Original Research
Donna Dowling, PhD, RN ❍ Section Editor
Improvements in Staff Quality of Work Life and Family Satisfaction Following the Move to Single-Family Room NICU Design Jo Watson, PhD, RN(EC); Marion DeLand, RNC-NIC, MN; Sharyn Gibbins, PhD, RN(EC); Elizabeth MacMillan York, RN; Kate Robson, MEd
ABSTRACT OBJECTIVE: The purpose of this study was to determine whether there were differences in staff quality of work life and parent satisfaction when a neonatal intensive care unit moved from an open-bay design to a single-room model of care. DESIGN: This descriptive study measured staff quality of work life and family satisfaction before and at 2 time periods after the relocation of a perinatal centre and the introduction of single-family room care. Differences in work life quality and satisfaction were determined using 2-sample t-tests. RESULT: There were improvements in staff quality of work life and family satisfaction at both time periods following the move. CONCLUSION: Lessons learned may be of value to other units considering such a move. A neonatal intensive care unit designed to contribute to parental and staff well-being is a model to be considered for future neonatal designs. Key Words: neonatal intensive care, parent satisfaction, quality of work life, single-family room NICU care
F
amily satisfaction is an important measure of healthcare performance.1 Dimensions of satisfaction include the art and science of giving care, accessibility, the physical environment, efficacy, education, and trust.2 When nurses are satisfied with their work, their care includes higher levels of patient safety, fewer medication errors, and improved Author Affiliations: Sunnybrook Health Sciences Centre, Toronto (Drs Watson and Gibbins and Mss DeLand, MacMillan York, and Robson), and LS Bloomberg Faculty of Nursing, University of Toronto (Drs Watson and Gibbins and Ms DeLand), Ontario, Canada. The authors declare no conflict of interest. Correspondence: Jo Watson, PhD, RN(EC), 2075 Bayview Ave, M4-162, Toronto, ON M4N 3M5, Canada ([email protected]). Copyright © 2014 by The National Association of Neonatal Nurses DOI: 10.1097/ANC.0000000000000046
patient satisfaction.3 Hospital departments that have higher employee satisfaction provide better patient experiences.4 Because of the importance and influence of satisfaction, we were interested in measuring changes that accompanied neonatal intensive care unit (NICU) redesign and relocation. A systematic review of 12 studies comparing open-bay versus single-family room (SFR) design has described positive outcomes related to the SFR model.5 In an open-bay model, several babies are cared for in 1 ward room. In SFR-designed units, each baby has a private room. Single-family room units were deemed superior for patient care and parent satisfaction, but healthcare professionals’ views varied. The authors hypothesized that greater parental presence in the SFR units contributed to better outcomes than when parental access was limited by NICU practices in an open-bay unit. These results are similar to those reported in other observational studies wherein families, who had unlimited access to their hospitalized infants, reported more comfort and confidence in their parenting abilities.6,7
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In an anonymous survey with parents and staff, families reported satisfaction with the care they received in both open-bay and SFR units.8 However, parents who had experience with both types of NICU design were more likely to perceive staff performance as better in the SFR. Similarly, it has been reported that parents preferred SFR because of the privacy it provided compared with the open-bay layout.9 Nurses indicated that the SFR environment increased their work demands (ie, more walking) and decreased their ability to visualize their patients. Nurses also reported SFR as less favorable because they were not as knowledgeable about other infants in the NICU. They also perceived that SFR decreased parents’ readiness for discharge.9 Another evaluation of a move to single-family NICU rooms reported that there was lower interaction among team members in the SFR model.10 These results are similar to those reported elsewhere. Seventy percent of nurses responding to 1 survey reported a decrease in their work-life satisfaction after moving to an SFR unit.11 Issues such as reduced opportunities for supporting colleagues were cited as significant stressors in an SFR environment. Although nurses reported improved satisfaction with SFR over time and indicated that SFR was preferable in terms of family privacy, environmental control, promotion of bonding, and
breastfeeding, they continued to prefer open-bay unit design. Reports of the impact of the move to single-family room design have been mixed, with families appreciating the design and staff finding SFRs more challenging to work in than open-bay units. Further research examining staff and family satisfaction following the move of NICU units to single-room care provides the opportunity to build on current evidence. When our program received approval to build a new neonatal intensive care unit as part of a merger with another hospital, we recognized the opportunity to measure changes in outcomes, including satisfaction and quality of work life. Our original NICU was constructed in the early 1980s, when open-bay design was considered to be the optimal way to provide intensive care to sick infants12-14 (Figure 1). The unit consisted of open rooms with approximately 40 square feet allocated to each infant space and 12 babies cared for in 1 room. Infants were exposed to unregulated amounts of noise and light.13,14 When the unit was originally built, the ability to have sophisticated and integrated monitoring was not available and staff had to be able to visualize infants to provide safe care. Unit environment was not recognized as an important element in the care and well-being of high-risk neonates and their families.13-15
FIGURE 1.
Our open-bay unit before the move. www.advancesinneonatalcare.org Copyright © 2014 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
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The new unit design incorporated information obtained from our review of the literature, along with input from families and staff, to determine what elements should be included in the new space (Figure 2). There was thoughtful consultation with other NICUs that had already gone through this process. Our new NICU would focus on embedding family-centered, developmentally supportive care at the core of the design, with infants having their own room. Follow-up clinic and all support staff workspaces would be integrated into 1 contiguous physical space (Figure 3). The process of redesigning and moving into the new unit occurred over a period of several years. There was extensive work done with all members of the healthcare team to become knowledgeable about the impact and functionality of single-family room design and function. Education and support were provided to staff to develop strategies to cope with change and with relocation. These strategies included tours of the new space at many different stages of construction and mocking up new work spaces and processes. The leadership team felt that these processes were important so that staff could anticipate changes to work flow and to minimize the potential for confusion once the move occurred. We recognized that redesigning the NICU provided the unique opportunity to improve how care
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was provided to patients and families. The goal of this observational study was to determine whether there were differences in staff quality of work life and parent satisfaction when a neonatal intensive care unit moved from open-bay design to a singleroom model of care. The study measured staff quality of work life and family satisfaction during 3 time periods, 6 months before, 6 months after, and 1 year after a level III NICU relocation and the addition of 5 neonatal intensive care beds. Data collection took place from April 2010 until September 2011. This article builds on the work done by others and summarizes move and design-related staff and family satisfaction measures in the NICU.9-11,15 Approval from the institution’s research ethics board was received to conduct this study.
METHODS Staff Quality of Work Life All staff who worked a minimum of 0.5 full-time equivalent status and who were expecting to continue to work in the unit following the move were approached to participate. Healthcare professionals were recruited through information sessions and posters describing the study. A member of the research team approached staff over a 2-week period and asked them whether they were interested in
FIGURE 2.
A single-family room in our new unit. Advances in Neonatal Care • Vol. 14, No. 2 Copyright © 2014 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
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FIGURE 3.
The floor plan in the single-family room unit.
completing an anonymous satisfaction survey. Staff members were reminded that their information would be kept confidential and presented only in aggregate format. Completion of the survey was considered informed consent. Staff who had been working during the premove survey were approached to complete to 2 postmove surveys as well. We used the quality-of-work-life survey developed and tested by Smith and colleagues.11 The original survey was a 104-item, 7-level Likertranking scale with possible responses ranging from “low quality” to “high quality.” We revised the original tool to include 60 items, using the same ranking scale, electing not to use the questions relating to off-the-job quality of life. The survey focuses on individuals’ perceptions of the quality of being an employee, the quality of the work environment, patient care, interaction with other team members, and interaction with technology. This tool has demonstrated high internal reliability based on computed values for the Cronbach alpha.10 Total perception scores were computed for each of the categories as well as the total survey score. Unpaired t-tests were used to determine significant differences between time periods. The level of statistical significance was set at P < .05.
Family Satisfaction The standard practice in the NICU is to use a telephone survey to obtain satisfaction information from families of babies admitted to the NICU for greater than 72 hours. The Neonatal Telephone
Satisfaction Survey was introduced in 2005 following a collaborative quality improvement project with the Vermont Oxford Network that developed the original tool to measure parent satisfaction.16,17 This tool incorporates the concepts of satisfaction with care, trust in the team, parental confidence as well as the opportunity to interact with other families and with unit staff. Parents were contacted by phone by unit staff. Data collection took place within 3 months of the baby’s transfer or discharge. Parents were reminded that their confidential information would be used for research and educational purposes to improve the quality of care for future families. Data from the survey were analyzed using computations of t tests for statistical significance for the mean scores of the survey questions. The level of statistical significance was set at P < .05.
RESULTS Staff Quality of Work Life One hundred seventy-one members of our staff were eligible to complete the survey 6 months before the move. Only personnel completing the initial survey were eligible to complete it again at 6 months and 1 year postmove. Nurses were the most frequent responders to the survey (Table 1). Quality-of-worklife total scores were significantly higher 6 months after the move and again at 1 year compared to premove scores (P < .040 and .000, respectively) (Table 2). Items for which there were no significant www.advancesinneonatalcare.org
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TABLE 1. Staff Participating in the Quality-of-Work-Life Survey Premove Registered nurses and nurse practitioners
Postmove Postmove 6 mo 1y
57
46
15
Allied health
9
13
1
Physicians
1
1
5
differences at either time period after the move included the overall quality of being an employee of the organization, the hectic nature of the work environment, team spirit, fatigue, the excitement of the job, and the ability to interact with supervisory personnel, parents, and patients. Elements of quality of work life that improved at both time periods following the move included the quality of the work environment, the ability to concentrate on the job, noise level, privacy for families and staff, and ease of communication. Staff also recognized the improved ability of parents to contribute to their babies’ care. Elements that were seen to improve only 1 year following the move included the ability of staff to interact with parents, on-the-job productivity, and staff morale (Table 3). There were no changes in sick time, turnover, or staff injury in the 1-year period following the move.
Parent Satisfaction Survey Results During the study period, 173 babies met survey criteria and 85 families responded to the telephone survey over the 3 time periods (n = 48, n = 22, n = 25, respectively). Response rates for the telephone survey were 51% premove, 54% six months postmove, and 68% at 1-year post move. Eighty-five percent of respondents were mothers of infants born at less than 32 weeks’ gestation. At both time periods following the move, there was a significant improvement in parents’ perceptions of the privacy afforded by the physical environment. Parents reported that they felt more comfortable spending time with their baby.
TABLE 2. Summary of Staff Quality-ofWork-Life Scores Group Pre (n = 55)
Mean
SD
P (2-Tailed) T1 vs T2: .040
181.290
23.5251
6 mo (n = 56) 206.553
51.2597
1 y (n = 9)
19.2685
219.555
T1 vs T3: .000
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At 1 year following the move, parents felt they knew their babies better, were more confident in feeding and comforting their babies, and reported more opportunities to interact with families. Parents reported adjusting better to having their babies at home and were less bothered by feeling anxious, angry, sad, or depressed. Parents were significantly more satisfied with the care their babies received 1 year after the move (Table 4).
DISCUSSION There are links between staff satisfaction, client satisfaction, and quality, making family and staff satisfaction key goals for healthcare leaders.4,16 When this is achieved, there is improved productivity, staff retention, and safety.18 NICU staff participating in this study reported significant improvements in the overall quality of work life at 6 months after the move and again at 1 year. It is noted that the response rate at 12 months after the move was small and should be interpreted with caution. These positive findings are similar to those previously reported, indicating that staff members were more satisfied in their new single-patient care environment.15 Unlike results reported by others,8,9,19 opportunities to interact with members of the healthcare team were improved for nurses participating in this study. We propose possible reasons for differences in staff experiences at our center. In the current design, opportunities to bring healthcare team members together on a frequent basis to discuss clinical care likely decreased isolation and concerns for infant safety. Staff work predominantly in pods that contain 12 single-patient rooms, with a central staff corridor where daily rounds and other staff interaction take place. The ability to contact team members through a voice-activated system may have provided additional assurance that help could be initiated whenever it was needed. Few studies have prospectively followed staff perceptions after a change in NICU design combined with a move to a new location.11 Staff perceptions in these studies were not consistently positive. Staff participating in this study were more satisfied at both time periods after the move. Further, parents reported high levels of satisfaction at 6 and 12 months postmove. This is consistent with other studies where families report increased satisfaction with the amount of privacy provided, improved ability to interact with their babies, and increased confidence in the team when care is provided within a model of SFR design.5,6,10 We were particularly interested in the significant improvement in parents’ reports of feeling less anxious, depressed, or sad after discharge from our new unit. The literature suggests that parents of preterm infants experience more stress and anxiety than
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TABLE 3. Staff Quality of Work Lifea Paired Differences 95% Confidence Interval of the Difference Mean
Lower
Upper
t
df
P (2-Tailed)
Quality of work environment
−1.51667
−1.93535
−1.09798
−7.249
59
.000
Quality of work environment
−1.09524
−1.81359
−.37688
−3.180
20
.005
Staff privacy
−1.81667
−2.40207
−1.23127
−6.210
59
.000
Staff privacy
−1.71429
−2.34408
−1.08449
−5.678
20
.000
Parental privacy
−3.25000
−3.75025
−2.74975
−13.000
59
.000
Parental privacy
−3.14286
−3.80697
–2.47875
−9.872
20
.000
There is enough room to work
−2.55932
−3.02417
−2.09447
−11.021
58
.000
There is enough room to work
−2.61905
−3.35972
−1.87838
−7.376
20
.000
−.71186
−1.15288
−.27085
−3.231
58
.002
Ability to concentrate Ability to concentrate
−.94737
−1.65635
−.23839
−2.807
18
.012
Noise level
−2.64407
−3.12983
−2.15830
−10.896
58
.000
Noise level
−2.09524
−2.86913
−1.32134
−5.648
20
.000
Design helps patients contribute to care
−2.33898
−2.76530
−1.91266
−10.982
58
.000
Design helps patients contribute to care
−2.57895
−3.49226
−1.66564
−5.932
18
.000
Ability to closely interact with patients
−1.05000
−1.86027
−.23973
−2.712
19
.014
Morale of unit
−1.00000
−1.77426
−.22574
−2.703
19
.014
−.76190
−1.37099
−.15281
−2.609
20
.017
Productivity of patient care team
Italic text = 6 months; nonitalic text = 1 year.
a
parents of term infants.20,21 Rates of postpartum depression as high as 40% have been reported in the literature.21 In addition, postnatal depressive symptoms appear to have a meaningful, dynamic influence on the cognitive outcomes of children born preterm, above and beyond family sociodemographics.22 The decrease in parents feeling anxious, angry, sad, or depressed is a marked improvement. No previous studies have explored families’ confidence in their ability to feed and comfort their baby in an SFR model of care, or parents’ confidence in knowing their baby well. Parenting self-efficacy and confidence are recognized as key factors in predicting parental depression, stress, relationship difficulties, and positive child outcomes.23,24 Three factors that predict parental stress include the ability to understand infant signals; to know how to soothe, settle, handle, and play with their infant; and the belief that they are doing a good job as a parent.25 Parents participating in this study reported improvement in these 3 dimensions following the move to SFR care. This may explain their reports of feeling less anxious and depressed. A model of care that
offers parents unlimited time with their infants, as does SFR design, provides the opportunity for parents to better understand their infants’ signals and develop skills in infant feeding contributing to developing parental confidence. A potential risk to SFR is that families do not feel prepared for discharge home. This problem was reported in other evaluations of single-room NICU design.8,10 A lack of parental preparedness was not identified in this study. If fact, parents responded that they felt more confident and adjusted better at home following discharge from the SFR unit. An earlier study reported that mothers of preterm infants cared for in units with single family rooms spent more time in the NICU than mothers whose infants were cared for in an open-bay NICU; however, they reported higher levels of stress.23 Other reports have suggested that isolation might have been a contributing factor to the increased stress.26,27 However, families in this study did not report higher levels of parental stress but rather described decreased stress and anxiety. One factor that could have prevented parental stress and isolation was the hiring of a parent www.advancesinneonatalcare.org
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TABLE 4. Family Satisfactiona Paired Differences 95% Confidence Interval of the Difference Mean
Lower
Upper
t
df
P (2-Tailed)
The physical environment allowed enough privacy for me to feel comfortable spending time with my baby
1.7000
0.5790
2.8209
3.431
9
.008
The physical environment allowed enough privacy for me to feel comfortable spending time with my baby
2.0000
1.1105
2.8895
4.899
12
.000
The opportunity to interact with other families
1.1539
0.3413
1.9663
3.094
12
.009
I know my baby very well
0.3846
0.0084
0.7777
2.132
12
.05
I feel confident feeding my baby
0.3846
0.0786
0.6906
2.739
12
.02
When my baby is crying or upset, I find it easy to comfort him/her
0.6154
0.0348
1.196
2.309
12
.04
My family is adjusting well to having the baby at home
0.5385
0.2249
0.852
3.742
12
.003
I am bothered by feeling irritable, anxious, depressed or sad
0.7692
–0.0169
1.5554
2.132
12
.05
Overall I was satisfied with the care my baby received while in the NICU
0.3846
–0.0084
0.7777
2.132
12
.05
Abbreviation: NICU, neonatal intensive care unit. aItalic text = 6 months; nonitalic text = 1 year.
coordinator 3 months after the move. This role, designed to be filled by a veteran NICU parent, has the key responsibility of encouraging families to participate in programmed group activities, including educational programs and holiday events. Orientation activities and group programs may have helped families feel less isolated and experience less stress in the new unit and this may have impacted their mood following discharge. Although the addition of the parent coordinator has been a real asset to the unit, this was likely a confounder to postmove parental satisfaction measures.
LIMITATIONS AND RECOMMENDATIONS There are limitations to this study that should be considered. Postmove measures at 6 and 12 months may not have captured the long-term impact of the move. It is possible that ongoing data collection that follows families and staff for 2 year following the move may have provided more insight regarding when staff transition from one model of care to another, and how long it takes for adjustment to a new environment and model of care. Improvements were seen in responses between 6 and 12 months and it is unknown whether there would be changes
at 24 months as reported elsewhere.11 A longer period of postmove measurement could be considered in future studies. Other limitations are the modest response rate for some of the surveys and that there was no matching of employees who completed the surveys pre- and postmove.
SUMMARY This study measured staff quality of work life and family satisfaction before and after the move to a model of single-room NICU design. Whereas earlier studies measuring satisfaction found improvements in parents’ experiences, those sometimes were at the expense of improved staff satisfaction.5,10 The current study found improvements in satisfaction for both parents and staff. This is one of the first studies of staff and family satisfaction related to NICU design that found improvements for all stakeholders. We recommend that other centers that are relocating or changing their model of care conduct research to measure staff and family satisfaction, as well as other outcome measures, to track the impact of the move. Redesign of a NICU is a time-consuming initiative that requires detailed planning and coordination. A successful redesign is one that achieves improvements
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in clinical outcomes as well as in satisfaction of families and staff. Lessons learned may be of value to other units considering such a move. A neonatal intensive care unit designed to contribute to parental well-being and staff well-being is a model to be considered for future neonatal designs.
References 1. Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2003. 2. Ware JE, Davies-Avery A, Steward AL. The measurement and meaning of patient satisfaction: a review of the literature. Health Med Serv Rev. 1978;1. http://www.rand.org/content/dam/rand/pubs/papers/ 2008/P6036.pdf 3. Rathert C, May DR. Health care work environments, employee satisfaction, and patient safety: care provider perspectives. Health Care Manage Rev. 2007;32:2-11. 4. Peltier J, Dahl A. The relationship between employee satisfaction and hospital patient experiences. Forum. April 2009. http://www.info-now .com/typo3conf/ext/p2wlib/pi1/press2web/html/userimg/FORUM/ Hospital%20Study%20-REslationship%20Btwn%20Emp.%20 Satisfaction%20and%20Pt.%20Experiences.pdf 5. Shahheidari M, Homer C. Impact of the design of neonatal intensive care units on neonates, staff, and families: a systematic literature review. J Perinat Neonatal Nurs. 2012;26:260-266. DOI:10.1097/ JPN.0b013e318261ca1d. 6. Carter BS, Carter A, Bennett S. Families’ views upon experiencing change in the neonatal intensive care unit environment: from the “baby barn” to the private room. J Perinatol. 2008;28:827-829. 7. Erdeve O, Arsan S, Yigit S, Armangil D, Atasay B, Korkmaz A. The impact of individual room on rehospitalization and health service utilization in preterms after discharge. Acta Paediatr. 2008;97:1351-1357. 8. Domanico R, Davis DK, Coleman F, Davis BO. Documenting the NICU design dilemma: comparative patient progress in open-ward and single family room units. J Perinatol. 2011;31:281-238. 9. Carlson B, Walsh S, Wergin T, Schwarzkopf K, Ecklund S. Challenges in design and transition to a private room model in the neonatal intensive care unit. Adv Neonatal Care. 2006;6:271-280. 10. Smith TJ, Schoenbeck K, Clayton S. Staff perceptions of work quality of a neonatal intensive care unit before and after transition from an open bay to a private room design. Work. 2009;33:211-227. 11. Walsh WF, McCullough KL, White RD. Room for improvement: nurses’ perceptions of providing care in a single room newborn intensive care setting. Adv Neonatal Care. 2006;6:261-270.
12. Milford CA, Zapalo BJ, Davis G. Transition to an individual-room NICU design: process and outcome measures. Neonatal Network. 2008; 27:299-305. 13. Harrell JW, Moon RG. Designs for the delicate: a look at evolving NICU design standards. Health Facil Manag. 2008;21:45-48. 14. White RD. The newborn intensive care unit environment of care: how we got here, where we’re headed, and why. Semin Perinatol. 2011; 35:2-7. 15. Stevens DC, Helseth CC, Khan MA, Munson DP, Smith TJ. Neonatal intensive care nursery staff perceive enhanced workplace quality with the single-family room design. J Perinatol. 2010;30:352-358. 16. Dunn MS, Reilly MC, Johnston AM, Hoopes RD, Abraham MR. Development and dissemination of potentially better practices for the provision of family-centered care in neonatology: the family-centered care map. Pediatrics. 2006;118:S95-S107. 17. Horbar JD, Plsek PE, Leahy K. NIC/Q 2000: establishing habits for improvement in neonatal intensive care units. Pediatrics. 2003: e397-e410. 18. Harter JK, Schmidt FL, Keyes CL. Well-being in the workplace and its relationship to business outcomes: a review of the Gallup studies. In: Keyes CL, Haidt J, eds. Flourishing: The Positive Person and the Good Life. Washington, DC: American Psychological Association; 2002:205224. 19. White RD. Individual rooms in the NICU—an evolving concept. J Perinatol. 2003;23:S22-S24. 20. Zanardo V, Gambina I, Begley C, et al. Psychological distress and early lactation performance in mothers of late preterm infants. Early Hum Dev. 2011;87:321-323. 21. Vingod SN, Villegas L, Dennis CL, Ross LE. Prevalence and risk factors for postpartum depression among women with preterm and low-birth-weight infants: a systematic review. BJOG. 2010;117: 540-550. 22. McManus BM, Poehlmann J. Maternal depression and perceived social support as predictors of cognitive function trajectories during the first 3 years of life for preterm infants in Wisconsin. Child Care Health Dev. 2012;38(3):425-434. doi:10.1111/j.1365-2214.2011.01253.x. 23. Jones TL, Prinz RJ. Potential roles of parental self-efficacy in parent and child adjustment: a review. Clin Psychol Rev. 2005;25:341-363. 24. Coleman PK, Karraker KH. Self efficacy and parenting quality: findings and future applications. Dev Rev. 1997;18:47-85. 25. Crncec R, Barnett B, Matthey S. Development of an instrument to assess perceived self-efficacy in the parents of infants. Res Nurs Health. 2008;31:442-453. 26. Pineda RG, Stransky KE, Rogers C, et al. The single-patient room in the NICU: maternal and family effects. J Perinatol. 2012;32:545-551. 27. Erdeve O, Arsan S, Canpolat FE, et al. Does individual room implemented family-centered care contribute to mother-infant interaction in preterm deliveries necessitating neonatal intensive care unit hospitalization? Am J Perinatol. 2009;26:159-64.
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Donna Dowling, PhD, RN ❍ Section Editor
Improvements in Staff Quality of Work Life and Family Satisfaction Following the Move to Single-Family Room NICU Design Jo Watson, PhD, RN(EC); Marion DeLand, RNC-NIC, MN; Sharyn Gibbins, PhD, RN(EC); Elizabeth MacMillan York, RN; Kate Robson, MEd
ABSTRACT OBJECTIVE: The purpose of this study was to determine whether there were differences in staff quality of work life and parent satisfaction when a neonatal intensive care unit moved from an open-bay design to a single-room model of care. DESIGN: This descriptive study measured staff quality of work life and family satisfaction before and at 2 time periods after the relocation of a perinatal centre and the introduction of single-family room care. Differences in work life quality and satisfaction were determined using 2-sample t-tests. RESULT: There were improvements in staff quality of work life and family satisfaction at both time periods following the move. CONCLUSION: Lessons learned may be of value to other units considering such a move. A neonatal intensive care unit designed to contribute to parental and staff well-being is a model to be considered for future neonatal designs. Key Words: neonatal intensive care, parent satisfaction, quality of work life, single-family room NICU care
F
amily satisfaction is an important measure of healthcare performance.1 Dimensions of satisfaction include the art and science of giving care, accessibility, the physical environment, efficacy, education, and trust.2 When nurses are satisfied with their work, their care includes higher levels of patient safety, fewer medication errors, and improved Author Affiliations: Sunnybrook Health Sciences Centre, Toronto (Drs Watson and Gibbins and Mss DeLand, MacMillan York, and Robson), and LS Bloomberg Faculty of Nursing, University of Toronto (Drs Watson and Gibbins and Ms DeLand), Ontario, Canada. The authors declare no conflict of interest. Correspondence: Jo Watson, PhD, RN(EC), 2075 Bayview Ave, M4-162, Toronto, ON M4N 3M5, Canada ([email protected]). Copyright © 2014 by The National Association of Neonatal Nurses DOI: 10.1097/ANC.0000000000000046
patient satisfaction.3 Hospital departments that have higher employee satisfaction provide better patient experiences.4 Because of the importance and influence of satisfaction, we were interested in measuring changes that accompanied neonatal intensive care unit (NICU) redesign and relocation. A systematic review of 12 studies comparing open-bay versus single-family room (SFR) design has described positive outcomes related to the SFR model.5 In an open-bay model, several babies are cared for in 1 ward room. In SFR-designed units, each baby has a private room. Single-family room units were deemed superior for patient care and parent satisfaction, but healthcare professionals’ views varied. The authors hypothesized that greater parental presence in the SFR units contributed to better outcomes than when parental access was limited by NICU practices in an open-bay unit. These results are similar to those reported in other observational studies wherein families, who had unlimited access to their hospitalized infants, reported more comfort and confidence in their parenting abilities.6,7
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In an anonymous survey with parents and staff, families reported satisfaction with the care they received in both open-bay and SFR units.8 However, parents who had experience with both types of NICU design were more likely to perceive staff performance as better in the SFR. Similarly, it has been reported that parents preferred SFR because of the privacy it provided compared with the open-bay layout.9 Nurses indicated that the SFR environment increased their work demands (ie, more walking) and decreased their ability to visualize their patients. Nurses also reported SFR as less favorable because they were not as knowledgeable about other infants in the NICU. They also perceived that SFR decreased parents’ readiness for discharge.9 Another evaluation of a move to single-family NICU rooms reported that there was lower interaction among team members in the SFR model.10 These results are similar to those reported elsewhere. Seventy percent of nurses responding to 1 survey reported a decrease in their work-life satisfaction after moving to an SFR unit.11 Issues such as reduced opportunities for supporting colleagues were cited as significant stressors in an SFR environment. Although nurses reported improved satisfaction with SFR over time and indicated that SFR was preferable in terms of family privacy, environmental control, promotion of bonding, and
breastfeeding, they continued to prefer open-bay unit design. Reports of the impact of the move to single-family room design have been mixed, with families appreciating the design and staff finding SFRs more challenging to work in than open-bay units. Further research examining staff and family satisfaction following the move of NICU units to single-room care provides the opportunity to build on current evidence. When our program received approval to build a new neonatal intensive care unit as part of a merger with another hospital, we recognized the opportunity to measure changes in outcomes, including satisfaction and quality of work life. Our original NICU was constructed in the early 1980s, when open-bay design was considered to be the optimal way to provide intensive care to sick infants12-14 (Figure 1). The unit consisted of open rooms with approximately 40 square feet allocated to each infant space and 12 babies cared for in 1 room. Infants were exposed to unregulated amounts of noise and light.13,14 When the unit was originally built, the ability to have sophisticated and integrated monitoring was not available and staff had to be able to visualize infants to provide safe care. Unit environment was not recognized as an important element in the care and well-being of high-risk neonates and their families.13-15
FIGURE 1.
Our open-bay unit before the move. www.advancesinneonatalcare.org Copyright © 2014 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
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The new unit design incorporated information obtained from our review of the literature, along with input from families and staff, to determine what elements should be included in the new space (Figure 2). There was thoughtful consultation with other NICUs that had already gone through this process. Our new NICU would focus on embedding family-centered, developmentally supportive care at the core of the design, with infants having their own room. Follow-up clinic and all support staff workspaces would be integrated into 1 contiguous physical space (Figure 3). The process of redesigning and moving into the new unit occurred over a period of several years. There was extensive work done with all members of the healthcare team to become knowledgeable about the impact and functionality of single-family room design and function. Education and support were provided to staff to develop strategies to cope with change and with relocation. These strategies included tours of the new space at many different stages of construction and mocking up new work spaces and processes. The leadership team felt that these processes were important so that staff could anticipate changes to work flow and to minimize the potential for confusion once the move occurred. We recognized that redesigning the NICU provided the unique opportunity to improve how care
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was provided to patients and families. The goal of this observational study was to determine whether there were differences in staff quality of work life and parent satisfaction when a neonatal intensive care unit moved from open-bay design to a singleroom model of care. The study measured staff quality of work life and family satisfaction during 3 time periods, 6 months before, 6 months after, and 1 year after a level III NICU relocation and the addition of 5 neonatal intensive care beds. Data collection took place from April 2010 until September 2011. This article builds on the work done by others and summarizes move and design-related staff and family satisfaction measures in the NICU.9-11,15 Approval from the institution’s research ethics board was received to conduct this study.
METHODS Staff Quality of Work Life All staff who worked a minimum of 0.5 full-time equivalent status and who were expecting to continue to work in the unit following the move were approached to participate. Healthcare professionals were recruited through information sessions and posters describing the study. A member of the research team approached staff over a 2-week period and asked them whether they were interested in
FIGURE 2.
A single-family room in our new unit. Advances in Neonatal Care • Vol. 14, No. 2 Copyright © 2014 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
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FIGURE 3.
The floor plan in the single-family room unit.
completing an anonymous satisfaction survey. Staff members were reminded that their information would be kept confidential and presented only in aggregate format. Completion of the survey was considered informed consent. Staff who had been working during the premove survey were approached to complete to 2 postmove surveys as well. We used the quality-of-work-life survey developed and tested by Smith and colleagues.11 The original survey was a 104-item, 7-level Likertranking scale with possible responses ranging from “low quality” to “high quality.” We revised the original tool to include 60 items, using the same ranking scale, electing not to use the questions relating to off-the-job quality of life. The survey focuses on individuals’ perceptions of the quality of being an employee, the quality of the work environment, patient care, interaction with other team members, and interaction with technology. This tool has demonstrated high internal reliability based on computed values for the Cronbach alpha.10 Total perception scores were computed for each of the categories as well as the total survey score. Unpaired t-tests were used to determine significant differences between time periods. The level of statistical significance was set at P < .05.
Family Satisfaction The standard practice in the NICU is to use a telephone survey to obtain satisfaction information from families of babies admitted to the NICU for greater than 72 hours. The Neonatal Telephone
Satisfaction Survey was introduced in 2005 following a collaborative quality improvement project with the Vermont Oxford Network that developed the original tool to measure parent satisfaction.16,17 This tool incorporates the concepts of satisfaction with care, trust in the team, parental confidence as well as the opportunity to interact with other families and with unit staff. Parents were contacted by phone by unit staff. Data collection took place within 3 months of the baby’s transfer or discharge. Parents were reminded that their confidential information would be used for research and educational purposes to improve the quality of care for future families. Data from the survey were analyzed using computations of t tests for statistical significance for the mean scores of the survey questions. The level of statistical significance was set at P < .05.
RESULTS Staff Quality of Work Life One hundred seventy-one members of our staff were eligible to complete the survey 6 months before the move. Only personnel completing the initial survey were eligible to complete it again at 6 months and 1 year postmove. Nurses were the most frequent responders to the survey (Table 1). Quality-of-worklife total scores were significantly higher 6 months after the move and again at 1 year compared to premove scores (P < .040 and .000, respectively) (Table 2). Items for which there were no significant www.advancesinneonatalcare.org
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TABLE 1. Staff Participating in the Quality-of-Work-Life Survey Premove Registered nurses and nurse practitioners
Postmove Postmove 6 mo 1y
57
46
15
Allied health
9
13
1
Physicians
1
1
5
differences at either time period after the move included the overall quality of being an employee of the organization, the hectic nature of the work environment, team spirit, fatigue, the excitement of the job, and the ability to interact with supervisory personnel, parents, and patients. Elements of quality of work life that improved at both time periods following the move included the quality of the work environment, the ability to concentrate on the job, noise level, privacy for families and staff, and ease of communication. Staff also recognized the improved ability of parents to contribute to their babies’ care. Elements that were seen to improve only 1 year following the move included the ability of staff to interact with parents, on-the-job productivity, and staff morale (Table 3). There were no changes in sick time, turnover, or staff injury in the 1-year period following the move.
Parent Satisfaction Survey Results During the study period, 173 babies met survey criteria and 85 families responded to the telephone survey over the 3 time periods (n = 48, n = 22, n = 25, respectively). Response rates for the telephone survey were 51% premove, 54% six months postmove, and 68% at 1-year post move. Eighty-five percent of respondents were mothers of infants born at less than 32 weeks’ gestation. At both time periods following the move, there was a significant improvement in parents’ perceptions of the privacy afforded by the physical environment. Parents reported that they felt more comfortable spending time with their baby.
TABLE 2. Summary of Staff Quality-ofWork-Life Scores Group Pre (n = 55)
Mean
SD
P (2-Tailed) T1 vs T2: .040
181.290
23.5251
6 mo (n = 56) 206.553
51.2597
1 y (n = 9)
19.2685
219.555
T1 vs T3: .000
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At 1 year following the move, parents felt they knew their babies better, were more confident in feeding and comforting their babies, and reported more opportunities to interact with families. Parents reported adjusting better to having their babies at home and were less bothered by feeling anxious, angry, sad, or depressed. Parents were significantly more satisfied with the care their babies received 1 year after the move (Table 4).
DISCUSSION There are links between staff satisfaction, client satisfaction, and quality, making family and staff satisfaction key goals for healthcare leaders.4,16 When this is achieved, there is improved productivity, staff retention, and safety.18 NICU staff participating in this study reported significant improvements in the overall quality of work life at 6 months after the move and again at 1 year. It is noted that the response rate at 12 months after the move was small and should be interpreted with caution. These positive findings are similar to those previously reported, indicating that staff members were more satisfied in their new single-patient care environment.15 Unlike results reported by others,8,9,19 opportunities to interact with members of the healthcare team were improved for nurses participating in this study. We propose possible reasons for differences in staff experiences at our center. In the current design, opportunities to bring healthcare team members together on a frequent basis to discuss clinical care likely decreased isolation and concerns for infant safety. Staff work predominantly in pods that contain 12 single-patient rooms, with a central staff corridor where daily rounds and other staff interaction take place. The ability to contact team members through a voice-activated system may have provided additional assurance that help could be initiated whenever it was needed. Few studies have prospectively followed staff perceptions after a change in NICU design combined with a move to a new location.11 Staff perceptions in these studies were not consistently positive. Staff participating in this study were more satisfied at both time periods after the move. Further, parents reported high levels of satisfaction at 6 and 12 months postmove. This is consistent with other studies where families report increased satisfaction with the amount of privacy provided, improved ability to interact with their babies, and increased confidence in the team when care is provided within a model of SFR design.5,6,10 We were particularly interested in the significant improvement in parents’ reports of feeling less anxious, depressed, or sad after discharge from our new unit. The literature suggests that parents of preterm infants experience more stress and anxiety than
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TABLE 3. Staff Quality of Work Lifea Paired Differences 95% Confidence Interval of the Difference Mean
Lower
Upper
t
df
P (2-Tailed)
Quality of work environment
−1.51667
−1.93535
−1.09798
−7.249
59
.000
Quality of work environment
−1.09524
−1.81359
−.37688
−3.180
20
.005
Staff privacy
−1.81667
−2.40207
−1.23127
−6.210
59
.000
Staff privacy
−1.71429
−2.34408
−1.08449
−5.678
20
.000
Parental privacy
−3.25000
−3.75025
−2.74975
−13.000
59
.000
Parental privacy
−3.14286
−3.80697
–2.47875
−9.872
20
.000
There is enough room to work
−2.55932
−3.02417
−2.09447
−11.021
58
.000
There is enough room to work
−2.61905
−3.35972
−1.87838
−7.376
20
.000
−.71186
−1.15288
−.27085
−3.231
58
.002
Ability to concentrate Ability to concentrate
−.94737
−1.65635
−.23839
−2.807
18
.012
Noise level
−2.64407
−3.12983
−2.15830
−10.896
58
.000
Noise level
−2.09524
−2.86913
−1.32134
−5.648
20
.000
Design helps patients contribute to care
−2.33898
−2.76530
−1.91266
−10.982
58
.000
Design helps patients contribute to care
−2.57895
−3.49226
−1.66564
−5.932
18
.000
Ability to closely interact with patients
−1.05000
−1.86027
−.23973
−2.712
19
.014
Morale of unit
−1.00000
−1.77426
−.22574
−2.703
19
.014
−.76190
−1.37099
−.15281
−2.609
20
.017
Productivity of patient care team
Italic text = 6 months; nonitalic text = 1 year.
a
parents of term infants.20,21 Rates of postpartum depression as high as 40% have been reported in the literature.21 In addition, postnatal depressive symptoms appear to have a meaningful, dynamic influence on the cognitive outcomes of children born preterm, above and beyond family sociodemographics.22 The decrease in parents feeling anxious, angry, sad, or depressed is a marked improvement. No previous studies have explored families’ confidence in their ability to feed and comfort their baby in an SFR model of care, or parents’ confidence in knowing their baby well. Parenting self-efficacy and confidence are recognized as key factors in predicting parental depression, stress, relationship difficulties, and positive child outcomes.23,24 Three factors that predict parental stress include the ability to understand infant signals; to know how to soothe, settle, handle, and play with their infant; and the belief that they are doing a good job as a parent.25 Parents participating in this study reported improvement in these 3 dimensions following the move to SFR care. This may explain their reports of feeling less anxious and depressed. A model of care that
offers parents unlimited time with their infants, as does SFR design, provides the opportunity for parents to better understand their infants’ signals and develop skills in infant feeding contributing to developing parental confidence. A potential risk to SFR is that families do not feel prepared for discharge home. This problem was reported in other evaluations of single-room NICU design.8,10 A lack of parental preparedness was not identified in this study. If fact, parents responded that they felt more confident and adjusted better at home following discharge from the SFR unit. An earlier study reported that mothers of preterm infants cared for in units with single family rooms spent more time in the NICU than mothers whose infants were cared for in an open-bay NICU; however, they reported higher levels of stress.23 Other reports have suggested that isolation might have been a contributing factor to the increased stress.26,27 However, families in this study did not report higher levels of parental stress but rather described decreased stress and anxiety. One factor that could have prevented parental stress and isolation was the hiring of a parent www.advancesinneonatalcare.org
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TABLE 4. Family Satisfactiona Paired Differences 95% Confidence Interval of the Difference Mean
Lower
Upper
t
df
P (2-Tailed)
The physical environment allowed enough privacy for me to feel comfortable spending time with my baby
1.7000
0.5790
2.8209
3.431
9
.008
The physical environment allowed enough privacy for me to feel comfortable spending time with my baby
2.0000
1.1105
2.8895
4.899
12
.000
The opportunity to interact with other families
1.1539
0.3413
1.9663
3.094
12
.009
I know my baby very well
0.3846
0.0084
0.7777
2.132
12
.05
I feel confident feeding my baby
0.3846
0.0786
0.6906
2.739
12
.02
When my baby is crying or upset, I find it easy to comfort him/her
0.6154
0.0348
1.196
2.309
12
.04
My family is adjusting well to having the baby at home
0.5385
0.2249
0.852
3.742
12
.003
I am bothered by feeling irritable, anxious, depressed or sad
0.7692
–0.0169
1.5554
2.132
12
.05
Overall I was satisfied with the care my baby received while in the NICU
0.3846
–0.0084
0.7777
2.132
12
.05
Abbreviation: NICU, neonatal intensive care unit. aItalic text = 6 months; nonitalic text = 1 year.
coordinator 3 months after the move. This role, designed to be filled by a veteran NICU parent, has the key responsibility of encouraging families to participate in programmed group activities, including educational programs and holiday events. Orientation activities and group programs may have helped families feel less isolated and experience less stress in the new unit and this may have impacted their mood following discharge. Although the addition of the parent coordinator has been a real asset to the unit, this was likely a confounder to postmove parental satisfaction measures.
LIMITATIONS AND RECOMMENDATIONS There are limitations to this study that should be considered. Postmove measures at 6 and 12 months may not have captured the long-term impact of the move. It is possible that ongoing data collection that follows families and staff for 2 year following the move may have provided more insight regarding when staff transition from one model of care to another, and how long it takes for adjustment to a new environment and model of care. Improvements were seen in responses between 6 and 12 months and it is unknown whether there would be changes
at 24 months as reported elsewhere.11 A longer period of postmove measurement could be considered in future studies. Other limitations are the modest response rate for some of the surveys and that there was no matching of employees who completed the surveys pre- and postmove.
SUMMARY This study measured staff quality of work life and family satisfaction before and after the move to a model of single-room NICU design. Whereas earlier studies measuring satisfaction found improvements in parents’ experiences, those sometimes were at the expense of improved staff satisfaction.5,10 The current study found improvements in satisfaction for both parents and staff. This is one of the first studies of staff and family satisfaction related to NICU design that found improvements for all stakeholders. We recommend that other centers that are relocating or changing their model of care conduct research to measure staff and family satisfaction, as well as other outcome measures, to track the impact of the move. Redesign of a NICU is a time-consuming initiative that requires detailed planning and coordination. A successful redesign is one that achieves improvements
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in clinical outcomes as well as in satisfaction of families and staff. Lessons learned may be of value to other units considering such a move. A neonatal intensive care unit designed to contribute to parental well-being and staff well-being is a model to be considered for future neonatal designs.
References 1. Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2003. 2. Ware JE, Davies-Avery A, Steward AL. The measurement and meaning of patient satisfaction: a review of the literature. Health Med Serv Rev. 1978;1. http://www.rand.org/content/dam/rand/pubs/papers/ 2008/P6036.pdf 3. Rathert C, May DR. Health care work environments, employee satisfaction, and patient safety: care provider perspectives. Health Care Manage Rev. 2007;32:2-11. 4. Peltier J, Dahl A. The relationship between employee satisfaction and hospital patient experiences. Forum. April 2009. http://www.info-now .com/typo3conf/ext/p2wlib/pi1/press2web/html/userimg/FORUM/ Hospital%20Study%20-REslationship%20Btwn%20Emp.%20 Satisfaction%20and%20Pt.%20Experiences.pdf 5. Shahheidari M, Homer C. Impact of the design of neonatal intensive care units on neonates, staff, and families: a systematic literature review. J Perinat Neonatal Nurs. 2012;26:260-266. DOI:10.1097/ JPN.0b013e318261ca1d. 6. Carter BS, Carter A, Bennett S. Families’ views upon experiencing change in the neonatal intensive care unit environment: from the “baby barn” to the private room. J Perinatol. 2008;28:827-829. 7. Erdeve O, Arsan S, Yigit S, Armangil D, Atasay B, Korkmaz A. The impact of individual room on rehospitalization and health service utilization in preterms after discharge. Acta Paediatr. 2008;97:1351-1357. 8. Domanico R, Davis DK, Coleman F, Davis BO. Documenting the NICU design dilemma: comparative patient progress in open-ward and single family room units. J Perinatol. 2011;31:281-238. 9. Carlson B, Walsh S, Wergin T, Schwarzkopf K, Ecklund S. Challenges in design and transition to a private room model in the neonatal intensive care unit. Adv Neonatal Care. 2006;6:271-280. 10. Smith TJ, Schoenbeck K, Clayton S. Staff perceptions of work quality of a neonatal intensive care unit before and after transition from an open bay to a private room design. Work. 2009;33:211-227. 11. Walsh WF, McCullough KL, White RD. Room for improvement: nurses’ perceptions of providing care in a single room newborn intensive care setting. Adv Neonatal Care. 2006;6:261-270.
12. Milford CA, Zapalo BJ, Davis G. Transition to an individual-room NICU design: process and outcome measures. Neonatal Network. 2008; 27:299-305. 13. Harrell JW, Moon RG. Designs for the delicate: a look at evolving NICU design standards. Health Facil Manag. 2008;21:45-48. 14. White RD. The newborn intensive care unit environment of care: how we got here, where we’re headed, and why. Semin Perinatol. 2011; 35:2-7. 15. Stevens DC, Helseth CC, Khan MA, Munson DP, Smith TJ. Neonatal intensive care nursery staff perceive enhanced workplace quality with the single-family room design. J Perinatol. 2010;30:352-358. 16. Dunn MS, Reilly MC, Johnston AM, Hoopes RD, Abraham MR. Development and dissemination of potentially better practices for the provision of family-centered care in neonatology: the family-centered care map. Pediatrics. 2006;118:S95-S107. 17. Horbar JD, Plsek PE, Leahy K. NIC/Q 2000: establishing habits for improvement in neonatal intensive care units. Pediatrics. 2003: e397-e410. 18. Harter JK, Schmidt FL, Keyes CL. Well-being in the workplace and its relationship to business outcomes: a review of the Gallup studies. In: Keyes CL, Haidt J, eds. Flourishing: The Positive Person and the Good Life. Washington, DC: American Psychological Association; 2002:205224. 19. White RD. Individual rooms in the NICU—an evolving concept. J Perinatol. 2003;23:S22-S24. 20. Zanardo V, Gambina I, Begley C, et al. Psychological distress and early lactation performance in mothers of late preterm infants. Early Hum Dev. 2011;87:321-323. 21. Vingod SN, Villegas L, Dennis CL, Ross LE. Prevalence and risk factors for postpartum depression among women with preterm and low-birth-weight infants: a systematic review. BJOG. 2010;117: 540-550. 22. McManus BM, Poehlmann J. Maternal depression and perceived social support as predictors of cognitive function trajectories during the first 3 years of life for preterm infants in Wisconsin. Child Care Health Dev. 2012;38(3):425-434. doi:10.1111/j.1365-2214.2011.01253.x. 23. Jones TL, Prinz RJ. Potential roles of parental self-efficacy in parent and child adjustment: a review. Clin Psychol Rev. 2005;25:341-363. 24. Coleman PK, Karraker KH. Self efficacy and parenting quality: findings and future applications. Dev Rev. 1997;18:47-85. 25. Crncec R, Barnett B, Matthey S. Development of an instrument to assess perceived self-efficacy in the parents of infants. Res Nurs Health. 2008;31:442-453. 26. Pineda RG, Stransky KE, Rogers C, et al. The single-patient room in the NICU: maternal and family effects. J Perinatol. 2012;32:545-551. 27. Erdeve O, Arsan S, Canpolat FE, et al. Does individual room implemented family-centered care contribute to mother-infant interaction in preterm deliveries necessitating neonatal intensive care unit hospitalization? Am J Perinatol. 2009;26:159-64.
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