of the patientroom several times to collect the medicineand medical supplies that are needed forthe patients’ care. For instance, I have tofind syringes, bedsheets, and Band-Aids. I alsolike to take time to chat with my colleaguesfrom the other patient rooms to catch up onwhat is going on in the ward. Sometimes,this means that there are colleagues runningin and out of patient rooms without havingpatient-related errands. I like, or maybe evenneed, to have the control of knowing how therest of the ward is doing. I become frustratedwhen I open the cabinets and find that whatI need is not there. I often go to find whatI need myself, but sometimes, I send my ANto do it. We do not have a systematic way offilling storage areas and cabinets; it is up toevery individual nursing staff member to de-cide. I miss having a strategy that can be ap-plied to the entire unit. It would be so mucheasier for my colleagues and me, especiallywhen we are introducing new staff members;we would be able to say that the cabinetsshould be filled with 4 bedsheets, 2 shirts,5 mL syringes, and so forth. Now, however, itis chaotic. When the cabinets are empty, thecare is delayed; meanwhile, I or my coworkerwill go and find what is needed. Sometimes,we forget to let each other know when weare back with the missing item, and the pa-tient has to wait longer because of our lack ofcommunication.

If you do not have everything you need, and that isoften the case, (it) means that you have to run (forthings) a lot of times.

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Room Design for Caring Environment 273

Being in a hierarchical system

I see the ANs not as equal colleagues but,rather, as assistants who should do what I tellthem to do when I tell them to do it. I studiedfor 4 years at university, and I am responsiblefor patient care. I know I have a higher rankthan them but am lower than the physicians. Ifeel secure when everybody know their placeand rank. It feels especially good when some-thing out of the ordinary or an acute incidentoccurs; then, we all know our responsibilitiesand duties around the patients.

Here is some medicine, and then, we turn (the pa-tient) when I get back, and we take a blood gasbefore.

Comprehensive understanding

The next step of the current study was toarrive at a comprehensive understanding bytaking the research question, researchers’preunderstandings, naive understanding,and thematic structural analysis into con-sideration and then reflecting on all theseunderstandings. The meaning of performingcaring and nursing activities is seen as a will-ingness to do what is best for the patients andhaving the patients’ well-being at the heart ofeverything done. However, there are differentways of achieving this. Sometimes, this meansobeying lists, guidelines, and medical chartsto accomplish what is of the utmost impor-tance for the patients. Sometimes, however,this attitude appears as passiveness: Compil-ing a list for producing care instead of doingwhat is best for the patient. This approachis perceived as caring with an instrumentalgaze. For some nurses, written guidelines andinstructions have the power to control thenursing activities. Such an approach lowersthe nurses’ critical thinking to a minimum,or sometimes, erases it. This risks the carebeing carried out in an unreflecting manner.This approach led to care that was managednot by the nursing staff’s inner selves but,instead, represented the execution of nurs-ing activities ruled by the medical chartsand guidelines, resulting in caring beinginvisible.

The other approach means being vigilanttoward the patients and letting their needsguide the care but without ignoring theguidelines instead of letting the needs con-trol the care more than the guidelines andmedical charts. A caring approach is charac-terized by reflection and critical questioningof the meanings in the care. This approachresults in more compassionate care that de-mands the confidence to question, and some-times even go against, decisions; this comesfrom the experience of knowing what is bestfor the unique patient in a specific situation.This approach is perceived as caring with anattentive and attuned gaze, leading to moreindividual and person-centered care for thepatients and their next of kin.

DISCUSSION

In this study, we sought to illuminate themeanings of nursing activities in different pa-tient room designs, where 1 room had beenrebuilt according to EBD. It was not obvi-ous that the design of the room had anyeffect on the staff’s caring activities. It ap-pears to be difficult to measure, observe, andfind environmental influences on well-beingin the ICU. Some previous researchers havefound environmental effects on intensive carepatients,34,35 while others have not.36,37 Thismay originate from the complexity of the na-ture of intensive care. Critically ill patients,who often have multiple malfunctions of vi-tal organs, are cared for in a high-tech envi-ronment with high staffing; therefore, thereare many aspects to consider when aim-ing to create a healing environment. How-ever, there are also many aspects to thinkabout when designing research studies in crit-ical care settings. The importance of contextwhen evaluating an intervention is crucial, asthis may act as a facilitator or a barrier tothe intervention’s effects.38 Research meth-ods may need to be refined and adapted tothis complex setting, since the built environ-ment’s effect on human behavior, especiallysuch subtle activities as caring, is difficult tocapture.

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274 CRITICAL CARE NURSING QUARTERLY/JULY–SEPTEMBER 2019

Nursing environment research primarilyconcentrates on the settings where caringand nursing take place, with the design char-acteristics and the physical environment infocus; in contrast, geographical research ex-plores the connection between environmentand health and has been an essential researchfield for many decades. Geographical researchhas importantly studied and illuminated whatcan be termed “place effects on health.”39

This raises the following questions: What po-sition does EBD belong to? Does EBD fo-cus only on the physical settings, or doesit encompass the place effects on health?Evidence-based design aims to create healingenvironments with the ambition that the builtenvironment will make physical or psycho-logical improvements for the patients. How-ever, as stated by Hamilton and Watkins,6

EBD is only a healing environment if it ispossible to evaluate its effect on patients’well-being.

Nursing and the environment are inter-twined. Nurses have significant roles in mak-ing their environment, and at the same time,the environments make the nursing.39 It isunlikely that EBD has as much effect as thecaring touch of an empathic nurse.6 How-ever, the design makes a difference in nurses’movements.40 “A good place” is not onlyphysically situated but also a state of mind.It appeared that when CCNs cared for dyingpatients and their families, they tried to re-design the bed space in the ICU.41 They ad-justed the light and sound in the room; theyplayed music and brought books and flow-ers. They did all this to create a good place.This idea is quite similar to the aim of de-signing the intervention room in this study,as it was refurbished to create “a good place”for all critically ill patients and not merelydying ones.

Our results showed the meanings ofcaring and nursing activities as 2 differentapproaches, interpreted as caring with anattentive and attuned gaze and caring withan instrumental gaze. Vigilance is the essenceof nursing, and caring is actualized throughvigilant watchfulness.42 Our results show

that caring cannot exist without a vigilantapproach. It was visible in our findings thatwhen caring was done with an attentive andattuned gaze, the caring and nursing activ-ities were reflected and critically thoughtout; thus, they were visible and could bearticulated. This approach was expressedas more individual, person-centered carefor the patients and their family members.The actions of the nursing staff who weremore ruled by the invisible and sometimesunspoken and unwritten, yet lived, rules andexpectations of the ward, in general, wereinterpreted as caring with an instrumentalgaze. This approach led to care not beingmanaged by the nursing staff but, instead, bythe written medical charts and guidelines.There is no caring in this approach, only anexecution of nursing activities. Benner43 andBenner et al44 claimed that when depictingthe professional development of nurses asgoing from novices to experts, followingrules contravenes successful performance.Nurses are not supposed to exclude rules,guidelines, and so forth, but instead, theyshould only let them be a part of the biggerpicture, not the only concern. The distinctapproaches of caring with an attentive andattuned gaze and caring with instrumentalgaze occurred in both the redesigned andoriginally designed patient rooms.

Caring is produced by bodies, and perform-ing care in the constraining environment ofthe ICU is demanding. This means that nurseshave to put aside their comfort while caringfor critically ill patients, bending and stretch-ing their bodies. Working in dim surround-ings was not unusual when caring for patientsin the originally designed room in this study.

It is said that the health care environmentcannot compensate for poor care, but thehealth care environment could and shouldsupport nursing care.45,46 Nursing does notmerely involve executing technical tasks; it isabout uniting an essential responsibility forthe places inhabited by patients and theirfamilies.8 Although an earlier study showedthat nurses’ experience working in an EBDICU room improved their caring ability,25 we

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Room Design for Caring Environment 275

could not confirm this finding in the currentstudy. It could be that either the interventionor the evaluation of the intervention shouldhave been performed differently. The follow-ing question remains: Does nursing staff caredifferently in different environments, or is thefeeling of performing care different for thestaff?

Methodological reflections

The present study is grounded in aphenomenological-hermeneutical perspe-ctive as described in the writings ofRicoeur27,47 and later developed by Lindsethand Norberg26 into a method suitable for re-search in a health care context. The strengthof this method is that the movements be-tween the 3 steps—naive understanding,thematic structural analysis, and compre-hensive understanding—act as internalvalidation. Examples of the thematic struc-tural analysis were presented (Tables 2 and3), and quotations were used for enhancingthe credibility of the research, letting thereader decide whether our interpretationsare reasonable. The choice of presentingthe results in narratives was derived fromLindseth and Norberg’s26 methodologicaldescriptions and, empirically, from the writ-ings of Lindahl et al,33 who attempted tonarrate the participants’ lived experiences.None of the researchers work at the studiedICU, which enhanced the possibility of main-taining objectivity. However, all the authorsare experienced CCNs, and the observer didstep in on occasion during the observationsto preserve patient safety. Because all thedata were transcribed, all the authors hadaccess to the material, and a consensus wasreached among them. A methodology ofphenomenological hermeneutics does notclaim to find the single fundamental truth26:There are always possible interpretations ofa text, and there are various ways of arguingfor and against an interpretation.26,47 Wecontend that the findings are built on arigorous analysis and thus reflect the caringand nursing activities in a believable way.

In this study, it was not obvious that the re-built environment per se supported caring ac-

tivities. Perhaps other research methods areneeded to discover the health care environ-ment’s effect on such elusive activities as car-ing. Another possible improvement to the de-sign of the study could be observing the samenursing staff in the differently designed pa-tient rooms. Research methodologies need tobe carefully contemplated, and observationalresearch is suitable and sometimes necessaryto capture the phenomenon.

CONCLUSIONS

The built environment’s influence onhuman behavior, especially such subtle activi-ties as caring, is difficult to capture. Differentresearch methodologies and approaches mayilluminate the consequences and meaningsthat the health care environment has forcaring. This study did not capture an obviousfinding that the rebuilt bed spaces created amore caring attitude. However, it could bethat it enriched the environmental supportand strengthened the nurses’ actions. Thus,we consider that more research is neededon whether and how a built environmentcan counteract caring ruled by an instru-mental approach. This study indicated thatcaring risks being lost when nurses use atask-oriented approach controlled by medicalcharts and guidelines, carrying out theirduties with an instrumental gaze—then,nurses practice only the execution of nursingactivities. In contrast, when they practice aperson-centered approach using an attentiveand attuned gaze, caring appears. Nursesneed to reflect on and consider how theyperform their nursing and caring activities sothat they progress in their professional de-velopment and enhance their caring for themost critically ill patients, as are present inthe ICUs.

Relevance to clinical practice

Caring in intensive care contexts needs tobe assisted by a supportive environment de-sign that cultivates the nursing caring ap-proach. The design of health care facili-ties must become a more important aspectof clinical nursing care. Environment is a

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276 CRITICAL CARE NURSING QUARTERLY/JULY–SEPTEMBER 2019

metaparadigm concept in nursing and, assuch, it needs to be thoroughly reflected on.Nurses must reflect on and consider howthey perform their caring activities so that

they can make progress in their professionaldevelopment, while more importantly, main-taining patient safety through a more person-centered care.

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Paper III

R E S E A R CH

Associations between healthcare environment design andadverse events in intensive care unit

Fredrika Sundberg PhD-student, CCRN1 |

Isabell Fridh CCRN, PhD, Associate Professor1,2 |

Berit Lindahl CCRN, PhD, Professor1 | Ingemar Kåreholt PhD, Professor3

1Faculty of Caring Science, Work Life and

Social Welfare, University of Borås, Borås,

Sweden

2Department of Anaesthesiology and Intensive

Care, Sahlgrenska University Hospital,

Gothenburg, Sweden

3School of Health and Welfare, Institute of

Gerontology, Jönköping University, Jönköping,

Sweden

Correspondence

Fredrika Sundberg, Faculty of Caring Science,

Work Life and Social Welfare, University of

Borås, Allégatan 1, 501 90 Borås, Sweden.

Email: fredrika.sundberg@hb.se

Funding information

Swedish Research Council, Grant/Award

Number: 521-2013-969

Abstract

Background: Healthcare environment can affect health. Adverse events (AEs) are

common because rapid changes in the patients' status can suddenly arise, and have

serious consequences, especially in intensive care. The relationship between the

design of intensive care units (ICUs) and AEs has not been fully explored. Hence, an

intensive care room was refurbished with cyclic lightning, sound absorbents and

unique interior, and exterior design to promote health.

Aims: The aim of this study was to evaluate the differences between a regular and a

refurbished intensive care room in risk for AEs among critically ill patients.

Design: This study retrospectively evaluated associations of AEs and compared the

incidence of AEs in patients who were assigned to a multidisciplinary ICU in a

refurbished two-bed patient room with patients in the control rooms between 2011

and 2018.

Methods: There were 1938 patients included in this study (1382 in control rooms;

556 in the intervention room). Descriptive statistics were used to present the experi-

enced AEs. Binary logistic regressions were conducted to estimate the relationship

between the intervention/control rooms and variables concerning AEs. Statistical

significance was set at P < 0.05.

Results: For the frequency of AEs, there were no significant differences between the

intervention room and the control rooms (10.6% vs 11%, respectively, P < 0.805). No

findings indicated the intervention room (the refurbished room) had a significant

influence on decreasing the number of experienced AEs in critically ill patients.

Conclusions: The findings revealed a low incident of AEs in both the intervention

room as well as in the control rooms, lower than previously described. However, our

study did not find any decreases in the AEs due to the design of the rooms.

Relevance to clinical practice: Further research is needed to determine the relation-

ship between the physical environment and AEs in critically ill patients.

K E YWORD S

complex interventions, critical care nursing, intensive care, quantitative research, research

Received: 29 July 2019 Revised: 17 April 2020 Accepted: 21 April 2020

DOI: 10.1111/nicc.12513

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any

medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

© 2020 The Authors. Nursing in Critical Care published by John Wiley & Sons, Ltd on behalf of British Association of Critical Care Nurses.

Nurs Crit Care. 2020;1–8. wileyonlinelibrary.com/journal/nicc 1

1 | INTRODUCTION

The current study focussed on Adverse events (AEs) in critically ill

patients. An AE is defined as an injury related to medical manage-

ment that may be either preventable or non-preventable.1 Unfor-

tunately, AEs are relatively common with incidence rates ranging

from 29% to 83% in intensive care settings,2-4 and they have seri-

ous consequences, including death, among already vulnerable

patients with life-threatening conditions. However, AEs are often

preventable, and an improved healthcare environment could sup-

port and reduce the number of AEs. In 2010, a refurbished patient

room was constructed in an eight-bed intensive care unit (ICU).5-7

This multifaceted intervention was intended to improve the

health and wellbeing of critically ill patients. The components that

were implemented were a circadian light system, sound absor-

bents, access to nature, and organic textiles and furniture. The

room was refurbished according to the principles of evidence-

based design (EBD), which aims to create healing healthcare

facilities.8,9

2 | BACKGROUND

2.1 | Design of the ICUs

The care of severely ill patients in ICUs requires access to advanced

technical medical equipment. Therefore, the ICU environment is filled

with and dominated by sophisticated technology that both promotes

as well as hinders care.10-12 The high acuity in intensive care requires

immediate responses from the staff,13 and more invasive procedures

can elevate the risk of AEs.

Florence Nightingale14 acknowledged the importance of a suit-

able environment for promoting patients' health and wellbeing.

However, since her time, medical technology has evolved remarkably

and overshadowed the development of the healthcare environment.

In the intensive care setting, this has had an enormous impact on the

layout of patient rooms. Instead of integrating new machinery into

the design, the technology is placed wherever there is free space.

Thus, the healthcare environment is complex; however, the environ-

ment has the possibility of promoting health and wellbeing,

prolonging illness and even causing AEs and other healthcare-related

illnesses.15,16

The concept of EBD originated from a study by Ulrich17 where

patients had shorter length of stay (LoS) and needed less analgesia if

they were assigned to a patient room facing nature. Later, EBD

evolved by integrating knowledge from various research disciplines

into designing healing environments. This inspired the present

research project as a collaboration between researchers representing

various disciplines.7 Patient safety is complex and multifaceted, as

such; the healthcare environment and design of healthcare facilities

are important aspects to investigate to ensure patient safety and

overall wellbeing.18

2.2 | Adverse events and critically ill patients

In ICUs, rapid changes in a patient's status may suddenly occur and

quick decisions need to be made. This puts ICU patients at an

extremely high risk of iatrogenic injuries. An AE is defined as an

injury related to medical management that may be either prevent-

able or non-preventable.1 The AE prevalence among ICU patients is

relatively high with an incidence rate of 29%-83%.2-4 Moreover,

AEs have serious consequences because patients in the ICU are

already in an extremely delicate situation and facing life-threatening

illnesses or conditions.19-21 Thus, there is a significant correlation

between AEs and mortality rates in intensive care patients.22 Com-

plications and AEs often led to prolonged LoS both in the hospital

and ICU.3 Prolonged LoS has been shown to increase both the suf-

fering for patients and family members and the financial cost on

society.

Poor environments in ICUs can be potentially inimical for the

critically ill patients.23 Inappropriate lighting has been shown to

cause incidents and increased heart rates, indicating the patients

are under stress.24,25 Noise is often still found to be well above

the WHO recommendations, resulting in disturbed circadian

rhythm and causing delirium in intensive care patients.26,27 How-

ever, by improving the sound environment in the ICU, the fre-

quency of delirium in critically ill patients was found to decrease

significantly.28

AEs, such as hospital-acquired infections, have been shown to

decrease when evidence-based guidelines such as, ventilator-

associated pneumonia prevention guideline, are followed.29-32 In addi-

tion, the frequencies of infections were found to decrease substan-

tially depending on the design of the ICU and by caring for intensive

care patients in single-patient rooms rather than multibed rooms.33,34

The mortality rate has also been shown to be connected to the design

of the ICU. For instance, when patients were assigned to a low-

WHAT IS KNOWN ABOUT THIS TOPIC• Healthcare environment can promote health and

wellbeing but can also cause illness.

• Critically ill patients have an extremely high risk of iatro-

genic injury.

• High nursing workload increases the risk of adverse

events in the ICU.

WHAT THIS PAPER ADDS• The findings revealed much lower percentage of AEs than

previous research has reported.

• Larger changes in the physical environment than those

analysed are needed to affect the risk for AEs.

• Reporting AEs should be on the agenda on daily basis.

2 SUNDBERG ET AL.

visibility patient room, where the nurses were unable to see their

patients at all times, there was a significant increase in mortality rate

for the most severely ill patients.35,36

Previous research has claimed that patient safety and the preva-

lence of AEs could be improved with a better healthcare environ-

ment.15,16,25 When evaluating the lighting environment in the

intervention room, the patients perceived the intervention room dif-

ferently from the control room.37 The intervention room was addi-

tionally shown to strengthen the nurses' experiences of caring.38

Thus, this raised the question whether the implemented interventions

could affect patient safety and more specifically reduce AEs.

2.3 | Aim

The aim of this study was to evaluate the differences between a regu-

lar and a refurbished intensive care room in risk for AEs among criti-

cally ill patients.

TABLE 1 Patient characteristics in the control and intervention rooms

Control rooms, n = 1382 Intervention room, n = 556P for differencea% (n)b % (n)b

Baseline characteristics

Female 44.1 (608) 48.0 (267) .113

Age, y, mean (min–max) 59.1 (0-99) 57.7 (0-95) .230c

Burden of care/day, mean (min-max) 12.0 (0.00-27.8) 11.7 (0.00-23.5) .280d

Length of stay (LoS), days, mean (min–max) 5.1 (0.03-60.1) 4.9 (0.06-53.4) .387d

Deceased (mortality) 11.8 (163) 15.3 (85) .037

Window bed 55.6 (768) 55.9 (311) .884

Reason for admission

Traumaf 12.0 (166) 9.7 (54) .149

Diseases of the respiratory system 44.0 (608) 46.4 (258) .335

Diseases of the circulatory system 28.1 (388) 29.0 (161) .697

Endocrine, nutritional and metabolic diseases 5.7 (79) 7.9 (44) .073

Diseases of the digestive system 25.3 (350) 23.4 (130) .370

Injury, poisoning and certain other consequences

of external causes

27.4 (378) 22.7 (126) .033

Patients' outcomes

Number of adverse events (AEs)

No AEs 89.0 (1230) 89.4 (497) .805

One AE 9.8 (136) 9.7 (54) .931

Two AEs 1.0 (14) 0.7 (4) .542

Three AEs 0.1 (2) 0.2 (1) 1.000

Specific AEs

Any AE 11 (152) 10.6 (59) .805

Ventilator-associated pneumonia (VAP) 1.6 (22) 3.2 (18) .021

Central line–associated bloodstream infection

(CLABSI)

0.9 (12) 0.2 (1) .125e

Night-time discharge 1.4 (19) 1.1 (6) .602

Reintubation 1.3 (18) 1.1 (6) .688

Readmission within 72 h 4.6 (64) 3.1 (17) .117

Other AE 1.3 (18) 1.1 (6) .688

aBased on χ2 tests unless otherwise stated.b% (n) unless otherwise stated.ct test.dMann–Whitney.eFisher's exact test.fIncluded in “Injury, poisoning and certain other consequences of external causes.”

SUNDBERG ET AL. 3

3 | METHODS

This study retrospectively evaluated the associations of AEs in

patients assigned to a refurbished, two-bed patient room in an ICU

between 2011 and 2018.

3.1 | Setting

3.1.1 | Intervention room

The principles of EBD guided the refurbishment of a two-bed patient

room in 2010.7 Acoustic panels were built into the walls and ceiling,

and new flooring was installed. In addition, prototype pendulums were

installed, equipped with lights, electrical sockets, and medical gas sup-

plies. Cyclic lighting, mimicking dusk to dawn lighting, was installed. The

same medical and technical devices were used, and the room had equal

capacity to care for critically ill patients as the other patient rooms in

the unit. The walls were painted in soothing shades, all furnishings were

constructed with ecological materials and textiles, and comfortable fur-

niture was placed in the room for visitors. The room had a window and

door leading onto a patio with furniture and seasonal plants outside,

and the patio was accessible to patients and their relatives. Two regular

two-bed patient rooms, identical to the intervention rooms prior to

refurbishment, were used as control rooms. The control and interven-

tion rooms had the same medical and technical equipment, and the

control rooms also had a window and a door leading onto a patio but

without any furniture or plants. The staff could be allocated to any

patient room in the ICU. The three rooms included in the research were

situated in a row next to each other with the intervention room being

farthest from the nurse station. During the period of data collection,

the ICU was not refurbished, meaning all the patient rooms were kept

the same throughout the entire research period.

3.2 | Data collection and sample

Patient data were collected among patients admitted to the multi-

disciplinary ICU between 2011 and 2018. As can be seen in Table 1,

there were no significant differences in baseline characteristics.

Patients in the refurbished intervention room and two control rooms

were eligible to be included in the data collection for this study. If both

the intervention room and two control rooms were empty, the nurse in

charge randomly assigned the patients to one of the rooms. If any of

the rooms contained a patient, to conserve staffing resources, the adja-

cent bed space was filled before assigning a patient to an empty room.

The study sample consisted of all the admitted patients (N = 2337).

Patients who were only admitted for observation and those who did

not meet the criteria for intensive care were excluded from further

analysis (n = 399). Ultimately, 1938 patients were included in this study

(1382 in the control rooms and 556 in the intervention room).

The patients in all the rooms were treated and cared for using the

same guidelines, meaning that no other aspects other than the room

they were assigned to differed. The nurse–patient ratio was 1:1 or 1:2

in both the intervention room and control rooms. The nurses and

intensivists who cared for the patients reported AEs to registries as

they usually do. The Swedish Intensive Care Registry (SIR, is a national

quality registry for intensive care to which Swedish ICUs report AEs

(Figure 1). All AEs in the ICU were first reported in the hospital regis-

ters and then further reported to SIR as is standard protocol.

In the current study, all the reported AEs that were registered were

included, not only the AEs with an obvious link to the healthcare envi-

ronment. Due to their extremely low or non-existent occurrence, the

following AEs were not examined further: multidrug-resistant bacteria,

Clostridium difficile enterocolitis, severe hypoglycaemia originating in the

ICU, pneumothorax requiring treatment, endotracheal/tracheostomy

dysfunction leading to AEs and postoperative meningitis. However, they

were included in the totals for “Any AEs” and the number of AEs.

Data were retrospectively collected from patient registers. The

authors had no direct access to the medical records; therefore, the data

were collected from the administration office of the clinic. They were

anonymized prior to being given to the authors to preserve confidentiality.

3.3 | Ethical considerations

The data collection was approved by the Regional Ethics Committee

(No. 695-10), and institutional permission was obtained from the

Head of ICU and the Head of Department. In Sweden and other Nor-

dic countries, informed consent is not required for registry-based

studies.39 The hospital reports data to SIR, and the data can be

obtained from SIR. However, we obtained the data from the hospital

as we then also had access to the specific patient room where the

patients were treated. The study followed the principles of ethical

research as stated in the Declaration of Helsinki.40

3.4 | Data analysis

All analyses were performed using SPSS Statistics version 25 by IBM.

Descriptive statistics were used to present descriptive data on AEs in

F IGURE 1 Supplementary figure for the online version. Adverseevents (AEs) that intensive care units (ICUs) report to the SwedishIntensive Care Registry (SIR)

4 SUNDBERG ET AL.

the patients who were assigned to the intervention and the control

rooms. Binary logistic regression was used to investigate the relation-

ship between the intervention/control room and variables concerning

AEs and complications. (Here, all were categorized as AEs). The statis-

tical significance was set at P < 0.05.

4 | RESULTS

A total of 1938 patients were included in this study, of which, 1382

were assigned to one of the two control rooms and 556 to the inter-

vention room (Table 1). Of the included patients, 1727 (89%) were

not reported to have any AEs. However, 211 patients (11%) had at

least one AE. Of the 211 patients with AEs, 190 patients were

reported as having one AE, 18 patients had two AEs, and 3 patients

had three AEs. When the frequency of AEs was controlled for, there

were no significant differences between the intervention room and

control rooms in terms of the number of AEs.

The proportion of patients with any kind of AE was 10.6% in the

intervention room and 11.0% in the control rooms. Readmission

within 72 hours was the most common AE (n = 81), whereas Central

line–associated bloodstream infection (CLABSI) (n = 13) had the low-

est frequency of the separately studied AEs.

The patients cared for in the intervention room were compared

with the patients in the control rooms (Table 1). More people in the

intervention room compared with those in the control rooms had

succumbed to their illnesses. There was a higher incidence of

Ventilator-associated pneumonia (VAP) in 2015 among the patients

in the intervention room (n = 5, 10%) than in the control rooms

(n = 0, 0%) where no VAP was reported (P < 0.001). There was no

significant difference in the VAP incidence in any other of the exam-

ined years, and if the data from 2015 were excluded, there would be

no significant differences between the intervention and control

rooms in the incidence of VAP (P = 0.359). Regarding reasons for

admission, the proportion with “injury, poisoning and certain other

consequences of external causes” was significantly lower in the

intervention room.

None of the patients who were admitted to the ICU as a result of

trauma had to be intubated again, and there was a lower percentage

of these patients in all the AEs, except night-time discharge, than

there were for other patient categories. The mean LoS was higher for

those patients with one or more AEs (11.3 days) compared with those

patients who had no complications (4.3 days).

Binary logistic regression was used to estimate the relationship

between the intervention/control room and variables concerning AEs.

Regressions were run on three different models (Table 2). Model 1 con-

trolled for the type of room (intervention versus control room), window

bed versus non-window bed, LoS and deceased versus not deceased. In

the fully adjusted model (model 3) age, sex, trauma versus no trauma,

reasons for admittance, burden of care, intubated versus not intubated

and tracheostomy versus no tracheostomy was additionally controlled.

The patients who were assigned to the intervention room had a ten-

dency towards lower risk for all AEs except VAP (Table 2), but none of

the differences were significant. The likelihood for VAP was signifi-

cantly higher in the intervention room (Table 2).

5 | DISCUSSION

The intervention room was refurbished with the intention of improv-

ing the outcomes and wellbeing of critically ill patients admitted to

the ICU. The findings revealed a low incidence rate of AEs, about

11%, in all of the examined patient rooms. This is a lower incidence

than what prior research has reported,2-4 also in Swedish settings of

critical care.41,42 There were no findings in this study that indicated

that the intervention room had any significant effect on decreasing

the number of AEs for the critically ill patients assigned to the

refurbished room. However, there was a tendency of fewer AEs for

the patients assigned to the intervention room. This noteworthy result

needs further and more specific research investigation. However, in

TABLE 2 Odds ratios (ORs) for an adverse event in the intervention room (reference category: control rooms)

Type of adverse event (AE)

Model

1 2 3

OR P-value CI OR P-value CI OR P-value CI

Any AE 0.98 .917 0.704-1.372 0.99 .948 0.708-1.382 0.98 .918 0.699-1.380

VAP 2.64 .006 1.327-5.234 2.63 .006 1.325-5.221 2.43 .013 1.210-4.891

CLABSI 0.21 .138 0.026-1.653 0.21 .143 0.027-1.689 0.21 .142 0.027-1.685

Night-time discharge 0.77 .573 0.303-1.937 0.77 .575 0.302-1.943 0.89 .814 0.345-2.305

Reintubation 0.83 .708 0.316-2.184 0.84 .728 0.320-2.217 0.72 .511 0.269-1.922

Readmission within 72 h 0.65 .126 0.379-1.126 0.68 .162 0.392-1.170 0.67 .147 0.383-1.155

Other AE 0.74 .533 0.289-1.901 0.77 .486 0.306-2.027 0.73 .531 0.279-1.930

Note: Model 1: controlled for window bed versus not window bed, length of stay (LoS) and deceased versus not deceased. Model 2: additionally controlled

for age and sex. Model 3: additionally controlled for trauma versus no trauma, reasons for admittance, burden of care, and intubated/tracheostomy versus

not intubated/tracheostomy patients.

Abbreviations: CLABSI, central venous line–associated bloodstream infection; VAP, ventilator-associated pneumonia.

SUNDBERG ET AL. 5

2015, VAP was significantly more frequent in the intervention room.

There was no significant difference in the likelihood for VAP in any of

the other examined years. It is impossible to draw any conclusions on

the reason for this result because we do not have any complementary

information.

A limitation of this study was that we had no access to the severity

of illness of the patients, and the result for 2015 could be linked to the

randomization, or lack thereof, of the patients. None of the patients in

the control rooms were reported to have VAP in 2015. In addition,

more deaths occurred in the intervention room, and this could have

influenced the randomization process. This may indicate that the staff

tended to place patients with more serious illnesses in the intervention

room, and such an argument could be considered in light of Liaschenko

et al's findings.43 They reported that, when caring for dying patients,

ICU nurses redesigned the bed spaces to create a more homely and

peaceful place with soft light, music and flowers. This could have

occurred and disturbed the randomization in this study. If the nurses

assigned the most vulnerable patients to the intervention room, it could

explain why the risk for VAP was higher in that room.

Because Ulrich17 found that a view of nature had positive effects

on patients' recovery, we tried to find positive aspects of being

assigned to window beds. Although all the beds had a view of nature

in both the intervention room and control rooms, the window beds

had extra access to the view of nature and greenery. However, no

associations between being assigned to a window bed and experienc-

ing AEs were found.

Earlier studies in intensive care settings concerning the healthcare

environment's influence on patient outcomes have had various

results. Some have found an environmental effect,44,45 while others

have not.46,47 It seems difficult to capture evidence in this research

area. In the present study, the included patients received medical

treatment and nursing care based on the same guidelines. To our

knowledge, the staff members were allocated to all patient rooms in

the unit. Nevertheless, there could have been a bias in staff allocation,

which affected the outcome due to individual differences among the

staff. All the rooms had the same equipment and access to the same

medications, thus no other aspects were different from the design of

the room to which the patients were assigned. Therefore, it may be

difficult to find any differences among the patient outcomes. When

exploring experiences of working in the intervention room, the partici-

pating nursing staff experienced working in the intervention room as

improving their own wellbeing and changing the way they cared for

patients.38 That was, however, not confirmed or observed as a differ-

ent behaviour among the staff.48

6 | LIMITATIONS

In terms of its strengths, this study included all registered AEs for

8 years (2011-2018), which is longer than most of the similar longitu-

dinal designs. The patient rooms that were included in this study all

contained the same medical and technological equipment, which

implies that the same level of care was provided. All the reported AEs

were included, although those with extremely low incidence were not

further examined.

Despite its strengths, the study also had limitations. Although the

intention was to randomly assign the patients to the different rooms,

as researchers, we had little control over how this process was truly

accomplished. The nurse in charge could have assigned terminal

patients to the intervention room for humanitarian reasons. There

may have been other aspects that were considered, such as the allo-

cation of the staff and the mandate to fill one room at a time before

opening another. Consequently, we could not evaluate the randomiza-

tion process. At the same time, this is what the unit always does when

assigning patients to their bed spaces, and therefore, this approach to

randomization is representative of this specific ICU workflow.

As the research group did not have access to the patients'

records, we relied on the administration office at the clinic. The data

depended on the registered AEs. We had no possibility to control mis-

sed reported AEs. We had to adjust our study to the data that were

routinely recorded by the clinic and could be given to us. For instance,

important data needed to control the findings of a higher incidence of

VAP in the intervention room, such as time on the ventilator, were

not accessible to us. Also missing were the Simplified Acute Physiol-

ogy Score III (SAPS III) scores.49 We contacted SIR to retrieve the

SAPS III scores because the ICU reports these scores to SIR. However,

when the scores were reported, they were organised in a way that

the patient room was not identified, and, therefore, the data could not

be matched to the intervention or control rooms.

7 | IMPLICATIONS ANDRECOMMENDATIONS FOR PRACTICE

The intensive care patients are individuals with different diagnoses,

anamneses, and outcomes. This makes it challenging to find single fac-

tors that have a decisive influence on patient outcomes. Moreover, the

complex setting of the ICU makes it difficult to conduct research with

ordinary methods. As such, new, refined research methods need to be

developed, tested, and implemented. Guidelines regarding reporting

AEs need to be implemented in the daily routine for the staff. It is also

difficult for the ICU staff to have different patient rooms in the same

unit. Therefore, we suggest doing baseline studies and intervention

research with a refurbished unit rather than a refurbished room.

8 | CONCLUSION

There was a low incidence of AEs in all the examined patient rooms,

much lower than other previous international and national studies have

found. Maybe this ICU standard room design is so refined that it

already decreases the number of AEs. Further comparisons among

countries or even hospitals need to be studied. This could also relate to

the reporting of incidents and AEs at the specific ICU. This was not

controlled in this study. However, we were unable to find that the

refurbished patient room with an enriched environment had any

6 SUNDBERG ET AL.

influence on decreasing AEs. The reason for this could be that the

design differences between the rooms were not extensive enough to

demonstrate any crucial outcomes concerning AEs and complications.

The impact of the environment on health outcomes in an ICU is multi-

faceted, which makes it challenging to isolate and tease apart all the

variables, such as patient circumstances complex interventions and

equipment, to determine which are influencing AEs. There is still a need

for additional research with design interventions and the impact of AEs.

ACKNOWLEDGEMENTS

The authors are grateful to Eva Lorentzon Rahn for contributing with

support during the data collection phase. This work was supported by

the Swedish Research Council, Stockholm, Sweden (grant number

521-2013-969). They had no involvement in any part of the research

process.

ETHICS STATEMENT

The data collection was approved by a regional ethics committee

(No. 695-10), The study followed the principles of ethical research as

stated in the Declaration of Helsinki (World Medical Association, 2013).

ORCID

Fredrika Sundberg https://orcid.org/0000-0002-7400-6574

Isabell Fridh https://orcid.org/0000-0002-9828-961X

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How to cite this article: Sundberg F, Fridh I, Lindahl B,

Kåreholt I. Associations between healthcare environment

design and adverse events in intensive care unit. Nurs Crit

Care. 2020;1–8. https://doi.org/10.1111/nicc.12513

8 SUNDBERG ET AL.

Paper IV

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 1

Visitor’s Experiences of an Evidence-Based Designed Healthcare Environment in an

ICU

Fredrika Sundberg1, Isabell Fridh1, Berit Lindahl1 and Ingemar Kåreholt2

1 Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Sweden

2 School of Health and Welfare, Institute of Gerontology, Jönköping University, Sweden

Author Note

Fredrika Sundberg https://orcid.org/0000-0002-7400-6574

Acknowledgments: The authors are grateful to Margareta Brogeby and her

colleagues for contributing their support during the data collection phase.

Conflict of interest: The Authors declares that there is no conflict of interest.

Funding information: This work was supported by the Swedish Research

Council, Stockholm, Sweden (grant number 521-2013-969). They had no involvement in any

part of the research process.

Correspondence concerning this article should be addressed to Fredrika

Sundberg, Faculty of Caring Science, Work Life and Social Welfare, University of Borås,

Allégatan 1, 501 90 Borås, Sweden. E-mail: fredrika.sundberg@hb.se

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 1

Visitor’s Experiences of an Evidence-Based Designed Healthcare Environment in an

ICU

Fredrika Sundberg1, Isabell Fridh1, Berit Lindahl1 and Ingemar Kåreholt2

1 Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Sweden

2 School of Health and Welfare, Institute of Gerontology, Jönköping University, Sweden

Author Note

Fredrika Sundberg https://orcid.org/0000-0002-7400-6574

Acknowledgments: The authors are grateful to Margareta Brogeby and her

colleagues for contributing their support during the data collection phase.

Conflict of interest: The Authors declares that there is no conflict of interest.

Funding information: This work was supported by the Swedish Research

Council, Stockholm, Sweden (grant number 521-2013-969). They had no involvement in any

part of the research process.

Correspondence concerning this article should be addressed to Fredrika

Sundberg, Faculty of Caring Science, Work Life and Social Welfare, University of Borås,

Allégatan 1, 501 90 Borås, Sweden. E-mail: fredrika.sundberg@hb.se

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 2

Abstract

Objectives: The objective of the research was to study the visitors’ experiences of different

healthcare environment designs of intensive care unit (ICU) patient rooms. Background: The

healthcare environment may seem frightening and overwhelming in times when life-

threatening conditions affect a family member or close friend and individuals visit the patient

in an ICU. A two-bed patient room was refurbished to enhance the wellbeing of patients and

their families according to the principles of evidence-based design (EBD). No prior research

has used the Person-centred Climate Questionnaire—Family Version (PCQ-F) or the

semantic environment description (SMB) in the ICU setting. Methods: A sample of 99

visitors to critically ill patients admitted to a multidisciplinary ICU completed a

questionnaire; 69 visited one of the two control rooms, while 30 visited the intervention

room. Results: For the dimension of everydayness in the PCQ-F, a significantly better

experience was expressed for the intervention room (p < 0.021); the dimension of safety

regarding the ward climate was also perceived as higher in the intervention room (p < 0.013).

No significance was found in the SMB. Conclusion: Designing and implementing an

enriched healthcare environment in the ICU setting increases person-centered care in relation

to both the patient and his/her visitors. This may lead to better impressions and affect the

outcomes for visitors in times of crisis.

Key words: Academic research, Family-centered care, intensive care units

(ICU), Interior design, Access to nature, Design research, Evidence-based design (EBD),

Nursing research, Patient/person-centered care, Patient room design

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 3

Background

Visiting The Intensive Care Unit

The environment in intensive care units (ICUs) is dominated by sophisticated

technology due to the seriousness of admitted patients’ conditions, which are often life

threatening. In times of stress and crisis, visiting relatives are exposed to an environment that

may seem frightening and overwhelming to them. The alien environment, with its advanced

monitoring and aggressive treatments of critically ill patients, is harsh for the family members

(Imanipour et al., 2019; Ruckholdt et al., 2019; Turner-Cobb et al., 2016). Experiences like

anxiety, sadness, depression, and fatigue in family members of ICU patients have been

reported repeatedly in prior studies (Apple, 2014; Celik et al., 2016; Day et al., 2013). These

stressful experiences can sometimes develop into more persistent conditions, such as post-

traumatic stress disorder (Petrinec & Daly, 2016). Despite the unfriendly environment, the

need and desire to visit and be close to the critically ill patient has had the same high priority

among family members for the last 40 years (Jacob et al., 2016; Plakas, Taket, Cant, Fouka,

& Vardaki, 2014). Despite this, many ICUs have restricted visiting hours. Nevertheless, the

ongoing trend is to shift toward open visiting hours, with more satisfied family members as a

result (Chapman et al., 2016). Open visiting hours represent one way of implementing

person/family-centered care in the ICU (Coombs et al., 2017; Davidson et al., 2017).

Person-Centered Care (PCC)

For a long time, healthcare has been dominated by the medical view, which

tends to fragment the patients into diagnoses or reduce them to body parts or even mere cells.

In contrast, person-centered care (PCC) emphasizes the significance of recognizing the

person behind the patient, as a human being with meaning, will, emotions, and needs (Ekman

et al., 2011; Mounier, 1952; World Health Organization. Regional Office for the Western

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 2

Abstract

Objectives: The objective of the research was to study the visitors’ experiences of different

healthcare environment designs of intensive care unit (ICU) patient rooms. Background: The

healthcare environment may seem frightening and overwhelming in times when life-

threatening conditions affect a family member or close friend and individuals visit the patient

in an ICU. A two-bed patient room was refurbished to enhance the wellbeing of patients and

their families according to the principles of evidence-based design (EBD). No prior research

has used the Person-centred Climate Questionnaire—Family Version (PCQ-F) or the

semantic environment description (SMB) in the ICU setting. Methods: A sample of 99

visitors to critically ill patients admitted to a multidisciplinary ICU completed a

questionnaire; 69 visited one of the two control rooms, while 30 visited the intervention

room. Results: For the dimension of everydayness in the PCQ-F, a significantly better

experience was expressed for the intervention room (p < 0.021); the dimension of safety

regarding the ward climate was also perceived as higher in the intervention room (p < 0.013).

No significance was found in the SMB. Conclusion: Designing and implementing an

enriched healthcare environment in the ICU setting increases person-centered care in relation

to both the patient and his/her visitors. This may lead to better impressions and affect the

outcomes for visitors in times of crisis.

Key words: Academic research, Family-centered care, intensive care units

(ICU), Interior design, Access to nature, Design research, Evidence-based design (EBD),

Nursing research, Patient/person-centered care, Patient room design

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 3

Background

Visiting The Intensive Care Unit

The environment in intensive care units (ICUs) is dominated by sophisticated

technology due to the seriousness of admitted patients’ conditions, which are often life

threatening. In times of stress and crisis, visiting relatives are exposed to an environment that

may seem frightening and overwhelming to them. The alien environment, with its advanced

monitoring and aggressive treatments of critically ill patients, is harsh for the family members

(Imanipour et al., 2019; Ruckholdt et al., 2019; Turner-Cobb et al., 2016). Experiences like

anxiety, sadness, depression, and fatigue in family members of ICU patients have been

reported repeatedly in prior studies (Apple, 2014; Celik et al., 2016; Day et al., 2013). These

stressful experiences can sometimes develop into more persistent conditions, such as post-

traumatic stress disorder (Petrinec & Daly, 2016). Despite the unfriendly environment, the

need and desire to visit and be close to the critically ill patient has had the same high priority

among family members for the last 40 years (Jacob et al., 2016; Plakas, Taket, Cant, Fouka,

& Vardaki, 2014). Despite this, many ICUs have restricted visiting hours. Nevertheless, the

ongoing trend is to shift toward open visiting hours, with more satisfied family members as a

result (Chapman et al., 2016). Open visiting hours represent one way of implementing

person/family-centered care in the ICU (Coombs et al., 2017; Davidson et al., 2017).

Person-Centered Care (PCC)

For a long time, healthcare has been dominated by the medical view, which

tends to fragment the patients into diagnoses or reduce them to body parts or even mere cells.

In contrast, person-centered care (PCC) emphasizes the significance of recognizing the

person behind the patient, as a human being with meaning, will, emotions, and needs (Ekman

et al., 2011; Mounier, 1952; World Health Organization. Regional Office for the Western

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 4

Pacific, 2007). By promoting humane and holistic ways, the goal for PCC is improving

outcomes for persons, families, health workers, organizations, and health systems. The values

and preferences expressed by individuals guide all aspects of healthcare in PCC. This is

accomplished via a relationship among individuals, their close ones and all relevant

contributors ("Person-Centered Care: A Definition and Essential Elements," 2016). This

paradigm shift from the medical point of view to the holistic view of PCC may reestablish

harmony and balance for individuals, as well as the harmony and affinity between people and

their environment (World Health Organization. Regional Office for the Western Pacific,

2007).

PCC has developed into the wider concept of family-centered care (FCC). In

intensive care settings, FCC has been defined as a respectful and responsive approach to

individual families’ needs and values (Davidson et al., 2017). The recognition of FCC is

considered a crucial part of high-quality care in ICUs, and implementation does not require

special equipment or significant financial investments (Gerritsen, Hartog, & Curtis, 2017).

Although an improved design and construction of the ICUs may facilitate FCC, it may also

cause disturbance for the staff (Rippin, Zimring, Samuels, & Denham, 2015). The difficulty

in implementing PCC in health care is not that the staff are skeptical of the concept, but

rather, that they are already under the impression they are working with a PCC approach even

though they are not (Ekman et al., 2011; Santana et al., 2018).

The Design Of Intensive Care Units (ICUs)

The environment in ICUs can affect patients, their visiting family members and

staff, by either increasing or decreasing their levels of distress. Evidence-based design (EBD)

has evolved as a research field where the effects of architecture on health environments are in

focus (Ulrich, Berry, Quan, & Parrish, 2010). The design of ICUs has not had the same

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 5

progress as the medical technology has, and therefore, new equipment is placed where there

is a free space rather than being integrated into the design. However, there have been

attempts to implement an enriched environment in intensive care. It has been found that

family members visiting hospital gardens show decreased distress (Ulrich et al., 2019).

Implementing access to nature during the ICU stay has positive effects for patients, families,

and staff (Minton & Batten, 2016; Sundberg, Olausson, Fridh, & Lindahl, 2017).

Family members of critically ill patients play a crucial part in the team around

the patient and are pivotal in the recovery and terminal phases. However, there is a risk that

they may be downprioritized or neglected by the staff due to their workload around the

patient care. Therefore, it is important to gain knowledge about how visitors at ICUs

experience the overall ward climate. This study attempts to give family members a voice to

describe the perceived healthcare environment that surrounds the critically ill patient.

Aim

The aim of the research was to study visitors’ experiences of different

healthcare environment designs of ICU patient rooms.

Methods

Setting

The study was executed at a 395-bed hospital in Sweden, which comprises a

multidisciplinary 10-bed ICU with 650 enrolments yearly. In 2010, a two-bed intensive care

patient room was refurbished through multidisciplinary teamwork (Lindahl & Bergbom,

2015), according to the principles of EBD and considering the guidance for complex

intervention research (Craig et al., 2008). The patient room was completely refurbished,

although this was done within the existing area. Acoustic panels were built into the walls and

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 4

Pacific, 2007). By promoting humane and holistic ways, the goal for PCC is improving

outcomes for persons, families, health workers, organizations, and health systems. The values

and preferences expressed by individuals guide all aspects of healthcare in PCC. This is

accomplished via a relationship among individuals, their close ones and all relevant

contributors ("Person-Centered Care: A Definition and Essential Elements," 2016). This

paradigm shift from the medical point of view to the holistic view of PCC may reestablish

harmony and balance for individuals, as well as the harmony and affinity between people and

their environment (World Health Organization. Regional Office for the Western Pacific,

2007).

PCC has developed into the wider concept of family-centered care (FCC). In

intensive care settings, FCC has been defined as a respectful and responsive approach to

individual families’ needs and values (Davidson et al., 2017). The recognition of FCC is

considered a crucial part of high-quality care in ICUs, and implementation does not require

special equipment or significant financial investments (Gerritsen, Hartog, & Curtis, 2017).

Although an improved design and construction of the ICUs may facilitate FCC, it may also

cause disturbance for the staff (Rippin, Zimring, Samuels, & Denham, 2015). The difficulty

in implementing PCC in health care is not that the staff are skeptical of the concept, but

rather, that they are already under the impression they are working with a PCC approach even

though they are not (Ekman et al., 2011; Santana et al., 2018).

The Design Of Intensive Care Units (ICUs)

The environment in ICUs can affect patients, their visiting family members and

staff, by either increasing or decreasing their levels of distress. Evidence-based design (EBD)

has evolved as a research field where the effects of architecture on health environments are in

focus (Ulrich, Berry, Quan, & Parrish, 2010). The design of ICUs has not had the same

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 5

progress as the medical technology has, and therefore, new equipment is placed where there

is a free space rather than being integrated into the design. However, there have been

attempts to implement an enriched environment in intensive care. It has been found that

family members visiting hospital gardens show decreased distress (Ulrich et al., 2019).

Implementing access to nature during the ICU stay has positive effects for patients, families,

and staff (Minton & Batten, 2016; Sundberg, Olausson, Fridh, & Lindahl, 2017).

Family members of critically ill patients play a crucial part in the team around

the patient and are pivotal in the recovery and terminal phases. However, there is a risk that

they may be downprioritized or neglected by the staff due to their workload around the

patient care. Therefore, it is important to gain knowledge about how visitors at ICUs

experience the overall ward climate. This study attempts to give family members a voice to

describe the perceived healthcare environment that surrounds the critically ill patient.

Aim

The aim of the research was to study visitors’ experiences of different

healthcare environment designs of ICU patient rooms.

Methods

Setting

The study was executed at a 395-bed hospital in Sweden, which comprises a

multidisciplinary 10-bed ICU with 650 enrolments yearly. In 2010, a two-bed intensive care

patient room was refurbished through multidisciplinary teamwork (Lindahl & Bergbom,

2015), according to the principles of EBD and considering the guidance for complex

intervention research (Craig et al., 2008). The patient room was completely refurbished,

although this was done within the existing area. Acoustic panels were built into the walls and

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 6

ceiling, and new flooring was installed. In addition, pendulums with electrical sockets and

medical gas supplies and cyclic lights—to preserve the patient’s circadian rhythm—were

installed. Calming colors were brought to the room by ecological textiles in bed sheets,

blankets, and curtains. All furnishings were constructed of ecological materials, while it was

ensured that the furniture for the visitors was comfortable. Patients and their visitors had

access to nature via a window and door leading onto a patio in the greenery, with furniture

and seasonal plants (Lindahl & Bergbom, 2015). Two rooms, which were identical to how

the intervention room was previously designed, were used as control rooms. There were no

refurbishments in the ICU during the data collection period.

Figure 1. © Lindahl. Drawing by Maria Berezecka, Chalmers University of Technology (Johansson et al., 2018). View into the intervention room from the hallway

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 7

Figure 2. © Lindahl. Drawing by Maria Berezecka, Chalmers University of Technology (Johansson et

al., 2018). View from patient’s bed in the intervention room

Figure 3. © Lindahl. Patient’s and visitor’s view and access to nature, in the intervention room

Questionnaires

The Person-Centred Climate Questionnaire—Family Version (PCQ-F).

The Person-Centred Climate Questionnaire—Family Version (PCQ-F; Lindahl, Elmqvist,

Thulesiusq, & Edvardsson, 2015), which evaluates the dimensions of safety, everydayness,

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 6

ceiling, and new flooring was installed. In addition, pendulums with electrical sockets and

medical gas supplies and cyclic lights—to preserve the patient’s circadian rhythm—were

installed. Calming colors were brought to the room by ecological textiles in bed sheets,

blankets, and curtains. All furnishings were constructed of ecological materials, while it was

ensured that the furniture for the visitors was comfortable. Patients and their visitors had

access to nature via a window and door leading onto a patio in the greenery, with furniture

and seasonal plants (Lindahl & Bergbom, 2015). Two rooms, which were identical to how

the intervention room was previously designed, were used as control rooms. There were no

refurbishments in the ICU during the data collection period.

Figure 1. © Lindahl. Drawing by Maria Berezecka, Chalmers University of Technology (Johansson et al., 2018). View into the intervention room from the hallway

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 7

Figure 2. © Lindahl. Drawing by Maria Berezecka, Chalmers University of Technology (Johansson et

al., 2018). View from patient’s bed in the intervention room

Figure 3. © Lindahl. Patient’s and visitor’s view and access to nature, in the intervention room

Questionnaires

The Person-Centred Climate Questionnaire—Family Version (PCQ-F).

The Person-Centred Climate Questionnaire—Family Version (PCQ-F; Lindahl, Elmqvist,

Thulesiusq, & Edvardsson, 2015), which evaluates the dimensions of safety, everydayness,

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 8

and hospitality of the psychosocial care climate, was used in this study. According to the

researchers that developed the questionnaire, different requirements need to be met for

sensing the three dimensions. A climate of safety can be perceived when family members

find staff available and approachable, viewing their actions as competent and

comprehensible. It is crucial for safety that, in addition to being clean, the environment

sanctions space for privacy and interaction with others. Because many of the questionnaire

items focus on the staff and not the built environment, we split the dimension into safety, staff

and ward climate safety (see Table 2). A climate of everydayness appears when patients and

families feels acquainted to the surrounding environment and sense tranquility, and when the

place offers positive distractions for patients and family members to divert their thoughts

from illness and treatment. Finally, a climate of hospitality is perceived when the

environment communicates a sense of welcoming and feeling that the care and treatment

appear to exceed expectations. It is essential for patients and family members to be seen, met,

and welcomed, and furthermore, to sense generosity from the staff (Lindahl et al., 2015). The

questionnaire contained questions on the dimensions with 6-point Likert-type scales (1 = No,

I disagree completely, 6 = Yes, I agree completely). An example of an item; A place that has

something nice to look at (e.g. views, artwork).

The semantic environment description (SMB). The semantic environment

description (Swedish; Semantisk miljöbeskrivning, SMB) is a structured method used for

describing the impression of an architectural environment, where the environment can be

interior, exterior, or simulated (Kuller, Preiser, Visher, & White, 1991). The SMB method is

a questionnaire containing 36 adjectives measuring the overall impression of an environment.

To identify how well each adjective agrees with the respondents’ perception of the

environment, the questionnaire contains scales in the range of 1–7 (1 = Slightly; 7 = Very).

The adjectives are clustered into the eight following factors: pleasantness, complexity, unity,

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 9

potency, social status, enclosedness, affection, and originality. Due to the development of

language and society, we have chosen to rename the factor affection as modern (Figure 1).

No other changes were made.

Data collection

The questionnaires were distributed to visitors over the age of 18, such as

family members and close friends, when they were visiting the critically ill patients cared for

in the ICU. The staff and one of the researchers (FS) managed the distribution. The staff were

instructed to invite the participants when they estimated the situation was suitable (respecting

the life-threatening condition of the patient). Visitors participating in this study were asked to

complete the questionnaires while in the patient room (either in the intervention room or one

of the two control rooms). This was done to ensure the participants were present in the real

environment being evaluated. The data collection took place in November 2015–April 2019,

and a total of 104 questionnaires were collected. Five questionnaires were excluded due to

missing information about which room the visitor had visited.

Analysis

The PCQ-F had item non-response from zero to eight. The data were analyzed

twice, both with and without imputed missing data, to control for potential bias from partial

non-response, which may have limited the results. However, there were no differences in the

results where the presented findings in this study were calculated on non-imputed data. The

items that concerned the staff and ward climate in general were analyzed separately because

this study’s main focus was on ward climate (see Tables 1 and 2).

Ethical considerations

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 8

and hospitality of the psychosocial care climate, was used in this study. According to the

researchers that developed the questionnaire, different requirements need to be met for

sensing the three dimensions. A climate of safety can be perceived when family members

find staff available and approachable, viewing their actions as competent and

comprehensible. It is crucial for safety that, in addition to being clean, the environment

sanctions space for privacy and interaction with others. Because many of the questionnaire

items focus on the staff and not the built environment, we split the dimension into safety, staff

and ward climate safety (see Table 2). A climate of everydayness appears when patients and

families feels acquainted to the surrounding environment and sense tranquility, and when the

place offers positive distractions for patients and family members to divert their thoughts

from illness and treatment. Finally, a climate of hospitality is perceived when the

environment communicates a sense of welcoming and feeling that the care and treatment

appear to exceed expectations. It is essential for patients and family members to be seen, met,

and welcomed, and furthermore, to sense generosity from the staff (Lindahl et al., 2015). The

questionnaire contained questions on the dimensions with 6-point Likert-type scales (1 = No,

I disagree completely, 6 = Yes, I agree completely). An example of an item; A place that has

something nice to look at (e.g. views, artwork).

The semantic environment description (SMB). The semantic environment

description (Swedish; Semantisk miljöbeskrivning, SMB) is a structured method used for

describing the impression of an architectural environment, where the environment can be

interior, exterior, or simulated (Kuller, Preiser, Visher, & White, 1991). The SMB method is

a questionnaire containing 36 adjectives measuring the overall impression of an environment.

To identify how well each adjective agrees with the respondents’ perception of the

environment, the questionnaire contains scales in the range of 1–7 (1 = Slightly; 7 = Very).

The adjectives are clustered into the eight following factors: pleasantness, complexity, unity,

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 9

potency, social status, enclosedness, affection, and originality. Due to the development of

language and society, we have chosen to rename the factor affection as modern (Figure 1).

No other changes were made.

Data collection

The questionnaires were distributed to visitors over the age of 18, such as

family members and close friends, when they were visiting the critically ill patients cared for

in the ICU. The staff and one of the researchers (FS) managed the distribution. The staff were

instructed to invite the participants when they estimated the situation was suitable (respecting

the life-threatening condition of the patient). Visitors participating in this study were asked to

complete the questionnaires while in the patient room (either in the intervention room or one

of the two control rooms). This was done to ensure the participants were present in the real

environment being evaluated. The data collection took place in November 2015–April 2019,

and a total of 104 questionnaires were collected. Five questionnaires were excluded due to

missing information about which room the visitor had visited.

Analysis

The PCQ-F had item non-response from zero to eight. The data were analyzed

twice, both with and without imputed missing data, to control for potential bias from partial

non-response, which may have limited the results. However, there were no differences in the

results where the presented findings in this study were calculated on non-imputed data. The

items that concerned the staff and ward climate in general were analyzed separately because

this study’s main focus was on ward climate (see Tables 1 and 2).

Ethical considerations

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 10

The data collection was authorized by The Regional Ethical Review Board in

Gothenburg, Sweden (No. 695-10), and institutional permission was obtained from the ward

manager. The study followed the principles of ethical research as stated in the Declaration of

Helsinki (World Medical Association, 2013) by assessing the risk, burdens, and benefits for

the study participants. Participation was voluntary. The questionnaires were answered

anonymously, and there was no information from the participants that could link the answers

to them or to any patient. The characteristics of the participants consisted of age, sex,

relationship to the critically ill patient, as well as information about how many visits the

participants had made and how long they had been in the room before conducting the

questionnaire.

Results

A total of 99 observations were included in this study, of which, 69 were from

one of the two control rooms and 30 were from the intervention room (Table 1). There were

no significant differences between the characteristics of the visitors in the control rooms and

the intervention room regarding sex, age, number of visits, and relationship to the patient;

likewise, there was no difference in whether the patient had changed patient room during the

stay at the ICU (Table 1).

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 11

Table 1. Characteristics of the visitors visiting in the control and intervention rooms

Control rooms n = 69

Intervention room n = 30

p for difference1

% (n)2 % (n)2 Female 59.4 (41) 70.0 (21) 0.317

Visitors of patients that changed room during ICU stay

39.1 (27) 63.3 (19) 0.062

Age, years, mean (min–max) 48.61 (18-84)

48.73 (20-77)

0.9723

Relationship Spouse/co-habitant Parent Child Other

27.5 (19) 14.5 (10) 23.2 (16) 34.8 (24)

26.7 (8) 20.0(6) 33.3(10) 20.0 (6)

0.929 0.5564 0.292 0.141

Number of visits, mean, median (min – max)

5.08, 3.00 (1-23)

4.30, 2.00 (1-12)

0.4003

PCQ-F 3 Ward Climate, General 4.995 5.379 0.006 Ward Climate Staff 5.419 5.486 0.474

Factors in SMB 5 5 5 Pleasantness 4.912 5.245 0.159 Complexity 3.522 3.307 0.314 Unity 5.101 5.212 0.622 Enclosedness 3.974 4.004 0.914 Potency 3.873 4.196 0.085 Social Status 5.202 5.303 0.729 Modernity 4.500 4.838 0.200 Originality 3.645 3.558 0.745

1) Based on χ2 tests unless otherwise stated; 2) % (n) unless otherwise stated; 3) t-test 4) Fisher’s exact test; 5) adjusted mean values based on linear regressions controlled for age, sex, relation to the patient, number of visits, and if patient had changed room during ICU stay.

The PCQ-F. Linear regression was used to estimate the difference between the

control and intervention rooms in the variables concerning the ward climate. Regression was

executed in three different models (Table 2). In Model 1, no control variables were included.

Model 2 was controlled for age, sex, and relationship to the patient. The fully adjusted model

(Model 3) was controlled for age, sex, relationship, number of visits, and whether the patient

had changed rooms during the ICU stay.

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 10

The data collection was authorized by The Regional Ethical Review Board in

Gothenburg, Sweden (No. 695-10), and institutional permission was obtained from the ward

manager. The study followed the principles of ethical research as stated in the Declaration of

Helsinki (World Medical Association, 2013) by assessing the risk, burdens, and benefits for

the study participants. Participation was voluntary. The questionnaires were answered

anonymously, and there was no information from the participants that could link the answers

to them or to any patient. The characteristics of the participants consisted of age, sex,

relationship to the critically ill patient, as well as information about how many visits the

participants had made and how long they had been in the room before conducting the

questionnaire.

Results

A total of 99 observations were included in this study, of which, 69 were from

one of the two control rooms and 30 were from the intervention room (Table 1). There were

no significant differences between the characteristics of the visitors in the control rooms and

the intervention room regarding sex, age, number of visits, and relationship to the patient;

likewise, there was no difference in whether the patient had changed patient room during the

stay at the ICU (Table 1).

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 11

Table 1. Characteristics of the visitors visiting in the control and intervention rooms

Control rooms n = 69

Intervention room n = 30

p for difference1

% (n)2 % (n)2 Female 59.4 (41) 70.0 (21) 0.317

Visitors of patients that changed room during ICU stay

39.1 (27) 63.3 (19) 0.062

Age, years, mean (min–max) 48.61 (18-84)

48.73 (20-77)

0.9723

Relationship Spouse/co-habitant Parent Child Other

27.5 (19) 14.5 (10) 23.2 (16) 34.8 (24)

26.7 (8) 20.0(6) 33.3(10) 20.0 (6)

0.929 0.5564 0.292 0.141

Number of visits, mean, median (min – max)

5.08, 3.00 (1-23)

4.30, 2.00 (1-12)

0.4003

PCQ-F 3 Ward Climate, General 4.995 5.379 0.006 Ward Climate Staff 5.419 5.486 0.474

Factors in SMB 5 5 5 Pleasantness 4.912 5.245 0.159 Complexity 3.522 3.307 0.314 Unity 5.101 5.212 0.622 Enclosedness 3.974 4.004 0.914 Potency 3.873 4.196 0.085 Social Status 5.202 5.303 0.729 Modernity 4.500 4.838 0.200 Originality 3.645 3.558 0.745

1) Based on χ2 tests unless otherwise stated; 2) % (n) unless otherwise stated; 3) t-test 4) Fisher’s exact test; 5) adjusted mean values based on linear regressions controlled for age, sex, relation to the patient, number of visits, and if patient had changed room during ICU stay.

The PCQ-F. Linear regression was used to estimate the difference between the

control and intervention rooms in the variables concerning the ward climate. Regression was

executed in three different models (Table 2). In Model 1, no control variables were included.

Model 2 was controlled for age, sex, and relationship to the patient. The fully adjusted model

(Model 3) was controlled for age, sex, relationship, number of visits, and whether the patient

had changed rooms during the ICU stay.

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 12

“The visitors who visited critically ill patients in the intervention room had

a significantly more positive scoring in their perceptions of the psychosocial ward

climate than those visiting in the control rooms did.

The visitors who visited critically ill patients in the intervention room had a

significantly more positive scoring in their perceptions of the psychosocial ward climate than

those visiting in the control rooms did (Table 2). Nevertheless, when assessing the ward

climate concerning the staff, there were no significant differences between the control rooms

and the intervention room (Table 2).

Table 2. Ward Climate Questionnaire

Ward climate

Model 1 Model 2 Model 3 β-

coefficient p-

value CI β-

coefficient p-

value CI β-

coefficient

p-value

CI

Ward climate general

0.384 0.006 0.115- 0.652 0.390 0.005 0.122- 0.659 0.369 0.013 0.081- 0.657

Ward climate, safety

0.162 0.048 0.001- 0.323 0.153 0.063 -0.008- 0.314 0.159 0.068 -0.012- 0.331

Everydayness 0.389 0.070 -0.032- 0.811 0.441 0.045 0.010- 0.872 0.539 0.021 0.082- 0.997

Ward Climate Staff

Ward Climate Staff

0.067 0.474 -0.199- 0.254 0.068 0.477 -0.12- 0.256 0.014 0.888 -0.189- 0.217

Safety, staff 0.094 0.220 -0.057- 0.244 0.089 0.241 -0.061- 0.239 0.079 0.320 -0.078- 0.236

Hospitality 0.225 0.233 -0.147- 0.597 0.228 0.248 -0.162- 0.617 0.229 0.277 -0.187- 0.644

Model 1: Crude differences between intervention room and control rooms. Model 2: Additionally controlled for age, sex and relationship to the patient. Model 3 Additionally controlled for, number of visits, and if patient changed room during ICU-stay

The SMB. Linear regression was used to study the different dimensions in the

different rooms. There were no significant differences between either of the dimensions in the

SMB between the control and intervention rooms (Figure 4).

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 13

Figure 4. Semantic environment description in control rooms and intervention room (SMB)*.

* The p-values were all > 0.1, except for the Potency dimension, where p = 0.085 (see Table

1). Controlled for age, sex, relationship to the patient, number of visits, whether the patient

changed rooms during the ICU stay.

Discussion

This study examined different features of the healthcare environment. Both

PCQ-F and SMB were used for the first time in an ICU context. One limitation of the study

was the small sample size. Despite the long period of data collection, only 99 questionnaires

were included in this study. Regardless of the low response rate, using the PCQ-F, the results

showed the intervention room was significantly perceived as having both a safer environment

and greater everydayness than the control rooms did. This indicates that the visits in the

refurbished environment in this high-tech context represented a more positive experience. For

the families and friends visiting the intervention room, this meant that the staff were

perceived as accessible, amenable, competent, and comprehensible. It also meant that the

room was viewed as more familiar, offering peacefulness and a positive distraction from

illness by having something beautiful to look at during the visits (Lindahl et al., 2015). Since

the staff in this study were not allocated to only one of the patient rooms at the ICU, but

0,0000

1,0000

2,0000

3,0000

4,0000

5,0000

6,0000

Control rooms Intervention room

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 12

“The visitors who visited critically ill patients in the intervention room had

a significantly more positive scoring in their perceptions of the psychosocial ward

climate than those visiting in the control rooms did.

The visitors who visited critically ill patients in the intervention room had a

significantly more positive scoring in their perceptions of the psychosocial ward climate than

those visiting in the control rooms did (Table 2). Nevertheless, when assessing the ward

climate concerning the staff, there were no significant differences between the control rooms

and the intervention room (Table 2).

Table 2. Ward Climate Questionnaire

Ward climate

Model 1 Model 2 Model 3 β-

coefficient p-

value CI β-

coefficient p-

value CI β-

coefficient

p-value

CI

Ward climate general

0.384 0.006 0.115- 0.652 0.390 0.005 0.122- 0.659 0.369 0.013 0.081- 0.657

Ward climate, safety

0.162 0.048 0.001- 0.323 0.153 0.063 -0.008- 0.314 0.159 0.068 -0.012- 0.331

Everydayness 0.389 0.070 -0.032- 0.811 0.441 0.045 0.010- 0.872 0.539 0.021 0.082- 0.997

Ward Climate Staff

Ward Climate Staff

0.067 0.474 -0.199- 0.254 0.068 0.477 -0.12- 0.256 0.014 0.888 -0.189- 0.217

Safety, staff 0.094 0.220 -0.057- 0.244 0.089 0.241 -0.061- 0.239 0.079 0.320 -0.078- 0.236

Hospitality 0.225 0.233 -0.147- 0.597 0.228 0.248 -0.162- 0.617 0.229 0.277 -0.187- 0.644

Model 1: Crude differences between intervention room and control rooms. Model 2: Additionally controlled for age, sex and relationship to the patient. Model 3 Additionally controlled for, number of visits, and if patient changed room during ICU-stay

The SMB. Linear regression was used to study the different dimensions in the

different rooms. There were no significant differences between either of the dimensions in the

SMB between the control and intervention rooms (Figure 4).

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 13

Figure 4. Semantic environment description in control rooms and intervention room (SMB)*.

* The p-values were all > 0.1, except for the Potency dimension, where p = 0.085 (see Table

1). Controlled for age, sex, relationship to the patient, number of visits, whether the patient

changed rooms during the ICU stay.

Discussion

This study examined different features of the healthcare environment. Both

PCQ-F and SMB were used for the first time in an ICU context. One limitation of the study

was the small sample size. Despite the long period of data collection, only 99 questionnaires

were included in this study. Regardless of the low response rate, using the PCQ-F, the results

showed the intervention room was significantly perceived as having both a safer environment

and greater everydayness than the control rooms did. This indicates that the visits in the

refurbished environment in this high-tech context represented a more positive experience. For

the families and friends visiting the intervention room, this meant that the staff were

perceived as accessible, amenable, competent, and comprehensible. It also meant that the

room was viewed as more familiar, offering peacefulness and a positive distraction from

illness by having something beautiful to look at during the visits (Lindahl et al., 2015). Since

the staff in this study were not allocated to only one of the patient rooms at the ICU, but

0,0000

1,0000

2,0000

3,0000

4,0000

5,0000

6,0000

Control rooms Intervention room

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 14

instead, worked in all the patient rooms, the result concerning the staff was not surprisingly

different between the differently designed patient rooms. The SMB results showed no

significant perceived differences between the control and intervention rooms by the visitors.

A critique of the SMB questionnaire is that may be obsolete because it was developed in the

1960s and ’70s. This may relate to the outcome in this study. Semantics encompasses the

meaning of language and significations of words (Merriam-Webster, 2020); since language

develops at the same pace as society, this questionnaire; the words it uses and even their

meanings now may seems outdated. Therefore, an updated version may have been in place as

it may have given clearer results. However, there are few questionnaires concerning the

semantics of the built environment.

Previous research has reported that families of critically ill patients cared for in

ICUs experience serious types of illbeing, such as depression, anxiety, and fatigue (Apple,

2014; Celik et al., 2016; Day et al., 2013); sometimes, they even develop post-traumatic

stress disorder (Petrinec & Daly, 2016; Stayt & Venes, 2019; Wintermann et al., 2016).

These findings from the refurbished intervention room can be a way of reducing some

elements of illbeing. Evidence-based design aims at implementing various research

disciplines into healing environments (Hamilton & Watkins, 2009), and this study

strengthens and contributes to that theory/idea; that is, the study shows that it is possible to

design and build for better health and wellbeing.

PCC aims to see the person behind the patient, so does caring science. We agree

with McCormack and McCance (2006) that there is no contradiction between PCC and caring

science. The foundation of caring science involves seeing the whole person (Arman,

Ranheim, Rydenlund, Rytterström, & Rehnsfeldt, 2015). Caring science has no difficulties

seeing the person behind the patient. The essential focus of caring science is on the patient’s

difficulties, needs, and wishes. PCC and caring science represent the direct opposite of

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 15

reduction (Ekman et al., 2011); both PCC and caring science have the same focus—putting

the patient/person at the center. It is all about having a holistic view and positioning the

patient centrally as a vulnerable human being. What is good for the patient is always the

center of caring science research (Arman et al., 2015; Eriksson, 2018). The focus on the

patient also includes the recognition of the whole family, since PCC and caring science aim

to provide health care that is humble and responsive to individual families’ needs and beliefs

(Davidson et al., 2017; Gerritsen et al., 2017).

“By designing and constructing enriched healthcare facilities, especially in

the intensive care context, where there is an extra dimension of saving lives, this study

facilitates increased health and wellbeing of the patients’ visitors.

By designing and constructing enriched healthcare facilities, especially in the

intensive care context, where there is an extra dimension of saving lives, this study facilitates

increased health and wellbeing of the patients’ visitors. Previous research has shown that this

also improves the wellbeing of the staff in intensive care settings (Sundberg et al., 2017). The

whole human being is far more complex than its parts are. The same is true of the healthcare

environment, where the wholeness can be termed atmosphere, defined as “a surrounding

influence or environment” (Merriam-Webster, 2020). Atmosphere is a synonym of climate,

which was used in this study via the PCQ-F’s term, ward climate. The design of healthcare

facilities plays a crucial part in not only the built environment but also the lived environment,

the atmosphere. Today, many of these healthcare facilities are constructed to enhance clinical

efficiency. This may cause great risks for depersonalization, but the trend has changed toward

designing more person-centered facilities today, and this often increases stakeholders’

wellbeing (McCormack, Dewing, & McCance, 2011). An aspect of comfort is linked to the

surrounding environment (Olausson, Fridh, Lindahl, & Torkildsby, 2019): It is even possible

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 14

instead, worked in all the patient rooms, the result concerning the staff was not surprisingly

different between the differently designed patient rooms. The SMB results showed no

significant perceived differences between the control and intervention rooms by the visitors.

A critique of the SMB questionnaire is that may be obsolete because it was developed in the

1960s and ’70s. This may relate to the outcome in this study. Semantics encompasses the

meaning of language and significations of words (Merriam-Webster, 2020); since language

develops at the same pace as society, this questionnaire; the words it uses and even their

meanings now may seems outdated. Therefore, an updated version may have been in place as

it may have given clearer results. However, there are few questionnaires concerning the

semantics of the built environment.

Previous research has reported that families of critically ill patients cared for in

ICUs experience serious types of illbeing, such as depression, anxiety, and fatigue (Apple,

2014; Celik et al., 2016; Day et al., 2013); sometimes, they even develop post-traumatic

stress disorder (Petrinec & Daly, 2016; Stayt & Venes, 2019; Wintermann et al., 2016).

These findings from the refurbished intervention room can be a way of reducing some

elements of illbeing. Evidence-based design aims at implementing various research

disciplines into healing environments (Hamilton & Watkins, 2009), and this study

strengthens and contributes to that theory/idea; that is, the study shows that it is possible to

design and build for better health and wellbeing.

PCC aims to see the person behind the patient, so does caring science. We agree

with McCormack and McCance (2006) that there is no contradiction between PCC and caring

science. The foundation of caring science involves seeing the whole person (Arman,

Ranheim, Rydenlund, Rytterström, & Rehnsfeldt, 2015). Caring science has no difficulties

seeing the person behind the patient. The essential focus of caring science is on the patient’s

difficulties, needs, and wishes. PCC and caring science represent the direct opposite of

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 15

reduction (Ekman et al., 2011); both PCC and caring science have the same focus—putting

the patient/person at the center. It is all about having a holistic view and positioning the

patient centrally as a vulnerable human being. What is good for the patient is always the

center of caring science research (Arman et al., 2015; Eriksson, 2018). The focus on the

patient also includes the recognition of the whole family, since PCC and caring science aim

to provide health care that is humble and responsive to individual families’ needs and beliefs

(Davidson et al., 2017; Gerritsen et al., 2017).

“By designing and constructing enriched healthcare facilities, especially in

the intensive care context, where there is an extra dimension of saving lives, this study

facilitates increased health and wellbeing of the patients’ visitors.

By designing and constructing enriched healthcare facilities, especially in the

intensive care context, where there is an extra dimension of saving lives, this study facilitates

increased health and wellbeing of the patients’ visitors. Previous research has shown that this

also improves the wellbeing of the staff in intensive care settings (Sundberg et al., 2017). The

whole human being is far more complex than its parts are. The same is true of the healthcare

environment, where the wholeness can be termed atmosphere, defined as “a surrounding

influence or environment” (Merriam-Webster, 2020). Atmosphere is a synonym of climate,

which was used in this study via the PCQ-F’s term, ward climate. The design of healthcare

facilities plays a crucial part in not only the built environment but also the lived environment,

the atmosphere. Today, many of these healthcare facilities are constructed to enhance clinical

efficiency. This may cause great risks for depersonalization, but the trend has changed toward

designing more person-centered facilities today, and this often increases stakeholders’

wellbeing (McCormack, Dewing, & McCance, 2011). An aspect of comfort is linked to the

surrounding environment (Olausson, Fridh, Lindahl, & Torkildsby, 2019): It is even possible

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 16

to experience at-homeness in such high-technology settings as ICUs when the design matches

the needs of the patients, their family, and the staff (Andersson, Fridh, & Lindahl, 2019).

“Evidence-based design aims to create healing environments, as does

caring science. Therefore, a match between these research fields is of great interest, and

more successful collaborations are needed in the future as these disciplines have the

same goal—to ensure persons in healthcare facilities have the highest possible

wellbeing.

Evidence-based design aims to create healing environments, as does caring

science. Therefore, a match between these research fields is of great interest, and more

successful collaborations are needed in the future as these disciplines have the same goal—to

ensure persons in healthcare facilities have the highest possible wellbeing.

Conflict of interest: The authors declare that there is no conflict of interest.

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 17

References

Andersson, M., Fridh, I., & Lindahl, B. (2019). Is it possible to feel at home in a patient room in an intensive care unit? Reflections on environmental aspects in technology-dense environments. Nursing Inquiry, 26(4), e12301. doi:10.1111/nin.12301

Apple, M. (2014). A comparative evaluation of Swedish intensive care patient rooms. Herd, 7(3), 78–93. doi:10.1177/193758671400700306

Arman, M., Ranheim, A., Rydenlund, K., Rytterström, P., & Rehnsfeldt, A. (2015). Article. The Nordic tradition of caring science: The works of three theorists. Nursing Science Quarterly, 28(4), 288–296. doi:10.1177/0894318415599220

Celik, S., Genc, G., Kinetli, Y., Asiliogli, M., Sari, M., & Madenoglu Kivanc, M. (2016). Sleep problems, anxiety, depression and fatigue on family members of adult intensive care unit patients. International Journal of Nursing Practice, 22(5), 512–522. doi:10.1111/ijn.12451

Chapman, D. K., Collingridge, D. S., Mitchell, L. A., Wright, E. S., Hopkins, R. O., Butler, J. M., & Brown, S. M. (2016). Satisfaction with elimination of all visitation restrictions in a mixed-profile intensive care unit. American Journal of Critical Care, 25(1), 46–50. doi:10.4037/ajcc2016789

Coombs, M. A., Davidson, J. E., Nunnally, M. E., Wickline, M. A., & Curtis, J. R. (2017). Using qualitative research to inform development of professional guidelines: A case study of the society of critical care medicine family-centered care guidelines. Critical Care Medicine, 45(8), 1352–1358. doi:10.1097/ccm.0000000000002523

Craig, P., Dieppe, P., Macintyre, S., Michie, S., Nazareth, I., & Petticrew, M. (2008). Developing and evaluating complex interventions: The new Medical Research Council guidance. BMJ, 337. doi:10.1136/bmj.a1655

Davidson, J. E., Aslakson, R. A., Long, A. C., Puntillo, K. A., Kross, E. K., Hart, J., . . . Curtis, J. R. (2017). Guidelines for family-centered care in the neonatal, pediatric, and adult ICU. Critical Care Medicine, 45(1), 103–128. doi:10.1097/ccm.0000000000002169

Day, A., Haj-Bakri, S., Lubchansky, S., & Mehta, S. (2013). Sleep, anxiety and fatigue in family members of patients admitted to the intensive care unit: A questionnaire study. Critical Care, 17(3), R91. doi:10.1186/cc12736

Ekman, I., Swedberg, K., Taft, C., Lindseth, A., Norberg, A., Brink, E., . . . Sunnerhagen, K. S. (2011). Person-centered care—Ready for prime time. European Journal of Cardiovascular Nursing, 10(4), 248–251. doi:10.1016/j.ejcnurse.2011.06.008

Eriksson, K. (2018). Vårdvetenskap : vetenskapen om vårdandet : om det tidlösa i tiden. Stockholm, Sweden: Liber.

Gerritsen, R. T., Hartog, C. S., & Curtis, J. R. (2017). New developments in the provision of family-centered care in the intensive care unit. Intensive Care Medicine, 43(4), 550–553. doi:10.1007/s00134-017-4684-5

Hamilton, D. K., & Watkins, D. H. (2009). Evidence-based design for multiple building types. Hoboken, N.J.: J. Wiley & Sons..

Imanipour, M., Kiwanuka, F., Akhavan Rad, S., Masaba, R., & Alemayehu, Y. H. (2019). Family members' experiences in adult intensive care units: A systematic review. Scandinavian Journal of Caring Sciences, 33(3), 569-581. doi:10.1111/scs.12675

Jacob, M., Horton, C., Rance-Ashley, S., Field, T., Patterson, R., Johnson, C., Frobos, C. (2016). Needs of Patients' Family Members in an Intensive Care Unit With Continuous Visitation. American Journal of Critical Care, 25(2), 118–125. doi:10.4037/ajcc2016258

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 16

to experience at-homeness in such high-technology settings as ICUs when the design matches

the needs of the patients, their family, and the staff (Andersson, Fridh, & Lindahl, 2019).

“Evidence-based design aims to create healing environments, as does

caring science. Therefore, a match between these research fields is of great interest, and

more successful collaborations are needed in the future as these disciplines have the

same goal—to ensure persons in healthcare facilities have the highest possible

wellbeing.

Evidence-based design aims to create healing environments, as does caring

science. Therefore, a match between these research fields is of great interest, and more

successful collaborations are needed in the future as these disciplines have the same goal—to

ensure persons in healthcare facilities have the highest possible wellbeing.

Conflict of interest: The authors declare that there is no conflict of interest.

EVIDENCE-BASED DESIGNED HEALTHCARE ENVIRONMENT IN AN ICU 17

References

Andersson, M., Fridh, I., & Lindahl, B. (2019). Is it possible to feel at home in a patient room in an intensive care unit? Reflections on environmental aspects in technology-dense environments. Nursing Inquiry, 26(4), e12301. doi:10.1111/nin.12301

Apple, M. (2014). A comparative evaluation of Swedish intensive care patient rooms. Herd, 7(3), 78–93. doi:10.1177/193758671400700306

Arman, M., Ranheim, A., Rydenlund, K., Rytterström, P., & Rehnsfeldt, A. (2015). Article. The Nordic tradition of caring science: The works of three theorists. Nursing Science Quarterly, 28(4), 288–296. doi:10.1177/0894318415599220

Celik, S., Genc, G., Kinetli, Y., Asiliogli, M., Sari, M., & Madenoglu Kivanc, M. (2016). Sleep problems, anxiety, depression and fatigue on family members of adult intensive care unit patients. International Journal of Nursing Practice, 22(5), 512–522. doi:10.1111/ijn.12451

Chapman, D. K., Collingridge, D. S., Mitchell, L. A., Wright, E. S., Hopkins, R. O., Butler, J. M., & Brown, S. M. (2016). Satisfaction with elimination of all visitation restrictions in a mixed-profile intensive care unit. American Journal of Critical Care, 25(1), 46–50. doi:10.4037/ajcc2016789

Coombs, M. A., Davidson, J. E., Nunnally, M. E., Wickline, M. A., & Curtis, J. R. (2017). Using qualitative research to inform development of professional guidelines: A case study of the society of critical care medicine family-centered care guidelines. Critical Care Medicine, 45(8), 1352–1358. doi:10.1097/ccm.0000000000002523

Craig, P., Dieppe, P., Macintyre, S., Michie, S., Nazareth, I., & Petticrew, M. (2008). Developing and evaluating complex interventions: The new Medical Research Council guidance. BMJ, 337. doi:10.1136/bmj.a1655

Davidson, J. E., Aslakson, R. A., Long, A. C., Puntillo, K. A., Kross, E. K., Hart, J., . . . Curtis, J. R. (2017). Guidelines for family-centered care in the neonatal, pediatric, and adult ICU. Critical Care Medicine, 45(1), 103–128. doi:10.1097/ccm.0000000000002169

Day, A., Haj-Bakri, S., Lubchansky, S., & Mehta, S. (2013). Sleep, anxiety and fatigue in family members of patients admitted to the intensive care unit: A questionnaire study. Critical Care, 17(3), R91. doi:10.1186/cc12736

Ekman, I., Swedberg, K., Taft, C., Lindseth, A., Norberg, A., Brink, E., . . . Sunnerhagen, K. S. (2011). Person-centered care—Ready for prime time. European Journal of Cardiovascular Nursing, 10(4), 248–251. doi:10.1016/j.ejcnurse.2011.06.008

Eriksson, K. (2018). Vårdvetenskap : vetenskapen om vårdandet : om det tidlösa i tiden. Stockholm, Sweden: Liber.

Gerritsen, R. T., Hartog, C. S., & Curtis, J. R. (2017). New developments in the provision of family-centered care in the intensive care unit. Intensive Care Medicine, 43(4), 550–553. doi:10.1007/s00134-017-4684-5

Hamilton, D. K., & Watkins, D. H. (2009). Evidence-based design for multiple building types. Hoboken, N.J.: J. Wiley & Sons..

Imanipour, M., Kiwanuka, F., Akhavan Rad, S., Masaba, R., & Alemayehu, Y. H. (2019). Family members' experiences in adult intensive care units: A systematic review. Scandinavian Journal of Caring Sciences, 33(3), 569-581. doi:10.1111/scs.12675

Jacob, M., Horton, C., Rance-Ashley, S., Field, T., Patterson, R., Johnson, C., Frobos, C. (2016). Needs of Patients' Family Members in an Intensive Care Unit With Continuous Visitation. American Journal of Critical Care, 25(2), 118–125. doi:10.4037/ajcc2016258

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