Presentation
The Built Environment Influences Team Processes and Individual Wellbeing Through Distinct Mechanisms in Operating Rooms
DescriptionBackground: Resilience has allowed for the continued evolution of the built environment. Hollnagel (2014) has discussed in depth the potential relationships between resilience engineering and the built environment noting the importance of the built environment to aid in the ability to recognize and respond to threats and disruptions. Within the resilience engineering literature, research on resilience and the built environment has predominantly centered on natural disasters, with comparatively limited attention to its relevance in healthcare contexts. However, within architecture, the field of evidence-based design has begun examining the connection between the built environment and factors related to resilience engineering such as adaptation and flexibility. Notably, Ransolin et al. (2022) published a systematic review of the evidence-based design literature examining the influence of the built environment on resilient healthcare. This review highlighted which design principles coordinate with the five guidelines noted in resilience engineering for coping with complexity.
Our previous work (Watral et al., 2024) examined the overall effect the layout of different operating rooms had on resilience performance of the individual and OR micro-organization (i.e. team) as well as other proxies of resilient performance including teamwork, communication, burnout, and wellbeing. Using Ransolin et al. (2024) resilience engineering informed design prescriptions and our results from functional scenario analysis, surveys, and focus groups, we made conceptual conclusions between the built environment and resilience. Namely, the layout and modernization of the OR space appears to have affected both team and individual resilience as well as communication and well-being. However, this finding was not supported in the functional scenario analysis as the most recently updated OR performed the worst on many of the analysis criteria.
While our initial findings suggest relationships between the built environment and resilience, our small sample size limited our ability to quantify specific pathways. To better understand the relationship between resilient performance, wellbeing, and the built environment, we repeated our data collection process with three ORs in a different hospital. Using partial least squares structural equation modeling (PLS-SEM), we were able to test competing theoretical pathways and identify specific mechanisms through which environmental design influences individual and team outcomes.
Methods: This study was carried out in three ORs on the same floor of the hospital. Clinical staff who worked in one or more of the ORs of interest were recruited to participate in this study (n=117). Each participant completed a survey that examined five key domains: perceptions of the built environment, team resilience, individual resilience, teamwork and communication, and wellbeing. All questions were answered on a 5-point Likert scale.
Complete cases (n=113) were then used to conduct the PLS-SEM analysis. PLS-SEM was selected due to its suitability for exploratory research with latent constructs, adequate performance with smaller sample sizes, and focus on predictive accuracy rather than model fit. Six competing theoretical models examined different mediation pathways from the built environment to wellbeing: (1) individual resilience mediation, (2) sequential team mediation, (3) direct team effects, (4) team resilience only mediation, (5) teamwork only mediation, and (6) multiple independent pathways model, where the built environment simultaneously influences wellbeing through individual resilience, team resilience, and teamwork quality without sequential relationships between mediators. Model selection was based on R2 values for wellbeing outcomes, with bootstrap procedures (n=1000) used to assess path significance.
Results: The multiple independent pathways model demonstrated the highest predictive accuracy for wellbeing (R2 = .45), indicating that the built environment influences well-being through multiple independent pathways. This model revealed several significant pathways. The built environment significantly predicted all mediating constructs: individual resilience (β = .52), team resilience (β = .54), and teamwork (β = .57). The built environment also had a significant direct effect on wellbeing (β = .51). Additionally, individual resilience significantly influenced wellbeing (β = .24). Team resilience and teamwork did not significantly predict wellbeing, however. These results demonstrate that the design of the physical environment affects both individual and team-level processes as well as staff wellbeing. Wellbeing appears to be mediated by individual psychological pathways, while team processes appear to be important intermediate outcomes affected by the built environment but do not serve as direct pathways to individual wellbeing.
Discussion: This study provides evidence that built environment design in OR settings influences both team functioning and staff wellbeing. The finding that perceptions of the physical workspace significantly predict all measured constructs (individual resilience, team resilience, teamwork, and wellbeing) demonstrates the broad organizational impact of environmental design decisions. However, the pattern of significant and non-significant pathways reveals important nuances about how these effects operate.
The lack of direct pathways from team-level processes to individual wellbeing suggests that environmental effects on individual outcomes operate through different mechanisms than those affecting team performance. The significant direct effect from built environment to wellbeing indicates that physical design features may influence staff wellbeing through multiple mechanisms beyond those measured in this study, potentially including comfort, wayfinding, or stress reduction.
These results have practical implications for OR design. Environmental interventions should target both team-level improvements and individual psychological factors. While better layouts can enhance team resilience and communication patterns, supporting individual wellbeing may require design features that directly address personal stress, cognitive load, and comfort rather than solely focusing on team coordination spaces.
Future work will examine which specific environmental features, such as layout configurations, lighting, and spatial organization, drive the direct pathways to wellbeing observed in this study. Understanding these direct environmental pathways will inform evidence-based design guidelines for optimizing both team performance and individual wellbeing in healthcare settings.
References
Hollnagel, E. (2014). Resilience engineering and the built environment. Building Research & Information, 42(2), 221–228. https://doi.org/10.1080/09613218.2014.862607
Ransolin, N., Saurin, T. A., Zani, C. M., Rapport, F., Formoso, C. T., & Clay-Williams, R. (2022). The Built Environment Influence on Resilient Healthcare: A Systematic Literature Review of Design Knowledge. HERD: Health Environments Research & Design Journal. https://doi.org/10.1177/19375867221077469
Ransolin, N., Saurin, T. A., Clay-Williams, R., Formoso, C. T., Rapport, F., & Cartmill, J. (2024). Beyond the operating room: Built environment design knowledge supportive of resilient surgical services. Engineering, Construction and Architectural Management. https://doi.org/10.1108/ECAM-10-2023-1063
Watral, A. T., Gill, S., Lim, L., Pulos, B., Thompson, B., McCoy, J., Phillips, M., Lopez, J. L., Potts, K., Young, S., Guyer, J., Evenson, L., Oloyede, A., & Blocker, R. (2025). Operating room built environment and One’s role in the OR impacts perceptions of resilience. Safety Science, 186, 106826. https://doi.org/10.1016/j.ssci.2025.106826
Our previous work (Watral et al., 2024) examined the overall effect the layout of different operating rooms had on resilience performance of the individual and OR micro-organization (i.e. team) as well as other proxies of resilient performance including teamwork, communication, burnout, and wellbeing. Using Ransolin et al. (2024) resilience engineering informed design prescriptions and our results from functional scenario analysis, surveys, and focus groups, we made conceptual conclusions between the built environment and resilience. Namely, the layout and modernization of the OR space appears to have affected both team and individual resilience as well as communication and well-being. However, this finding was not supported in the functional scenario analysis as the most recently updated OR performed the worst on many of the analysis criteria.
While our initial findings suggest relationships between the built environment and resilience, our small sample size limited our ability to quantify specific pathways. To better understand the relationship between resilient performance, wellbeing, and the built environment, we repeated our data collection process with three ORs in a different hospital. Using partial least squares structural equation modeling (PLS-SEM), we were able to test competing theoretical pathways and identify specific mechanisms through which environmental design influences individual and team outcomes.
Methods: This study was carried out in three ORs on the same floor of the hospital. Clinical staff who worked in one or more of the ORs of interest were recruited to participate in this study (n=117). Each participant completed a survey that examined five key domains: perceptions of the built environment, team resilience, individual resilience, teamwork and communication, and wellbeing. All questions were answered on a 5-point Likert scale.
Complete cases (n=113) were then used to conduct the PLS-SEM analysis. PLS-SEM was selected due to its suitability for exploratory research with latent constructs, adequate performance with smaller sample sizes, and focus on predictive accuracy rather than model fit. Six competing theoretical models examined different mediation pathways from the built environment to wellbeing: (1) individual resilience mediation, (2) sequential team mediation, (3) direct team effects, (4) team resilience only mediation, (5) teamwork only mediation, and (6) multiple independent pathways model, where the built environment simultaneously influences wellbeing through individual resilience, team resilience, and teamwork quality without sequential relationships between mediators. Model selection was based on R2 values for wellbeing outcomes, with bootstrap procedures (n=1000) used to assess path significance.
Results: The multiple independent pathways model demonstrated the highest predictive accuracy for wellbeing (R2 = .45), indicating that the built environment influences well-being through multiple independent pathways. This model revealed several significant pathways. The built environment significantly predicted all mediating constructs: individual resilience (β = .52), team resilience (β = .54), and teamwork (β = .57). The built environment also had a significant direct effect on wellbeing (β = .51). Additionally, individual resilience significantly influenced wellbeing (β = .24). Team resilience and teamwork did not significantly predict wellbeing, however. These results demonstrate that the design of the physical environment affects both individual and team-level processes as well as staff wellbeing. Wellbeing appears to be mediated by individual psychological pathways, while team processes appear to be important intermediate outcomes affected by the built environment but do not serve as direct pathways to individual wellbeing.
Discussion: This study provides evidence that built environment design in OR settings influences both team functioning and staff wellbeing. The finding that perceptions of the physical workspace significantly predict all measured constructs (individual resilience, team resilience, teamwork, and wellbeing) demonstrates the broad organizational impact of environmental design decisions. However, the pattern of significant and non-significant pathways reveals important nuances about how these effects operate.
The lack of direct pathways from team-level processes to individual wellbeing suggests that environmental effects on individual outcomes operate through different mechanisms than those affecting team performance. The significant direct effect from built environment to wellbeing indicates that physical design features may influence staff wellbeing through multiple mechanisms beyond those measured in this study, potentially including comfort, wayfinding, or stress reduction.
These results have practical implications for OR design. Environmental interventions should target both team-level improvements and individual psychological factors. While better layouts can enhance team resilience and communication patterns, supporting individual wellbeing may require design features that directly address personal stress, cognitive load, and comfort rather than solely focusing on team coordination spaces.
Future work will examine which specific environmental features, such as layout configurations, lighting, and spatial organization, drive the direct pathways to wellbeing observed in this study. Understanding these direct environmental pathways will inform evidence-based design guidelines for optimizing both team performance and individual wellbeing in healthcare settings.
References
Hollnagel, E. (2014). Resilience engineering and the built environment. Building Research & Information, 42(2), 221–228. https://doi.org/10.1080/09613218.2014.862607
Ransolin, N., Saurin, T. A., Zani, C. M., Rapport, F., Formoso, C. T., & Clay-Williams, R. (2022). The Built Environment Influence on Resilient Healthcare: A Systematic Literature Review of Design Knowledge. HERD: Health Environments Research & Design Journal. https://doi.org/10.1177/19375867221077469
Ransolin, N., Saurin, T. A., Clay-Williams, R., Formoso, C. T., Rapport, F., & Cartmill, J. (2024). Beyond the operating room: Built environment design knowledge supportive of resilient surgical services. Engineering, Construction and Architectural Management. https://doi.org/10.1108/ECAM-10-2023-1063
Watral, A. T., Gill, S., Lim, L., Pulos, B., Thompson, B., McCoy, J., Phillips, M., Lopez, J. L., Potts, K., Young, S., Guyer, J., Evenson, L., Oloyede, A., & Blocker, R. (2025). Operating room built environment and One’s role in the OR impacts perceptions of resilience. Safety Science, 186, 106826. https://doi.org/10.1016/j.ssci.2025.106826
Event Type
Oral Presentations
TimeTuesday, March 249:30am - 10:00am EDT
LocationMurray Hill West
Hospital Environments