Physical Environment Features and Healthcare Interruptions: A Scoping Review Across Clinical Settings

Abstract

Aim: This review aims to identify empirical studies that examine the relationship between physical environment features and the occurrence of interruptions in healthcare settings. Background: Studies have shown that interruptions are a significant cause of errors, which are a primary contributor to adverse events that can result in severe injury or even death. Built environmental factors contribute to these interruptions, yet comprehensive studies examining how environmental variables impact interruption frequency remain scarce. Therefore, it is essential to consider how the physical environment exacerbates or alleviates disruptions to enhance patient safety. Method: A scoping review following PRISMA guidelines analyzed 33 empirical studies from medical, nursing, engineering, and architectural design fields. Data were extracted regarding study design, setting, participants, environmental variables, and outcomes related to interruptions. Result: The findings indicate that physical environment features influencing interruptions include no-interruption zones, signage, medication room configurations, physical barriers, workstation layouts, and traffic-related factors. However, inconsistencies in how interruption-related terms are defined across studies make comparisons challenging. The reviewed studies cover a variety of healthcare settings—including medical units, operating rooms, emergency departments, and intensive care units—and involve participants such as nurses, physicians, pharmacists, patients, and support staff. Conclusion: This review concludes that significant gaps remain in understanding how physical environment features impact interruptions. Future research should systematically examine physical environment features across healthcare settings to enhance safety, optimize workflow, and reduce errors.

Keywords

physical environment scoping review healthcare interruptions healthcare design

Introduction

Patient safety is the primary concern in the healthcare industry (Yoder et al., 2015). According to the World Health Organization, medical errors account for 1.3 million injuries annually and one death every day (WHO, 2017) in the USA. Medication error is the third most common cause of death in the USA (Makary & Daniel, 2016). Interruption is one of the significant contributors to medication errors (Flynn et al., 2016). According to Sasangohar et al. (2014), registered nurses are interrupted every 3 min on average during their tasks. Interruptions, while essential for information sharing (McCurdie et al., 2017), may disrupt working memory and induce errors (Chen et al., 2024). Mitigating interruptions, particularly in the intensive care unit (ICU), can improve safety and reduce medication errors.

Individual research studies have identified the influence of several features of facility layout on interruptions or the events that lead to interruptions (e.g., nurse interaction) including layout compactness, visibility of work areas, proximity to supportive clinical spaces, level of connectivity between different areas, the complexity of the layout and movement paths, transition density, level of betweenness, and isovist connectivity (IC), defined as participant's visual exposure (Hadi, 2020; Joshi et al., 2023; Sasangohar, 2015; Zadeh et al., 2012).

Literature reviews have been conducted on the relationship between physical environment features or interventions and interruption events in healthcare settings (Bayramzadeh et al., 2021). Most of the reviews focused on intervention effectiveness, non-environmental interventions, or were conducted in specific settings. To the authors’ knowledge, there are no literature reviews comprehensively mapping the evidence regarding physical environment impacts on the occurrence of interruption in different healthcare environments. Therefore, this research aimed to examine empirical evidence regarding how physical environmental features and physical-environment-related interventions affect the frequency of interruption across various clinical settings.

Concepts and Definitions

In this review, “Physical Environment” refers to the stationary and mobile physical elements in space (Bayramzadeh et al., 2021), which include configuration, layout, doors, walls, colors, lighting, technologies, equipment, fixtures, and furniture. The continuous interaction between the physical environment and other elements such as people, technologies, and tasks determines spatiotemporal events including interruptions (Bayramzadeh et al., 2021; Hadi, 2020).

“Interruption” is defined: (1) as actions by staff or environmental events that disrupt nurses’ tasks, affect their activity performance, and cause discontinuation of cognitive processes (Zadeh et al., 2012); and (2) as an external intrusion of a secondary, unplanned, and unexpected task that leads to discontinuity in task performance (Brixey et al., 2007).

Materials and Methods

This literature review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Scoping Review guidelines (Figure 1) (Moher et al., 2009). A scoping review is typically undertaken to consolidate knowledge, chart evidence within a specific domain, and pinpoint concepts, theories, and areas where research is lacking (Fulop, 2001; Tricco et al., 2018). Therefore, the scoping review methodology was chosen due to the complexity and emerging nature of this type of research featuring heterogeneous study designs, settings, outcomes, and intervention types.

Search Strategy

The literature search was performed between May 2023 and August 2024 using the following databases: EBSCO, ProQuest databases, PsycINFO, Web of Science, JSTOR, CINAHL, Medline, and PubMed. Additional studies were also identified by scanning selected articles’ references. The investigator used a diverse combination of keywords in two categories to ensure the search captures relevant studies: (1) Interruption-related: “interruption*” OR “distraction*” OR “disruption*” OR “cognitive disruption*” OR “work break*” OR “resumption*” OR “work disruption*”. (2) Spatial layout- related: “Spatial layout*” OR “physical environment*” OR “ design feature*” OR “hospital design*” OR “ICU design*” OR “healthcare design*” OR “Layout*” OR “interior design*” OR “design*” OR “healthcare environment*” OR “healthcare facility*” OR “hospital design” OR “Physical space*” OR “Building design” OR “Buildings hospital design” OR “Environmental psychology*” OR “hospital design*” OR “hospital plan*” OR “Art*” OR “healthcare plan*” OR “nurse station*” OR “medication room*” OR “medication station*” OR “patient room*” OR Space* OR “acute care*” OR “emergency room*” OR “emergency department*” OR “clinic*” OR “outpatient*” OR “lighting*” OR “Intensive care unit*” OR “Critical care unit*”. The same terms and search strategy were used for each database.

Inclusion and Exclusion Criteria

The search targeted peer-reviewed articles published between 1990 and August 2024. Studies were included if they: (1) evaluated the impacts of physical environmental factors or physical environment-related interventions; (2) were conducted in healthcare settings; (3) evaluated interruption events during clinical processes; (4) reported empirical research; (5) were in English; and (6) were peer-reviewed publications. Studies evaluating only non-environmental factors were excluded.

Selection Process

The researcher applied Covidence, a computer program widely used for streamlining the PRISMA review process, to assist this study. Two reviewers screened titles and abstracts and reviewed the full text to ensure thorough evaluation and resolve discrepancies. This approach enhances reliability and transparency. Following the PRISMA extension for scoping reviews, we used a five-stage protocol: Stage 1: research questions were identified. Stage 2: relevant studies were located across databases. The initial search yielded 14,125 articles from the databases, with an additional 42 captured through snowballing. Stage 3: Studies were imported into Covidence, which removed 6,278 duplicates, leaving 7,899 studies in the pool. After screening titles, 273 studies remained and advanced to abstract review. Following abstract screening, articles were ranked 1–5 (1 = lowest relevance, 5 = highest relevance) based on how much information each article provided to answer the research questions. Thirty-three articles ranked higher than 4, which met the inclusion criteria, advanced to data extraction. Stage 4: study data were extracted. Stage 5: findings were reported through descriptive numerical and narrative summaries (Figure 1).

Figure 1.

Search and selection process based on the preferred reporting items for systematic reviews and meta-analyses scoping review guidelines.

Data Extraction

We extracted data from the selected studies into 14 categories that include (1) year of publication; (2) research aims/ questions/ hypotheses; (3) research design; (4) study locations; (5) sample size; (6) types of healthcare settings; (7) data collection methods; (8) data analysis methods; (9) dependent variables; (10) independent variables (physical environmental); (11) terminology definition; (12) study unit; (13) studied clinical procedure; and (14) relationship between dependent and independent variables.

Data Analysis and Synthesis

The analysis and synthesis of data for this scoping review followed a systematic approach to ensure a comprehensive examination of the relationship between physical environmental factors and healthcare interruptions. The process involved multiple stages of data organization, coding, and thematic analysis. First, all extracted data from the 33 selected studies were compiled into a structured database, categorizing information according to the 14 predetermined extraction fields. This organization facilitated comparative analysis across studies. For qualitative synthesis, a content analysis approach was employed to identify recurring themes, methodological patterns, and knowledge gaps (Elo & Kyngäs, 2008). Studies were coded according to physical environmental interventions and factors, non-physical environmental interventions, healthcare settings, participant characteristics, data collection and analysis methods, and outcome measurements. Quantitative data were analyzed descriptively, summarizing frequencies, percentages, and ranges of findings across studies. Due to the heterogeneity in study designs, definitions, and outcome measures, a formal meta-analysis was not conducted. Instead, evidence was narratively synthesized to identify patterns, contradictions, and emerging insights regarding the impact of built environmental features on interruptions.

Results

Overview of Selected Studies

Most selected articles were published after 2005, with increasing annual frequencies observed between 2005 and 2024. Research was primarily conducted in the U.S. (n = 20), Europe (n = 7), Canada (n = 2), Australia (n = 2), and Turkey (n = 1), with some not reporting location. Studies covered different fields: seven in architectural design, four in engineering, and nineteen in medicine or nursing.

Research settings varied across hospital departments: medical/surgical units (n = 10), ICU (n = 3), emergency departments (n = 3), progressive care units (n = 2), operating rooms (ORs) (n = 3), and acute care unit (general, pediatric, or inpatient) (n = 4), geriatric unit (n = 1), cardiac and thoracic step-down unit (n = 1), pediatric post anesthesia unit (n = 1), and 4 studies also did not mention the name specific unit in hospital. Table 1 provides detailed information about the specific settings and procedures examined across all studies. Nurses in various roles were the most common study participants (n = 18), including various nursing roles. Studies also use other medical staff (n = 6) such as physicians, pharmacists, pharmacy technicians, respiratory therapists (RT), and ECMO personnel as study participants. The number of participants in these studies was between 8 and 360 nurses (mean = 40.33, SD = 32.27, after removing 360 that is considered as outlier). Another sample unit across studies was clinical procedure (n = 13) including medication administration, surgical procedure, and hand off, with procedure sample sizes between 10 and 130 (mean = 41.21, SD = 30.84). Two studies used the number of observations (n = 59 and 1158 observations) (Freeman et al., 2013) as the study unit, and one study used the surgery unit (n = 7 units) as the study unit (Tomietto et al., 2012).

Table 1.

Study Designs, Studied Procedures, Settings, Variables, and Data Analysis Methods.

Design	Citation	Procedure	Setting	Environmental Variables (Relationship With Outcome Variable)	Outcome Variable	Data Analysis
Interventional	Pape et al. (2005)	Medication administration	Hospital	Signage (S−)	Number of distractions	Discriptive t-test
	Klejka (2012)	Medication preparation and administration	Medical nursing unit	Quiet Zone (−)	Nonurgent nursing interruptions	Discriptive analysis and mean comparision
	Klejka (2012)	Medication preparation and administration	Medical nursing unit	Quiet Zone (−)	Distraction	Discriptive analysis and mean comparision
	Tomietto et al. (2012)	Medication rounds	Hospital	Dedicated medication room (−)	Interruption duration	Discriptive analysis and students t-test
					Percentage of interruptions (POI) during verification
					POI during administration
				Dedicated medication room (+)	POI during preparation
	Colligan et al. (2012)	Medication process	Pediatric acute ward	Walls barriers	Number of interruptions	Mann–Whitney U test
	Mortaro et al. (2019)	Medication preparation and administration	Geriatric unit	NIZ (S−)	Interruption number (IN)	Qualitative analysis, student’s t-test, z-test, and χ² test
					IN per patient rate and round
					IN per drug per round
					Interruption time
	Huckels-Baumgart et al. (2021)	Medication preparation	Medical and surgical unit	Separate medication room (S−)	Mean interruptions (MI)/dayInterruption rate/hourMI per drug	Discriptive analysis, independent two-sided t test, and post hoc power analysis
				Separate medication room (S+)	MI per hourInterruption free preparation time
				Separate medication room (NS)	MI per nurseMean duration of interruptions in min
Quasi-experimental–quality/ process improvement	Kavanagh and Donnelly (2020)	Medication Administration	Acute inpatient unit	Dedicated medication room (safe space) (+)	Interruption duration	Discriptive analysis
	Kavanagh and Donnelly (2020)	Medication Administration	Acute inpatient unit	Dedicated medication room (−)	Interruption frequency	Discriptive analysis
	Pape (2013)	Medication delivery	Medical and surgical unit	Quiet zone marked off by floor tape (−)Do Not Interrupt signs (−)	Distractions and interruptions (−)	Discriptive analysis
Quasi-experimental	Freeman et al. (2013)	Medication process	Cardiac and thoracic step-down unit	NIZ (S−)	Number of interruptions	Descriptive analysis
	Freeman et al. (2013)	Medication process	Cardiac and thoracic step-down unit	Signage (S−)	Number of interruptions	Descriptive analysis
	Williams et al. (2014)	Medication preparation	Surgical progressive care unit	NIZ (S−)	Distractions and interruptions number	Descriptive statistics and Mann–Whitney U tests
	Williams et al. (2014)	Medication preparation	Surgical progressive care unit	Signage (S−)	Distractions and interruptions number	Descriptive statistics and Mann–Whitney U tests
	Spooner et al. (2019)	Nurse handover	Medical and surgical ICU	Handover location: central vs. bedside (NS)	FrequencyInterruptions reasons	Descriptive statistics, and t-test
	Flynn et al. (2016)	Medication Administration	Progressive cardiac care unit	Signage (S−)	Interruption numbers	Post hoc analysis
				Quiet zone (S−)
				NIZ (S−)
	Conrad et al. (2010)	Medication Process	Progressive care unit	Dedicated medication room (MR) (−)Organization of MR (−)Ergonomic safety (−)Remove charting station (−)Signage (−)	Number of interruptionsMedication administration time	Qualitative analysis
	Yoder et al. (2015)	Medication administration	Medical unit	Safe zone (S+)	Interruption number	two-tailed t test
	Joshi et al. (2021)	Handoffs	Emergency department	Open vs. enclosed vs. semi-open workstation (S+)	Mean interruptions from residents, head unit coordinator, family, phone, and other equipment	Discriptive analysis, Kruskal–Wallis test, one-way ANOVA, and paired student’s t test
	Joshi et al. (2021)	Handoffs	Emergency department	Open vs. enclosed vs. semi-open workstation (S+)	Interruption number during exchange and dialogue as well as handoff preparation
	(Joshi et al., 2023)	Handoffs	Emergency department	Physicians location within the workstation (S) Handoff approach (S) Position during handoff (sitting or standing) (S)	Isovist connectivity level	DepthmapX (syntactic analysis) Hierarchical clustering–Ward’s Descriptive summaries
	(Joshi et al., 2023)	Handoffs	Emergency department	Isovist connectivity level (S+)	Number of interruptions	Pearson X2 Regression model
	Filer et al. (2017)	Paranesthesia assessment	Pediatric post anesthesia care unit	NIZ with signage (S−)	Mean number of interruptions (MOI) per observation and verbal and physical interruptionsMOI of self-interruptionsTime between (TB) self-interruptionsTB interruptionsReturned to original taskTB physical or verbal interruptions	Discriptive analysis, t test, and chi-square
				NIZ with signage (NS)
				NIZ with signage (S+)
Quasi-experimental	Joseph et al. (2019)	Surgical procedures	Operating room	Traffic-related factors (NS)Number of transitions in OR (+)Number of transitions to and from one transitional zone to other one (S+)	Rate of major FDs	Linear regression and logistic regression model


	Anthony et al. (2010)	Medication preparation	Medical and surgical ICU	NIZ (S−)	Number of interruptions	two-tailed independent t test
Observational–cross-sectional	Bennett et al. (2006)	Medication administration	General medical unit	Medication CartDecentralized bedside medication	Number of interruptions (distributed 64% lower than centralized)	Qualitative analysis
Observational–cross-sectional	Duruk et al. (2016)	Medication preparation process	Hospital	Joined medication preparation room	Frequency and duration of interruptions	Discriptive analysis, Mann-Whitney U-test, and spearman correlation
	Antoniadis et al. (2014)	Surgical flow	Surgical clinics	Work environment-related (related to OR environment, e.g., diathermy pedals in the wrong place)(S)	Frequency and level of interference of interruptions	Spearman Rho correlation, c2 test, and ANOVA.
	Blikkendaal et al. (2017)	Surgical flow	Surgery suite	Conventional OR VS. integrated OR(NS)	Surgical flow disturbances	Chi-square analysis
	Smeulers et al. (2013)	Medication administration		Ward environment: noise and conversation	Frequency and duration of interruptions	Descriptive statistics, non-parametric Mann-Whitney U tests, and qualitative analysis
	Neyens et al. (2019)	Surgical flow	Operating room	OR layouts (divided into transitional and functional zones)(S)	Frequency of flow disruptions’ type	Logistic regression and Quasi-Poisson regression models
	Cohen et al. (2016)	Surgical procedure	Hospital	Equipment issuesOR Layout	Frequency and duration of flow disruptions	Discriptive analysis, chi-square tests, and one-way MANOVA
	Hall et al. (2010)		Medical and surgical unit	Environmental noise (busy nursing station)	Interruption	Discriptive analysis, qualitative analysis, and t-test
	Bayramzadeh et al. (2018)	Surgical flow	Operating room	Adjacencies of functionally different areas within operating rooms (ORs) (58.3% of all flow disruption occurred in transitional zones)	Movement pattern of nurses.Interruption pattern in different zones	Spaghetti and bubble diagrams, and discriptive analysis
Observational–cross-sectional	Mihandoust et al. (2024)	–Admission and intubation–Cardiac arrest–ECMO cannulation	Pediatric intensive care unit (PICU)	Room size and spatial constraints (+)	Flow disruptions (FDs)	Descriptive statisticsQualitative coding
				Functional zones design (+)
				Electrical outlet location
				Equipment positioning (+)
				Clutter and congestion (+)
	(Bennett et al., 2006)	Medication process	Medical unit	Medication cart vs. Decentralized cupboard system (time and number of interruptions decreased in Decentralized system)	Time spent preparing and administering medication	Time studyFrequency countsComparative analysisEfficiency calculationsThematic analysis
					Time looking for missing doses
					Number of interruptions per shift
					Technician time spent on bin exchange
Case study	Zadeh et al. (2012)		Acute care nursing unit	Noise, traffic density, location, distance and connectivity between support functions areas centralized vs. decentralized design, and visibility	Interruption events	Numerical analysis on the visual model, and justified permeability diagram (JPD)
Critical ethnography	Brixey et al. (2008)	General	ED trauma section	Physical environmental design	Physicians and Registered Nurses interruptions	Qualitatve analysis: Hybrid Method
		General	ED trauma section	Unavailable supplies	Physicians and Registered Nurses interruptions	Qualitatve analysis: Hybrid Method
	Liu et al. (2014)	Medication communication processes	Acute care unit (medical ward)	Medication room configuration: Locked vs. open medication roomStaff working spaces: individually designated spaces vs Central staff station accessible for all staff	Ward 1 Design Issues: (1) Pharmacist's desk near entrance increased visitor interruptions. (2) Multiple medication preparation locations increase interruptions. (3) Lack of bedside workspace and medication room space forced inefficient workflows.Ward 2 Design Issues: (1) Staff avoided using bedside spaces, preferring the central station for team collaboration. (2) Single Pyxis created traffic. (3) Relocated medication drawers and centralized documentation disrupted workflow	NA

EMAR: electronic medication administration record. NIZ: no-interruption-zone. eMDS: evidence-based structured electronic minimum data set.

Terminology Definitions

Interruption and disruption terms were defined distinctly but used interchangeably (see Table 2). Among reviewed studies, 13 used “interruption,” seven used “flow disruption,” and eight used combinations of interruption and distraction. Six studies provided no terminology definitions. Table 2 presents the complete range of terminology definitions used across different healthcare settings, demonstrating the variation in how researchers conceptualize and operationalize these concepts. These terms varied in their operational variables, categories, and overlaps. Hall et al. (2010) also defined additional terms: intrusions (unexpected interruptions causing temporary stops), breaks (planned/spontaneous pauses), and discrepancies (inconsistencies between knowledge and observations). Conrad et al. (2010) defined necessary interruptions as interruptions adding value to patient care, customer service, or nurse satisfaction that could not be postponed.

Table 2.

Terminology Definitions.

Term	Setting	Citation	Definition
Interruption	Surgical unit	Tomietto et al. (2012)	A pause in ongoing activity, which can be due to internal factors (such as a nurse's decision) or external factors (such as environmental stimuli).
	Medical and surgical unit	Zadeh et al. (2012)	Actions by other staff or environmental occurrences that disrupt the performance of a nursing process activity.
	Medical and surgical unit	Huckels-Baumgart et al. (2021)	Sound or conversation that causes a break in the human activity performance initiated by an internal or external source resulting in the nurse pausing their primary task to respond to an external stimulus.
	ICU	Spooner et al. (2019)
	Emergency department	Bennett et al. (2006); Brixey et al. (2008)
	Emergency department	Joshi et al. (2021); Joshi et al. (2023)	Event that is occurring in the surrounding area (outside stimulus) that diverted the staff’s concentration away from the primary task.
	Cardiac and thoracic step-down unit	Freeman et al. (2013)
	Progressive cardiac care unit (PCCU)	Flynn et al. (2016)	Event that pauses the process, causing the nurse to stop the task at hand and then return to it after addressing the disruption caused by another task or event.
	Acute medical Admissions unit	Relihan et al. (2010)	An external factor causing the cessation of productive activity before a current task is complete.
	Pediatric post anesthesia care unit	Filer et al. (2017)	Break of attention to the task that can be physical or verbal, self-interruption, or environmental stimuli.
	Geriatric unit	Mortaro et al. (2019)	Primary task cessation that is not directly relevant to.
Flow disruption	Operating room	Joseph et al. (2019)	Events cause pause or break in the primary activity.
		Bayramzadeh et al. (2018)	Events hinder or interrupt the activity performance flow leading to distraction or major disruption or sentinel events.
		Blikkendaal et al. (2017)	Stimuli distracting one or more members of team
		Cohen et al. (2016); Neyens et al. (2019)	Events that may impede the ability of the team to mentally focus on critical tasks.
		Palmer et al. (2013)	Events like seemingly trivial events, such as tripping over a cord or spilling saline.
	ICU	Mihandoust et al. (2024)	Flow Disruption is defined as deviations from the natural progression of a procedure that potentially compromises safety or efficiency.
Distraction and interruption	Medical and surgical unit	Hall et al. (2010)	Psychological reactions triggered by external stimuli or secondary activities (not related to the primary task) interrupt nurses’ concentration on primary tasks.
	Hospital setting	Smeulers et al. (2013)	Event initiated by other professional(s) or something else, and when a nurse interrupted him/herself.
	Pediatric acute ward	Colligan et al. (2012)	Intrusion of a secondary unplanned and unscheduled task into a primary task that can be endogenous (self-initiated) or exogenous (initiated by someone else).
	Operating room	Antoniadis et al. (2014)	Events that potentially distract a team or member from a primary task or momentarily interrupt it.
	Acute inpatient unit	Kavanagh and Donnelly (2020)	Anything that disrupts an individual from the current task by diverting one’s attention from the cognitive task.
	Medical unit	Yoder et al. (2015)
	Hospital setting	Pape (2013); Pape et al. (2005)	Anything that draws away, diverts, or disturbs attention from achieving a goal.

Research Designs

The reviewed studies fall into two categories: observational and experimental. Observational studies (n = 11) examined the natural occurrence of interruptions without introducing any interventions. These studies provided valuable insights into the characteristics and contributing factors of interruptions. Experimental studies included interventional (n = 13) and quasi-experimental designs (n = 3), evaluating intervention effectiveness on reducing interruptions. Table 1 categorizes each study by design type and shows the relationship between research design and the types of environmental interventions examined.

Data Collection Methods

Studies employed various methods including field observation (n = 27), video observation (n = 7), individual interviews (n = 3), focus groups (n = 3), surveys (n = 8), and self-reporting (n = 5). Observation was the most common method, conducted by one or more observers. Observation sample units varied across studies, including observation hours (n = 12, 8–2880 h, mean = 64.33, median = 31.25, SD = 85.26 excluding 2880 as outlier), number of observations (78, 99, 122, and 1158), observed participants (n = 9, 13–360, mean = 36, median = 27.5, mode = 24, SD = 21.71 excluding 360 as outlier), and processes (medication rounds, preparation, surgeries, handovers). The specific procedures and data collection approaches for each study are detailed in Table 1. Observed procedures ranged from 10–277 (n = 13, median = 44, mode = 32, mean = 72.75, SD = 70.69). For video observations, the number of observed procedures ranged from 10 to 40 (n = 4, mean = 28.25, median = 31.25, SD = 13.12) with observation hours between 1.25 and 103.75 (n = 5, mean = 27.06, median = 35, SD = 17.25, excluding outlier).

Data Analysis Methods

Various analysis methods were used across studies based on their goals and methodologies. These included descriptive analysis, mean comparison, Student's t-test, Mann-Whitney U test, chi-square test, qualitative analysis, regression models, and ANOVA. Table 1 shows the specific analytical approaches employed by each study and how these methods align with different research questions and study designs. Descriptive analysis summarized data and provided results overview (Klejka, 2012; Mihandoust et al., 2024; Pape, 2013). Mean comparison compared outcomes between groups (Klejka, 2012). Student's T-test and Mann-Whitney U test compared group differences (Colligan et al., 2012; Filer et al., 2017; Tomietto et al., 2012). Chi-square tests examined relationships between categorical variables (Blikkendaal et al., 2017; Cohen et al., 2016). Qualitative analysis provided deeper insights into interruption reasons and impacts (Antoniadis et al., 2014; Mortaro et al., 2019). Regression models and ANOVA analyzed multiple factors’ impact on outcomes (Joshi et al., 2021; Neyens et al., 2019).

Variables

Study variables are categorized into dependent variables and independent variables (physical environmental), which were analyzed to understand the impacts on healthcare workflow and interruptions. Table 1 provides a comprehensive overview of study designs, environmental variables, outcome measures, and analytical approaches across all included studies.

Dependent Variables

These measured intervention effectiveness in reducing interruptions and distractions, including metrics such as number (Klejka, 2012; Mortaro et al., 2019; Pape et al., 2005; Spooner et al., 2019) and duration of interruption, percentage of interruption (Huckels-Baumgart et al., 2021; Tomietto et al., 2012), interruption-free preparation time (Huckels-Baumgart et al., 2021), and interruption sources (Mortaro et al., 2019; Spooner et al., 2019). The relationship between environmental variables and these outcome measures is systematically presented in Table 1, showing both positive and negative correlations across different studies.

Independent Variables: Physical Environment Factors

These features can be grouped into several categories including visual signaling elements, designated quiet areas, physical barriers and separations, workspace design and layout, and traffic flow and spatial arrangements.

Visual Signaling Elements. Six studies employed signage in areas where interruption minimization was essential (Conrad et al., 2010; Filer et al., 2017; Freeman et al., 2013; Pape, 2013; Pape et al., 2005; Williams et al., 2014). These investigations, conducted across diverse healthcare settings, utilized signage to mitigate interruptions during various clinical procedures, including medication processes (n = 5) and pre-anesthesia assessment (n = 1). All studies consistently demonstrated that signage was associated with reduced interruptions and distractions (see Table 3 for a comprehensive summary of effectiveness across all physical environmental factors).

All studies consistently demonstrated that signage was associated with reduced interruptions and distractions.

Table 3.

Environmental Variables’ Main Findings.

Physical Factor	Studies and Citations	Key Findings	Effectiveness	Additional Notes
Visual Signaling Elements	Six studies: Conrad et al. (2010); Filer et al. (2017); Freeman et al. (2013); Pape (2013); Pape et al. (2005); Williams et al. (2014)	All studies showed signage associated with reduced interruptions and distractions	✓ Consistently effective	Used in medication processes (n = 5) and pre-anesthesia assessment (n = 1); often combined with other interventions
No-Interruption Zones (NIZ)	Nine studies: Anthony et al. (2010); Filer et al. (2017); Flynn et al. (2016); Freeman et al. (2013); Klejka (2012); Mortaro et al. (2019); Pape (2013); Williams et al. (2014); Yoder et al. (2015)	Most studies showed significant reductions in interruption frequency	✓ Mostly effective	Created through signage, physical barriers, or floor tape; Yoder et al. (2015) showed increased interruptions due to heightened awareness
Physical Barriers	One study: Colligan et al. (2012)	Frosted glass walls significantly reduced interruption rate per minute	✓ Effective for frequency	No effect on interruption duration or distribution of types; maintained sight lines to patient rooms
Dedicated Medication Rooms	Eight studies: Conrad et al. (2010); Duruk et al. (2016); Huckels-Baumgart et al. (2021); Joshi et al. (2021); Joshi et al. (2023); Kavanagh & Donnelly (2020); Liu et al. (2014); Tomietto et al. (2012)	Consistently fewer interruptions in dedicated rooms vs. open/central areas	✓ Consistently effective	Conflicting results on interruption duration: Tomietto et al. (2012) found reduction, Huckels-Baumgart et al. (2021) no effect, Kavanagh and Donnelly (2020) increase
Workstation Enclosure Levels	Joshi et al. (2021); Joshi et al. (2023)	Open > Semi-open > Enclosed workstations for interruption frequency	✓ More enclosure = fewer interruptions	Joshi et al. (2023): High isovist connectivity (IC) locations had highest interruption frequency
Workstation Location	Two studies: Bennett et al. (2006); Spooner et al. (2019)	Mixed results for central vs. bedside configurations	⚬ Mixed effectiveness	Spooner et al. (2019): non-significant reduction; Bennett et al. (2006): decentralized systems had fewer interruptions
Spatial Configuration (OR)	Five studies: Bayramzadeh et al. (2018); Blikkendaal et al. (2017); Cohen et al. (2016); Conrad et al. (2010); Neyens et al. (2019)	Variable results across different OR designs and layouts	⚬ Variable effectiveness	Bayramzadeh et al. (2018): 58% of interruptions in transitional zones; Cohen et al. (2016): different staff experienced different layout issues
Traffic Flow Patterns	Joseph et al. (2019); Zadeh et al. (2012)	High traffic areas (corridors, nurses’ stations) have highest interruption probability	⚬Observational finding	Joseph et al. (2019): Traffic density, transitions, and movement patterns correlate with disruption rates
Environmental Noise	Three studies: Hall et al. (2010); Smeulers et al. (2013); Zadeh et al. (2012)	Ward noise contributes to interruption events (25% of non-verbal interruptions)	× Negative impact	Smeulers et al. (2013): Sources include pagers, conversations, housekeeping, pharmacy activities
Design Centralization	Zadeh et al. (2012); Liu et al. (2014)	Centralized vs. decentralized design affects interruption patterns	⚬ Context dependent	Distance between support areas and connectivity influence
Supply Availability	Brixey et al. (2008)	Unavailable supplies contributed to 12.19% of physicians and 14.2% of nurse interruptions	× Negative impact	Physical environment factors overall accounted for ∼18% of interruptions

Several studies implemented signage in combination with other physical environment interventions, such as quiet zones and no-interruption zone (NIZ) (Filer et al., 2017; Pape, 2013; Williams et al., 2014), or in conjunction with non-physical environment interventions, including protocols, safety vests, and education programs. These combined approaches resulted in decreased interruption rates (Conrad et al., 2010; Pape, 2013; Williams et al., 2014).

Designated Areas. Nine studies employed NIZ, quiet zones, or safe zones created through signage, physical barriers, or floor tape (Anthony et al., 2010; Filer et al., 2017; Flynn et al., 2016; Freeman et al., 2013; Klejka, 2012; Mortaro et al., 2019; Pape, 2013; Williams et al., 2014; Yoder et al., 2015). All studies except Anthony et al. (2010) and Filer et al. (2017) implemented NIZ in conjunction with non-physical environmental interventions, including safety vests, education, and standardized protocols for medication processes.

Most studies demonstrated significant improvements in outcome variables, including interruption frequency. However, Yoder et al. (2015) observed increased interruptions following intervention implementation, potentially attributable to heightened awareness of interruptions, inquiries about safety vests, and non-adherence to safe zone protocols. Table 3 provides a detailed comparison of the effectiveness ratings for NIZ interventions alongside other physical environmental factors. Mortaro et al. (2019) demonstrated that NIZ implementation reduced interruptions per patient and per drug administration, decreased time wasted due to interruptions, increased postponement of interruptions, and enhanced nurses’ attention to primary tasks. Filer et al. (2017) reported that while NIZ implementation reduced the mean number of interruptions per observation, effects varied across interruption types; specifically, NIZ significantly reduced verbal and physical interruptions but had non-significant effects on self-interruptions. This study also demonstrated that NIZ significantly increased time between interruptions overall, particularly between physical and verbal interruptions, with non-significant effects on intervals between self-interruptions.

Physical Barriers and Separations. Colligan et al. (2012) implemented frosted glass wall barriers around vulnerable areas to create visual and physical separation while maintaining sight lines to patient rooms and staff workplaces, simultaneously allowing visibility of nursing staff. The results of this intervention demonstrated a significant reduction in interruption rate per minute; however, no significant effects were observed regarding the duration of interruption events or the distribution of interruption types (self-initiated versus other-initiated, direct patient care versus indirect patient care). As shown in Table 3, physical barriers represent one of the less frequently studied but consistently effective interventions.

Workstation Layout Design and Location. Eight studies evaluated interruption measures across different medication room or workstation configurations, dedicated rooms (referred as separate room, quiet medication room, and safe space) vs central, semi-open, or open area (Conrad et al., 2010; Duruk et al., 2016; Huckels-Baumgart et al., 2021; Joshi et al., 2021; Joshi et al., 2023; Kavanagh & Donnelly, 2020; Liu et al., 2014; Tomietto et al., 2012). All these studies focused on medication room configurations and consistently reported fewer interruptions in dedicated medication rooms. Conrad et al. (2010) evaluated the medication room design features, such as organization of the medication room, ergonomic safety, and removing the charting station, and found a decrease in medication administration time and number of interruptions. Joshi et al. (2021) evaluated interruption events during handoffs at physician workstations with various levels of enclosure (open, semi-open, and enclosed). They found that physicians experienced significantly more interruptions in open workstations compared to semi-open workstations, which in turn had more interruptions than enclosed workstations. Studies show conflicting results on these physical environmental features’ impact on interruption duration. Tomietto et al. (2012) found a significant reduction, Huckels-Baumgart et al. (2021) reported non-significant effects, and Kavanagh and Donnelly (2020) noted an increase in interruption duration. These features also affected other outcomes—interruption percentage during different tasks (Tomietto et al., 2012), increase in interruption-free preparation time (Huckels-Baumgart et al., 2021), and decrease in medication administration time (Conrad et al., 2010). As summarized in Table 3, dedicated medication rooms consistently showed effectiveness across studies, though results varied for interruption duration.

Joshi et al. (2023) measured IC across enclosed, semi-open, and open workstations and indicated that interruption frequency was highest in high IC locations (open workstations). Duruk et al. (2016) conducted a descriptive cross-sectional study to identify factors causing medication preparation interruptions and found that the lack of dedicated preparation spaces significantly contributed to interruptions. A study by Liu et al. (2014) conducted a critical ethnography study to compare medication communication across two hospital wards with different spatial configurations and showed that the workstation near the entrance, visibility to the workstation, designated working area, traffic in the medication room, and an enclosed medication room can affect interruption events.

Two studies evaluated interruption events across different workstation locations, comparing central versus bedside configurations (Bennett et al., 2006; Spooner et al., 2019). Table 3 shows that workstation location interventions had mixed effectiveness compared to other physical environmental factors. Spooner et al. (2019) reported a non-significant reduction in interruption frequency following an intervention that relocated handover from a central location to the bedside, incorporated a structured electronic minimum data set (eMDS) to streamline information transfer, and provided education and implementation support for nursing staff. Bennett et al. (2006) compared interruption patterns between medication cart and bedside medication systems, demonstrating that decentralized medication systems were associated with fewer interruptions and reduced time spent on medication preparation and distribution activities.

Spatial Configuration. Five studies examined the impact of spatial configurations and layouts on interruptions (Bayramzadeh et al., 2018; Blikkendaal et al., 2017; Cohen et al., 2016; Neyens et al., 2019), all of which focused on surgical interruptions and OR design. Blikkendaal et al. (2017) found no significant differences in surgical flow disturbances between two types of conventional cart-based ORs (operating rooms in which surgical and imaging equipment are brought in on mobile carts) and dedicated integrated ORs (fully integrated surgical suites where equipment and systems are built in). Neyens et al. (2019) demonstrated significant differences in circulating nurse work patterns and flow distribution across three different ORs. Similarly, Bayramzadeh et al. (2018) examined variations in nurses’ movement patterns and flow disruptions across three distinct ORs, finding comparable movement and flow patterns across these units and revealing that 58% of interruptions occurred in transitional zones. Cohen et al. (2016) identified the frequency and nature of flow disruptions in the OR relative to anesthetists, circulating nurses, and perfusionists. They categorized flow disruptions into six major types: communication (verbal and non-verbal), usability, layout, environmental hazards, interruptions, and equipment failure. Their analysis revealed that anesthetists and perfusionists experienced more layout-related issues, while circulating nurses encountered more coordination disruptions and interruptions.

Traffic Flow and Spatial Arrangements. Joseph et al. (2019) investigated the relationship between traffic-related factors, movement patterns, and interruption rates. Their findings revealed that while traffic-related factors did not significantly correlate with major flow disruptions. Several variables, including the average density of transitional zones, the frequency of transitions to and from individual zones, and the total number of transitions within the OR, showed a significant positive relationship with disruption rates. Complementing these findings, a case study conducted by Zadeh et al. (2012) demonstrated that caregiver movement occurs most frequently in patient corridors and at nurses’ stations, suggesting these areas present the highest probability for interruption events.

Other Factors. Zadeh et al. (2012) identified several environmental factors that may influence interruption events, including noise, location, distance between support function areas, centralization of design, and visibility. Additional research by Smeulers et al. (2013) and Hall et al. (2010) demonstrated that ward noise specifically contributes to interruption events. Table 3 categorizes environmental noise as having a negative impact on interruption rates, consistent across the limited studies that examined this factor. In their study, Smeulers et al. (2013) determined that 25% of non-verbal interruptions stemmed from the ward environment, such as noise from pagers, nearby conversations, housekeeping activities, and pharmacy staff conducting inventory management. The environmental noise typical of busy nursing stations with multiple service providers interacting simultaneously creates distractions that can lead to gaps in care delivery (Hall et al., 2010). In an examination of workflow interruptions, Brixey et al. (2008) found that physical environment and design factors accounted for 17.98% of physician interruptions, while unavailable supplies represented 12.19%. These same factors contributed to 18% and 14.2% of nurse interruptions, respectively. Besides, Zadeh et al. (2012) used a justified permeability diagram in five case studies and reported variables such as distance and connectivity between support function areas and centralized versus decentralized as influential features.

The effectiveness of physical environment interventions varies across healthcare settings. Table 1 details the specific environmental interventions, outcome variables, and their relationships across different healthcare settings and study designs. In medication preparation settings, dedicated medication rooms consistently showed reduced interruptions across eight studies (Conrad et al., 2010; Duruk et al., 2016; Huckels-Baumgart et al., 2021; Joshi et al., 2021; Joshi et al., 2023; Kavanagh & Donnelly, 2020; Liu et al., 2014; Tomietto et al., 2012), and nine studies successfully implemented NIZ or quiet zones primarily in medical units (Anthony et al., 2010; Filer et al., 2017; Flynn et al., 2016; Freeman et al., 2013; Klejka, 2012; Mortaro et al., 2019; Pape, 2013; Williams et al., 2014; Yoder et al., 2015). However, in ORs, interventions focused on spatial configuration and traffic flow management, with Bayramzadeh et al. (2018) finding that 58% of interruptions occurred in transitional zones. Emergency department studies examined workstation design, with Joshi et al. (2021, 2023) demonstrating that physicians experienced significantly more interruptions in open workstations compared to semi-open and enclosed configurations. The varied analytical approaches and outcome measurements across studies (detailed in Table 1) may contribute to these mixed findings. Table 3 provides a comprehensive summary of how different physical environmental factors perform across various healthcare settings, highlighting the context-dependent nature of intervention effectiveness. The variation in applicable interventions across settings reflects different operational characteristics, with some environments more conducive to static barriers and designated quiet areas, while others require focus on workflow patterns and spatial arrangements.

Discussion

This scoping review reveals key findings about built environmental features’ impact on healthcare interruptions and clinicians’ movement patterns. The synthesis of 33 empirical studies identified physical environmental factors that affect interruption events and significant research gaps requiring further investigation.

Methodological Considerations and Limitations

A notable finding is the inconsistent definitions of interruption-related terminology and measurements across studies. While 13 studies used the term “interruption,” seven used “flow disruption” and eight used interruptions and distractions terms interchangeably, with six studies providing no definitions at all. Additionally, some studies focused on interruption frequency, others examined duration, type, or impact. This variability creates challenges in comparing results across settings and contexts. The operational definitions ranged from considering interruptions as pauses in activity to more complex characterizations involving cognitive disruptions and task cessation. The methodological approaches also varied considerably. Most studies (27 out of 33) relied on observational methods, with few employing rigorous experimental designs. The predominance of observational and quasi-experimental designs limits causal inference. More experimental interventions using rigorous quasi-experimental designs are needed to establish the effectiveness of specific interventions. Moreover, the lack of long-term follow-up studies presents a gap in understanding the sustainability and scalability of environmental interventions.

Environmental Interventions and Their Effects

The review reveals promising environmental interventions for reducing healthcare interruptions. NIZ, the most frequently evaluated intervention across nine studies, consistently reduced interruption rates, though Yoder et al. (2015) highlighted implementation challenges such as heightened interruption awareness and poor protocol adherence that may limit effectiveness. Workstation design emerged as another significant factor, with enclosed medication rooms demonstrating consistent reductions in interruption frequency, albeit with variable effects on interruption duration, suggesting physical barriers primarily prevent interruptions rather than altering their temporal characteristics. The spatial positioning of workstations also appears influential, as our analysis indicates centralized stations often introduce more distractions compared to decentralized configurations that facilitate reduced interruption events.

Other studied factors include spatial configurations in five studies that primarily focused on surgical environments. In surgical environments, the evidence regarding optimal OR configurations remains inconclusive. The approach of measuring visual connectivity through IC scores (Joshi et al., 2023) offers promising insight into how spatial visibility impacts interruption dynamics, with higher visual exposure correlating with increased interruption frequency. Limited studies have evaluated the effects of traffic flow, spatial arrangements, physical barriers, and noise on healthcare settings, highlighting the need for further research into these features. Besides, future interventional and observational studies could help confirm the relationship between these spatial variables such as distance and connectivity between support function areas and centralized versus decentralized and interruption events reported by Zadeh et al. (2012).

Conflicting Findings

Design recommendations vary across studies, from fully enclosed rooms to semi-enclosed compromises at the cost of task duration and interdisciplinary communication that suggest optimal solutions depending on institutional priorities and workflow requirements. The literature reveals complex relationships between workspace design and healthcare collaboration. While enclosed workstations improved physician collaboration in Joshi et al.'s (2021) study, other research noted potential communication barriers between disciplines such as isolation issues (Tomietto et al., 2012) and balancing between need for privacy and teamwork (Kavanagh & Donnelly, 2020). These divergent findings suggest that the relationship between spatial design and collaboration is complex and may depend on specific contextual factors. Tomietto et al.'s (2012) findings on NIZ demonstrate that intervention effectiveness varies by interruption source, suggesting the need for nuanced design approaches that address both patient and staff-initiated interruptions.

Integration With Non-Physical Interventions

Physical environment modifications appear most effective when implemented alongside operational protocols and staff education. Most studies show a significant reduction in interruptions combining physical features with organizational strategies such as standardized protocols, education programs, and communication policies. This suggests that comprehensive approaches addressing both environmental and behavioral factors yield the best outcomes.

Physical environment modifications appear most effective when implemented alongside operational protocols and staff education.

Identified Gaps and Future Directions

Several important gaps in the current literature were identified. First, there is limited research in high-stakes environments such as ICUs, with only three studies (Anthony et al., 2010; Mihandoust et al., 2024; Spooner et al., 2019) examining intensive care settings. Second, few studies have investigated how multiple environmental features might work synergistically, suggesting the need for comprehensive approaches combining various design strategies. Third, limited studies have evaluated the impact of layout features and interruption event characteristics. Fourth, limited research has explored nurses’ lived experiences using qualitative methods such as interviews or focus groups. Future work could include a meta-analysis stratified by setting type and acuity level. The fact that only six studies were conducted within environmental design fields indicates a critical need for focused research on how architectural and spatial elements influence healthcare interruptions.

Only six studies were conducted within environmental design fields indicates a critical need for focused research on how architectural and spatial elements influence healthcare interruptions.

Design Implications

The synthesis of research on built environmental features and healthcare interruptions reveals complex relationships that demand careful consideration in healthcare facility design. The effectiveness of environmental interventions varies significantly across healthcare settings, emphasizing the need for context-specific rather than universal design solutions. These physical modifications prove most effective when implemented alongside operational protocols and staff training, indicating the importance of a comprehensive approach to interruption management.

The effectiveness of environmental interventions varies significantly across healthcare settings, emphasizing the need for context-specific rather than universal design solutions.

Study Limitations

This review has several limitations. First, the inclusion of only English-language publications may have missed relevant studies from other regions. Second, the heterogeneity in study designs and outcome measures made it difficult to conduct more rigorous comparative analyses. Third, while a narrower scope may have improved the flow of the review, we intentionally adopted a broader scope to capture a more comprehensive body of previous research. However, this approach introduces limitations related to the homogeneity of healthcare settings and acuity levels, which may affect the generalizability of the findings. Finally, the review's focus on peer-reviewed literature may have excluded relevant findings from gray literature or unpublished studies. However, this comprehensive review provides valuable insights into the role of building environmental features in managing interruptions in healthcare settings while highlighting critical areas for future research.

Conclusion

Significant research gaps exist in understanding how built environments affect healthcare interruptions, particularly in ICUs. More research is needed on how multiple design strategies work together and impact interruptions from an environmental design perspective. While environmental modifications can effectively manage interruptions, success depends on thoughtful implementation considering the complex interactions between physical space, workflow, and communication requirements. Future research should address these gaps and develop standardized approaches to measuring physical design interventions’ impact on healthcare interruptions.

Implications for Practice

Implement visual signaling and designated quiet zones through clear signage and NIZs for critical clinical tasks such as medication preparation and administration.

Prioritize enclosed or semi-enclosed workspaces such as dedicated medication rooms for high-risk activities like medication preparation and physician handoffs.

Combine physical environmental modifications with operational protocols, staff training, and communication strategies for comprehensive interruption reduction.

Develop context-specific design solutions based on the particular healthcare setting, workflow patterns, and interruption types rather than one-size-fits-all approaches.

Position critical workstations strategically to minimize visual exposure while maintaining necessary sight lines for patient safety and team coordination.

Footnotes

ORCID iDs

Homa Pesarakli, PhD

Farzan Sasangohar, PhD

Zhipeng Lu, PhD

Author Contributions

Homa Pesarakli: Conceptualization, Protocol Development, Literature Search, Study Selection, Data Charting, Data Analysis, Writing – Original Draft.

Farzan Sasangohar: Conceptualization, Supervision, Writing – Review and Editing.

Amir Hossein Javid: Literature Search, Study Selection, Data Charting.

Zhipeng Lu: Supervision, Writing – Review and Editing.

All authors have read and approved the final version of the manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Joseph G. Sprague New Investigator Award, The Center for Health Design.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability

The data supporting the findings of this scoping review consists of published articles and publicly available sources, all of which are cited in the reference list. Additional data extraction tables and materials used during the review process are available from the corresponding author upon reasonable request.

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