Research

Finding a Middle Ground:

Exploring the Impact of
Patient- and Family-Centered
Design on NurseFamily
Interactions in the Neuro ICU

Health Environments Research

& Design Journal
2015, Vol. 9(1) 80-98
The Author(s) 2015
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1937586715593551
herd.sagepub.com

Allyn S. Rippin, MS, EDAC1, Craig Zimring, PhD2,

Owen Samuels, MD3, and Megan E. Denham, MAEd, EDAC2

Abstract
Objective: This comparative study of two adult neuro critical care units examined the impact of patientand family-centered design on nursefamily interactions in a unit designed to increase family involvement.
Background: A growing evidence base suggests that the built environment can facilitate the delivery of
patient- and family-centered care (PFCC). However, few studies examine how the PFCC model impacts
the delivery of care, specifically the role of design in nursefamily interactions in the adult intensive care
unit (ICU) from the perspective of the bedside nurse. Methods: Two neuro ICUs with the same patient
population and staff, but with different layouts, were compared. Structured observations were conducted to assess changes in the frequency, location, and content of interactions between the two units.
Discussions with staff provided additional insights into nurse attitudes, perceptions, and experiences
caring for families. Results: Nurses reported challenges balancing the needs of many stakeholders in a
complex clinical environment, regardless of unit layout. However, differences in communication patterns
between the clinician- and family-centered units were observed. More interactions were observed in
nurse workstations in the PFCC unit, with most initiated by family. While the new unit was seen as more
conducive to the delivery of PFCC, some nurses reported a loss of workspace control. Conclusions:
Patient- and family-centered design created new spatial and temporal opportunities for nursefamily
interactions in the adult ICU, thus supporting PFCC goals. However, greater exposure to unplanned family
encounters may increase nurse stress without adequate spatial and organizational support.
Keywords
critical care, patient- and family-centered care, evidence-based design, nursefamily interactions, stress
1

Plural Space, LLC, Atlanta, GA, USA

Georgia Institute of Technology, Atlanta, GA, USA
3
Neuroscience Critical Care, Emory Healthcare, Atlanta, GA, USA
2

To earn continuing education units on this article visit herd.sagepub.com/supplemental

Corresponding Author:
Allyn Rippin, MS, EDAC, Plural Space, LLC, PO Box 77891, Atlanta, GA 30357, USA.
Email: alrippin@hotmail.com

Rippin et al.

Introduction
Critical care stands at an important moment of
transition. The trend toward patient- and familycentered care (PFCC) is steadily transforming
attitudes and behaviors toward family members
with a loved one in the adult intensive care unit
(ICU). For many years, restrictions have been
placed on family presence in these highly charged
environments in an effort to protect the critical
patient and staff privacy. However, an emerging
body of evidence confirms what has long been
intuited: Families play a vital role in patient and
family healing, particularly during an acute medical crisis (Davidson et al., 2007). In response,
ICUs across the United States are increasingly
opening their doors to families (to varying
degrees), with policies and processes that recognize family as valuable partnersnot just visitorsin the care and recovery of their loved one.
While the traditional, clinician-centered approach to critical care has limited family involvement,
PFCC invites families to take a more active role.
The intent is to bring wholeness to the patient
through collaboration and personalized care that
respects the values, beliefs, and experiences of the
individual. This collaborative approach, catalyzed
by an increasingly consumer-driven marketplace,
is bringing policy and departmental changes. Physical spaces, too, are being redesigned to better
support the multifaceted needs of families. Comfortable waiting areas, designated family zones inside
the patient room, thoughtful amenities, and flexible
visiting hours encourage longer stays and ongoing
communication with the care team.
While family presence benefits patients, families, and providers, PFCC requires substantial
cultural and procedural change for ICU staff.
Organizational and consumer expectations of
timely, well-coordinated care are high, and transitioning to this new care environment can create
stress for staff. This is particularly cogent in the
ICU workplace where rates of nurse burnout are
high (France et al., 2008; Poncet et al., 2007).
While much of the conversation in healthcare
has focused on improving the patient and family
experience, less is known about the impact of this
new care environment and culture on frontline caregivers, particularly the bedside nurse who works in

81

close contact with families each day. Even less is

known about the impact of patient- and familycentered design on nursefamily interactions
within the adult critical care setting.

While much of the conversation in

healthcare has focused on improving
the patient and family experience,
less is known about the impact of this
new care environment and culture on
frontline caregivers
This exploratory study takes first steps in
understanding the context of caring for patients
and families in a high-acuity ICU from the perspective of the bedside nurse. Using a U.S. university teaching hospital as a case study, this article
explores how the design of the family-centered
ICU impacts the nurses ability to deliver PFCC
and the relationship between nurse and family,
including its potential to create workplace challenges for the nurse. Patterns of behavior derived
from observational research and conversations
with staff are examined in relation to the built
environment. Key recommendations and opportunities for future research are also presented.

Background
Literature Review
Family members of an adult patient in the ICU
have traditionally been restricted when visiting
their loved one during hospitalization. Concerns
for patient safety and staff privacy prevailed
despite growing awareness of the need for family presence in the care of patients. This began
to change in 1988 when The Picker Institute recommended the inclusion of patient and family in
care delivery (Ciufo, Hader, & Holly, 2011).
Since then, advocacy groups and professional
organizations continue to define the standards
of PFCC and set forth guidelines that encourage
family partnership (Conway et al., 2006; Davidson et al., 2007; Kohn, Corrigan, & Donaldson,
2001). These guidelines reflect a wealth of
research demonstrating the needs of family,
including proximity to loved ones, assurance of
good care, and honest, timely information (Lam

Rippin et al.

Introduction
Critical care stands at an important moment of
transition. The trend toward patient- and familycentered care (PFCC) is steadily transforming
attitudes and behaviors toward family members
with a loved one in the adult intensive care unit
(ICU). For many years, restrictions have been
placed on family presence in these highly charged
environments in an effort to protect the critical
patient and staff privacy. However, an emerging
body of evidence confirms what has long been
intuited: Families play a vital role in patient and
family healing, particularly during an acute medical crisis (Davidson et al., 2007). In response,
ICUs across the United States are increasingly
opening their doors to families (to varying
degrees), with policies and processes that recognize family as valuable partnersnot just visitorsin the care and recovery of their loved one.
While the traditional, clinician-centered approach to critical care has limited family involvement,
PFCC invites families to take a more active role.
The intent is to bring wholeness to the patient
through collaboration and personalized care that
respects the values, beliefs, and experiences of the
individual. This collaborative approach, catalyzed
by an increasingly consumer-driven marketplace,
is bringing policy and departmental changes. Physical spaces, too, are being redesigned to better
support the multifaceted needs of families. Comfortable waiting areas, designated family zones inside
the patient room, thoughtful amenities, and flexible
visiting hours encourage longer stays and ongoing
communication with the care team.
While family presence benefits patients, families, and providers, PFCC requires substantial
cultural and procedural change for ICU staff.
Organizational and consumer expectations of
timely, well-coordinated care are high, and transitioning to this new care environment can create
stress for staff. This is particularly cogent in the
ICU workplace where rates of nurse burnout are
high (France et al., 2008; Poncet et al., 2007).
While much of the conversation in healthcare
has focused on improving the patient and family
experience, less is known about the impact of this
new care environment and culture on frontline caregivers, particularly the bedside nurse who works in

81

close contact with families each day. Even less is

known about the impact of patient- and familycentered design on nursefamily interactions
within the adult critical care setting.

While much of the conversation in

healthcare has focused on improving
the patient and family experience,
less is known about the impact of this
new care environment and culture on
frontline caregivers
This exploratory study takes first steps in
understanding the context of caring for patients
and families in a high-acuity ICU from the perspective of the bedside nurse. Using a U.S. university teaching hospital as a case study, this article
explores how the design of the family-centered
ICU impacts the nurses ability to deliver PFCC
and the relationship between nurse and family,
including its potential to create workplace challenges for the nurse. Patterns of behavior derived
from observational research and conversations
with staff are examined in relation to the built
environment. Key recommendations and opportunities for future research are also presented.

Background
Literature Review
Family members of an adult patient in the ICU
have traditionally been restricted when visiting
their loved one during hospitalization. Concerns
for patient safety and staff privacy prevailed
despite growing awareness of the need for family presence in the care of patients. This began
to change in 1988 when The Picker Institute recommended the inclusion of patient and family in
care delivery (Ciufo, Hader, & Holly, 2011).
Since then, advocacy groups and professional
organizations continue to define the standards
of PFCC and set forth guidelines that encourage
family partnership (Conway et al., 2006; Davidson et al., 2007; Kohn, Corrigan, & Donaldson,
2001). These guidelines reflect a wealth of
research demonstrating the needs of family,
including proximity to loved ones, assurance of
good care, and honest, timely information (Lam

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Health Environments Research & Design Journal 9(1)

& Beaulieu, 2004; Leske, 1986; McAdam, Arai,

& Puntillo, 2008; Molter, 1978).

alerting staff to changes in patient condition

(Davidson, 2009).

PFCC in practice. The Institute for Patient- and

Family-Centered Care (IPFCC, 2010) defines
PFCC as an approach to the planning, delivery,
and evaluation of health care that is grounded in
mutually beneficial partnerships among health
care providers, patients and families. According
to the institute, PFCC is guided by four key concepts: Respect and dignity for individual knowledge, beliefs, and values that are incorporated
into the planning and delivery of care; timely,
complete, and accurate information sharing; participation in care and decision making at their
level of choice; and collaboration with patients
and families on the development, implementation, and evaluation of PFCC policies and programs (IPFCC, 2010). Inviting family presence
during episodes of care (e.g., cardiopulmonary
resuscitation [CPR], invasive procedures [IPs],
and physician rounding) and creating flexible visitation policies are several ways to translate
PFCC into practice (Davidson et al., 2007). More
recently, facility design has become a recognized
vehicle to support PFCC. A review of awardwinning ICU designs over the past two decades
shows increased acceptance of family as an integral part of the healing process (Cadenhead &
Anderson, 2009; Rashid, 2014).

Perceived concerns of PFCC. Despite its many benefits, family presence brings its share of concerns.
Much of the available literature focuses on family
presence (FP) during episodes of care (e.g., CPR)
rather than day-to-day family presence on the unit.
One common concern among staff is that family
can disrupt patient care (Egging et al., 2011). In
one study, nurses perceived family as taking focus
away from patient duties, which could result in
medication errors (Farrell, Joseph, & SchwartzBarcott, 2005). Other concerns include patient privacy, prolonged futile resuscitation, and litigation
(Pankop, Chang, Thorlton, & Spitzer, 2013).
According to the American Association of
Critical-Care Nurses (AACN, 2010) recommendations, however, there is little concrete evidence
that family presence negatively impacts safety or
interferes with patient care or staff performance.
In fact, a comparison of data between 2004 and
2010 shows that concerns about family interruptions during CPR/IP have decreased, with no
reports of litigation (Pankop et al., 2013). Moreover, when staff gains clinical confidence and
experience working alongside families, attitudes
appear to change (Mian, Warchal, Whitney, Fitzmaurice, & Tancredi, 2007; Robinson et al., 1998).
There is a robust body of literature and wellfounded concern, however, for the psychological
health of families. Davidson, Daly, Agan, Brady,
and Higgins (2010) report that up to 80% of family members may experience long-lasting anxiety, depression, and symptoms of post-traumatic
stress disorder (PTSD) following a stay in the
ICUa condition known as post-intensive care
syndrome-family. Exposure to an unfamiliar,
frightening environment, coupled with pressures
to make life and death decisions on behalf of
loved ones, can significantly heighten stress
(Azoulay et al., 2001; Engstrom, Uusitalo, &
Engstrom, 2011). Consequently, nurses may be
reluctant to include family in potentially disturbing events such as CRP (Robinson et al., 1998),
although recent studies suggest nurses have more
favorable views of FP than other health professionals (Duran et al., 2007; Meyers et al., 2000).
In a prospective, cluster-randomized control trial,

Perceived benefits of PFCC. Studies highlight many

advantages of family presence and involvement
in the care of critical patients. Family can help
calm an agitated or disoriented patient, increase
a patients sense of safety and comfort, and assist
in decision making when a loved one is unable to
speak (Hupcey, 1999). Families receive therapeutic benefits from their participation as well
(Hammond, 1995). Presence during CPR or IP
can help a family grasp the seriousness of the
patients condition (Duran, Oman, Abel, Koziel,
& Szymanski, 2007; Tawil et al., 2014), reassure
them that everything was done for their loved one
(Meyers et al., 2000), and help facilitate the grief
process (Robinson, Mackenzie-Ross, Hewson,
Egleston, & Prevost, 1998). Family members can
also provide personalized information to guide
the plan of care and reduce medical errors by

Rippin et al.

Jabre et al. (2013) report a significantly lower

incidence of PTSD-related symptoms in family
members given the option to observe CPR.
PFCC from the nurse perspective. Despite its benefits, PFCC can introduce challenges in the delivery of care. The Nursing Stress Scale was one of
the first measures to acknowledge that nurses
may feel unprepared to meet the emotional needs
of patients and families within a demanding ICU
environment (Gray-Toft & Anderson, 1981).
Numerous studies since have shed light on the
challenges of balancing the needs of critical
patients and loved ones (Cassem & Hackett,
1972; Corr, 1999; Farrell et al., 2005; Stayt,
2009; Yetman, 2009). When caring for two critical patients, the bedside nurse must make difficult
choices between attending to a familys needs,
while another critical patient needs attention in
the next room (Hupcey, 1999). Patient and family
needs can also compete. For example, a patient
may need to rest, while the family seeks reassurance by the bedside (Yetman, 2009). When
communicating with family, striking a balance
between transparency and sensitivity is a widely
reported challenge (Stayt, 2009; Vreeland &
Ellis, 1969). Even the way in which a provider
delivers news can be more important to the recipient than the news itself (Haskard, DiMatteo,
& Heritage, 2009; Jurkovich, Pierce, Pananen,
& Rivara, 2000). Managing family visitation
poses an additional layer of workplace complexity. In an open-access ICU, the nurse must continuously evaluate the condition of the patient,
the needs of the family, and his or her own workload while integrating flexible visitation into
gard & Lomborg,
daily treatment and care (A
2011). An inconsistent enforcement of such policies can lead to tensions among nurses and with
family (Livesay, Gilliam, Mokracek, Sebastian,
& Hickey, 2005).
PFCC and design. Healthcare organizations are
increasingly recognizing the value of design in
supporting PFCC goals and practices. Private
consult areas, dedicated space for family in the
patient room, kitchen and laundry areas, and so
on, are a few of the recommended ways to help
meet a familys needs in the ICU (Thompson

83

et al., 2012). This trend in family-centered design

comes as part of a broader movement of basing
design decisions on the latest credible evidence,
or evidence-based design (EBD). Facility design
has been shown to play an important role in healing for patients, families, and staff by reducing
infections and medical errors, decreasing stress,
and improving privacy, among other positive outcomes (Zimring et al., 2008).
An emerging body of literature suggests that
the built environment can increase family presence and satisfaction, involvement with care,
and other desired outcomes of PFCC (Choi &
Bosch, 2012; Jongerden et al., 2013; Olausson,
sterberg, 2014; Zimring et al.,
Ekebergh, & O
2008). One study reported an increase in family
satisfaction and perceptions that nurses were
more supportive, compassionate, and courteous
after a series of changes were made in the ICU
(e.g., single-bed rooms and more space around
the bedside; Jongerden et al., 2013). One author
suggests design may encourage more familycentered staff behaviors (Hartog & Jensen,
2013). Private consult areas (e.g., patient room)
may increase the quality, frequency, and dura stedt-Kurki, Paavilainen,
tion of interactions (A
Tammentie, & Paunonen-Ilmonen, 2001). In a
recent study by Choi and Bosch (2012), family
presence at the bedside increased in rooms that
provided a family zone with comfortable seating
for several members. Conversely, nurse reports
suggest that design can also hamper PFCC. In one
study, nurses discouraged family from staying overnight when the room was considered uncomfortable
(Farrell et al., 2005). Another study found that
small ICU rooms limit family presence during
rounds (Santiago, Lazar, Jiang, & Burns, 2014).

An emerging body of literature suggests

that the built environment can increase
family presence and satisfaction,
involvement with care, and other
desired outcomes of PFCC
Communication is a key driver for safe and
effective healthcare delivery (Hua, Becker, Wurmser, Bliss-Holtz, & Hedges, 2011). Unplanned
encounters are especially important for realizing
workplace and patient safety (van Marrewijk &

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Health Environments Research & Design Journal 9(1)

Yanow, 2010, p. 45) and managing the complexity

of patient care. Corridors, for example, can support
ad hoc teaching moments and information sharing
among staff. A growing body of literature in office
and healthcare settings demonstrates an important
link between design and communication (Rashid
& Zimring, 2005; Zimring et al., 2008). However,
the relationship between design and nursefamily
interactions in the adult ICU is less well understood. This article aims to address this gap in the
literature by exploring how space influences patterns of behavior and communication between
nurse and family in a unit specifically designed
with family needs in mind.

Research Setting
Two neuroscience ICUs at a leading U.S. university teaching hospital served as the research settings for this study. In the neuro ICU, patients
have suffered a traumatic brain injury or illness
and often require life-sustaining intervention.
Mortality is high (1:5), which means family presence is important to coordinate care and make
difficult end-of-life decisions. In 2007, one of
the two units underwent renovations that incorporated EBD and principles of PFCC with the
intent to increase family involvement and improve
outcomes. This study was completed as a postoccupancy evaluation 3 years after opening the
new unit. Data were collected from both the renovated 20-bed patient- and family-centered unit
(FCU) and the older 7-bed clinician-centered unit
(CCU). The setting posed a unique opportunity
to compare two ICUs that share many of the same
workplace characteristics yet differ significantly in
terms of layout. Both units are located on the same
floor of the hospital and share the same patient
population and staff. Nurses work in one unit per
shift but may alternate units during the week. The
units also share the same patient- and familycentered culture and policies, which were enacted
at the same time the FCU opened. Visiting hours
are 24/7, and family members are invited to stay
overnight and be present during shift changes.
While both units support PFCC, their layouts
reflect the dramatic shift toward family involvement in the ICU. In the smaller CCUthe
control group of this studystaff work in a

Figure 1. Clinician-centered unit (CCU), floor plan.

Reprinted with permission from WHR Architects.

centralized station, while families are situated

in waiting areas connected by a semiprivate corridor around the periphery (Figures 1 and 2).
Separate entrances and hallways keep staff and
family flow separate and limit most interactions
to the patient room. Small rooms (180 sq ft) and
reduced visibility to the nursing station from the
family hallway further inhibit family presence
and communication with the care team.
In contrast, the FCU physically integrates family into the fabric of the unit (Figures 3 and 4).
Nurses work between centralized nursing stations
and decentralized alcoves just outside patient
rooms for improved monitoring and safety. Rooms
are larger (245 sq ft) with more space around the
bedside. In addition, a private studio adjacent to
the patient room allows family to gather during the
day and stay overnight within footsteps of staff and
loved one. Staff and visitors have separate
entrances but share the same interior hallway,
which means family members walk past clinical
workstations to access the patient room and studio.
There is also a main waiting area just outside the
clinical entry with a family coordinator and a range
of amenities (e.g., kitchen and shower) to support
long-term and out-of-town visitors.

Study Rationale
Three years after the unit reopened, nurses
reported high levels of workplace stress. An
in-house survey found that 42% of registered

Rippin et al.

85

Figure 2. Images of clinician-centered unit (CCU). (a) Clinician hallway with centralized nursing station.
(b) Semiprivate family hallway, facing patient room. Reprinted with permission from WHR Architects.

Figure 3. Patient- and family-centered unit (FCU), floor plan. Reprinted with permission from Blake Marvin and
HKS, Inc.

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Health Environments Research & Design Journal 9(1)

Figure 4. Images of family-centered unit (FCU). (a) Shared hallway with central nursing station (left), nurse
alcove (center), and patient rooms to the left and right of alcove. (4b) Private family studio, facing patient room.
Reprinted with permission from Blake Marvin and HKS, Inc.

nurses (RNs) rated interactions with an upset/

challenging family as the leading cause of emotional distressabove death of a patient

(22%). This striking finding prompted an immediate concern: Was increased family presence and
involvementfacilitated by the new design

Rippin et al.

contributing to nurse stress? The following exploratory questions formed the basis for this study:
 What defines a challenging family from
the nurse perspective? More broadly, what
are the challenges of PFCC?
 What role does the built environment play
in these (real and perceived) challenges?
 How does patient- and family-centered
design impact the quality of nursefamily
interactions?

Method
Structured observations and on-site discussions
with nursing staff were conducted in the CCU and
FCU over a 2-month period.

Structured Observations
Two methods of data collection were used. First,
a series of structured observations were conducted using behavior mapping as the primary
tool. Behavior mapping is a quantitative technique that relates behavior to the space in which
it is observed (Proshansky, Ittelson, & Rivlin,
1970). Behaviors are recorded directly onto a
floor plan using a defined set of criteria and are
collected over a specified period of time (Figure 5).
In this study, nurse and family behaviors were
observed at both a global and local level.
First, systematic walk-throughs of the entire unit
offered a global, birds-eye perspective of nurse
and family presence along with the frequency and
location of interactions. Each unit was observed
for 4 days in one given week (Wednesday/Friday/Saturday/Sunday). One walk-through (or
set) was recorded every 15 min in 2-hr time
intervals for approximately 6 hours each day
(911 a.m., 13 p.m., and 68 p.m.). To protect
family privacy, interactions in the family studio
were recorded only when observable from the
hallway. Time, frequency, and duration of observations were selected to (1) allow global and
local observations to be conducted in tandem
due to time constraints and (2) maximize opportunities to observe interactions (e.g., day shift,
shift change, etc.). Upon completion of the
walk-throughs, individual maps were aggregated

87

into a digital file to create a snapshot of activity. Snapshots of the two units were then compared to see how layouts generated different
patterns of behavior.
Second, nurses were shadowed locally in and
around workstations to capture interactions at a
more granular level. Frequency, location, and
content of interactions, as well as instances of
copresence, were recorded over a 4-day period
(see above). In this study, interaction is
defined as a one- or two-way verbal communication initiated by a nurse or family member.
Copresence is defined as the potential for
interaction when nurse and family are colocated
in the patient room. The observation period was
bound by (1) whether or not the nurse made a
trip into the patient room and/or (2) whether
an interaction was observed. Nurses were typically assigned to care for two patients (i.e., two
room pairs) at a time. Nurses were shadowed
after visual identification and/or nurse confirmation that at least one family member was
present on the unit (e.g., in the room, hallway,
and bathroom). In the event of no interactions,
observations were limited to a 10-min cap to
ensure all room pairs were observed at least
once. Room pairs were drawn at random. Once
all rooms meeting family presence criteria were
observed, the cycle repeated.

Nurse Discussions
In addition to behavior mapping, informal discussions were held with frontline staff to gain
richer insight into the day-to-day life of the ICU
and attitudes toward PFCC. Twelve RNs and
six additional care team members (one chaplain, one nurse practitioner, two doctors, and
two family coordinators) were approached at
individual workstations and asked for feedback
and opinions about their experiences working in
a FCU. Conversations lasted between 20 min
and 1 hour each. Unstructured questioning
allowed participants to lead the discussion and
show the researcher what was most important
to them. The majority of conversations were not
recorded, with most participants preferring to
speak off the record. Their identity was protected throughout the study. Field notes

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Health Environments Research & Design Journal 9(1)

Figure 5. Sample behavior maps, structured observations, CCU (global and local).

containing key words, scenarios, and quotes

were manually coded and categorized by theme
as patterns emerged from the data.

Results
Structured Observations
In the seven-bed CCU, 65 global walk-throughs
(or sets) were recorded, yielding nine interactions and 12 counts of copresence (Figure 6;
Table 1). All interactions took place in the
patient room. No family members or nursefamily interactions were observed in the clinician
hallway. A high frequency of interactions and
copresence in the CCU suggests that the patient
room is the primary locus for family to interact
with staff and be near their loved one. Thus,
family may feel the need to be present in the
room for longer periods of time. In the 20-bed
FCU, 82 global walk-throughs were recorded,
yielding 47 interactions and 19 counts of copresence (Figure 7; Table 1). Most interactions
took place in the patient room (n 35), with

Figure 6. Frequency and location of nursefamily

interactions and copresence in CCU, behavior map
(global).

12 additional interactions in various locations.

In contrast to the CCU, fewer instances of copresence suggest that the availability of proximal
spaces to wait or communicate with staff may
reduce the need to stay by the bedside.

Rippin et al.

89

Table 1. Frequency and Location of NurseFamily

Interactions and Copresence in Clinician-Centered
Unit (CCU) and Patient- and Family-Centered Unit
(FCU; Global).
Location
CCU
Nurse hallway
Nursing station
Patient room
Family hallway
Waiting room
Total
FCU
Alcove
Hallway
Patient room
Nursing station
Family studio
Total

Interactions

Copresence

0
0
9
0
0
9

0
0
12
0
0
12

6
3
35
1
2
47

0
0
19
0
0
19

While layout appeared to change interaction

behaviors, it did not make a difference in the
overall global distribution pattern. Nurse and
family tended to cluster in their respective
domains in both units. In other words, nurses
were located most often in workspaces, while
family members were located primarily in dedicated family domains. Family members were
located in the patient room more often than
nurses. In this study, domain is defined as a
spatial area intended to support activities specific
to nurse or family. For example, a waiting room is
a family domain, a nursing station is a nurse
domain, and the patient room is a shared domain.
In addition, family presence varied from room to
room regardless of layout, thus suggesting an
unpredictable caseload for the nurse.
Local observations revealed notable patterns
as well. In the CCU, 27 shadowing periods (trips)
yielded 24 total interactions and one instance of

Figure 7. Frequency and location of nursefamily interactions and copresence in FCU, behavior map (global).

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Health Environments Research & Design Journal 9(1)

Table 2. Comparison of Interaction Frequency, Location, and Who Initiated Interactions Where in ClinicianCentered Unit (CCU) and Patient- and Family-Centered Unit (FCU; Local).
Location
CCU
Nurse hallway (nurse domain)
Patient room (shared domain)
Family Hallway (family domain)
Total
FCU
Nurse alcove (nurse domain)
Patient room (shared domain)
Family studio (family domain)
Total

Interaction Frequency

Nurse Initiated

Family Initiated

5
17
2
24

1
13
2
16

4
4
0
8

16
14
2
32

4
7
2
13

12
7
0
19

copresence (Table 2). Nurses made three trips

without family in the room, thus no interactions.
Of the 24 interactions, most took place in the
patient room (n 17), with a few in the clinician
hallway. Nurses initiated more than half of the
total interactions, and most of these took place in
the patient room. Family initiated most hallway
encounters in the CCU to which nurses responded
with an immediate trip into the patient room
(Table 3). This suggests that in a restricted unit
family may delay communication with staff until
a matter is urgent or staff seek to enforce the rules
of the unit. For local observations in the FCU, 43
total trips yielded 32 interactions and six instances
of copresence (Table 2). There were four trips
without family in the room, thus no interaction.
Of these 32 interactions, slightly more took place
in alcoves (n 16) than in patient rooms (n
14). Overall, family initiated contact more often
than nurses, and mostly in alcoves. When family
initiated contact in alcoves, nurses stayed seated
about half the time rather than make an immediate
trip into the patient room (Table 3). When nurses
initiated contact in alcoves, they always stayed
seated. This behavior suggests that some interactions do not require immediate action and may
be perceived as less urgent in nature.
During local observations, topics of conversation were also recorded (Table 4). Interactions
in the clinical hallway in the CCU were directly
related to patient care or redirecting family
flow. In the FCU, topics in alcoves ranged from
discussions around patient care to informal
social exchanges (e.g., family making requests

Table 3. Nurse Response Immediately Following

Interaction in Clinician-Centered Unit (CCU) and
Patient- and Family-Centered Unit (FCU) Workspace
(Local).
Frequency of nurse trips and CCU/Nursing FCU/
who initiated interactions
Station
Alcove
Trip into room
Family initiated
Nurse initiated
No trip into room
Family initiated
Nurse initiated

5
4
1
0
0
0

4
4
0
10
6
4

on behalf of the patient, nurse inquiring about

family, etc.). Conversations in patient rooms
were diverse and included discussions about the
plan of care, family education, formal introductions, and mutually supportive gestures (e.g.,
nurse offering emotional support to family, family praising nurse for good work, etc.).
While nurse and family body language was
not formally assessed, a few observations are
worth noting. In the CCU, some family members
appeared tentative when approaching the nurse
in the central work area. Several were observed
gesturing to their nurse from the patient room
doorway rather than crossing the threshold into
the hall. When family did enter the hallway, they
appeared to do so without knowing the rules
and were quickly directed by staff back to the
room or visitors entrance. In contrast, families
appeared to approach nurses with greater ease
and familiarity in the FCU. Some paused at the

Rippin et al.

91

Table 4. Content of NurseFamily Interactions by Location (Local).

Clinician-Centered Unit (CCU)
Location
Content type
Patient advocacy (PA)
Patient care (PC)
Staff introduction (SI)
Verbal support for nurse (NS)
Plan of care (PC)
Family education (EDU)
Social interaction (SO)
Verbal support for family (FS)
Notification (NT)
Request for doctor (MD)

Nurse Hallway

Patient Room

Family Hallway

Total

1
2
2

1
7
4
3
5
9
5
4

2
10
6
3
6
9
5
5

Patient- and Family-Centered Unit (FCU)

Location
Content type
Patient advocacy (PA)
Patient care (PC)
Staff introduction (SI)
Verbal support for nurse (NS)
Plan of care (PC)
Family education (EDU)
Social interaction (SO)
Verbal support for family (FS)
Notification (NT)
Request for doctor (MD)

Alcove

Patient Room

Family Studio

Total

7
1

2
1
2
1

2
10
2
2
4
4

9
13
2
2
6
4
2
3
2
1

alcove before entering the patient room or leaving the unit, and others engaged in longer conversations. This is explained, in part, by the location
of alcoves in the shared hall and just outside the
patient rooma necessary route for visitors. In
some cases, nurses appeared receptive, turning
their faces and bodies toward approaching family
and, at times, initiating contact. Other times they
appeared to delay or avoid interaction. For example, one nurse kept her body facing the computer
while a family member stood by, only turning her
head when spoken to.

Nurse Discussions
In addition to structured observations, conversations were held with nursing staff to gain
insight into their experiences working in a

PFCC unit. While many participants described

family care as an important and satisfying
aspect of their work, discussions tended to
focus on challenges faced. Nurses described a
range of challenging family behaviors (e.g.,
disruptive, passive aggressive, and confrontational) that could flare during certain times
(e.g., soon after admission) and potentially
impede the teams work. Religious differences
and moral and ethical disagreements over the
plan of care could also raise tensions. However, challenging family behaviors were considered the minority of cases and were not
ascribed to a specific unit. As conversations
progressed, a more nuanced portrait of the
complexities of balancing patient and family
care in a high-acuity clinical setting emerged.
The following three major themes were

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identified: (1) The ICU is unpredictable, so are

families; (2) Patient and family care is complex
and, at times, paradoxical; and (3) Patient- and
family-centered design creates a paradoxical
nursefamily dynamic.
The ICU is unpredictable, so are families. Participants described the neuro ICU as a volatile
workplace where patient condition can change
at any moment and caseloads vary each day.
Treatments, procedures, and communications
with colleagues are often unplanned, which
means much of a nurses work is conducted
on the fly. Nurses reported that family presence and interactions are also ad hoc. Families
rarely arrive as a group, which makes it difficult
to predict who, when, and how many family
members will be present. The definition of family included pastors, friends, neighbors, and so
on, which means identifying the best family
spokesperson can be a challenge. In addition,
each member brings a different personality, set
of coping skills, and expectation of care (Every
family is different.), further increasing the unpredictable nature of encounters.
Patient and family care is complex and, at times,
paradoxical. Overall, participants painted a complex picture of caregiving in the ICU where the
needs of patients and families can conflict and
compete. While families were often seen as a
valuable presence (e.g., a source of comfort for
the patient and an extra pair of eyes and ears
for staff), the majority of participants worried that
family could, at times, impede their ability to care
for the patient. Troubleshooting family queries,
for example, consumed time and resources that
could result in missed tests, delayed treatments,
and falling behind on work. Nurses described
wearing many hats (e.g., therapist, educator, confidante, even a spiritual, and financial advisor) to
support a family in crisis. Consequently, some
felt torn between their dual roles (The patient
is the focus . . . family takes away your focus
from what you have to do, but you dont want
to dismiss them.).
Another reported challenge was simultaneously caring for two critical patients and their
respective families. Oftentimes, this meant

Health Environments Research & Design Journal 9(1)

having to prioritize one critical patient over

another at the risk of upsetting the other
patients family (who see their loved one as the
priority). Some nurses experienced increased
stress when answering a familys question while
an unstable patient needed attention in the next
room. Sharing information also required a delicate balancing act, where family might misinterpret a nurses tone or manner in the urgency to
attend to the next patient.
Several nurses described PFCC as good in
theory yet questioned the degree of appropriateness in the neuro ICU. While most believed
hands-on family involvement was best for
intact (e.g., conscious) patients, unstable, neurologically impaired patients were seen as needing additional safeguarding, even from a
familys good intentions. This included prohibiting or supervising feeding, limiting physical
touch (which in some cases, was believed to
increase intracranial pressure), and terminating
conversations viewed as tiring or stressful for the
patient. Conversely, nurses also expressed concern for the well-being of family after prolonged
stays. In some cases, distressed or overwhelmed
family members were encouraged to take time
away from the unit.
Patient- and family-centered design creates a
paradoxical nursefamily dynamic. When asked
about the design of the two ICUs, most participants agreed the CCU hampered their ability
to deliver family-centered care. Participants
reported greater difficulty locating family, sharing information, and gaining consent quickly. In
addition, the CCU waiting areas were seen as
uncomfortable and discouraging visitor stays.
However, the unit was perceived as more conducive to teamwork due to its small size and
central nursing station. In contrast, the FCU was
viewed as more conducive to the delivery of
PFCC. Greater proximity and visibility meant
family could see everything being done for their
loved one. It also helped staff gain consent and
consensus more quickly.
The design of the FCU brought advantages,
but also trade-offs, for nurses. On one hand, the
family studio allowed nurses to work at the bedside, while family had their own space nearby.

Rippin et al.

On the other hand, continuous family presence

meant that interactions were often peppered
throughout the day rather than all at once.
While this pattern of frequent communication
increased opportunities for education and relationship building, it could also lead to repetitious
questioning and/or interruptions that could fatigue
the nurse. This paradoxical dynamiccreated
by spatial conditions of co-visibility and colocationwas also reported in alcoves. Seeing
nurses at work built familiarity and trust but
also led to misperceptions (Family see me on
the computer and think Im on the Internet surfing, but Im charting.). Some nurses cited frequent approaches by family in alcoves, which
added to a perceived loss of workspace privacy
and breathing room to reflect. (The only
time I have alone is in the bathroom stall.)
A staff break room was available on the unit,
yet some perceived it as too far from patients
requiring vigilant monitoring.
To reassert workspace boundaries, nurses used
verbal and nonverbal strategies, such as avoiding
eye contact with an approaching family member,
diverting to another area of the unit, and putting families to work at the bedside. Managing
information was another tactic used to modify
family behaviors and interactions. This included
adjusting equipment parameters to reduce the frequency of alarms to minimize family hypervigilance by the bedside. Nurses also reported using
eye contact and verbal instruction to keep families moving in the shared hallway to protect
patient privacy.
The complex nature of PFCC was further
underscored by the need for organizational
resources to support staff in meeting the needs
of patients and families (as well as their own).
Several RNs expressed a desire for greater departmental structure to help navigate potentially challenging family interactions and scenarios. This
included regimented protocols and team-based
strategies, nurse education and training (e.g.,
communication skills, role playing, etc.), and
education for families (e.g., clear behavioral
codes and guidelines, family contracts, etc.). Others expressed a need for greater clarity about the
definition of PFCC and the extent of their roles
and responsibilities.

93

Conclusions
Together, these results suggest that the built environment has the potential to help or hinder the
nurses ability to deliver PFCC. Nurses perceived
the FCU as more conducive to the delivery of
PFCC. Moreover, behavioral changes in the frequency, location, and content of interactions that
were observed in this study supported this perception. In the traditional unit (CCU), architectural
boundaries emphasize separation rather than integration. As such, interactions were largely confined
to the patient room, while family appeared more
cautious when initiating contact inside the clinician
hallway. Nurses also tended to get up from their
seats to enforce workspace boundaries. In contrast,
greater co-visibility and colocation in the new unit
created new spatial and temporal opportunities
for family to interact with staff. As staff and family
mixed and intermingled in the shared hallway, clinical workspaces became public domain. Importantly, alcoves emerged as a key locus of
interaction beyond their intended use as a charting
and patient monitoring station. More than half of
interactions took place in alcoves, most of which
were initiated by family membersa notable finding in a unit designed to empower families and
increase their participation. Observed communication behaviors around alcoves point to an overall
finding that the new unit relaxed physical boundaries, body language, and communication styles.
Nurses tended to stay seated when approached and
informal social exchanges were observed.

. . . greater co-visibility and colocation in

the new unit created new spatial and
temporal opportunities for family
to interact with staff.
Design appears to facilitate some of the
important communications that define PFCC.
However, this study raises an important question: Is PFCC easier to deliver in theory than
in practice? Caring for patients and their loved
ones in a high-stakes ICU is complex and paradoxical work. Over several decades, nurses have
reported numerous benefitsbut also inherent
challengeswhen caring for the needs of many
in an ever-shifting clinical and social landscape.

94

Health Environments Research & Design Journal 9(1)

Discussions with staff reinforce existing research

that suggests the complexities and contradictions
of caring for critical patients and their loved ones
are part and parcel of PFCC, regardless of unit
layout. However, the findings presented in this
research add new insights into the role of the
built environment. Increased exposure to the
unplanned, unpredictable nature of family interactions (and families themselves) that is facilitated,
in part, by design may add to this complexity.
On one hand, the dissolving of physical and temporal boundaries around workstations in the FCU
may create opportunities for information sharing,
patient advocacy, and social rapport. Conversely,
increased visibility and proximity between nurse
and family may also lead to interruptions, misperceptions about nurse activities, and loss of workspace privacy. Findings suggest these encounters
may not always be timely for the nurse. This study
proposes that nurse stress increases in this new
care setting without adequate spatial and organizational support measures in place.

Over several decades, nurses have

reported numerous benefitsbut also
inherent challengeswhen caring for
the needs of many in an ever-shifting
clinical and social landscape.
Hospitals are increasingly opening their doors,
expanding visitation policies, and carving out
spaces that invite family presence and participation in the ICU. PFCC seeks to enhance communication and collaboration between families and
care providers. This study is one of the first to
examine nursefamily interactions within its spatial and cultural context. Special attention to the
physical setting and how it connects to nurse perceptions and stakeholder behaviors has been integral to the research. In order to fully assess the
impact and effectiveness of PFCC in critical care
in the future, connecting these dots is essential.
The findings presented here capture a unit in transition but also an industry. Designing for family
participation and mutually beneficial partnerships
in the adult ICU continues to be an evolving practice. Adapting to this new environment can be a
challenge for staff. Design is a powerful organizational resource that can aid or inhibit the

success and sustainability of PFCC. In the end,

PFCC is neither good nor bad but complex.
Design interventions must be considered within
this broader context, including the day-to-day
realities of the critical care nurse working in close
contact with family. As hospitals continue to
redefine policies and spaces within the adult ICU,
a holistic view is needed more than ever.

Recommendations
It is critical that architects and healthcare professionals work together to design PFCC ICUs that
support the functions and needs of nurses, while
remaining hospitable to families. Achieving this
balance requires consideration of both architectural and organizational factors that support this
complex ecosystem. From a design perspective,
nurses need spaces that allow them to be at times
separate from, yet still connected to, family.
This means redefining backstage as a means
to support both connectivity and privacy, with
an ability to flex between the two. The staff
break room offers backstage retreat, albeit with
reduced proximity to patient and family. Thus,
a variety of backstage spaces are recommended
to act as both a tether to and a pressure valve
from work demands, family purview, and so
on. For instance, the family studio in the FCU
created this opportunity for breathing room
while allowing the nurse to remain accessible
to family. While separating staff and family flow
is a common approach in ICU design, this study
suggests that alcoves set within a shared hallway
create opportunities for social rapport. Separate
circulations could potentially eliminate these
vital microclimates. Alternatively, a partial wall
around the alcove could invite family engagement while still giving privacy to the nurse.
While design plays an important role in facilitating PFCC, a well-designed unit alone does
not guarantee staff will transition smoothly to
the new environment or fully integrate family
as active participantseven when the benefits
are widely acknowledged. Rather, space must
be supported by organizational culture. Conversations with staff highlight the importance of
building shared understanding about the extent
of their roles, responsibilities, and expectations

Rippin et al.

in relation to familyin addition to design strategies. This includes clearly defining PFCC in
the context of the organization. Building consensus also involves empowering staff with
tools and training to prepare them for a variety
of circumstances that will undoubtedly arise
when working with families under duress. Role
playing, scripting, team-based strategies, and
other structured approaches to managing challenging caseswhile providing an outlet for
staff to share issues in a safe, respectful environmentare some examples. Connecting their
work with positive outcomes, in terms of family
feedback and research illustrating the benefits
of PFCC (e.g., lower rates of litigation, etc.),
can also help overcome concerns and bolster a
sense of mission. In sum, design and culture
must work hand-in-hand to encourage familycentered behaviors in an environment that supports patients and families and the nurses who
care for them.

While design plays an important role in

facilitating PFCC, a well-designed unit
alone does not guarantee staff will
transition smoothly to the new
environment or fully integrate family as
active participantseven when the
benefits are widely acknowledged.

Limitations and Future Research

The purpose of this exploratory study is to present
preliminary findings on the important dynamic
between design, communication, and the delivery
of PFCC; to identify potential areas for further
research; and to stimulate discussion within the
design community. There are, however, methodological limitations. Nurses reported frequent
interactions with family; however, the observed
frequency of interactions was low. This discrepancy between actual and perceived frequency
can be attributed to several factors. Reported
observations represent a snapshot in time. While
this methodology captures a global perspective
on a complex system with many activities occurring simultaneously, it is less likely to account for
all interactions over a span of time. In addition,

95

family members in the neuro ICU often stay for

weeks or months, leading to lower turnover rates
than in other types of ICUs. It is unclear how family behaviors change depending on length of stay.
Additional research is needed to evaluate how
nursefamily interactions change across a range
of ICUs with various lengths of stay. Future
directions include exploration of nurse perceptions of patient flow, factors that shape feelings
and perceptions, and ways to address them. This
includes a more formal interview process via
one-on-one interviews and/or focus groups to
elicit feedback.
While the results of this research are based
on a study of one organization, many of the
findings are generalizable to other hospitals
engaged in PFCC as well as to other ICU populations. This is supported, in part, by strong
similarities between this and previous studies
illustrating the complex nature of PFCC. However, nurses raise an important question about
the degree of appropriateness of PFCC for neurologically impaired patients. While the need
for family involvement is especially high in the
neuro ICU, there may be special considerations
that impact the way care is delivered and family
is engaged. Future study should take a reciprocal and complementary look at the patient and
family perspectives in a unit designed specifically for them. As the movement toward PFCC
in critical care continues, additional research by
multidisciplinary teams is needed to ensure this
new care model is adapted seamlessly and
effectively.

Implications for Practice

 A combination of patient- and familycentered design strategies (i.e., a dedicated
family studio, shared hallway, and decentralized alcoves)along with an open visitation policymay increase spatial and
temporal opportunities for nursefamily
interactions.
 The built environment holds the potential
to help or hinder the delivery of PFCC and
nursefamily communication. However,
design and organizational culture must

96

Health Environments Research & Design Journal 9(1)

work hand-in-hand to create a model of

care and clinical environment that is both
sustainable for the nurse and hospitable
to families.
 PFCC is a complex approach to care delivery that requires careful consideration of
the needs and challenges of all stakeholders, including the bedside nurse.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of
interest with respect to the research, authorship,
and/or publication of this article.
Funding
The author(s) received no financial support for
the research, authorship, and/or publication of
this article.
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