nachri_2009_positive distraction study

Healthcare

Positive Distractions

Engineering the Waiting Experience of Pediatric Patients

Presenters

2009 NACHRI F iliti D i2009 NACHRI Facilities Design Conference, Austin, TX

Debajyoti Pati, PhD, FIIA, HKS Architects

Jeff Stouffer, FAIA, HKS Architects

The Ongoing Debate

In a time of rising health… In a time of rising health costs, it doesn’t make a ton of sense for facilities to be spending lavishly on perks.

Jacob Goldstein, in Behind Hospitals’ Pretty Facades, Dingy Rooms for Patients, Wall Street Journal, August 20, 2008

Question

What role do hospital waiting areas play?

Learning Objectives

Understand the influence of positive distractions on pediatric patients while waitingUnderstand the role of positive distractions in the parents’ waiting experienceDistinguish the difference between uni-gsensory and multi-sensory distractions

Agenda

Waiting ExperiencePositive DistractionsPositive DistractionsStudy ObjectivesStudy ProcedureChildren’s Data AnalysisyParent’s Data AnalysisImplicationsImplications

Acknowledgments

Children’s Medical Center Dallas

American Art Resources

Mohawk

Catherine Mayer Fine Art

Henry Domke Fine Art

Acknowledgments

Co-InvestigatorsDr Upali Nanda, American Art Resources

Laurie Waggener, WHR Architectsgg ,

Agenda


Waiting Experience

The Cornell University Studyy y

Location: Weill Cornell Medical College, New York

Six clinical outpatient servicesSix clinical outpatient services

Key findings:Physical environment attractiveness correlated with perceived care quality and anxietyanxiety

Physical environment attractiveness correlated with perceived waiting timeperceived waiting time

Agenda


Positive Distractions

Outcomes during procedures:p

Better pain control

Reduced anxiety, fatigue and distress

Reduced patient-controlled sedation doses

Reduced pulse rate

Greater relaxation

Most studies on adult patients

Agenda


Study Objective # 1

Can positive distractions produce positiveCan positive distractions produce positive behavioral outcomes in children (with and without neurological disorders)?without neurological disorders)?

Study Objective # 2

Do positive distractions in an environment actDo positive distractions in an environment act as points of focus that can improve the overall waiting experience?overall waiting experience?

Study Objective # 3

Are multisensory distractions more effective than purely visual distractions?

Agenda


Study Site # 1

Children’s Medical Center Dallas - Dental Clinic

Study Site # 2

Children’s Medical Center Dallas – Cardiac Clinic

Distraction Conditions

5 positive distraction conditionsStill nature photo slide show Naturep

Ambient Art

Ambient Art with Sound

Nature Slides

Aquarium

Aquarium with soundAmbient Art

All nature themes

No-Distraction condition as control

Aquarium

Subjects and Data Collection

Subjects:Pediatric patients visiting the

Process:10 min randomized distraction

clinic

>= 5 years old

With and without

10 min no-distraction

Trained observers

O b hildWith and without developmental/neurological problems

One observer per child

Parent questionnaire

Data CollectionDental Clinic: 6 days in

Sample sizeChildren data: 81 (Dental) + 77

December 2008

Cardiac Clinic: 6 days in January 2009

(Cardiac)

Parents: 51 (Dental) + 24 (Cardiac)

Subject Attributes

Dental ClinicAge = 10.95 (mean); 5 – 17 years

Cardiac ClinicAge = 11.57 (mean); 5 – 17 yearsg ( ) y

EthnicityWhite = 25.3%

Bl k 13 9%

g ( ) y

EthnicityWhite = 40.8%

Bl k 22 4%Black = 13.9%

Hispanic = 58.2%

Asian = 2.5%

Black = 22.4%

Hispanic = 35.5%

Asian = 1.3%

GenderMale = 59.3%

Female = 40 7%

GenderMale = 53.9%

Female = 46 1%Female = 40.7%

Developmental/ Neurological deficiencies

P t 47 8%

Female = 46.1%

Developmental/ Neurological deficiencies

P t 12 5%Present = 47.8% Present = 12.5%

Outcome Measures

AttentionPositive distraction

Other art work

Toy

B kBook

Wall

Ceilingg

Floor

Door

Window

Furniture

PeoplePeople

Themselves

Outcome Measures

Physical BehaviorCalm

Fidgety

Fine movement

Gross movement

Intense

Outcome Measures

ActivityPlaying with toysy g y

Playing with non-toys

Non-play activity or other play

Outcome Measures

LocationIn seat

Out of seat

On Lap

Outcome Measures

Social BehaviorPositive interaction

Negative interaction

Solitary behavior

Analytical Procedures

Paired sample t-tests for identifying significant differences between distraction and no-distraction

diticonditions

Covariance models to compare the five distraction conditionsconditions

Factorial Design to identify main effects

C l ti A l i t l l ti hi b tCorrelation Analysis to explore relationships between children’s behavior and parent’s perception

Mediation analysis to explore the true pattern ofMediation analysis to explore the true pattern of relationship between waiting experience and perceived care quality

Agenda


Distraction vs No-Distraction

What differences in attention, behavior and at d e e ces atte t o , be a o a dactivities were observed during the presence of positive distraction conditions?

Attention :: Dental Clinic

Attention Type

Distraction No-Distraction

Difference Significance

TV Monitor 27 73 2 16 25 57 0 000TV Monitor 27.73 2.16 25.57 0.000

Other Artwork 0.36 0.42 -0.06 0.886

Toy 4.24 8.22 -3.98 0.007

Book 1.97 2.17 -0.2 0.829

Wall 7.1 7.57 -0.47 0.818

Ceiling 2.91 2.52 0.39 0.723

Floor 2.66 3.83 -1.17 0.373

Door 3.65 3.5 0.15 0.910

Window 3 52 5 7 2 18 0 179Window 3.52 5.7 -2.18 0.179

Furniture 3.19 5.16 -1.97 0.245

People 36.12 51.64 -15.52 0.000

Themselves 6.53 7.10 -0.57 0.792

Attention :: Cardiac Clinic

Attention Type


Difference Significance

TV Monitor 20 58 0 41 20 17 0 000TV Monitor 20.58 0.41 20.17 0.000

Other Artwork 1.52 1.24 0.28 0.825

Toy 19.13 13.16 5.97 0.081

Book 8.09 15.47 -7.83 0.017

Wall 1.95 3.0 -1.05 0.333

Ceiling 0.52 0.37 0.15 0.737

Floor 3.42 3.04 0.38 0.726

Door 0.75 1.02 -0.27 0.737

Window 4 03 5 11 1 08 0 369Window 4.03 5.11 -1.08 0.369

Furniture 0.97 1.21 -0.24 0.730

People 32.27 44.36 -12.09 0.008

Themselves 6.75 11.6 -4.85 0.028

Attention :: Key Inferences

Substantial diversion of attention to the TV monitor during distraction conditions

Presence of distraction conditions diverted attention from two or more of the following to the TV monitor: people, book, toy, themselves

Positive Distraction do help focus attention

“People” drew most attention even in the presence of distraction conditionsdistraction conditions

Physical Behavior: Dental Clinic

Behavior Type


Difference SignificanceType Distraction

Calm 64.92 58.3 6.62 0.080

Fidgety 20.99 19.41 1.58 0.570

Fine 10 79 15 36 4 57 0 051Fine Movement

10.79 15.36 -4.57 0.051

Gross Movement

2.63 5.18 -2.55 0.079

Intense Movement

0.67 1.75 -1.08 0.153

Physical Behavior :: Cardiac Clinic

Behavior Type


Difference SignificanceType Distraction

Calm 68.88 59.92 8.96 0.029

Fidgety 11.50 13.08 -1.58 0.473

Fine Movement 18 33 23 32 4 99 0 183Fine Movement 18.33 23.32 -4.99 0.183

Gross Movement

1.28 3.49 -2.21 0.049

Intense 0 00 0 19 -0 19 0 176Intense Movement

0.00 0.19 0.19 0.176

Distraction vs No-Distraction Inferrences

Dental Clinic Cardiac Clinic

Most children were observed to be ‘calm’, ‘solitary behavior’, ‘in seat’, ‘not playing’, and ‘watching

Most children were observed to be ‘calm’, ‘solitary behavior’, ‘in seat’, ‘not playing’, and ‘watching

other people’.

Distraction condition results in:

other people’.

Distraction condition results in:Distraction condition results in:

More attention on TV Monitor

More calm; less fine and t

Distraction condition results in:

More attention on TV Monitor

More calm; less gross tgross movement movement

Distraction Conditions Comparison

How is attention distributed between the distraction conditions?

Distribution of Attention

Dental Clinic % Attention

Cardiac Clinic % Attention

Ambient Art with Sound 42.35 Ambient Art 37.18

Aquarium 28.87 Ambient Art with Sound 23.67

Still Art 28.00 Aquarium with Sound 23.00

A i ith S d 23 49 A i 14 53Aquarium with Sound 23.49 Aquarium 14.53

Ambient Art 4.66 Still Art 9.11

Both Clinics %Distribution by Clinic Both Clinics % Attention

Ambient Art with Sound 66.02

Distribution by Clinic

Aquarium with Sound 46.48

Aquarium 43.40

Ambient Art 41.84

Still Art 37.11Combined Mean Distribution

Distribution of Attention :: Key Inferences

Overall, multi-sensory (visual + auditory) stimuli attract greater attention

Still nature slide show demonstrate least preference

HOWEVERHOWEVER

Substantial differences between the two clinics

A pattern observable for cardiac population

Ambient art conditions, Aquarium conditions, Still , q ,Nature

No meaningful pattern identifiable for dental population

Interaction Effects?

Did bj t tt ib t ( th i itDid subject attribute (ethnicity, developmental disability, illness type) interact with attention and behavior?interact with attention and behavior?

Physical Behavior :: CALM

CALM(Most to Least)


Aquarium Ambient Art

Ambient Art with Sound Aquarium with Sound

Still Art Ambient Art with Sound

Aquarium with Sound Still ArtAquarium with Sound Still Art

Ambient Art Aquarium

Pole ReversalPole Reversal

Physical Behavior :: FIDGETY

FIDGETY(Least to Most)


Ambient Art with Sound Aquarium

Still Art Aquarium with Sound


Aquarium with Sound Ambient Art with SoundAquarium with Sound Ambient Art with Sound

Ambient Art Still Art

Block ShiftBlock Shift

Physical Behavior :: FINE MOVEMENT

FINE MOVEMENT(Least to Most)


Ambient Art with Sound Ambient Art

Aquarium Still Art

Aquarium with Sound Ambient Art with Sound

Still Art Aquarium with SoundStill Art Aquarium with Sound



Physical Behavior :: GROSS MOVEMENT

GROSS MOVEMENT(Least to Most)



Aquarium with Sound Still Art

Ambient Art with Sound Ambient Art with Sound

Still Art Aquarium with SoundStill Art Aquarium with Sound


Total ReversalTotal Reversal

Activity :: PLAY TOY

PLAY TOY(Most to Least)


Aquarium Aquarium with Sound

Ambient Art with Sound Aquarium

Still Art Still Art

Aquarium with Sound Ambient Art with SoundAquarium with Sound Ambient Art with Sound

Ambient Art Ambient Art

Partial ReversalPartial Reversal

Activity :: PLAY NON-TOY

PLAY NON-TOY(Most to Least)



Ambient Art Ambient Art with Sound

Still Art Aquarium

Ambient Art with Sound Aquarium with SoundAmbient Art with Sound Aquarium with Sound



Location :: OUT OF SEAT

OUT OF SEAT(Least to Most)


Aquarium Still Art


Aquarium with Sound Aquarium

Ambient Art Aquarium with SoundAmbient Art Aquarium with Sound


Partial ReversalPartial Reversal

Location :: IN SEAT

IN SEAT(Most to Least)


Aquarium Still Art


Ambient Art with Sound Aquarium with Sound

Ambient Art Ambient ArtAmbient Art Ambient Art

Aquarium with Sound Aquarium


Social Behavior :: POSITIVE INTERACTION

POSITIVE INTERACTION(Most to Least)


Aquarium with Sound Still Art( ost to east)Ambient Art with Sound Ambient Art


Ambient Art Ambient Art with SoundAmbient Art Ambient Art with Sound

Still Art Aquarium


Social Behavior :: SOLITARY BEHAVIOR

SOLITARY BEHAVIOR(Least to Most)





Ambient Art Ambient Art with SoundAmbient Art Ambient Art with Sound

Still Art Aquarium


Key Behavioral Inferences

Population attribute (ethnicity, developmental disability, illness type) may constitute a y, yp ) yfactor determining physical and social behavior

Most frequent top and bottom conditions:

Dental Clinic Cardiac ClinicMost frequently at the top

Aquarium Ambient Art + Still Art

Most frequently at the bottom


Question

Is patient attribute (as defined by clinic) a major predictor of behavior?

Method: 2 x 5 Factorial Designg

Still Art Ambient Art

Ambient Art +

Aquarium Aquarium + Sound

SoundDentalCardiac

Factorial Analysis: Attention

Attention WITHOUT Covariate

Clinic Distraction Interaction

WITH Covariate


TV Monitor Yes

Other Art

Toy Yes

Yes

Yes

Book Yes

Wall Yes Yes

Ceiling Yes

Yes Yes

Ceiling Yes

Floor

Door Yes Yes

Window

Furniture Yes

People

Yes

Themselves

Factorial Analysis: Behavior and Activity

Attention WITHOUT Covariate


Calm

WITH Covariate


Calm

Fidgety Yes

Fine Movement Yes

Gross Movement Yes

Yes

Yes

Gross Movement Yes

Intense

Play Toy Yes

Play Non-ToyPlay Non Toy

None/Other Play Yes Yes

Out of Seat

In Seat

On Lap Yes

Positive Int Yes

Negative Int

Yes

Yes

YesNegative Int

Solitary Yes

Yes

Yes

Key Inferences

A number of behavior outcomes associated with patient attribute:

Culture and/or Neurological State and/or Illness Type

Difference reduces when controlled for no-distraction condition data

Multi-sensory distractions more effective in Dental Clinic

Behavior Dental Clinic Cardiac ClinicCalm Ambient Art (S); Aquarium Ambient ArtFidgety Ambient Art (S) Aquariumg y ( ) qFine Movement Ambient Art (S) Ambient ArtGross Movement Aquarium Ambient ArtIntense Movement Aquarium (S) Aquariumq ( ) qPositive Interaction Aquarium (S) Still ArtNegative Interaction Aquarium Still ArtSolitary Behavior Aquarium (S) Still ArtSolitary Behavior Aquarium (S) Still Art

Agenda


Inferences

Presence of distraction conditions associated with change in children’s attention, activities and behavior

P ’ i i i i d i h hild ’ iParents’ waiting experience associated with children’s attention, activities and behavior

Elements of parents’ waiting experience associated with their perceived waiting time

Parent’s waiting experience (including perceived waiting time) associated with their:associated with their:

Exam room experience

Perception regarding staff

Overall visit

Overall experience

Question

Any explanations for the apparent importance of waiting experience?

Items in Overall Visit and Experience

Felt caredChild treated in timely mannerChild treated in timely mannerFelt welcomeLess anxiety feelingRecommend this clinic to othersQuality of care child receivedQuality of service parent’s receivedQuality of service parent s receivedQuality of interaction with staffQuality of interaction with doctor

Mediation Analysis

Perception

Wait Area

regarding Staff

Overall

Perception regarding

Exam Room

ExperienceOverall

g gStaff

The Ongoing Debate

… In a time of rising health costs it doesn’t make a toncosts, it doesn t make a ton of sense for facilities to be spending lavishly on perks.p g y p

Jacob Goldstein, in Behind Hospitals’ Pretty F d Di R f P ti t W llFacades, Dingy Rooms for Patients, Wall Street Journal, August 20, 2008

Agenda


Implications

Waiting experience associated with keyCarefully engineer

waiting experienceassociated with key organizational objectivesobjectives

Implications

All positive distractions are not the same

Culture and/or neurological state and/or li i t i t d ithclinic type associated with

behavioral outcomes

Positive distractions are attention grabbers

Locate distraction conditions carefully

Positive distractions associated with calmbehavior

Take advantage of behavioral influence of positive distractionbehavior positive distraction

Implications

Attention on People:Do not ignore physical placement,

dj i iWhether distraction conditions were switched on or not, most attention was fixated on other

adjacencies, view corridors, and activities aroundwas fixated on other

peopleactivities around hospital waiting areas

Q U E S T I O N S

Definitions of Terms: AttentionAttention Eye-fixation on any object/person will be recorded as

attention. Objects can include art work, toys, furniture, etc.

Positive distraction The flat screen TV in the waiting room on which artwork/music will be displayed

Other artwork Any other artwork in the waiting area: painting, sculpture, … at any location in the waiting lounge

Toy Any piece of toy/game in the waiting area or brought in by the subjectin by the subject

Book Book or books in the waiting lounge or brought in by the subject

Wall Blank portions of any of the wall in the waiting room

Ceiling Ceiling of the waiting roomFloor Floor of the waiting roomDoor Any of the doors of the waiting roomWindow Any window – external or internal – in the waiting

room, including the reception desk/windowg p

Furniture Any unoccupied furniture in the waiting lounge –without any person or thing on the furniture

P l A i h i iPeople Any person in the waiting roomThemselves Any portion of the patient’s own body

Definition of Terms: Physical Behavior

Calm No visible major motor movementFidgety This will be coded whenever repetitive,

restless motor movements is observed which appeared to be primarily purposeless (e.g., taping a pencil, kicking one's foot)p g pe c , c g o e s oo )

Fine Movement Defined as fine motor movement involving very low intensity purposeful movements of body parts.

Gross Movement Defined as gross motor movement involving taking one or more steps or, if sitting, moving the buttocks from one spot to another

Intense Defined as engaging in inappropriate or excessively vigorous physical activities (e.g., throwing toys, running about, yelling or singing loudly)

Definition of Terms: Activity and Location

Playing with toys Defined as playing with toys in the room (ifPlaying with toys Defined as playing with toys in the room (if available)

Playing with non toys Defined as playing with non toy objects in the room (e.g., doorknob, table)

Non-play activity/ Other Play Defined as neither playing with a toy or non-toy item (e.g., standing and gazing at the door; reading; eating; drinking)OROther play activities (not involving toys or non-toys)

Out of seat This will be coded if a child left the seat entirely at the time of observation

In-seat This will be coded if a child is in his/her seat at the time of observation

Parent’s lap This will be coded if a child is sitting on the lap of another accompanying adult.

Definition of Terms: Social Behavior

Positive interaction All vocalizations directed to sibling/parent/objects excluding screams, shouts, cries, and whines; all cooperative responses involved with sharing an object; and espo ses vo ved w s g objec ; dhugs and holding hands

Negative interaction Screams, shouts, or other utterances that indicate rejecting and oppositional behavior; hit, pinch, kick, and “nonplaying” push or pull; grabbing objects from sibling/parent; and destroying possessions of sibling/parent

Solitary behavior All solitary activity (excluding parallel play conducted between two children within two feet of one another)