John Christopher Haddox, PhD

Shan Jiang, PhD

West Virginia University School of Design and Community Development

Correspondence concerning this article should be addressed to:

John Christopher Haddox, West Virginia University School of Design and Community Development, PO Box 6124, Morgantown, WV, 26506-6124

Contact: chris.haddox@mail.wvu.edu

Abstract

In recent years the design of healthcare facilities has shifted from a pure efficiency-oriented approach to include a more deliberate emphasis on patient experience. To reduce stress and facilitate patients’ recovery, three essential components need to be considered in any physical environment of healthcare facilities, including fostering patient’s sense of control, enhancing social support, and having access to positive distractions.  The objective of this study was to explore, via the Virtual Shelf, the extent to which self-selected imagery displays could enhance patients’ sense of control, facilitate social support and communication between patients and care givers, and improve patients’ hospitalization satisfaction during stay.  Using a format termed the Virtual Shelf, study participants were provided the opportunity to access meaningful pictures during their extended in-patient stay—pictures they had selected pre-admission from their own personalized photo collections. Pictures were incorporated into a personalized slide show that was available to them in their patient room. Researchers met with participants throughout the study, gathering feedback from participants as well as hospital staff and analyzed how the viewing of the slideshows—by themselves, with family, and with hospital staff—may have impacted the patient experience. Findings report on the challenges and opportunities of implementing this approach in an extended stay in-patient setting.

Keywords: Qualitative inquiry, patient experience, case study, feasibility study, control over room environment

Introduction

The root idea for this study, what we are calling the Virtual Shelf (the display of patient selected imagery on the in-room television monitor), arose while attending the 2015 Center for Health Design annual conference in Orlando, FL. Several sessions at the conference focused on the incorporation of art as a component of the in-patient experience. In some situations, the patient was engaged in the creation of art/imagery as a form a therapy and in others the researchers were selecting the art/imagery to be displayed in the hospital setting. In no cases, however, was the patient engaged in the selection of art/imagery to be displayed in the patient room during a stay. The question arose in the researcher’s mind about the use of patient-selected imagery (Virtual Shelf) as a way to allow the patient some degree of control over their hospital room environment. While the Virtual Shelf protocol focused on still imagery, it did not specify the imagery subject matter. Participants were encouraged to include images of anything that would bring comfort such as pictures of loved ones, or other items they might display on their shelves of their home. These images would be digitized and available for display via a flash drive or DVD on the patient’s in-room television.

Research Background

Patient-centered care and patient experience

Patient-centered care has been the focus of discussion and patient experience has been emphasized as a top priority regarding high-quality care at least in the recent 30 years. Patient-centered care is a quality of personal, professional, and organization relationship in which the individual patient’s specific health needs and desired health outcomes are centered, with a broader and more engaging participations between the patient and the family members in the whole healthcare procedures (Epstein & Street, 2011). Date to 1988, the Picker Commonwealth Program for Patient-Centered Care and the Picker Institute identified eight essential dimensions of patient-centered care and measures of patient experience for each dimension. Dimensions included access; respect for patients’ values and preferences; coordination of care; information, communication, and education; physical comfort; emotional support; involvement of friends and family; and preparation for discharge and transitions in care (Gerteis, Edgman-Levitan, Daley, & Delbanco, 2002).

Results from a recent literature review and synthesis study revealed that there is need of a clear and concise definition of “patient experience” (Wolf, Niederhauser, Marshburn, & LaVela, 2014). There are eight consistent themes of “patient experience” repeated in the body of literature regarding patient experience, including: emotional and physical lived experience, personal interactions, spanning across the continuum, shaped by the organization/culture, and importance of partnership/patient involvement (Wolf, Niederhauser, Marshburn, & LaVela, 2014, 12). To make a positive patient experience, Robinson (2014) summarized four basic emotional needs that the ideal patient experience should meet: confidence, integrity, pride and passion. Prior studies have also identified five primary drivers of excellent patient care and experience, according to the findings of an Institute for Healthcare Improvement (IHI) white paper, including (1) leadership – the governance and executive leaders demonstrate a strong culture of focusing on patient and family-centered care; (2) hearts and minds – the hearts and minds of staff and providers are fully engaged; (3) respectful partnership – every care interaction is anchored in a respectful partnership, anticipating and responding to patient and family needs; (4) reliable care – hospital systems deliver reliable, quality care 24/7; and (5) evidence-based care – the care team instills confidence by providing collaborative, evidence-based care (Balik, Conway, Zipperer, & Watson, 2011).

Supportive design

A majority of patients experience stress during healthcare, and much of the stress is aroused by environmental features, named “stressors” (Taylor & Aspinwall, 1993; Ulrich, 1999). Stress is both a significant outcome in itself, and it directly affects many other health outcomes. Negative health impacts of environmental stress include psychological/emotional (e.g., negative moods, sadness, fear), physiological (e.g., increased blood pressure, skin conductance, and respiration rate), behavioral (e.g., sleeplessness, angry outbursts), and neuroendocrine aspects (e.g., directly impact the levels of several hormones), which significantly impact patients’ immune systems (Ulrich, 1999; Kopec, 2006).

To reduce environmental stressors and create a supportive, holistic care environment, Ulrich (1991) conceptualized the theory of supportive design for healthcare physical-social environment aiming to help reduce stress and improve patients’ well-being. First, do no harm - a supportive healthcare environment should not raise obstacles to coping with stress, contain features that are in themselves stressors. The healthcare physical and social environments are exemplary supportive environments if they are designed to foster three components: (1) sense of control with respect to physical-social surroundings, (2) access to social support, and (3) access to positive distractions (Ulrich, 1991, 99). Such a supportive, holistic care environment should not just target patients but also be effective to various groups of users including care givers, healthcare staff, family members and visitors.

Sense of control

Sense of control is the central component of the supportive design framework since it’s an important factor influencing stress levels and wellness. A sense of control is the opportunity to have an impact on various aspects of one’s life and the surrounding environment, and to exert mastery (Fisher, 1990; Huang, Robertson, & Chang, 2004; Andrade & Devlin, 2015). Huang, Robertson and Chang (2004) reviewed the benefits of employees’ sense of control over their physical office work environment, including directly improved workplace satisfaction and job performance, and indirectly contribution to these outcomes through mediating people’s perceptions, distractions, privacy, stress, and communication. Lee and Brand (2005) systematically reviewed the effects of control over office workspace and employees’ work outcomes and confirmed that stronger sense of control over the physical environment could improve self-reported job satisfaction, work performance, and group cohesiveness among co-workers.

“In healthcare contexts, lack of control is a pervasive problem that increases stress and adversely affects wellness” (Ulrich, 1991, 100). In hospitals, the established routine may render inpatients helpless and cause the lack of control. In some illnesses, such as cancer, patients’ bodies and received treatments are totally out of their control. In this case, enriching design opportunities for patients to exert control over the physical environment may help combat their sense of helplessness; recommendations include being able to control over light, adjust window blinds, and access to food to patients’ choices (Andrade & Devlin, 2015). Patient’s sense of control could be enhanced when they are able to choose their own art (Suter & Baylin, 2007). In a recent literature review study, “personalized atmosphere” and “engaging positive distractions” were promoted as parts of the future trends of hospital spatial design to enhance patient experience (Selami Cifter & Cifter, 2017).

Social support

Patients benefit from frequent or prolonged contact with family and friends who are supportive, named social support. Specifically, social support is defined as “intentional human interaction that includes one or more of the following elements: (1) affect, which refers to appreciation, admiration, respect or love; (2) affirmation, which includes reinforcement, feedback and influencing the individual’s way of making decisions; and (3) aid, such as objects or money and spending time in order to help someone” (Rantanen, Kaunonen, Astedt-Kurki, & Tarkka, 2004).

Prior studies have proven that social support is associated with various health outcomes such as stress, illness rates, and long-term survival rates among patients who have sever diseases, such as myocardial infarction (Ulrich, 1991). A recent study concluded that lower social support is associated with worse health status and more depressive symptoms 12 months after Acute Myocardial Infarction in both young men and women, and sex did not modify the effect of social support (Bucholz, et al., 2014). A stronger sense of belonging and connection to a group of others indicates better physical health and fewer physical symptoms for young adults (Hale, Hannum, & Espelage, 2005). Research has shown that in a range of healthcare and non-healthcare settings, people who receive higher levels of social support, tend to be less stressed and have better health status than more socially isolated people (Cooper Marcus & Barnes, 1999). In addition, a meta-analysis study provided solid empirical evidence that social support has significantly positive effects on health status, role function and behaviors, psychosocial adjustment, adjustment of life, coping behavior, health belief, health promotion behavior, quality of life, well-being, and self-actualization (Wang, W, & Liu, 2003, 347). On the contrary, social support had significantly negative effects on physical symptoms and responses, psychologic symptoms and responses, depression, role burden, and stress (ibid.).

Influenced by the patient-centered care philosophy, hospital environments are being designed to foster social support by accommodating family members and friends who make visits (Berkman, Glass, Brissette, & Seeman, 2000). According to a Cornell University research report, seven design guidelines were recommended for hospital spatial design that promotes social support, including: (1) spaces should be flexible and easily controlled by patients and families in order to adjust to situational needs; (2) providing patients with single rooms that have designated family areas; (3) providing family lounges and waiting areas near patients (4) creating a comfortable environment by incorporating “soft” finishes, furnishings, and materials into the design; (5) creating an environment that reduces negative nose but allows for positive stimulation; (6) using technology to foster social support; and (7) incorporating nature and gardens for patients and families to use (Levine & Lipson, 2010).

Positive distractions

A positive distraction is an environmental feature or situation that elicits positive feelings, holds attention and interest, and eventually fosters beneficial changes in physiological systems (Ulrich, 1981). Typical positive distractions that have been either been identified by patients as desirable, or that have been tested effective by previous studies included items such as color, local artwork, artwork with positive meanings, exposure to nature, music, and ambient scent (Fenko & Loock, 2014; Haddox, 2015; Jiang, Powers, Allison, & Vincent, 2016; Nanda, Eisen, Zadeh, & Owen, 2011; Raanaas, Patil, & Hartig, 2012). Ulrich’s supportive design theory was not systematically tested by empirical studies, until a recent experimental study by Andrade and Devlin (2015). In that simulated study, participants were required to imagine a hospitalization scenario in a patient room where eight combinations of supportive design elements were provided. They found out that participants expected significantly less stress in the situations where elements indicating social support and positive distractions were present. In addition, the number of supportive design elements affected people’s perceived levels of stress: the more the supportive design elements present in a room, the less the stress they expected. However, the effects of the sense of control were not statistically significant on stress-reduction (ibid.).

Research Questions and Objectives

The primary research question was this: could the display of patient selected imagery in the in-patient setting impact patient experience in a positive way? The primary objective was to build upon the body of research on interplay of supportive healthcare environments and health outcomes by exploring the potential for providing patients an additional level of control over their hospital experience (pre-admission through in-patient stay) via the display of patient selected imagery in their rooms.

Methodology

Method and research design

The research was conducted as a qualitative study whereby we would make use of observations, patient feedback, and staff feedback in order to arrive at some initial conclusions as to the efficacy of the display of self-selected imagery on improving patient experience in the in-patient setting. Figure 1 illustrates the planned initial research procedures. The study schema was our anticipated roadmap and was developed in conjunction with the nursing staff of the West Virginia University’s Cancer Institute, Bone Marrow Transplant Unit (BMTU), and the Spiritual Care and Counseling unit. Footnotes to Figure 1 explain the major variances to our schema that occurred over the course of the study.

Figure 1. Study schema

Implementing the Research

Participant identification and informed consent

The participant pool was identified by the staff of the Cancer Instituter and potential participants were introduced the study. If there was interest, an introduction was made to the researchers and a meeting was set for the process of obtaining the informed consent of the participant. The goal was to have the participant identified, informed, and consented at least one week prior to admission in order to provide time for the participant’s selected imagery to be collected, organized, and formatted onto either a flashdrive or a DVD so that it would be available to the participant upon their admission to the BMTU.

Image collection

Participants had several options for providing the researchers with their selected images: they could upload pictures to a personalized Dropbox folder set up by the researchers; they could bring in hard copies of pictures for the researchers to scan/copy to a flashdrive or DVD; they could bring in their own hard drive of pictures; or they could use a combination of these methods. Regardless of the collection method the images were ultimately transferred to a flashdrive (no DVDs were needed as all television monitors used ended up being flashdrive compatible), formatted for an automatic slide show with a 10 second interval and given to the participant upon or as near admission as possible.

Image display

The plan was for the patient to be in complete control over when the images were viewed. The BMTU staff, however, was instrumental in assisting the participants with displaying their images as in all cases as the participant did not have access to a remote that would control the television’s auxiliary input options, so staff needed to run those controls manually from the controls on the back of the television. In a few instances, the staff had technical difficulties, but eventually all participants were able to view their images without difficulty.

Data Collection

Data were to be collected in the following ways:

1. Researchers notes/observations from visits with participants during their stay. These conversations were to be general in nature and not rely on a structured set of questions. Rather, they were mainly to check in with the patient and see how they were doing. Also, these times were used to check with staff to see if there were any unsolved technical difficulties.

2. Participants completed a small follow up survey upon discharge. The survey consisted of eight open ended questions that allowed the participant to comment on various aspects of the study. Researchers followed up with participants to flesh out/clarify information when the situation allowed.

3. BMTU nursing staff were to record observations on the use of the Virtual Shelf by the participants and/or their families/support at least once per shift. These data were to be recorded in the Electronic Health Record (EHR) is fields created especially for this project. The fields were designed in coordination with the EHR manager and the Spiritual Care and Counseling Director and reflected a set of fields already in use by the health team for recording emotional state of patients. As fields in the EHR are visible to all hospital staff entering data, our fields had a notation that they were only for the BMTU Virtual Shelf study and not applicable to any other patient in the hospital system.

4. BMTU nurses were to complete a brief survey on their experiences with the Virtual Shelf and the participants. The survey options included paper and electronic.

5. If possible, the researchers were to conduct a focus group with the BMTU nurses post-study

Data Content analysis and inductive coding

Content analysis is “any technique for making inferences by objectively and systematically identifying specified characteristics of messages” (Holsti, 1969, 14). We didn’t limit our content analysis to manifest content and frequency counts, but also conducted inductive coding and allowed the themes/coding frame to emerge from the content of the raw data. According to Druckman (2011) Important issues for content analysis are the coding accuracy (reliability) and the meaning of the coding categories (validity) (p. 258). To ensure the coding validity, two analysts studied the survey replies and observation notes individually, in an inductive coding manner, to arrive at a family of themes. Themes, along with the supporting statements, were compared and the family of themes condensed into a set of seven themes that researchers agreed adequately represented the essence of the collected data.

Results

Participant recruitment and demographics

The goal of N=10 was set in conjunction with the staff of the Cancer Institute and based upon their best estimates about how many potential recruits would be in the BMTU pipeline over the anticipated timeframe of our study. We were eventually able to discuss the study with eight potential participants. The day we were to inform/consent the ninth, she was deemed by the Cancer Institute to be too sick to go through the BMT process. Six chose to participate, with one of those passing away during the study. Of the two who chose not to participate, one was a young woman in her mid-20s who indicated she did not have many pictures, did not want to gather them, and she felt pictures of things she loved would just make her homesick during her stay. Another, a woman in her mid-40s, liked the idea of the image display, but she felt she would just look at things on her smart phone, indicating that if she was not feeling well enough to do that, she would not be looking at them on a television monitor. Ultimately, five participants completed the study, resulting in a completion rate of 62.5%.

Content analysis of participant comments

While the number of participants enrolled and eventually completing the study did not meet our desired n = 10, we were able to gather data from those who did participate to indicate that our approach has some merit in terms of impacting patient experience in a positive manner and that the method is worthy of refinement and implementation with another population of participants.

Table 1 provides identifies the themes and examples of supporting comments. These comments were taken from the follow up interview/surveys conducted with the participants. In a few cases the participant’s comments were incomplete sentences, but contained enough description for the researchers to surmise the main point of the comment. Researchers analyzed and coded the comments separately, then compared their categorizations to arrive at the final themes indicated in Table 1.

Researchers observations

The nature of the study necessitated continued interaction between the researchers and participants. Hospital staff were extremely helpful, but understandably not able to address all questions or situations that arose during the course of the study. For example, researchers engaged directly with participants or participant’s family members/friends in the initial informing/consenting process and in the collection of the imagery and thus were party to a variety of comments and observations participants expressed about the study. While collection of these comments was not overly systematic nor standardized, this small amount of data meshes nicely with and supports the written/verbal data gathered from the participants via the post-study comments. A few examples of representative comments/observations are illustrated in Table 2.

Analysis of nursing staff comments

While only one nurse completed the follow up survey (several attempted and were foiled by technology challenges with the online survey), the respondent was a primary contact and her input corroborated comments the researchers heard from other staff and the nursing manager during my visits to the floor. It should also be noted that the nursing staff on the BMTU is small and this particular nurse was involved with each of the participants in the study, so her commentary is especially valuable.

This nurse expressed an overall positive view of the study and particularly noted how it often facilitated conversations between staff and participants (discussing various pictures that were on display), but did not facilitate conversations about the participant’s current health situation. In other words, patients seemed to enjoy the positive distraction and talking with staff about the family members the staff may have not met during a family visit.

Discussion

Our initial findings warrant a more systematic and widespread implementation of the Virtual Shelf. Comments from participants indicate that they found value in the approach and that the Virtual Shelf could provide an additional, customized positive distraction from what can be a very long and trying ordeal in the BMTU. Despite what seemed to be a fairly straightforward implementation of the protocol, there were numerous hurdles along the way. Each hurdle is discussed below, along with recommendations for eliminating that hurdle in the next iteration of the project.

Protocol review and monitoring committee and institutional review board approval

From initial discussion with the Patient Relations unit of hospital to final IRB approval of the project totaled fifteen months, despite nearly all decision makers along the way nodding their heads in approval of the idea. The exception was the Protocol Review Monitoring Committee of the Cancer Center. As our project did not fit well with the Cancer Center’s typical quantitative, treatment based research, we had to build our case for health care providers who largely did not value our qualitative research approach as a viable methodology. This was an interesting and surprising perspective as so much of the practice of medicine relies on qualitative data and because physicians are trained early on to rely upon open ended questions when working with their patients. While we eventually prevailed, we had to defend both our lack of statistics and our use of the word “data” for the information we gathered from both patients, health care staff, and our own observations.

Going into the project we were planning on consistency with in-house staff involved with the project in terms of the BMTU staff (discussed later in this section) and the Spiritual Care and Counseling staff. Because of the overall length of both the informal and formal approval, our Spiritual Care and Counseling resident that was going to be our constant in-house contact for the project was no longer available. It would have been very helpful to have a single point of contact in-house that was interacting with the patients, recording observations, and the like. Unfortunately, we did not have someone to assume that role as we had planned. Aside from the lack of constant contact/continuity, we missed an opportunity to examine the project from a Spiritual Care and Counseling perspective and to report out in that discipline’s academic outlets.

Challenges with in-room technology

When assessing the rooms on the BMTU with the nursing manager for flashdrive and/or DVD capabilities, we found variation in the types of televisions among the patient rooms. As we were not able to know in advance what rooms would house participants in the study, we had to wait until a participant was admitted, then deal with any equipment issues. In some cases, the television/flashdrive set up worked just fine right from the start. In a few others, however, the television was not compatible with the flashdrive and the floor manager was able to get facilities management to install a compatible television. In one case the equipment issue was addressed, only to have the participant then moved to a different room with the same incompatibility issue as before. We had initially discussed with hospital staff the notion of providing our own wall mounted digital picture frames, but facilities personnel were not receptive to that idea. Using our own technology could have eliminated these issues and also dealt with the need for staff to physically manage the viewing of the images for the patient (as none of the televisions had a remote that could operate the flashdrive input).

Communications with nursing staff

In spite of the multiple meetings with the floor manager of the BMTU, there were still issues with the nursing staff understanding their role in the project, especially regarding the recording of data in the Electronic Health Record (EHR). The EHR fields were designed to require a simple “yes” or “no” answer to five questions relating to what the nurse/staff passively observed with the patient and/or the family/support and the use of the Virtual Shelf. We were informed by the Directors of both the Spiritual Care and Counseling unit and the BMTU this would be a simple process for the staff to follow. Entries were to be made after each rounding visit with the patient. We were also informed that as the BMTU did not have the floating nursing staff common to other units, they would quickly pick up on the data entry. The researchers continued to receive questions from the nursing staff on what they were supposed to be doing (“are we supposed to be making the patient watch their pictures a certain number of times each day?”) and (“are we supposed to be asking them questions about their pictures?”) were common questions.

To add to the confusion, a change in nursing management mid-project led to a misconception that the project had ended, when in fact we still had participants enrolled and were actively enrolling more. When the new floor manager was informed of the project and the challenges we were experiencing with the EHR aspect of the project, he indicated that he would make sure that at a recording was made at least once per participant per shift—something that unfortunately never played out.

Conclusions and Future Research

The process of selecting and displaying personalized imagery in a patient’s room, via the Virtual Shelf, holds promise as a means of enhancing patient experience. The hospital provides access to other enhancing services that have been institutionalized and are part of the daily routine on the floor and participants reported enjoying those services during their stays (music therapy, massage, and the Care Channel—a service the hospital subscribes to that provides patients access to soothing video imagery and music). It is plausible that the Virtual Shelf could enjoy this same status and provide unique opportunities to both impact patient experience and to provide a platform for additional academic research on how personalizing the in-patient experience can impact both health outcomes, patient/staff relations, and staff experiences/outcomes.

A future implementation of the Virtual Shelf should incorporate researcher controlled technology (simple wall mounted e-picture frames of adequate size for viewing from a bed length’s distance) and it would be useful to do a sample/control type of study, utilizing a standardized method of assessing patient experience as related to the Virtual Shelf intervention. While the long-term stay nature of the BMTU provides an enticing setting for the study, it should be considered that the benefits could also accrue to patients in other in-patient settings.

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