The relationship between birth unit design and safe, satisfying birth: Developing a hypothetical model
Introduction
The environment in which health care occurs has substantial effects on patient health and safety, effectiveness of care, staff efficiency and morale (Ulrich and Barach, 2006). Each year in Australia, as in many other countries, expenditure on the building or refurbishment of health facilities is considerable (around $Aus two billion). Recent advances in cross-disciplinary studies linking architecture and neuroscience have revealed that much of the built environment for health-care delivery may actually impair rather than improve health outcomes by increasing patient and staff stress (Stichler and Kirk Hamilton, 2008, Ulrich and Zimring, 2008). Stress initiates and exacerbates illness, and impacts on the quality of communication between patients and staff and between staff, and poor communication increases the risk of medical errors and adverse patient outcomes (Committee on Quality Health Care in America, 2001, Leonard and Graham, 2004). This is also true for maternity care provision, where it is suggested that the environment can impact on the experiences and outcomes for birthing women (Hodnett et al., 2009). It is increasingly evident that the environment of the labour ward is important, and research on the safety of maternity care needs to include this aspect of the provision of care.
The aim of this paper is to describe the development of a conceptual model that has been based on a range of maternity and wider health-care literature on the health-care environment and other possible influencing factors on patient safety, including communication, relationships and models of care. In particular, the paper explores the potential influence of birth unit design on the quality of communication between health professionals, birthing women and their supporters.1 It is recognised that these are complex issues and the inter-relationships between them are equally multifaceted. Poor-quality communication contributes to stress for birthing women, leading to changes in materno-fetal physiology, increasing the likelihood of intervention being required, and decreasing the likelihood of a safe, satisfying birth (Foureur, 2008). At the same time, birth unit design impacts on staff stress, with physiological, behavioural and cognitive consequences that may lead to impaired decision making (Altimier, 2004, Ulrich and Zimring, 2008). The possible relationships between design, models of care, communication, women’s stress and outcomes are hypothesised using a conceptual model, and this is presented in an effort to encourage others to consider birth unit design in research on patient safety.
This paper commences with a brief description of the evidence in relation to design of the environment and the impact on stress, safety and error. Next, communication in the health-care environment and its possible relationships with models of care and design are discussed. Lastly, the conceptual model is introduced, indicating that safe, satisfying birth is reliant on the level of stress experienced by a woman and the staff around her, communication with women and between staff, mediated by the design of the birth unit and model of care. It is emphasised that the conceptual model describes hypothesised relationships and that the model is offered to inform future research agendas.
Section snippets
Design, stress and safety
‘What can rigorous research tell us about ‘good’ and ‘bad’ hospital design? Can improved design make hospitals less risky and stressful and promote health for patients, their families and staff? Is there scientifically credible evidence that design affects clinical outcomes and effectiveness in delivering care?’ (Ulrich et al., 2008, p. 2). These three questions provided a framework for a recent systematic review of 450 studies addressing evidence-based health-care design, undertaken by Ulrich
Design of birth units
Birth facilities are of particular interest in considering a link between design and outcomes as pregnant women are generally healthy, and pregnancy and childbirth are usually considered to be normal life events rather than an illness or disease. In Australia, the National Review of Maternity Services recognised this, saying that women ‘should be able to feel they are in control of what is happening during pregnancy, childbirth and the postnatal period, based on their individual needs and
The influence of design
There is increasing evidence articulating how the design and aesthetics of the spaces we inhabit impact on our physicality, behaviour, neurophysiology and well-being (Fleming and Baum, 1984, Dilani, 2001, Edelstein, 2004, de Botton, 2006, Ulrich and Barach, 2006). Several recent studies have considered the impact of spaces built to house birthing women outside of their homes, and how these environments may impact on maternal and infant outcomes (Lock and Gibb, 2003, Walsh and Downe, 2004,
Design and communication
It is recognised that effective communication is essential for the delivery of high-quality, safe patient care (Committee on Quality Health Care in America, 2001, Leonard and Graham, 2004). Communication refers to interactions between staff and patients in health care and those between staff members. Many studies and reviews have highlighted the importance of effective communication in health care (Rowe and Garcia, 2001, Carroll, 2006, Manning, 2006, Braithwaite and Iedema, 2007, Iedema, 2007,
Can design influence birth outcomes?
It seems evident that design influences stress and communication. It also seems likely that the model of care can influence communication and possibly stress. Therefore, can these factors also influence birth outcomes and how are they mediated by one another? Optimal birth outcomes for mothers and infants are an aim of maternity care. For example, midwives across the USA believed that ‘optimal health of the woman and baby’ was their most important outcome (Kennedy, 2000). This goal was
The safe, satisfying birth conceptual model
The conceptual model (Fig. 1) is an attempt to articulate the inter-twined and inter-related concepts that may contribute to safe, satisfying birth. It seems likely that safe, satisfying birth is influenced by communication patterns and styles, both between staff and women and between staff. Stress levels are influenced by design elements as shown in Ulrich’s review of the literature, and these effects are likely to alter communication patterns and, ultimately, women’s experience of safe,
Conclusion
Less than optimal environments and models of care can contribute to patient and staff stress, and poor levels of communication. It is hypothesised that a safe, satisfying birth experience is reliant on the level of stress experienced by women and staff, the level of staff communication with women and between staff themselves, mediated overall by the birth environment and model of care. This paper has presented a conceptual model to deepen the understanding of the complex relationships between a
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