Methods:
A mixed method approach was used including a cross-sectional survey, measurement of lower extremity activity (ActiPal TM) and semi-structured interviews with RNs.
Twelve RNs from 3 M/S (mixed M/S, general surgery/burn and oncology) and 8 RNs from 2 ICUs (medical/surgical and cardiac).The investigator developed Nurse Lower Extremity Discomfort Questionnaire was used for this study. This 172- item questionnaire including sections on: work information, health status and history, organizational risk factors, physical risk factors, psychosocial risk factors, workspace design, and demographic information. Several scales were used from previous validated measures including the NASA TLX workload scale (Hart, 1988), and the Nordic questionnaire for musculoskeletal symptoms (Kuorinka et al., 1987). New items were developed from literature reviews, and expert opinion. The instrument was pilot tested with staff nurses. Cronbach’s alpha for scales ranged from .65-.90.
Physical activity measurement was assessed using the three-axis accelerometer(ActivPalTM ) which calculated walking, standing and sitting time over 12-hour shifts. Data was collected on 29 shifts for M/S (18 day and 11 night) and 21 shifts for ICU (11 day and 10 night). The nursing unit layouts differ considerably by number of beds, square footage, unit shape, location of nursing station, accessibility of equipment/supplies, drugs and locations of computer workstations. M/S units included a: 1) 22 bed linear shaped unit with rooms on two hallways, 2) a 12-room pod design with rooms on two hallways and 3) a 23-bed large rectangular shape unit with rooms on three hallways. The ICU units include a 14- bed linear shape unit consisting of two 12-bed pods with patient rooms on one side of the hallway and a 30-bed half-moon circular unit. Semi-structured interviews were conducted, recorded and transcribed following the completion of the activity measurement. Interview questions related to physical discomfort, unit layout, physical work environment and workflow efficiency.
Surveys were analyzed using descriptive data. Statistical comparisons were made between nursing units using t-tests and one-way analysis of variance. The activPalTM data was processed using the associated software package and measures time sitting, time standing, time stepping, and actual step count. Interview data was analyzed using a constant comparative method.
Results: The mean age of participating RNs was 21 years (range 22-51 years). Mean years of nursing experience was 5.6 (range 0.25- 30 years). Eighteen woman and two men were included. Aim 1: The 12 month prevalence of lower extremity discomfort was high (75%). Foot/ankle discomfort was reported by 63.6% of M/S RNs and 57.1% of ICU RNs. Aim 2: There were significant differences in the activity of the RNs on the 3 M/S layouts and 2 ICU layouts. RNs who worked on the larger centralized rectangular shaped M/S unit spent significantly less time sitting (23.1% of shift), more time standing (60.6% of shift) and more time walking (16.3% of shift) when compared to RNs who worked linear and pod designed M/S units. RNs who worked in the circular centralized ICU spent significantly less time sitting (21%) and more time standing (64.8%) when compared to RNs who worked on the linear shaped decentralized ICU. Overall, the combined percentage of time MS nurses spent on their feet (combined sitting and standing) in a 12-hour period ranged from 61% to 77% that translates to 7.3-9.2 hours. This was similar to ICU RNs who spend 62%-79% of their 12 hours shift on their feet (7.4 to 9.5 hours). Aim 3: Intensive care RNs expressed a preference for the larger centralized circular unit over the decentralized pod units. M/S RNs who worked on the long linear unit and rectangular shaped unit expressed dissatisfaction associated with long distances between rooms and lack of patient visibility. Preferred location for charting differed between ICU and M/S RNs with ICU nurses preferring to chart in the patient room and M/S RNs preferring to walk to the nursing station to chart. Participants all expressed challenges associated with the location of supplies and medication rooms. RNs described workarounds such as setting up mock supply rooms to decrease unnecessary walking for supplies/medications. The process used to make patient assignments relative to workflow was described by most of the participants as less than ideal. Nurse-patient assignments with patient rooms not clustered together caused concerns about patient visibility, inability to hear patient alarms and ineffectual teamwork. RNs overall preferred to stand rather than sit because chairs were often not located in an ideal physical location to complete work, or there were simply not enough chairs to accommodate the staff. Sitting was often disrupted by phone calls, alarms, call lights and other requests.
Conclusion:
The lower extremity discomfort was a definitive concern for these RNS who mean age was below US national average. The percent of time on the feet (combined standing and walking) was relatively high although time spend walking was less than anticipated. Unit layouts and shapes have a large impact on the time spent on the feet, workflow and teamwork. Despite a movement toward decentralized units, RNs still report the need to walk long distances to obtain supplies and medications. Designers of nursing work environments must consider the physical demands required of RNs and include thoughtful ergonomic designs to minimize long term disability associated with standing for extended periods. Even though hospital designs have moved towards decentralization of units with multiple decentralized pods, this type of design is only impactful in tandem with thoughtful clustering of patient assignments and equipment/medication storage areas that are convenient to the pod.