NICU redesign from open ward to private room: a longitudinal study of parent and staff perceptions

Abstract

Objective:

Assess the attitudes and perceptions of parents and healthcare providers regarding the neonatal intensive care unit (NICU) environment while transitioning from an open ward (OW) to private-room (PR) NICU.

Study Design:

Parents and staff were surveyed 6 months before and 1 and 8 months after moving from OW to PR in a Level III NICU in 2009. Questions were scored on a 0 to 10 scale in areas of teamwork, communication, development, facility, safety and privacy.

Results:

In OW, parents and medical staff were satisfied with the teamwork. After 1 month in the PR, advanced practitioners reported higher scores whereas nurses reported declines in teamwork and safety but gains in other areas. Advanced practitioners’ scores did not vary between surveys in the PR. Nurses were initially satisfied with the PR, but by 8 months, the scores declined. Parental satisfaction scores were consistently higher than medical staff in both settings.

Conclusions:

Parental satisfaction is likely due to focus on their infant rather than facilities. In the PR, lower nursing scores are likely due to decreased interaction with peers. Research is needed to ensure that improvements gained from a PR NICU are meaningfully consistent.

Introduction

The concept of a private-room neonatal intensive care unit (NICU) design was first proposed nearly 20 years ago.1 Since then, the development of private-room (PR) NICUs as opposed to the traditional ‘open-ward’ (OW) unit has seen a growing trend. Open ward NICU design limits privacy and conversation and can be intimidating and overwhelming for families; OWs also poorly limit environmental distractions and may lead to over stimulation of the infant and family.2 This environment can affect family perceptions on the delivery of care, amount of attention devoted to their infant as well as the relationships they form with nursing, advanced practitioners and other families.3, 4 A PR NICU design, touted for optimal development of the vulnerable patient population, also presents challenges in logistics, operational changes and staff culture with the physical changes that occur in transitioning from the OW design.5

These conflicting issues between NICU designs afford an opportunity to evaluate the potential effects transitioning from one style type to the other. However, the literature evaluating these effects is limited. Domanico et al.6 demonstrated that parents of NICU patients had different views of NICU design compared to health care staff. Parents who only experienced one of the designs felt staff performance was similar in both and that except for noise disturbance, the physical facilities were comfortable and adequate. The authors found that nursing staff preferred the OW design whereas neonatologists favored the PR layout. Others have found varying results in staff and family perceptions of the design dilemma.7, 8, 9, 10, 11, 12 In a separate paper, Domanico et al.13 also showed that the PR design was more conducive to family-centered care and breast-feeding success than their previous OW design. It has also been postulated that a PR NICU design may improve infant neurobehavioral development at discharge through a variety of mechanisms, including decreased sound levels from neighboring equipment.14, 15, 16

The purpose of this study was to examine the effects of transitioning from an OW NICU design to a PR NICU design on advanced practitioners (neonatologists, nurse practitioners, physician assistants), nursing staff and parents in several categories across three different epochs of the transition (pre-, post- and 8 months post transition). It was hypothesized that the PR NICU design would be preferred to the OW design across all categories and that this preference would be sustained.

Methods

An observational crossover cohort study design was used to assess the perceptions of study subjects to an OW NICU design compared with a PR NICU (PR) design at a single hospital site. In February 2009, the NICU service at Morristown Medical Center, Morristown, NJ, moved from an OW (9200 ft2; 42 bed spaces; 219 ft2 per bed space) to a PR design (17 855 ft2; 34 rooms, 54 bed spaces in 34 rooms; 330 ft2/bed space). Approval from the institutional review board was obtained prior to the study. Individual consent was assumed with the return of the survey.

The perceptions of the study subjects were assessed with an anonymous written questionnaire at three time points: 6 months prior to the OW to PR move (OW epoch), 1 month after the OW to PR move (transitional epoch) and 8 months after the OW to PR move (PR epoch). We decided a priori to resurvey parents and staff 8 months after the move to the PR NICU. Our intent was to survey the staff after several cycles of infant turnover (the hospital length of stay for the smallest infants ranges from 60 to 90 days in our NICU) to ensure validity of the data and to evaluate sustainability of perceptions of the nursing and advanced practitioner staff.

The study population consisted of three defined study groups: parents of NICU patients, NICU nurses and advanced practice (AP) NICU providers (neonatologists, neonatal nurse practitioners and neonatal physician assistants). The questionnaire was a closed-ended survey of 22 questions that queried perceptions in six general categories: Team, defined as the sense of being part of the healthcare team; communication, defined as the ease with which one could contact/communicate with others; development, defined as the subjective sense of a neurodevelopmentally appropriate environment; facility, defined as the appeal of the physical environment; safety, defined as the sense of patient safety; and privacy, defined as the sense of family privacy. Questionnaire responses were based on a 10-point response scale, with 0 being the lowest and 10 being the highest end of the queried dimension. The questionnaire was modeled from a survey developed by the Picker Institute, an independent not-for-profit organization dedicated to advancing the principles of patient-centered care.

Questionnaires were provided to study subjects with an unmarked envelope with instructions to return the sealed, completed questionnaire to a designated collection site. The same questionnaire was administered to nurses and AP subjects during all three epochs. For parents, the questionnaire was administered only during the OW and PR epochs. This was decided a priori, given that parents from a transitional epoch would compose a singular unique cohort whose experiences, although interesting, would not directly relate to the study objectives.

Responses from returned surveys were recorded in a computerized database. Normality of data was assumed for questionnaire responses. Data were summarized with means and standard deviations; one-way analysis of variance with Tukey’s honestly significant difference (HSD) post-hoc testing or Student’s t-test were used, as appropriate, for comparisons of groups within a given epoch and within each study group. A P-value <0.05 was considered statistically significant. SPSS 15.0 for Windows software (Chicago, IL, USA) was used for statistical analyses.

Results

A total of 248 surveys were completed during the study period: 42 (17%) from APs, 55 (22%) from parents and 151 (61%) from nurses. During the OW epoch, 15 surveys were from APs, 33 from parents and 42 from nurses. During the transitional epoch, 15 surveys were from APs and 58 from nurses. During the PR epoch, 12 surveys were from APs, 22 from parents and 51 from nurses. APs returned 78% of surveys handed out, nurses returned 68% and parents returned 56%.

Among neonatal nurses, only three categories in the OW had mean responses >7: safety (8.5±1.3), team (8.1±1.1) and communication (7.6±1.0). Low mean scores were given for development (6.4±1.2), facility (5.4±1.7) and privacy (4.3±2.1). One month after moving into the PR (transitional epoch), nursing perceptions improved for development, facility and privacy (P-value<0.05). However, there was a statistically significant decrease in nursing perception of team. After 8 months in the PR, the improvements in nursing perceptions of development, facility and privacy persisted (P-value<0.05, compared with OW) and the nursing sense of team increased to a mean score that was no longer statistically different than that in the OW. Interestingly, there were no significant changes in nursing perceptions of communication or safety throughout the study periods (Figure 1a).

Figure 1
figure1

Survey responses from NICU nurses (a), advanced practitioners (b) and parents (c). Columns represent mean values±s.d. of survey responses from nurses (a), advanced practitioners (b) and parents (c) during the open ward (), transitional (), and private room () epochs. Responses were on a scale of 0 to 10. *P<0.05 within group (one-way ANOVA with Tukey HSD post-hoc testing using parent baseline or Student’s t-test as appropriate). #P<0.05 within epoch (one-way ANOVA with Tukey HSD post-hoc testing using parent baseline or Student’s t-test as appropriate). For development during open ward, all groups were statistically different from each other.

Among advanced neonatal practice providers (AP), only three categories in the OW had mean responses >7, similar to nursing perceptions: team (8.3±1.0), safety (7.8±1.5) and communication (7.5±1.2). Low mean scores were given for development (5.4±1.6), privacy (4.8±2.4) and facility (4.5±2.0). In the transitional epoch, 1 month after moving into the PR, similar to that observed with nursing, AP perceptions improved for development, facility and privacy (P-value<0.05). After 8 months in the PR, the improvements in AP perceptions of development, facility and privacy persisted (P-value<0.05, compared to OW NICU). There were no significant changes in AP perceptions of team, communication or safety throughout the study periods (Figure 1b).

In the OW, parents were more satisfied than nurses or AP providers with safety, development, communication and facility and more satisfied than nurses with privacy (P-value<0.05) (Figure 1c). In the OW, there were no perceptual differences between nurses and APs in any category other than development, with APs giving statistically significant lower mean scores. Nurses, parents and APs had similar high perceptions of team in the OW. In the transitional phase, APs perceived a higher degree of team and communication than nurses (P-value<0.05); there were no other differences between these two groups during this epoch.

In the PR, parents continued to report statistically significant higher degrees of satisfaction than nurses or AP providers with safety, facility, development, communication and privacy and higher scores for team than nurses (Figure 1c).

There were no statistically significant differences in survey responses among parents when controlling for duration of NICU hospitalization or NICU daily census, among AP providers when controlling for physician versus nonphysician status, or among nurses when controlling for shift (day versus night) or years of experience.

Discussion

The results of our prospective survey study provide new information on parent, staff and practitioner attitudes on moving from an OW NICU to a PR NICU, a growing trend in the USA. Aside from the lengthy decision making process and resources required to pursue a PR NICU design, care should also be given to monitor staff and family attitudes both before and after the transition to ensure that support and facilities are appropriate for everyone affected. Our study demonstrated several issues that should be addressed or considered before transitioning from an OW to PR NICU design.

Parent perceptions

Overall scores from parents were universally high except for privacy in the OW. Although there were statistically significant improvements between OW and PR in the categories of communication, development and facility, the scores were high in both NICU designs. Of note, parents perceived developmental care and the facilities to be of a higher caliber than the NICU staff regardless of setting. Other studies have shown similar findings.6, 7 In contrast, Domanico et al.17 found that 59% parents who were experienced to both types of NICU design favored the PR design compared with the OW. It is a well-known phenomenon that there are perception disparities between parents and NICU staff in what is important in the care of their infant. It could be assumed the consistently high scores found in our study in both NICU environments is a function of the focus of families on their infant rather than on the environmental or facility.

A concern of our social services department was the possibility that PRs would prevent families from developing relationships with other NICU families. Preparations to implement social activities were made to offset this potential void including ‘family dinner night’ and sibling social events located in our NICU lounge. Parent surveys, however, revealed this was a perceived possible change that did not come to fruition. Developing relationships with other families remained strong in parent survey results. One reason for this unexpected result may be increased visitation. Visitation allows for more contact with families in other areas of the NICU and hospital (lounge, cafeteria, etc.). Pineda et al.11 showed that parents of infants in their PR NICU spent significantly more time visiting than those in the open-ward NICU, from an average of 19 to 32 h per week. This increase persisted over the first four weeks of hospitalization but was no longer significantly increased from week 5 until discharge. We did not change our visitation policy and although we did not collect any of this data, we did not see an increase in visitation.

Nursing staff and advanced practitioner perceptions

There were noteworthy perceptions of the nursing staff based on the survey results. The sense of teamwork decreased significantly in the transition epoch and was lower than parents or advanced practitioners perceived it. Although teamwork improved 8 months after the move, scores were still lower than the two other study groups. The fact that the scores were no longer significantly different likely reflects nursing staff feeling more comfortable with their new surroundings, accepting changes to workflow issues such as daily rounds and being more comfortable to no longer having advanced practitioners easily visible.

Nursing communication scores were also unchanged between epochs and were significantly lower than both parents and advanced practitioner scores. Previous studies have demonstrated conflicting results on this phenomenon.6, 8, 18 As part of the move to the PR, a communications system was installed (Vocera, San Jose, CA, USA) that allowed immediate transmission of vital sign alarms to a nurse in a separate room. This has been shown to improve nursing workflow as well as communication in a previous study.19 Nursing perceptions of teamwork and communication are likely due to the feeling of being more isolated from coworkers, a larger facility spreading nursing staff out and more dependence on electronic communication in the PR compared with the OW.

Neonatologists, neonatal nurse practitioners and neonatal physician assistants perceived the PR to be more developmentally appropriate, safer, more private and more environmentally appealing than the OW. Like the nursing staff, their scores were lower than parent scores in every category except teamwork. Other than as mentioned above in the categories of teamwork and communication, their scores were similar to that of nursing staff perceptions. The manner in which this group functions within the NICU could account for the static scores in both teamwork and communication compared with the nursing staff. In either NICU design, this group rounds on all patients thereby automatically giving them the knowledge of all patients regardless of location. They are also made aware of any other situation or event such as admissions, discharges and changes in clinical status that other members of the healthcare team may not be as aware of in the PR design. Statistical analyses of the various types of advanced practitioners were not done due to staff number limitations.

Evaluating the possibility of pursuing a PR design requires a lengthy decision process and securement of resources. The aesthetic appeal, potential to foster family-centered care and increased customer satisfaction must be balanced with the overall impact to all parties. Consideration must be taken into account for finances, the need for equipment and storage changes, supportive technology, work flow processes, ancillary services and the culture within the NICU.

These considerations can pose barriers that must be overcome to successfully transition to a PR setting.20 Our survey did not reveal an increase in customer satisfaction (that is, a significant increase in survey scores across all six categories) that was an expected benefit of the PR design, although not the primary reason for the transition. Family response seemed to view all categories similarly in both NICU settings. Length of stay (data not shown) did not seem to influence this result. This seems to suggest that the family focuses on their infant rather than on the environmental surroundings. Other factors that could account for this response include the continued use of family-centered care principles that were already in place in the OW, the ability to be present during daily rounds and involvement in their infant’s care and no significant changes in the medical or nursing care given to their infant. All of these factors have been shown to be a driver of parent satisfaction, whereas the physical environment has a very small role.21, 22

The impact of the new unit fell with greatest intensity on the nursing staff. This impact was universal, regardless of the years of experience in NICU care, years of employment in our NICU or shift worked. The geographical limitation on visibility of their peers and the entire patient care area could result in a feeling of being isolated and prevent nurses from having comprehensive knowledge of unit activities. These perceptions likely contribute to feelings of decreased communication and a lack of teamwork. Although nursing staff had these negative perceptions, there was no change in staff turnover after the move to the PR setting. A great deal of support, new communication venues and utilization of staff input may decrease these perceptions over time.

Conclusion

Parents had consistently high scores in all categories in both OW and PR epochs. Nurses and APs found significant improvement in development, safety and facility, which was sustained. Nursing staff, however, felt that teamwork initially was poor, although 8 months post transition, this feeling was no longer statistically significant. The amenities, physical environment, privacy and developmentally appropriate environment of a PR are undoubtedly a worthwhile endeavor. A cautionary tale is the expectation that the change will foster an improved perception of family-centered care and customer satisfaction. The authors suggest a thorough investigation that includes ability to meet targeted goals and expectations before embarking on a significant change in NICU design.

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Acknowledgements

We would like to thank Karen Young, Alexandra Valentino and Emily Valentino for their help in collecting surveys from parent volunteers as well as all the physicians, advanced practitioners, nurses and parents for taking part in this study.

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Correspondence to J R Swanson.

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Swanson, J., Peters, C. & Lee, B. NICU redesign from open ward to private room: a longitudinal study of parent and staff perceptions. J Perinatol 33, 466–469 (2013). https://doi.org/10.1038/jp.2012.157

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Keywords

  • intensive care unit
  • family-centered care
  • neonate
  • NICU design

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