Evolution of the ER: a visual mixed-methods examination of nurses’ perspectives on evolving physical space in a hospital Emergency Department

Purpose: : The physical structure of emergency departments may impact quality and efficiency of health care and may contribute to patient safety and satisfaction. The physical space of emergency departments have changed significantly over recent years in both form and function, yet relatively few studies have examined nurses’ perspectives on the impact of physical changes.
Following a significant physical renovation and expansion of a midsize hospital and regional trauma center Emergency Department in 2019, this study aimed to examine nurses’ perspectives on the impact of changes in the physical space on patient safety, quality of care, and work efficiency.

Design: : The project was conducted using a mixed methods approach consisting of a novel questionnaire and semi-structured interviews using photo and video visual aids.

Setting:: A mid-size regional medical and trauma center.

Sample:: A convenience sample of 55 Emergency Department nurses.

Methods: : The project was conducted using a mixed methods approach consisting of the following components:
1. Semi-structured interviews utilizing visual photo aids depicting physical changes to the ED space over time.
2. Structured questionnaire: The questionnaire was developed based on the literature, and included 5 demographic questions and 14 questions examining impact of the renovation on work habits and environment using a 5-point Likert scale. Reliability testing showed Cronbach's alpha of .866 for the instrument.

Results: : Forty-five nurses from the ED responded to the questionnaire (mean age 37.5, mean ED seniority 8.5 years). Ten experienced nurses were interviewed (mean age 43.7, mean seniority 16.7 years). The questionnaire indicated that nurses perceived that the new triage room and updated triage procedure improved their ability to identify patients' medical condition (mean 4.31, SD .85) and improved work-flow efficiency (mean 4.53, SD .69). Likewise, nurses reported that the integration of a new ambulatory wing into the main ED improved work collaboration (mean 4.07, SD .99) and efficiency (mean 4.2, SD .76). Nurses reported that the new physical structure contributed to the safety and comfort of the patient (average: 3.53, SD= .84), and improved quality of care (average: 3.89, SD= .84).
From the semi-structured interviews, three main themes were identified: (1) improved ability to identify and fulfill patients' medical needs (especially regarding the triage process), (2) improved patient safety (particularly fall-risk and changes in patient condition), (3) impact on work efficiency and communication between ED staff (both positive and negative effects).

Implications:: The ED is a continuously developing entity, changing in real-time along with changing populations, patient acuity, demand and other internal and external factors. While ED work-flow and capacity changes frequently, physical changes/renovations to the space are infrequent. Changes in the physical structure can impact efficiency in work procedures, patient safety, quality of care and cooperation between staff. However, it is important to consult and involve care teams in the design and implementation of renovations. Use of photos and video as visual aids for interviews in addition to a quantitative questionnaire was effective and is recommended for future projects/studies.