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Objective: The primary objective of the thesis is to advance proactive thinking in designing healthcare facilities for safety by constructing theory to bridge gaps between evidence-based design (EBD) and human factors/ergonomics (HF/E). Background: Adverse events are a pervasive issue in healthcare, with causes and prevention measures under increased scrutiny for the past 15 years. The physical environment can be an underlying condition of safety and healthcare (HC) facility design can be seen as a layer of defense in accident causation theory. However, HC facility design is complicated and complex, and the implications of decisions can be felt for decades. While architects excel at problem solving, they are not fully versed in healthcare work tasks, flow, and function, resulting in complex system interactions. Evidence-based design (EBD) is a process that uses research as a foundation for decision-making in HC facility design. While the EBD process acknowledges the importance of system factors, its focus is on understanding specific facility design interventions on outcomes such as safety, efficiency, quality of care, and satisfaction. HF/E focuses on humans interacting with a system with a goal of optimizing human well-being and overall system performance. Although HF/E recognizes the physical environment as a system component, the ergonomic definition of the environment lacks clarity and influences are frequently considered at a microergonomic level. In summary, EBD supports desired outcomes of a system through building design, while HF/E more often supports desired outcomes of the system through work design. Methods: The thesis leverages a grant to create a Safety Risk Assessment (SRA) toolkit for HC facility design using: (1) consensus-based methods to develop built-environment considerations for falls in HC facility design, (2) a mixed methods approach to test the SRA in hypothetical scenarios, (3) a mixed methods approach to test the SRA in real-world scenarios, (4) quantitative and qualitative analysis using an inductive and abductive approach to construct grounded theory to develop a core theme and a theoretical framework for proactively considering safety in HC facility design, (5) an extended systematic literature review to identify additional system considerations of the organization and people, and (6) established thinking to advance new theoretical frameworks to achieve the thesis objectives. Results: Two theoretical frameworks are proposed. The first framework, Safety as Complexity of the Organization, People and Environment (SCOPE) is based on the Dial-F systems model (Hignett 2013). The evolution includes: the definition of the ergonomic environment using building design as the most stable element of the system, identifying built environment interventions to mitigate the risk of falls (SCOPE 1.0); the addition of non-building design interventions of the system such as organizational and people-based conditions (SCOPE 2.0); and the integration of HF/E design principles to reframe thinking about hospital falls (DEEP SCOPE). The second framework evolves from grounded theory constructed through data from SRA testing proposing safe design as a participatory process to anticipate, participate, and integrate solutions. A participatory ergonomics framework (Haines and Wilson 1998) is integrated with a mesoergonomic framework of inquiry (Karsh, Waterson, and Holden 2014, Karsh 2006) to advance a theoretical framework of participatory mesoergonomics using the SRA and SCOPE content as inputs over the course of a HC facility design project to achieve safety. Conclusion: The gap between EBD and HF/E can be bridged using safety (falls) as a proactive consideration during HC facility design using theoretical frameworks. These frameworks address (1) the definition of building design and design considerations in the HF/E context and (2) integration of the EBD process with HF/E methods to understand interactions of the system.

Falls, with and without injury, in acute care hospitals are quite common but can be prevented if appropriate interventions are in place to address this issue. It is imperative that nurses assess fall risks of all patients admitted to the hospital and advocate for appropriate interventions to prevent falls in those who are found to be at risk. The purpose of this project was to recommend changes to the current fall prevention protocol in the project facility, an acute care hospital, based on best practices identified in a systematic review of the literature. At the time of the project, the hospital had a high rate of falls. The clinical practice question addressed by this project focused on the evidence-based fall prevention interventions that have resulted in a decreased fall rate among patients on medical-surgical units in an acute inpatient hospital setting. This doctoral project was informed by Kolcaba's theory of caring, and the major source of evidence was a systematic review of the literature focusing on fall prevention. Findings indicated that identification of fall risk factors and implementation of multifactorial fall prevention interventions, such as fall prevention teams, unit fall team champions and use of a fall risk scale, can reduce falls on medical surgical units in acute care hospitals. It was recommended that a multidisciplinary fall prevention team be developed in conjunction with unit fall team champions and that a fall risk scale be used to bridge the practice gap. If implemented, these changes may benefit patients, nurses, and the organization as a whole through decreased falls, lengths of stay, and health care costs.