Design of pediatric outpatient procedure environments: A pilot study to understand the perceptions of patients and their parents

Why does this study matter?
Although outpatient procedures are becoming more commonplace, procedure-related anxiety among children and their parents remains. Positive distractions and the presence of parents or caregivers have been shown to alleviate pediatric patient stress, but research specific to the outpatient setting is scarce. The findings from this study suggest design features preferred by children and their parents that provide distraction and can potentially reduce their anxiety.

How was the study done?
In this mixed-method study, researchers presented photographs of distinct facility areas: waiting room, pre-procedure room, procedure room, and the recovery room) via iPad as both child and parent participants visited each respective space. Participants were asked to select features on the photographs that they liked/disliked and then elaborate on their selections via open-ended questions. On the procedure day, researchers met with participants to obtain verbal consent before collecting survey data that included a) reactions to photographs, b) state-anxiety data using the 6-question State-Trait Anxiety Inventory (STAI-6) and c) two physiologic indicators of stress collected via wristband: heart rate variability (HRV) and skin conduction response (SCR). Children answered survey questions and physiologic data were recorded at the four points previously mentioned: waiting room, pre-procedure room, procedure room, and the recovery room. Researchers collected the same data from caregivers at similar points: the pre-procedure room, waiting area, and the recovery room.     

So what do we learn from the study?
Descriptive analyses revealed that both adults & children experienced the highest levels of anxiety in the waiting room with children having greater anxiety in the waiting room prior to the procedure and parents experiencing greater anxiety while waiting during the child’s procedure. In children, the procedure room and pre-procedure room were next on the list. In adults, the pre-procedure area was the second most anxiety-provoking space. Both children and adults showed the lowest levels of anxiety in the recovery room and there were no significant differences in heart rate variability or skin conduction response across treatment locations.

In the waiting room, both children and adults indicated they liked the art, spatial layout, and double chairs that allowed children to sit with their parents but did not like that there were empty shelves or that windows were glazed.

In the pre-procedure room children most liked warm blankets and while adults liked proximity to the nurse’s station, they disliked the small rooms. Both children and adults appreciated seating adjacent to the patient bed, nature photographs, wall-mounted television and clock, and the wall colors.
In the procedure room, researchers concluded that the combination of equipment and impending procedure increased children’s anxiety based on the number of dislikes associated with exposed medical equipment such as IV poles, anesthesia equipment, and scope machines.

In the recovery area, children liked warm blankets, proximity to bathrooms, and viewing the nurses’ station, and the workstations on wheels, but adults desired more privacy than the curtains in the open bay provided. Adults and children liked that seating was next to the patient bed and windows provided natural light. However, some indicated dislike of the IV pole and blood pressure monitor.  

Can we say the results are definitive?
Researchers did not account for potential confounders that may influence anxiety, lacked long-term follow-up beyond the day of the procedure, and relied on self-reported data which may be biased or influenced by transient emotional states. The lack of a comparison group and the low number of participants limited statistical analysis such that the generalization of conclusions regarding relationships between elements of the built environment and anxiety would require further evidence.

What’s the takeaway?
Because children experienced the highest anxiety levels before their procedure, providing age-appropriate positive distractions in the waiting room and pre-procedure room such as toys, games, posters, television, or a window may be beneficial. Children were more likely to favor features that made them feel calm or comfortable while adults were most concerned with the child’s comfort or functionality of the space. Both adults and children appreciated furnishings that fostered familial closeness. Adults suggested more charging ports in the waiting room, possibly to provide distraction and/or alleviate their own anxiety while their children were undergoing procedures. 

Summary of: Goel, S., Mihandoust, S., Joseph, A., Markowitz, J., Gonzales, A., Browning, M. (2024) Design of pediatric outpatient procedure environments: A pilot study to understand the perceptions of patients and their parents. HERD: Health Environments Research & Design Journal, Pages in press

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