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Working environments: Operating room architecture and design and the effects on staff morale

Innovative OR workplace and lighting solutions from specialists such as Trumpf help to raise staff morale


Surgical suites are costly and complex, with multiple needs. What can nurses’ own experience of their workplace do to make their design more conducive to staff wellbeing?

Healthcare in Australia is in a process of change, a transformation that is occurring at every level and in every profession. Simultaneously, the profile of nursing is diversifying due to the economic reality that always accompanies change1. Nursing is a multifaceted profession, incorporating both the fundamental nursing skills as practised on the wards as well as the more technical skills found in critical care areas such as perioperative nursing.

This specialised environment is a complex system, combining patients, personnel, technology and pharmacodynamics in a physical environment and producing highly specific outcomes2. The purpose of this study is to establish the need for further exploration on how the morale of skilled professionals is affected by the architecture and design of their working environment. The significance of this research will allow further insight into the notion of morale and the working environment of perioperative nurses, which seemed to be absent from the literature reviewed.

Perioperative nursing
In order to grasp the reasoning behind this study, it is important to define both the terms ‘morale’ and ‘perioperative nursing’. Morale is described as “the mental and emotional condition (including enthusiasm, confidence and psychological wellbeing) which provides a sense of common purpose and success with respect to an individual or group”3.

Historically, the term OR or theatre nursing was used to describe patient care in the immediate pre, intra and postoperative period of the surgical experience, thus intimating that nursing care activities were circumscribed to the geographic limits of the operating suite4.

The idiom perioperative nursing has since replaced the former term and defines the role as the total surgical experience that encompasses, as previously mentioned, the pre, intra and postoperative phases of a surgical patient’s care5, 6. The role of the perioperative nurse has always seemed ambiguous to the general public – there is some doubt that the job perioperative nurses do could even be called nursing due to the perception that they are removed from patient care.

This view has been fostered by the tendency to hide behind the technology, surgical scrubs and masks7. Yet perioperative nursing is dynamic and reflects the changing nature of healthcare in society today; it consists of flexible boundaries that are responsive to the changing needs.

Technological improvements, advancing changes in surgical techniques, specialised educational training and documentation recording have driven the need for functional changes in this specialised environment, yet without compromising standards and guidelines. Today, the perioperative nurse plans, implements and evaluates patient care, manages sophisticated technology, interacts and effectively communicates with patients, families and other healthcare providers, supervises, educates and advocates for patients and colleagues, and continually responds to changes in healthcare delivery8.

It is because of this rapid change in technology that many hospitals are forced to upgrade equipment and rethink the design and structure of their facilities, including specialist units, in order to accommodate the experienced growth.

Perioperative architecture
Healthcare architecture, building and design are complex issues involving many key sectors including providers, consumers, employers, employees, the government and a number of professional institutions, guidelines and standards. A cooperation of all sectors is vital in order to ensure effectiveness. Therefore, it is important that each sector understands not only its own role within the healthcare system, but the roles of others as well9,10.

Over the past 300 years, the design of ORs and ancillary spaces has responded to changes in surgical needs and practice. Architects have been compared to the artists of the Renaissance; however, unlike these patron-guided artists, architects of the time were expected to cope with the rapidly expanding bureaucracy, technological changes and the immense building programme of hospital facilities11. The closing decade of the 20th century in particular revealed amazing transformation in environmental design of healthcare facilities. These changes have been historically compared with the influence of Florence Nightingale, whose observations and facilitation of the nursing profession some 150 years ago left a lasting impression on healthcare settings12.

A significant history exists regarding hospital architecture that reaches back to the Roman military hospitals in the first century AD. Architecture and the design of hospitals are not the only entities that have undergone extreme change. The discovery of anaesthesia in 1846, the use of carbolic spray in 1866 during surgery to avoid infection, Von Bergmann’s introduction to aseptic technique and the sterilisation of instrumentation in the late 1800s through to the introduction of keyhole surgery in the 20th century has made it necessary to provide designated facilities to encompass these technological changes in a safe environment13.

Further, a number of standards, guidelines and procedures must be adhered to when viewing architecture and design of a healthcare facility, including specialised units such as the operating suite. Today, the surgical suite is the most costly area to renovate or construct; moreover, it is the most needs intensive in regards to staff, equipment, material and building systems14,15, 16.

It is no wonder that the design of the perioperative environment offers an immense challenge to the planning and architectural team in order to optimise and accommodate efficiency and, at the same time, allow for flexibility and future expansion6,13. However, when done well, the facility planning and design of the hospital, and in particular the OR, becomes a physical embodiment of operational philosophies and procedures11,17,18.

Integrating advances in medical technology with the operating theatre environment in a way that supports staff is a key design priority of new solutions, such as the i-Suite, from Stryker

Literature review
An extensive (1968-2007) and exhaustive search was carried out of various databases (CINAHL, Nursing & Allied Health Collection, Ebsco and Medline), journal articles (including nursing, architectural and healthcare management), and a variety of texts. Key words ranged from architecture, design, OR (and variations thereof), hospital, staff morale, aesthetics and interior design, through to combinations of these words and inclusions of further information such as effective and optimal design.

The search revealed that there has been much literature written regarding architecture and design of healthcare facilities and ORs in general. However, much less has been documented regarding the effects of these designs on staff morale. Furthermore, it included information on healthcare, educational, office and business facilities, with the expectation of revealing insight into the relationship between morale and design in other professions. Only one textbook by Calderhead19, Hospitals for People, provided a significant amount of relevant background information of the effects on staff morale resulting from visual surroundings, noise, smell and the importance of good design. People appreciate good visual surroundings and will travel great distances to be among them. It is therefore vital to encourage good design and aesthetics for healthcare environments as they can have a profound influence on the behaviour and morale of both staff and clients utilising these facilities19.

Perioperative nurses spend a considerable amount of time caring for the surgical patient and addressing their needs. The workload carried by the staff leaves little or no time to address their own needs, therefore, the issue of staff morale is of low priority within the OR, until a crisis occurs20. When the issue of staff morale was addressed in the literature review, it was related to a specific point, such as significant workload, shift work and management issues. However, no reference was made to the actual structural work environment and if this was a consideration in providing a conducive working arena.

William and County21 acknowledge the issues raised in the previous article by Appold20 and have identified a number of factors, such as poor communication, ineffective training and development, which are shown to cause low morale within the perioperative environment.

However, no consideration was given to the architecture and design of the OR or whether it could contribute to the effects on staff morale. In most of the literature, the authors begin addressing discussions with a historical excerpt regarding the foundations of architecture and design of healthcare facilities, followed by their intended topic ranging from the design of the OR to the importance of colour in interior design.

Yet there are no simple universal solutions to designing buildings whose aim is the provision of healthcare. Numerous features of the design of existing hospitals make them profoundly enervating and difficult to work in, including alienating corridors and stark white walls with no decorative or directional variation to break the monotony22. ORs of the past were sometimes hosts to a comedy of errors as they consisted of wooden floors and were created to accommodate hordes of medical students who learned by watching their professors perform surgery in an amphitheatre-style classroom.

The surgical suites in the 1960s and 1970s were designed for the functionality and technology of the era, with commonalities including ceramic tile walls and conductive flooring15,23. Today, hospital and OR design must have both presence and the ability to assist the functionality of a hospital, yet not work against the patient’s healing process.

The creation of a pleasant working ambience is vital when considering all aspects of architecture and design when an upgrade and/or new ORs are being built24,25. The importance of the physical environment as a rich source of information enables people working in the area to manage experiences. Furthermore, the human senses are like antennae, constantly scanning the environment to receive signals regarding their particular surroundings22,26.

Thus the assumption that aesthetics of a specific space have a behavioural and psychological impact on staff does carry merit. Colour, furniture, paintings, space, light, furnishings and wall lights are some of the interior design aesthetics that are considered equally as important as good architecture and design and of great importance to staff morale. The correct use of these materials facilitates the creation of a feeling of trust and calm towards the patient and the staff member27.

Colour choice can prove to be an insight into the emotional wellbeing of both the patient and the staff member alike. Colour plays a significant role in life, particularly in the recovery of patients and the impact and effect on staff morale28. In addition, it has been proven that people actually work better and foster better performance in the presence of certain colours. While effective on their own, greater benefit can be obtained by combining colours and, as colour is produced by different wavelengths of light, people respond to these different energy levels.

The principle behind colour therapy and colour choice is that people choose the colours that they need as it is an indication of what they are feeling (Table 1)28. Similarly, the emphasis on natural light, space, and the use of windows was also acknowledged on a number of occasions throughout the literature review. In relation to space, the use of curved bricks can provide a visual lift to the corridors, ward and specialist units, providing a sense of flow from once space to another. Furthermore, exterior windows utilising borrowed light, colourful work stations and bordered OR areas can induce a feeling of comfort and motivation and have proved to be the most effective way to reduce staff stress and ultimately lead to an increase in staff morale15,29.

Today's operating room, such as RTKL's design at the Community Hospital North, Indianapolis, USA, must have presence and be functional without compromising the patient's healing process or staff morale


Emerging themes
Many themes emerged from the literature reviewed. In particular, patients’ perceptions of the healthcare facility, ward and/or specialist area are at the forefront of priorities when addressing architecture and design issues. Today’s healthcare facility designers endeavour to create a more aesthetically pleasing and therapeutically sound environment in order to facilitate the healing process of patients.

Interior design is categorised as function and aesthetics, both of which are important and must work together. That is why design teams address issues such as the introduction of colour schemes, the integration of Feng Shui principles, waterfalls, natural light through windows and landscaped gardens22,27,30. One article in particular concurred with these comments and went on to note that the role of the environment is an important tool for patient care; however, it was no longer sufficient for the environment to function entirely for the staff. The environment needed to provide an ambience of warmth and comfort within elegant surroundings, reflecting the values and vision of the particular institution.

The question is then posed, if patients are provided with an exceptional aesthetically pleasing environment, would this improve the morale and efficiency of staff working in this area? This question has application and relevance across all areas regardless of their specialism31.

Hospitals that made the prestigious list of Fortune’s 100 best companies to work for found that an inextricable link was identified between patients and staff. Improving customer service to patients resulted in a happier workforce, not only in consumer-friendly innovations and technological expertise but in the architecture and design of healthcare facilities.

Moreover, it prompted a sense of confidence that is reassuring both physically and spiritually for patient and staff wellbeing31. A pictorial text by Norio Ohba shows a variety of facilities built in Tokyo from hospitals to mental health and rehabilitation facilities and the importance of aesthetics, natural light, colours and windows by “bringing the outside, in”.

Calderhead19 agreed with this concept, albeit that the introduction of external stimuli such as landscaping, air and generally a sense of the ‘outside world’ would be quite difficult to achieve. It is evident that this concept is not new and that it has completed a full circle. It is vital that the architecture and design of the perioperative, or any working environment, must be conducive to the staff providing the services and functional facilities within this arena, thus alleviating the sense of frustration that develops through ineffective designs19.

Research method
The purpose of this qualitative study was to examine the architecture and design of OR and its effect on staff morale through a focus group interview with practising perioperative staff members. The purpose of selecting the naturalistic approach of phenomenology was not to extract or explain theoretical terms, but to understand its underlying meanings by allowing the participant to draw a vivid and detailed picture of the effects on morale in relation to architecture and design within this specialised environment33.

Even though significant interest was evoked by various other specialist departments, only perioperative nurses were invited to participate. The rationale behind this was that the expert in the field can, through explorative questions, articulate their knowledge and understanding of an issue and is willing to give complete and insightful accounts of the topic. The component of personal knowledge is essential in order to appreciate the meaning of any subject addressed in qualitative studies, including issues of morale based on the nurse’s background, expertise and knowledge of a particular working environment33, 34.

The goal to extract meaningful information from participants regarding their experiences was achieved via means of a videotaped interview and the use of various tools such as photographic evidence, colour specifications and a proposed floor plan. From this focus group interview, various issues arose that would require further investigation, including a detailed insight into specific areas within the perioperative environment and their individual requirements. Suggestions and insights offered throughout the interview by both the participants and the researcher paved the way for further research on the topic of architecture and design of ORs and the effects on staff morale.

Data collection
Fifteen expressions of interest were randomly distributed (male and female) to practising perioperative staff members across three major metropolitan hospitals in Western Australia. Prior to the focus group interview, discussions regarding the intention, techniques and aspects of confidentiality were held with each participant. Staff members were asked to complete and return a consent form and an agreed date, time and place were set to address any issues/questions prior to the commencement of the interview.

Of the 15 invitations, six members confirmed their participation (minimum); additional participants were unable to attend the scheduled interview due to heavy working commitments and shift work. The option of a taped one-on-one interview was offered if the member was unable to attend the scheduled date or did not wish to participate in the focus group; however, no participant took up this offer.

The six participants were all female, aged between 23-60 years of age. Their backgrounds ranged across various specialisms within the perioperative arena, including anaesthetics, intraoperative, recovery room and endoscopy. Their perioperative experience began at three years since graduation to more than 30 years as a practising registered nurse.

The expertise and knowledge scope was extensive, from junior, senior and management staff. The focus group approach was chosen to allow for multiple interactions among colleagues; it was also conducive to the collection of in-depth information and the meticulousness of data.

The recruitment of a neutral associate eliminated the potential bias that may have occurred during the data analysis. Any preconceived ideas or judgments were eliminated prior to the interview as it was vital that the participants’ experiences, perceptions and opinions were analysed rather than that of the interviewer.

Permission letters were required to enter agencies to obtain photographic evidence of each perioperative suite as part of the study. Once access was confirmed, appointments were set with unit managers to further discuss the rationale and outline of the study. A number of meetings were organised with the architectural draftsperson who became an integral part in the development and design of a proposed OR suite for perusal, comments and suggestions by the participants during the interview. Various interviewing strategies were used, including but not limited to, pre-selected and open-ended questions.

Colour specifications and samples were obtained through hardware stores and upholstery manufacturers to facilitate discussions on internal design and its effects, if any. Photographic evidence of perioperative suites and a proposed basic floor plan of an OR were used to facilitate data collection.

The photographic evidence was vital to the study as it provided the basis of discussion for how architecture and design of ORs can affect staff morale. Furthermore, certain architecture and design pictorial text books were used as reference material32, 35.

One of the most important ethical considerations for this study was that the participants were entitled to privacy, confidentiality and informed consent. The videotaped focus group interview was carried out at one of the participating major hospitals in a designated tutorial room away from the perioperative working environment to allow for privacy, confidentiality and to ensure that no interruptions occurred. The interview lasted approximately 1.5 hours, with the option of a follow-up interview if insufficient data were collected. A neutral associate was employed to videotape the interview and the proceedings, including objectives and questions, were outlined and provided to each participant on arrival.

A 100% response rate was received from the three agencies approached for access to their ORs to obtain necessary photographic evidence required for this study. Six out of the 15 perioperative staff members invited to participate provided a 40% participation rate to the study. The pressure on staff was enormous to be released in time to attend the interview, and shift work proved to be a major factor in the ability for further participation by other members.

Definitions for ‘morale’ and ‘perioperative nursing’ were provided at the beginning of the interview to establish the study’s foundation. Participants were asked to individually identify with the term morale and what it meant to them.

Comments such as “working environment, the people you work with the positive effects”, “how people talk to you, how you are treated, the area that you’ve got to work in” and “... a huge effect, because I find that under fluoro lights [pointing to the ceiling] after a while you are like an indoor plant and you sort of die by the end of the day” were put into context by the researcher, confirming with the participants that the phenomenon of ‘morale’ can be related to and have an effect in relation to the architecture and design of a person’s working environment.

Bringing the ‘outside, in’
Furthermore, a comment made in regards to windows – “... there are a lot of areas that don’t see the daylight; sometimes, somebody will say ‘it’s raining’ – oh really? So you look for the nearest window to see what is happening in the real world” – confirms the findings19,32 that the concept of ‘bringing the outside, in’ has a profound impact on staff morale as they find themselves aware of their confinement. This particular discussion evoked a continual comparative approach, with members reflecting on other establishments that they had worked in and how they compared to their current environment.

Members of staff are the first to come in contact with their environment, and therefore this space holds great significance. The workplace should provide a welcoming atmosphere with clear-cut directional emphasis19,26. As personal senses become offended, people become stressed and lose the effectiveness to accomplish designated tasks within the work setting. Staff energy is therefore focused on reacting to the stress rather than working at the task at hand.

The frustration associated with the architecture and design of a working environment proved to be one of the major themes that emerged from this study. The participants identified that distance and time associated with moving between various areas within the perioperative suite was a concern that should be addressed when designing the environment.

Surgical suites are designed to service patients with advanced medical technology and allow for the incorporation of a universal design to accommodate the conversion from one speciality to another without further changes and/or construction15. A basic central corridor, hotel-style floor plan was developed to ascertain the perceptions and opinions of the participants. Consisting of operating and recovery rooms, administrative and ancillary facilities, it created an atmosphere of excitement, positive remarks and anticipation in the development of a workspace that would facilitate an increase in staff morale.

The photographic evidence of ORs, recovery rooms and ancillary spaces proved to be a contributing factor in the practical ability and application of participants to address and discuss the research topic. Feelings of aversion with comments such

Integrating advances in medical technology with the operating room environment in a way that supports staff is a key design priority of new solutions, such as the i-Suite, from Stryker as “that’s awful”, “that’s terrible” were forthcoming when photographs of these areas were viewed. This reaction also revealed another emerging theme, space.

This issue was anticipated to be significant to the participants; therefore the proposed basic floor plan provided ensured that dimensions of the perioperative workspace were addressed with the architectural draftsperson during the design process. The floorplan reflected the issues of space and light, with the inclusion of windows surrounding the suite.

Furthermore, relevant traffic, movement patterns and dimensions of the particular perioperative space were acknowledged and adhered to according to appropriate standards and guidelines. The issue of colour specifications and schemes also proved to be important. The focus group was presented with various colour samples ranging from modern bold and bright representations (e.g. burnt orange, shades of purple/lavender and green) to a more contemporary selection of pastel colours (green, blue, pink and beige, for example), which facilitated discussions.

Statements made by the participants concur with the literature reviewed, proving that colour has a tremendous effect on staff morale within a working environment. During the interview, comments such as “...the layout also affects your ability to function without feeling frenzied or stressed” and “...colour schemes can play a big part” not only agree with the literature reviewed, but serve as a testimony to the aim of this study.

The importance of the design team (including management, architects, engineers and actual staff members working in the specialist environment) was highlighted throughout the literature reviewed. During the actual study, the participants critically reviewed the photographs provided as a group. This evoked collaboration between them as they began working together as a team to design their own working environment, utilising sections of one area and placing them into another, thus identifying the ‘ideal’ perioperative setting.

However, it was interesting to note that even though only two out of the six focus group participants had spent time on a design team, both revealed that it was a negative experience and had not been aware of the standards and guidelines that exist to govern this issue.

Discussion
Advances in technology, alongside the diversity and growth of hospitals, have led to the need for more specialised healthcare settings and furnishings, thus new and insightful architecture and design of healthcare facilities. Today, healthcare architects are taking into account these needs when developing designs that are conducive to patient-centred care. At the same time, however, the needs of the staff should also be considered, therefore their participation in the architectural design team, the design evaluation, building and commissioning process is crucial36.

The group dynamics of the interviews were also of interest, as the characteristics of the participants represented personnel currently employed within the perioperative clinical setting. The vast difference between the participants’ backgrounds, experience, knowledge and expertise contributed to the diversity of information, perspectives, opinions and comments offered throughout the focus group interview.

Participant responses revealed a number of emerging themes such as frustration and low morale by the participants due to a working environment that was not conducive to staff. The question is then posed: is the nursing profession (and nurses’) opinions not important or as highly regarded as others in the design process when addressing their own workspace? The most notable themes that emerged were feelings of frustration regarding the architecture and design of current work settings; identifying and addressing the discontent and disappointment in that participant opinions and recommendations were not being valued when attempting to partake in likely working environment changes; and the excitement at the prospect of being a part of a study where these participants were considered the experts that would ultimately produce an effective, efficient and conducive workspace. From the literature reviewed and previous research conducted in the areas of architecture and design, the results were consistent.

Architecture and design, colour specifications, layout, furnishings, aesthetics and interior design in general have the ability to increase staff morale and at the same time produce a beneficial working environment. Overall, the information was well received by the focus group, with participants identifying/highlighting areas of concern and anticipated issues that would possibly arise during the design process. The willingness to partake as part of the design, evaluation and
commissioning team was overwhelming, with participants and management requesting to peruse the research proposal and remain informed on the outcome of this study.

The researcher believes that this study would benefit further from the undertaking of a longitudinal study incorporating facility-specific focus group interviews in order to gain alternative perceptions and insight from external organisations and perioperative staff members.

Conducting interviews with staff members who have participated in the design, evaluation and commissioning process of an OR would provide further validation to research results. Further research on this topic would clarify the position of the perioperative nurse in the scope of this role and identify the need for educational sessions highlighting specific guidelines and standards governing OR architecture and design. Finally, follow-up interviews with participants would facilitate the verification of research findings and allow for additional input as required.

Conclusion
Technological advancements have brought about profound changes to hospital buildings and the design of the OR. Organisations are now eager to re-examine how they can add to their performance by re-engineering their approach to the use of buildings, space and facilities. Recommended guidelines and standards such as the Guidelines for construction and equipment of hospitals and medical facilities from the American Institute of Architects Committee on Architecture for Health & Assistance37 and the Australian College of Operating Room Nurses ACORN standards and guidelines36 may service organisational demands and increase profits; unfortunately they fail on staff satisfaction and lead to low morale in providing a positive working environment.

Nursing has never been a 9-5 job and most areas operate on a 24 hour basis to accommodate patients’ needs38. Additionally, a healthcare facility is a tangible, living testimony of the organisation’s beliefs and priorities towards staff and patients. A true-life enhancing environment is, in fact, one that shows respect for human dignity12. The OR is an interactive environment and can be seen as an autonomous unit due to its terminal location38. Out of all the literature reviewed, only one text was found to acknowledge that architecture and design, in this instance the isolation of the OR location, can begin to affect staff morale, as interaction between other departments/units and other personnel can be non-existent. Therefore, choosing the correct ‘treatment’ to create an environment that expresses hospitality and reduces stress – such as a real sense of openness in what is a closed environment – is an integral component for setting the tone of architecture and design38.

The surgical suite is the most costly area to renovate or construct; moreover it is the most needs-intensive in regards to staff, equipment, material and building systems. Functional planning, future operational flexibility and architectural design all contribute to the creation and/or refurbishment of a hospital or a designated department. Good design, sensitive use of materials, contrast of colours, textures and furnishings can turn corridors, ORs and the department in general into a pleasant, reassuring and conducive environment for staff, patients and visitors. The expected results would be a more positive setting, leading to an improvement in quality of staff morale and ultimately patient care. For most people, knowledge on how all the pieces fit together to form a holistic picture is important. Perioperative staff are in a prime position to convey relevant information which will enable them to ultimately produce a structure and/or department that reflects the needs of those personnel who work within the unit12.

Kamaree Berry is an undergraduate and postgraduate lecturer at the School of Nursing, Midwifery and Postgraduate Medicine at Edith Cowan University, Perth, Western Australia.

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