Introduction

A construction boom in health care is currently occurring around the world.1,2 Construction and infrastructure renewal represent great opportunities for designing units that enhance patient care, as well as support the work of clinicians.3,4 Research concerning healthcare design has recently flourished in response to growing awareness of the role of physical environments in patient and clinical staff outcomes, as well as the trend toward evidence-based design.4 Much of the literature has focused on the effects of healthcare designs on patients, but the empirical work concerning effects on healthcare professionals is more circumscribed and disparate. Articles on the topic reveal a wide variety of designs evaluated, as well as diverse measures used to evaluate them.

Unit design and staff outcomes: what is known?

Despite mounting evidence concerning the impact of workplace design on clinicians, a preliminary search for reviews in MEDLINE and CINAHL on the topic reveals a dominant focus on patient outcomes,5-9 with limited coverage of impact on healthcare professionals.4,6,9 Of the three reviews offering insight into clinician outcomes, two mostly target patients,4,9 and one offers a narrow focus on teamwork and communication.6 Ulrich et al.,4 in their review of environmental design across all healthcare settings, found that assistive devices such as lifts played a role in reducing occupational injuries for staff. This highlights the important place of equipment and technology in healthcare facility design, with type and frequency of use varying with the level of acuity of the setting.10 Other environmental elements, such as reduced noise, increased light and single-bed versus multi-bed patient rooms, have been shown to reduce staff stress and improve job satisfaction.4 These findings are of interest, as healthcare workers' stress has been associated with negative effects on their mental health and on quality of patient care.11 In addition, adapting unit configurations to the needs of workers, while reducing noise and distractions, has been shown to improve staff performance.4 More specifically for team dynamics, evidence points to unit layout (spatial arrangement and location), visibility and accessibility as key for communication and teamwork.6

Critical care units, including adult intensive care units (ICUs), pediatric intensive care units (PICUs) and neonatal intensive care units (NICUs), have been established in response to the need for constant care of critically ill patients.9,12,13 The high level of acuity of these units calls for an adapted environment with advanced technology to support clinical care.13 Moreover, ICU healthcare workers experience high levels of stress,4,9,14 with critical care nurses reporting higher moral distress compared to their nursing colleagues working in other areas.15 A systematic review of NICU design outcomes revealed that single-patient rooms lead to increased walking, higher workload and communication challenges for staff.14 In a study of nurses' lived experiences of ICU bed spaces in Sweden, Olausson et al.16 highlighted the effects of physical environments on nurses. As an instrument of observation, technology was perceived as an extension of the nurse's body and a significant part of the place's identity.16 Nurses felt that the design of the physical environment hindered their ability to care for the critically ill, and from the perspective of the nurse, this signified a broken promise because it hindered support of healing.16

Qualitative studies give an enriching perspective on physical environments that differs from quantitative work, and are mostly absent from the more pointed reviews retrieved.4,6,9 A scoping review allows broader inclusion of works from diverse research traditions.17 Critical care settings are particularly relevant to this study in relation to design, as these units present unique realities in terms of physical spaces, such as the significant use of technology, that differ from other clinical areas.12,13,16 Moreover, Ulrich et al.4 suggest environmental elements can play a role in the experience of stress, and this is especially important to investigate in highly stressful settings, such as critical care.

In summary, a growing body of evidence is showing how unit designs can impact clinical staff, but no reviews have been found that focus exclusively on clinicians within ICU settings. A scoping review focusing on clinician outcomes is necessary to offer a more comprehensive portrait of which environmental design elements have been studied and which measures are being used to quantify and qualify outcomes for clinicians. A scoping review would map what is known on the topic in order to identify important gaps in evidence and orient future research avenues. This scoping review aims to identify the range of known impacts of unit design on ICU clinicians. A scoping review highlighting design impact on ICU clinicians and, particularly, exploring similarities and differences across ICUs, PICUs and NICUs, can stimulate creative reflection around architecture and construction in critical care, thereby informing future healthcare environments on ways to support critical care clinicians.

Review questions

i. Which unit designs (e.g. single-patient rooms, position of equipment) have been studied empirically in relation to ICU clinician outcomes?

ii. What is the range of known impact (that is, outcomes, effects and/or experiences of ICU clinicians) of unit design on ICU clinicians?

iii. Which outcome measures have been reported to assess impact?

iv. What are the similarities and differences for each of the three questions above, across multiple ICU settings (adult ICUs, PICUs and NICUs)?

Inclusion criteria

Participants

The review will consider studies that include clinicians working in intensive care settings (e.g. nurses, physicians, therapists). In this review, clinicians are defined as healthcare staff who offer direct patient care. Patients, visitors and staff who are not involved in direct patient care (e.g. administrative staff, laboratory workers) will be excluded from this review. Studies that group non-clinical and clinical staff together (thus making it impossible to separate clinician and non-clinician results) and studies that are concerned with measuring environmental variables (e.g. noise) without clinician participation will also be excluded.

Concept

Studies that focus on the impact of design on staff (e.g. perception, quality of work life, efficiency) will be included. Design refers to physical environment features of a hospital unit (including technology and equipment) and excludes elements of the workplace that are not physically tangible (e.g. leadership, culture). Moreover, the review will not consider studies focusing exclusively on patient outcomes (e.g. better care, higher safety for patients); this may be challenging as the "care" versus "caring" is sometimes difficult to separate. Studies that focus on the adaptation or change process in relation to the physical environment will also be excluded.

Context

The review will target hospital ICUs in adult or pediatric settings (including medical ICUs, surgical ICUs, and specialty ICUs such as cardiac ICUs, PICUs and NICUs). The following settings will be excluded from the review: outside the hospital setting (e.g. clinics, community care), acute care units that are not "intensive care" (e.g. acute medicine, oncology, operating room), and psychiatric ICUs, since the clinical interventions and the environment are significantly different from other ICUs (e.g. use of seclusion rooms).

Types of sources

Empirical studies using quantitative, qualitative or mixed methods designs will be included in this review. This scoping review will consider both experimental and quasi-experimental study designs including randomized controlled trials, non-randomized controlled trials, before and after studies and interrupted time-series studies. In addition, analytical observational studies including prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies will be considered for inclusion. This review will also consider descriptive observational study designs including case studies, individual case reports and descriptive cross-sectional studies for inclusion.

Qualitative studies will also be considered that focus on data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, qualitative description, action research and feminist research.

Studies published in English and French will be included. Studies published from database inception to present will be included as the topic of designing units has been of interest for a long time (e.g. some articles date back to inception of databases) and is booming currently. Since there is a substantial human dimension to the experience of physical environments, older articles that may seem outdated in relation to architectural savoir-faire can still contribute to understanding this human dimension. Moreover, the volume of literature is moderate, making it feasible to extend the time frame for the search.

Methods

The proposed systematic review will be conducted in accordance with the JBI methodology for scoping reviews,17 building on the works of Arksey and O'Malley18 and Levac et al.19 A scoping review allows mapping of the available evidence concerning a broader question,17,18,20 which is consistent with the current scoping review objective. This type of review is particularly well suited "for bringing together evidence from disparate or heterogeneous sources,"17^(p.8) which is found in the scholarly literature concerning impact of unit design on ICU clinicians. Moreover, the design of a hospital unit is a complex endeavor and reviews that include qualitative, quantitative and mixed methods studies are useful to "better understand complex interventions, programs, and phenomena in health sciences."21^(p.12) The current pool of evidence on the topic holds qualitative, quantitative and mixed methods studies that can enrich the understanding of this question. Any deviations to this protocol will be documented in a methodological log and reported in the full scoping review report.

Search strategy

The search strategy aims to find published and unpublished studies. For published studies, the search strategy will follow the iterative three step process recommended by JBI; however, for the second step of the process, only articles identified as relevant during initial screening will be used to inform the final search, as recommended by Morris et al.20 An initial limited search of MEDLINE and CINAHL has been undertaken by a librarian (FF) and peer reviewed by a second librarian (the initial search strategies for MEDLINE-Ovid and CINAHL are detailed in Appendix I). Both sets of search results were exported into EndNote X9 (Clarivate, PA, USA) for initial screening by a librarian (FF). The results will be screened by two reviewers (JF and DO) for articles meeting the inclusion criteria. Articles meeting the inclusion criteria will be analyzed by a librarian (FF) using PubReMiner and Yale's Medical Subject Headings [MeSH] analyzer20 to identify frequently recurring keywords and MeSH subject headings. Any keywords or MeSH subject headings (and their equivalent in CINAHL) not included in the initial MEDLINE and CINAHL searches will be added to those searches, and these will inform the development of a final comprehensive search strategy, which will be translated into each additional database. Duplicates will be removed across Ovid databases using Ovid's duplicate removal feature, and again across all databases in EndNote using the Bramer et al.22 method.

A second round of screening of results from all databases (excluding those already screened) will be undertaken by two reviewers (JF and DO) after duplicates are removed. These reviewers will screen the reference list of all relevant studies for additional relevant studies. A librarian (FF) will use Google Scholar, Web of Science Core Collection and Scopus to identify citing articles of relevant studies, and the two reviewers (JF and DO) will screen these citing articles for inclusion. Reviewers will contact authors of primary studies or reviews for further information, if necessary.17

Information sources

The databases to be searched will include: Embase (1947 - present), MEDLINE (1946 - present), PsycINFO (1806 - present), Healthstar (1966 - present) and CINAHL. For unpublished studies, gray literature will be searched. This will include an Internet search using the search engine DuckDuckGo,23 examining the first 50-100 hits24 for keywords: "ICU design clinicians", "NICU design clinicians", "PICU design clinicians", "unit design clinicians", "ICU ergonomics clinicians", "NICU ergonomics clinicians", "PICU ergonomics clinicians", "unit ergonomics clinicians", "ICU work environment", "NICU work environment", "PICU work environment", "unit design clinicians", "ICU ergonomics clinicians", "NICU ergonomics clinicians", "PICU ergonomics clinicians", and "hospital design". ProQuest Dissertations and Theses Global; websites of relevant associations and organizations such as Clinicians for Design, Canadian Healthcare Engineering Society (CHES), Nursing Institute for Healthcare Design (NIHD), and The Canadian Foundation for Healthcare Improvement; and direct communication with researchers known to have published on the topic will also be used.

Study selection

Following the final search, all identified citations will be collated and uploaded into EndNote and duplicates removed. Titles and abstracts will then be screened by two independent reviewers (JF and DO) for assessment against the inclusion criteria for the review. Studies that may meet the inclusion criteria will be retrieved in full and their details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; Joanna Briggs Institute, Adelaide, Australia). The full text of selected studies will be retrieved and assessed in detail against the inclusion criteria. Full-text studies that do not meet the inclusion criteria will be excluded, and reasons for exclusion will be provided in an appendix in the final systematic review report. Included studies will undergo a process of critical appraisal using the Mixed Methods Appraisal Tool (MMAT).25,26 Quality appraisal is not a standard component of scoping reviews, but it can enrich the interpretation that readers make of review findings19 and highlight gaps in evidence, thus better informing future research and design. The MMAT was selected because it is a reliable tool that allows the evaluation of the methodological quality of qualitative, quantitative and mixed methods studies (which will all be included in this review).25-27 Quality scores are presented through four descriptors (low quality - high quality).27 The results of the search will be reported in full in the final report and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.28 Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer (MLT).

Data extraction

Data will be extracted from papers included in the scoping review by two independent reviewers (JF and DO) using Microsoft Excel (Redmond, Washington, USA) to create a spreadsheet to store extracted data. The data extracted will include specific details about the population, concept, context, study methods and key findings relevant to the review objective. A draft charting table is provided (see Appendix II). This draft data extraction tool will be modified and revised, in an iterative manner, during the process of extracting data from included studies.

Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer (MLT). Authors of papers will be contacted to request missing or additional data, where required.

Data presentation

The extracted data will be presented in diagrammatic or tabular form in a manner that aligns with the objective of this scoping review (see Appendix III). A narrative summary will accompany the tabulated and/or charted results and will describe how the results relate to the review's objective and questions.

Acknowledgments

JF would like to thank the Fonds de recherche du Quebec - Sante (FRQ-S), the Quebec Network on Nursing Intervention Research (RRISIQ), the Institut universitaire en sante mentale de Montreal - Research Center, and McGill University for their doctoral financial support.

Appendix I: Search strategies for MEDLINE and CINAHL

Search date: May 2018

MEDLINE

1. (attitude^* or efficiency or efficient or retention or turnover or preference^* or intention^* or stress or perception^* or autonomy or competence or relatedness or psycholog^* or motivation or workload^*).tw,kf.

2. Attitude of Health Personnel/

3. Motivation/

4. Workload/

5. exp Psychology, Industrial/

6. Personnel Turnover/

7. Personnel loyalty/

8. Workplace/px [Psychology]

9. Occupational stress/

10. Occupation Health/

11. exp Patient Care Team/px [Psychology]

12. exp Health personnel/px [Psychology]

13. Personal Satisfaction/

14. Job Satisfaction/

15. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14

16. ICU$1.tw,kw.

17. PICU$1.tw,kw.

18. NICU$1.tw,kw.

19. high dependency unit^*.tw,kf.

20. (intensiv^* or critical or post an?esthesia or acute) adj (care or unit^* or treat^* or therap^*)).tw,kf.

21. exp Intensive Care Units/

22. exp Critical Care/

23. 16 or 17 or 18 or 19 or 20 or 21 or 22

24. (unit^* or floor) adj1 (design^* or construction or plan$1 or architecture)).tw,kf.

25. (physical or work^*) adj1 environment^*).tw,kf.

26. exp "Facility Design and Construction"/

27. exp Architecture/

28. Health Facility Environment/

29. "Interior Design and Furnishings"/

30. Engineering/

31. Ergonomics/

32. Patients' Rooms/og, st, td or nursing stations/og, st, td

33. 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32

34. 15 and 23 and 33

35. limit 34 to (English or French)

CINAHL

(((TI ((attitude^* OR efficiency OR efficient OR retention OR turnover OR care^* OR preference^* OR intention^* OR stress OR perception^* OR autonomy OR competence OR relatedness OR psycholog^* OR motivation OR workload^*))) OR (AB ((attitude^* OR efficiency OR efficient OR retention OR turnover OR care^* OR preference^* OR intention^* OR stress OR perception^* OR autonomy OR competence OR relatedness OR psycholog^* OR motivation OR workload^*)))) OR ((MH "Attitude of Health Personnel+")) OR ((MH "Attitude")) OR ((MH "Psychology, Occupational+")) OR ((MH "Personnel Turnover") OR (MH "Personnel Retention") OR (MH "Personnel Loyalty") OR (MH "Motivation") OR (MH "Workload")) OR ((MH "Work Environment/PF")) OR ((MH "Stress, Occupational")) OR ((MH "Occupational Health")) OR ((MH "Health Personnel+/PF")) OR ((MH "Personal Satisfaction") OR (MH "Job Satisfaction"))) AND (((TI (icu^* OR picu^* OR nicu^*)) OR (AB (icu^* OR picu^* OR nicu^*))) OR ((TI high dependency unit^*) OR (AB high dependency unit^*)) OR (TI post an?esthesia) OR (TI (post an?esthesia N1 (care OR unit^*))) OR ((TI ((intensiv^* OR critical OR post an?esthesia OR acute) N1 (care OR unit^* OR treat^* OR therap^*))) OR (AB ((intensiv^* OR critical OR post an?esthesia OR acute) N1 (care OR unit^* OR treat^* OR therap^*)))) OR ((MH "Intensive Care Units+")) OR ((MH "Critical Care") OR (MH "Intensive Care, Neonatal"))) AND (((TI ((unit^* OR floor) N1 (design^* OR construction OR plan$1 OR architecture))) OR (AB ((unit^* OR floor) N1 (design^* OR construction OR plan$1 OR architecture)))) OR ((TI ((physical OR work^*) N1 environment^*)) OR (AB ((physical OR work^*) N1 environment^*))) OR ((MH "Architecture+")) OR ((MH "Engineering") OR (MH "Ergonomics")) OR ((MH "Health Facility Environment")) OR ((MH "Patients' Rooms/OG/ST/TD")))

Appendix II: Draft charting table

Appendix III: Draft table of outcomes

References