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Presenters
2009 NACHRI F iliti D i2009 NACHRI Facilities Design Conference, Austin, TX
Debajyoti Pati, PhD, FIIA, HKS Architects
Jeff Stouffer, FAIA, HKS Architects
The Ongoing Debate
In a time of rising health… In a time of rising health costs, it doesn’t make a ton of sense for facilities to be spending lavishly on perks.
Jacob Goldstein, in Behind Hospitals’ Pretty Facades, Dingy Rooms for Patients, Wall Street Journal, August 20, 2008
Learning Objectives
Understand the influence of positive distractions on pediatric patients while waitingUnderstand the role of positive distractions in the parents’ waiting experienceDistinguish the difference between uni-gsensory and multi-sensory distractions
Agenda
Waiting ExperiencePositive DistractionsPositive DistractionsStudy ObjectivesStudy ProcedureChildren’s Data AnalysisyParent’s Data AnalysisImplicationsImplications
Acknowledgments
Children’s Medical Center Dallas
American Art Resources
Mohawk
Catherine Mayer Fine Art
Henry Domke Fine Art
Acknowledgments
Co-InvestigatorsDr Upali Nanda, American Art Resources
Laurie Waggener, WHR Architectsgg ,
Agenda
Waiting ExperiencePositive DistractionsPositive DistractionsStudy ObjectivesStudy ProcedureChildren’s Data AnalysisyParent’s Data AnalysisImplicationsImplications
Waiting Experience
The Cornell University Studyy y
Location: Weill Cornell Medical College, New York
Six clinical outpatient servicesSix clinical outpatient services
Key findings:Physical environment attractiveness correlated with perceived care quality and anxietyanxiety
Physical environment attractiveness correlated with perceived waiting timeperceived waiting time
Agenda
Waiting ExperiencePositive DistractionsPositive DistractionsStudy ObjectivesStudy ProcedureChildren’s Data AnalysisyParent’s Data AnalysisImplicationsImplications
Positive Distractions
Outcomes during procedures:p
Better pain control
Reduced anxiety, fatigue and distress
Reduced patient-controlled sedation doses
Reduced pulse rate
Greater relaxation
Most studies on adult patients
Agenda
Waiting ExperiencePositive DistractionsPositive DistractionsStudy ObjectivesStudy ProcedureChildren’s Data AnalysisyParent’s Data AnalysisImplicationsImplications
Study Objective # 1
Can positive distractions produce positiveCan positive distractions produce positive behavioral outcomes in children (with and without neurological disorders)?without neurological disorders)?
Study Objective # 2
Do positive distractions in an environment actDo positive distractions in an environment act as points of focus that can improve the overall waiting experience?overall waiting experience?
Agenda
Waiting ExperiencePositive DistractionsPositive DistractionsStudy ObjectivesStudy ProcedureChildren’s Data AnalysisyParent’s Data AnalysisImplicationsImplications
Distraction Conditions
5 positive distraction conditionsStill nature photo slide show Naturep
Ambient Art
Ambient Art with Sound
Nature Slides
Aquarium
Aquarium with soundAmbient Art
All nature themes
No-Distraction condition as control
Aquarium
Subjects and Data Collection
Subjects:Pediatric patients visiting the
Process:10 min randomized distraction
clinic
>= 5 years old
With and without
10 min no-distraction
Trained observers
O b hildWith and without developmental/neurological problems
One observer per child
Parent questionnaire
Data CollectionDental Clinic: 6 days in
Sample sizeChildren data: 81 (Dental) + 77
December 2008
Cardiac Clinic: 6 days in January 2009
(Cardiac)
Parents: 51 (Dental) + 24 (Cardiac)
Subject Attributes
Dental ClinicAge = 10.95 (mean); 5 – 17 years
Cardiac ClinicAge = 11.57 (mean); 5 – 17 yearsg ( ) y
EthnicityWhite = 25.3%
Bl k 13 9%
g ( ) y
EthnicityWhite = 40.8%
Bl k 22 4%Black = 13.9%
Hispanic = 58.2%
Asian = 2.5%
Black = 22.4%
Hispanic = 35.5%
Asian = 1.3%
GenderMale = 59.3%
Female = 40 7%
GenderMale = 53.9%
Female = 46 1%Female = 40.7%
Developmental/ Neurological deficiencies
P t 47 8%
Female = 46.1%
Developmental/ Neurological deficiencies
P t 12 5%Present = 47.8% Present = 12.5%
Outcome Measures
AttentionPositive distraction
Other art work
Toy
B kBook
Wall
Ceilingg
Floor
Door
Window
Furniture
PeoplePeople
Themselves
Outcome Measures
ActivityPlaying with toysy g y
Playing with non-toys
Non-play activity or other play
Analytical Procedures
Paired sample t-tests for identifying significant differences between distraction and no-distraction
diticonditions
Covariance models to compare the five distraction conditionsconditions
Factorial Design to identify main effects
C l ti A l i t l l ti hi b tCorrelation Analysis to explore relationships between children’s behavior and parent’s perception
Mediation analysis to explore the true pattern ofMediation analysis to explore the true pattern of relationship between waiting experience and perceived care quality
Agenda
Waiting ExperiencePositive DistractionsPositive DistractionsStudy ObjectivesStudy ProcedureChildren’s Data AnalysisyParent’s Data AnalysisImplicationsImplications
Distraction vs No-Distraction
What differences in attention, behavior and at d e e ces atte t o , be a o a dactivities were observed during the presence of positive distraction conditions?
Attention :: Dental Clinic
Attention Type
Distraction No-Distraction
Difference Significance
TV Monitor 27 73 2 16 25 57 0 000TV Monitor 27.73 2.16 25.57 0.000
Other Artwork 0.36 0.42 -0.06 0.886
Toy 4.24 8.22 -3.98 0.007
Book 1.97 2.17 -0.2 0.829
Wall 7.1 7.57 -0.47 0.818
Ceiling 2.91 2.52 0.39 0.723
Floor 2.66 3.83 -1.17 0.373
Door 3.65 3.5 0.15 0.910
Window 3 52 5 7 2 18 0 179Window 3.52 5.7 -2.18 0.179
Furniture 3.19 5.16 -1.97 0.245
People 36.12 51.64 -15.52 0.000
Themselves 6.53 7.10 -0.57 0.792
Attention :: Cardiac Clinic
Attention Type
Distraction No-Distraction
Difference Significance
TV Monitor 20 58 0 41 20 17 0 000TV Monitor 20.58 0.41 20.17 0.000
Other Artwork 1.52 1.24 0.28 0.825
Toy 19.13 13.16 5.97 0.081
Book 8.09 15.47 -7.83 0.017
Wall 1.95 3.0 -1.05 0.333
Ceiling 0.52 0.37 0.15 0.737
Floor 3.42 3.04 0.38 0.726
Door 0.75 1.02 -0.27 0.737
Window 4 03 5 11 1 08 0 369Window 4.03 5.11 -1.08 0.369
Furniture 0.97 1.21 -0.24 0.730
People 32.27 44.36 -12.09 0.008
Themselves 6.75 11.6 -4.85 0.028
Attention :: Key Inferences
Substantial diversion of attention to the TV monitor during distraction conditions
Presence of distraction conditions diverted attention from two or more of the following to the TV monitor: people, book, toy, themselves
Positive Distraction do help focus attention
“People” drew most attention even in the presence of distraction conditionsdistraction conditions
Physical Behavior: Dental Clinic
Behavior Type
Distraction No-Distraction
Difference SignificanceType Distraction
Calm 64.92 58.3 6.62 0.080
Fidgety 20.99 19.41 1.58 0.570
Fine 10 79 15 36 4 57 0 051Fine Movement
10.79 15.36 -4.57 0.051
Gross Movement
2.63 5.18 -2.55 0.079
Intense Movement
0.67 1.75 -1.08 0.153
Physical Behavior :: Cardiac Clinic
Behavior Type
Distraction No-Distraction
Difference SignificanceType Distraction
Calm 68.88 59.92 8.96 0.029
Fidgety 11.50 13.08 -1.58 0.473
Fine Movement 18 33 23 32 4 99 0 183Fine Movement 18.33 23.32 -4.99 0.183
Gross Movement
1.28 3.49 -2.21 0.049
Intense 0 00 0 19 -0 19 0 176Intense Movement
0.00 0.19 0.19 0.176
Distraction vs No-Distraction Inferrences
Dental Clinic Cardiac Clinic
Most children were observed to be ‘calm’, ‘solitary behavior’, ‘in seat’, ‘not playing’, and ‘watching
Most children were observed to be ‘calm’, ‘solitary behavior’, ‘in seat’, ‘not playing’, and ‘watching
other people’.
Distraction condition results in:
other people’.
Distraction condition results in:Distraction condition results in:
More attention on TV Monitor
More calm; less fine and t
Distraction condition results in:
More attention on TV Monitor
More calm; less gross tgross movement movement
Distribution of Attention
Dental Clinic % Attention
Cardiac Clinic % Attention
Ambient Art with Sound 42.35 Ambient Art 37.18
Aquarium 28.87 Ambient Art with Sound 23.67
Still Art 28.00 Aquarium with Sound 23.00
A i ith S d 23 49 A i 14 53Aquarium with Sound 23.49 Aquarium 14.53
Ambient Art 4.66 Still Art 9.11
Both Clinics %Distribution by Clinic Both Clinics % Attention
Ambient Art with Sound 66.02
Distribution by Clinic
Aquarium with Sound 46.48
Aquarium 43.40
Ambient Art 41.84
Still Art 37.11Combined Mean Distribution
Distribution of Attention :: Key Inferences
Overall, multi-sensory (visual + auditory) stimuli attract greater attention
Still nature slide show demonstrate least preference
HOWEVERHOWEVER
Substantial differences between the two clinics
A pattern observable for cardiac population
Ambient art conditions, Aquarium conditions, Still , q ,Nature
No meaningful pattern identifiable for dental population
Interaction Effects?
Did bj t tt ib t ( th i itDid subject attribute (ethnicity, developmental disability, illness type) interact with attention and behavior?interact with attention and behavior?
Physical Behavior :: CALM
CALM(Most to Least)
Dental Clinic Cardiac Clinic
Aquarium Ambient Art
Ambient Art with Sound Aquarium with Sound
Still Art Ambient Art with Sound
Aquarium with Sound Still ArtAquarium with Sound Still Art
Ambient Art Aquarium
Pole ReversalPole Reversal
Physical Behavior :: FIDGETY
FIDGETY(Least to Most)
Dental Clinic Cardiac Clinic
Ambient Art with Sound Aquarium
Still Art Aquarium with Sound
Aquarium Ambient Art
Aquarium with Sound Ambient Art with SoundAquarium with Sound Ambient Art with Sound
Ambient Art Still Art
Block ShiftBlock Shift
Physical Behavior :: FINE MOVEMENT
FINE MOVEMENT(Least to Most)
Dental Clinic Cardiac Clinic
Ambient Art with Sound Ambient Art
Aquarium Still Art
Aquarium with Sound Ambient Art with Sound
Still Art Aquarium with SoundStill Art Aquarium with Sound
Ambient Art Aquarium
Pole ReversalPole Reversal
Physical Behavior :: GROSS MOVEMENT
GROSS MOVEMENT(Least to Most)
Dental Clinic Cardiac Clinic
Aquarium Ambient Art
Aquarium with Sound Still Art
Ambient Art with Sound Ambient Art with Sound
Still Art Aquarium with SoundStill Art Aquarium with Sound
Ambient Art Aquarium
Total ReversalTotal Reversal
Activity :: PLAY TOY
PLAY TOY(Most to Least)
Dental Clinic Cardiac Clinic
Aquarium Aquarium with Sound
Ambient Art with Sound Aquarium
Still Art Still Art
Aquarium with Sound Ambient Art with SoundAquarium with Sound Ambient Art with Sound
Ambient Art Ambient Art
Partial ReversalPartial Reversal
Activity :: PLAY NON-TOY
PLAY NON-TOY(Most to Least)
Dental Clinic Cardiac Clinic
Aquarium with Sound Still Art
Ambient Art Ambient Art with Sound
Still Art Aquarium
Ambient Art with Sound Aquarium with SoundAmbient Art with Sound Aquarium with Sound
Aquarium Ambient Art
Block ShiftBlock Shift
Location :: OUT OF SEAT
OUT OF SEAT(Least to Most)
Dental Clinic Cardiac Clinic
Aquarium Still Art
Still Art Ambient Art with Sound
Aquarium with Sound Aquarium
Ambient Art Aquarium with SoundAmbient Art Aquarium with Sound
Ambient Art with Sound Ambient Art
Partial ReversalPartial Reversal
Location :: IN SEAT
IN SEAT(Most to Least)
Dental Clinic Cardiac Clinic
Aquarium Still Art
Still Art Ambient Art with Sound
Ambient Art with Sound Aquarium with Sound
Ambient Art Ambient ArtAmbient Art Ambient Art
Aquarium with Sound Aquarium
Pole ReversalPole Reversal
Social Behavior :: POSITIVE INTERACTION
POSITIVE INTERACTION(Most to Least)
Dental Clinic Cardiac Clinic
Aquarium with Sound Still Art( ost to east)Ambient Art with Sound Ambient Art
Aquarium Aquarium with Sound
Ambient Art Ambient Art with SoundAmbient Art Ambient Art with Sound
Still Art Aquarium
Pole ReversalPole Reversal
Social Behavior :: SOLITARY BEHAVIOR
SOLITARY BEHAVIOR(Least to Most)
Dental Clinic Cardiac Clinic
Aquarium with Sound Still Art
Ambient Art with Sound Ambient Art
Aquarium Aquarium with Sound
Ambient Art Ambient Art with SoundAmbient Art Ambient Art with Sound
Still Art Aquarium
Block ShiftBlock Shift
Key Behavioral Inferences
Population attribute (ethnicity, developmental disability, illness type) may constitute a y, yp ) yfactor determining physical and social behavior
Most frequent top and bottom conditions:
Dental Clinic Cardiac ClinicMost frequently at the top
Aquarium Ambient Art + Still Art
Most frequently at the bottom
Ambient Art Aquarium
Question
Is patient attribute (as defined by clinic) a major predictor of behavior?
Method: 2 x 5 Factorial Designg
Still Art Ambient Art
Ambient Art +
Aquarium Aquarium + Sound
SoundDentalCardiac
Factorial Analysis: Attention
Attention WITHOUT Covariate
Clinic Distraction Interaction
WITH Covariate
Clinic Distraction Interaction
TV Monitor Yes
Other Art
Toy Yes
Yes
Yes
Book Yes
Wall Yes Yes
Ceiling Yes
Yes Yes
Ceiling Yes
Floor
Door Yes Yes
Window
Furniture Yes
People
Yes
Themselves
Factorial Analysis: Behavior and Activity
Attention WITHOUT Covariate
Clinic Distraction Interaction
Calm
WITH Covariate
Clinic Distraction Interaction
Calm
Fidgety Yes
Fine Movement Yes
Gross Movement Yes
Yes
Yes
Gross Movement Yes
Intense
Play Toy Yes
Play Non-ToyPlay Non Toy
None/Other Play Yes Yes
Out of Seat
In Seat
On Lap Yes
Positive Int Yes
Negative Int
Yes
Yes
YesNegative Int
Solitary Yes
Yes
Yes
Key Inferences
A number of behavior outcomes associated with patient attribute:
Culture and/or Neurological State and/or Illness Type
Difference reduces when controlled for no-distraction condition data
Multi-sensory distractions more effective in Dental Clinic
Behavior Dental Clinic Cardiac ClinicCalm Ambient Art (S); Aquarium Ambient ArtFidgety Ambient Art (S) Aquariumg y ( ) qFine Movement Ambient Art (S) Ambient ArtGross Movement Aquarium Ambient ArtIntense Movement Aquarium (S) Aquariumq ( ) qPositive Interaction Aquarium (S) Still ArtNegative Interaction Aquarium Still ArtSolitary Behavior Aquarium (S) Still ArtSolitary Behavior Aquarium (S) Still Art
Agenda
Waiting ExperiencePositive DistractionsPositive DistractionsStudy ObjectivesStudy ProcedureChildren’s Data AnalysisyParent’s Data AnalysisImplicationsImplications
Inferences
Presence of distraction conditions associated with change in children’s attention, activities and behavior
P ’ i i i i d i h hild ’ iParents’ waiting experience associated with children’s attention, activities and behavior
Elements of parents’ waiting experience associated with their perceived waiting time
Parent’s waiting experience (including perceived waiting time) associated with their:associated with their:
Exam room experience
Perception regarding staff
Overall visit
Overall experience
Items in Overall Visit and Experience
Felt caredChild treated in timely mannerChild treated in timely mannerFelt welcomeLess anxiety feelingRecommend this clinic to othersQuality of care child receivedQuality of service parent’s receivedQuality of service parent s receivedQuality of interaction with staffQuality of interaction with doctor
Mediation Analysis
Perception
Wait Area
regarding Staff
Overall
Perception regarding
Exam Room
ExperienceOverall
g gStaff
The Ongoing Debate
… In a time of rising health costs it doesn’t make a toncosts, it doesn t make a ton of sense for facilities to be spending lavishly on perks.p g y p
Jacob Goldstein, in Behind Hospitals’ Pretty F d Di R f P ti t W llFacades, Dingy Rooms for Patients, Wall Street Journal, August 20, 2008
Agenda
Waiting ExperiencePositive DistractionsPositive DistractionsStudy ObjectivesStudy ProcedureChildren’s Data AnalysisyParent’s Data AnalysisImplicationsImplications
Implications
Waiting experience associated with keyCarefully engineer
waiting experienceassociated with key organizational objectivesobjectives
Implications
All positive distractions are not the same
Culture and/or neurological state and/or li i t i t d ithclinic type associated with
behavioral outcomes
Positive distractions are attention grabbers
Locate distraction conditions carefully
Positive distractions associated with calmbehavior
Take advantage of behavioral influence of positive distractionbehavior positive distraction
Implications
Attention on People:Do not ignore physical placement,
dj i iWhether distraction conditions were switched on or not, most attention was fixated on other
adjacencies, view corridors, and activities aroundwas fixated on other
peopleactivities around hospital waiting areas
Definitions of Terms: AttentionAttention Eye-fixation on any object/person will be recorded as
attention. Objects can include art work, toys, furniture, etc.
Positive distraction The flat screen TV in the waiting room on which artwork/music will be displayed
Other artwork Any other artwork in the waiting area: painting, sculpture, … at any location in the waiting lounge
Toy Any piece of toy/game in the waiting area or brought in by the subjectin by the subject
Book Book or books in the waiting lounge or brought in by the subject
Wall Blank portions of any of the wall in the waiting room
Ceiling Ceiling of the waiting roomFloor Floor of the waiting roomDoor Any of the doors of the waiting roomWindow Any window – external or internal – in the waiting
room, including the reception desk/windowg p
Furniture Any unoccupied furniture in the waiting lounge –without any person or thing on the furniture
P l A i h i iPeople Any person in the waiting roomThemselves Any portion of the patient’s own body
Definition of Terms: Physical Behavior
Calm No visible major motor movementFidgety This will be coded whenever repetitive,
restless motor movements is observed which appeared to be primarily purposeless (e.g., taping a pencil, kicking one's foot)p g pe c , c g o e s oo )
Fine Movement Defined as fine motor movement involving very low intensity purposeful movements of body parts.
Gross Movement Defined as gross motor movement involving taking one or more steps or, if sitting, moving the buttocks from one spot to another
Intense Defined as engaging in inappropriate or excessively vigorous physical activities (e.g., throwing toys, running about, yelling or singing loudly)
Definition of Terms: Activity and Location
Playing with toys Defined as playing with toys in the room (ifPlaying with toys Defined as playing with toys in the room (if available)
Playing with non toys Defined as playing with non toy objects in the room (e.g., doorknob, table)
Non-play activity/ Other Play Defined as neither playing with a toy or non-toy item (e.g., standing and gazing at the door; reading; eating; drinking)OROther play activities (not involving toys or non-toys)
Out of seat This will be coded if a child left the seat entirely at the time of observation
In-seat This will be coded if a child is in his/her seat at the time of observation
Parent’s lap This will be coded if a child is sitting on the lap of another accompanying adult.
Definition of Terms: Social Behavior
Positive interaction All vocalizations directed to sibling/parent/objects excluding screams, shouts, cries, and whines; all cooperative responses involved with sharing an object; and espo ses vo ved w s g objec ; dhugs and holding hands
Negative interaction Screams, shouts, or other utterances that indicate rejecting and oppositional behavior; hit, pinch, kick, and “nonplaying” push or pull; grabbing objects from sibling/parent; and destroying possessions of sibling/parent
Solitary behavior All solitary activity (excluding parallel play conducted between two children within two feet of one another)