What landscape elements are needed for hospital healing spaces? Evidence from an empirical study of 10 compact hospitals

Background

Modern medical research shows that a rationally planned landscape environment helps patients recover. With the growing number of hospital patients and the tightening of per capita medical landscape land, the use of limited landscape resources to serve patients has become challenging.

Methods

This study focused on the landscape environment of 10 hospitals in Guangdong Province, China. Based on the KANO theoretical model, a survey questionnaire was designed and administered to 410 participants. The data were analyzed based on demand attributes, importance, sensitivity, and group differences.

Results

The maintenance requirements were the most important item in the sensitivity ranking. Furthermore, the analysis revealed that the users need a safe, quiet, and private environment, owing to their higher requirements, including visual healing, rehabilitation activities, shading and heat preservation, and medical escort. Moreover, adolescents and older adult patients have common and contradictory environmental needs. For example, the landscape environment should provide both an active space and a quiet rehabilitation environment.

Conclusion

This study evaluates how landscape resources can be better utilized from the perspective of the user and expands the theory of healing landscapes, which has practical implications for hospital renovation and landscape environment strategies.

Evaluating Therapeutic Healthcare Environmental Criteria: Architectural Designers' Perspectives

This study presents architectural designers’ perception of the importance of healthcare environmental criteria in the implementation of user-centered, therapeutic hospital design. Architectural designers with over three years of professional experience (N = 182) in South Korea were surveyed using an empirical questionnaire. The extensive interviews of 15 hospital design experts followed to interpret the survey results and discuss the barriers and suggestions for the successful delivery of therapeutic healthcare design practice. Among the 27 variables selected from the preliminary literature review, factor analyses revealed seven important therapeutic environmental criteria (i.e., management, interior design, spatial quality, service, nature and rest, ambient indoor comfort, and social program and space; χ2 = 1783.088, df = 300, p < 0.001). Analyses of variance revealed the level of importance among these criteria related to respondents’ personal and professional characteristics. Significant differences were found for the variables from the management, interior design, and spatial quality factors in relation to the respondents sex and age. For the successful delivery of therapeutic healthcare design, the design experts highlighted the implementation of evidence-based design practice that integrates local and international knowledge from various hospital users and multi-disciplinary specialists participating in the healthcare design process.

Promoting Health and Behavior Change through Evidence-Based Landscape Interventions in Rural Communities: A Pilot Protocol

Rural communities in the United States have many public health issues, including a high prevalence of physical inactivity, obesity, and higher risks for major non-communicable diseases. A lack of safe and convenient places to exercise could intensify healthy lifestyle disparities. Individually adapted physical activity prescriptions at the primary level of healthcare could play a role in behavior change for rural residents. Healthcare professionals and designers created the rural wellness hub concept, which integrates walking trails and therapeutic landscape features on the clinic site, to support patient physician-prescribed activities and treatments. This research protocol reports the design and implementation of the rural wellness hub at a clinic in Clay County, West Virginia. Following a participatory, evidence-based landscape intervention (EBLI) protocol, 58 user representatives (patient = 49; clinic employee = 9) participated in the four-phase protocol: (1) pre-design survey, (2) design and development, (3) post-design interview, and (4) post-occupancy evaluation. Survey and interview data from all phases were collected and analyzed. The preliminary results indicate that the redesigned clinic campus could promote several health programs among local communities, with the benefits of walking trails, in particular, highlighted. The rigorous EBLI protocol could serve as a template for rural communities that seek to develop similar healthcare intervention programs.

Influence of Hospital Outdoor Rest Space on the Eye Movement Measures and Self-Rating Restoration of Staff

Objective

To investigate the effect of hospital outdoor rest space on the eye movement measures and self-rating restoration of staff.

Background

Relieving the pressure of hospital staff through exposure to hospital outdoor rest space is essential, but there is a scarcity of research on the impact of hospital outdoor rest space on the eye movement measures and self-rating restoration of staff, especially for large Chinese hospitals.

Methods

Cross-analysis was conducted based on the eye movement measures of 76 staff members obtained by eye movement tracking equipment in combination with the self-rating restoration scale and hospital outdoor rest space picture attributes (element proportion and position, brightness and saturation).

Results

The differences in eye movement measures of different staff attributes (occupation, age, and gender) were identified, and the effects of hospital outdoor rest space picture attributes on the eye movement measures and self-rating restoration scale of staff were summarized. A number of proposals were also formulated: hospital outdoor rest space should be set up close to the working area of the group of medical staff; attention should be paid to the actual needs of senior staff members and the work pressure of junior nurses; the exposure to natural environment should be increased and the proportion of hard artificial elements should be reduced; the natural environment should be placed in the visual center; the saturation and brightness of hospital outdoor rest space should be increased; and staff members should have access to the sky environment in a variety of ways.

Conclusion

The present study is an empirical study of evidence-based design on hospital outdoor rest space in China, and the results reveal the effects of hospital outdoor rest space on the eye movement measures and self-rating restoration of staff.

Factors Influencing the Visit to the Courtyard Gardens in Public Hospitals in Malaysia

Individuals mental health and well-being are significantly influenced by being in a natural setting and viewing nature. Hospital courtyard gardens (HCG) is a common feature found in public hospitals in Malaysia. Nevertheless, the factors influencing the visitation and non-visitation to the HCG are less understood. This study attempts to investigate factors influencing the visit and non-visitation of patients, staff and visitors to the HCGs in three Malaysian public hospitals. The research findings are instrumental to the architects and landscape architects to make necessary improvements for future HCG design and the hospital managers to enhance and retrofit the existing HCG.

Influence of Hospital Outdoor Space on Physiological Electroencephalography (EEG) Feedback of Staff

OBJECTIVES

To investigate the differences and relationships between different outdoor spaces of hospitals on the physiological electroencephalography (EEG) feedback (PEEGF) of staff.

BACKGROUND

Relieving the pressure of hospital staff is essential, and several studies have revealed that even short-term exposure to outdoor space has a decompression effect. Yet, the focus is scarcely centered on the differences and influential relationships between the PEEGF from different outdoor spaces where the staff spend time, particularly in large-scale hospitals in China.

METHODS

EEG measurement equipment was utilized to obtain the value of β wave (vβw) that represents the stress and anxiety of staff in three different outdoor spaces: open, traffic, and rest. On the basis of EEG data, correlation analysis was conducted in accordance with the proportion of space elements.

RESULTS

The proportion of natural elements, such as landscape (r = -.800** p=.005) and waterscape (r = -.782* p=.013), were negatively correlated with the vβw produced by staff, while the proportion of hard paving was positive (r = .817** p=.004) with more vβw produced by staff. In other words, the percentage of landscape and waterscape can reduce stress, while hard paving has the opposite effect. Further, there was a difference in the amount of vβw generated between nurses and administrators in the open space at the entrance of the main building (p = .043).

CONCLUSIONS

The present study revealed the influence of different outdoor space elements of the hospital on the physiological feedback of staff, demonstrated the practical necessity of evidence-based design, and proposed relevant optimization suggestions.

Small Garden, Big Impact: Emotional and Behavioral Responses of Visitors to a Rooftop Atrium in a Major Hospital

PURPOSE

To measure hospital visitors' satisfaction with a rooftop atrium and its resultant impact on the visitors' behavioral intentions toward the healing garden, the hospital, and overall satisfaction with the hospital.

BACKGROUND

There is a significant lack of empirical research that links the emotional and behavioral responses toward healing gardens and the hospitals providing them.

METHODS

A purposeful sample of 96 visitors to the healing garden in the rooftop atrium of a surgery building in a major hospital in the Southeastern United States completed a survey based on Roger Ulrich's Theory of Supportive Gardens and the Stimulus, Organism, Response (S-O-R) paradigm.

RESULTS

Findings of this study suggest visitors' experience with the healing garden can lead to overall satisfaction with the hospital and behavioral intentions toward the hospital. Visitors' satisfaction with the healing garden significantly predicted their satisfaction with the hospital, their intend to revisit the hospital, and their intend to recommend it.

CONCLUSIONS

This study demonstrates that a small healing garden can be a powerful enough space to impact visitors' overall satisfaction with the hospital and their intentions regarding their future behavior toward the hospital, such as revisiting or recommending the hospital.

Health Benefits Derived from Forest: A Review

In this paper the scientific literature on the association between forests, stress relief and relaxation is reviewed with the purpose to understand common patterns of research, the main techniques used for analysis, findings relevant to forest-therapy-oriented management, and knowledge gaps. The database of studies was collected with a keyword search on the Web, which returned a set of 32 studies that were included in the analysis. The main findings and patterns were identified with a text mining analysis of the abstract to search for keyword patterns across studies. The analysis indicates that most studies compared rest and relaxation performances across urban and forest environments and used a combination of self-reported measure of stress or rest collected with validate scales, e.g., the Profile of Mood of States (POMS) and the Restoration Outcome Scale (ROS), and a minority-only set of these two groups of indicators. Results of this review indicate that primary studies identified a positive association between forest exposure and mental well-being, in particular when compared to urban environments, thus suggesting that forest are effective in lowering stress levels. This study found that, to date, the characteristics of forests and characteristics of the visit are little investigated in the literature. For this reason, more research with a focus on forest variables such as tree species composition, tree density and other variables affecting forest landscape should be further investigated to inform forest management. Similarly, the characteristics of the visits (e.g., length of visit and frequency) should be further explored to provide robust forest therapy guidelines.

Neuroscience Application for the Analysis of Cultural Ecosystem Services Related to Stress Relief in Forest

The paper presents an integrated methodology to assess psychological and physiological responses of people when exposed to forests, with the main objective of assessing the suitability of different stands for stress recovery on the basis of tree species and density. From the methodological viewpoint, the study applies both a Restoration Outcome Scale (ROS) questionnaire and a neuroscientific technique grounded on electro-encephalographic (EEG) measurement. Results show different outcomes for conifers and broadleaves as well as a statistical significance of density in the evaluation of an individual’s emotional state. A forest with a high density of conifers and low density of broadleaves seems to be the proper combination for stress recovery. The differences among psychological stated preferences and EEG trends highlights potential conflict among “needs” and “wants” of people in the topic of stress relief. Potential applications of the research for health care and territorial marketing operations are suggested.

Therapeutic gardens as a design approach for optimising the healing environment of patients with Alzheimer's disease and other dementias: A narrative review

PURPOSE

The first half of this paper documents the role of nature in healthcare environments and its impact on wellness, with a particular focus on gardens. The second half presents a scientific evaluation of the role of gardens as a therapeutic intervention to optimise the clinical outcomes in patients with Alzheimer's disease (AD) and dementia, including a review of the innovative application of technologies alongside nature to promote cognitive rehabilitation in this particular patient population.

METHODS

Using search engines such as the Institute for Scientific Information (ISI) Web of Science, PubMed, ProQuest Central, MEDLINE, Scopus and Google Scholar, a relevant literature search on the positive health implications of therapeutic gardens (TG) on AD and dementia patients in the healthcare milieu was conducted.

RESULTS

The health implications of TG for AD and dementia patients span physical, social, psychological and cognitive effects. Virtual reality (VR) technologies that display natural environments also offer positive cognitive outcomes for AD and dementia patients.

CONCLUSION

TG should be used to improve the health and wellbeing of AD and dementia patients, and its application should be extended to other patient populations to promote quicker recovery. Future directions in the design of TG, with a focus on patients with AD and other dementias, is also discussed.

Accessing Green Spaces Within a Healthcare Setting: A Mixed Studies Review of Barriers and Facilitators

This review describes the facilitators and barriers impacting on passive access to green spaces within healthcare settings. A systematic mixed-studies review was undertaken to review the quantitative and qualitative evidence on access to green spaces within healthcare settings, as well as to review the methodological quality of the studies eligible for inclusion. A total of 24 articles met the inclusion criteria and were included in the review. The barriers to access were grouped into three themes: "awareness," "accessibility," and "comfort." The facilitators were grouped into 13 themes: "flora and foliage," "views," "water features," "sun, rain, fresh air, wind," "animal life," "diverse textures, heights, shapes," "lawn," "natural versus artificial material," "rest areas," "shade," "private areas," "play equipment," and "safety." These findings can be explained through multiple lenses, using existing theories on contact with nature and supportive garden design. In an era of elevated stress, patient admissions, and staff turnover in hospitals, and rising costs of providing healthcare services, the creation of settings conducive to health promotion, stress reduction, and faster recovery is relevant and timely. This article, which has collated over three decades of research evidence, is invaluable in addressing this issue.

The Influences of Landscape Features on Visitation of Hospital Green Spaces-A Choice Experiment Approach

Studies have suggested that visiting and viewing landscaping at hospitals accelerates patient's recovery from surgery and help staff's recovery from mental fatigue. To plan and construct such landscapes, we need to unravel landscape features desirable to different groups so that the space can benefit a wide range of hospital users. Using discrete choice modeling, we developed experimental choice sets to investigate how landscape features influence the visitations of different users in a large regional hospital in Taiwan. The empirical survey provides quantitative estimates of the influence of each landscape feature on four user groups, including patients, caregivers, staff, and neighborhood residents. Our findings suggest that different types of features promote visits from specific user groups. Landscape features facilitating physical activities effectively encourage visits across user groups especially for caregivers and staff. Patients in this study specify a strong need for contact with nature. The nearby community favors the features designed for children's play and family activities. People across user groups value the features that provide a mitigated microclimate of comfort, such as a shelter. Study implications and limitations are also discussed. Our study provides information essential for creating a better healing environment in a hospital setting.

Stressed spaces: mental health and architecture

OBJECTIVE

To present a comprehensive review of the research literature on the effects of the architectural designs of mental health facilities on the users.

BACKGROUND

Using a team of cross-disciplinary researchers, this review builds upon previous reviews on general and geriatric healthcare design in order to focus on research undertaken for mental health care facility design.

METHODS

Sources were gathered in 2010 and 2011. In 2010 a broad search was undertaken across health and architecture; in 2011, using keywords and 13 databases, researchers conducted a systematic search of peer reviewed literature addressing mental health care and architectural design published between 2005 to 2012, as well as a systematic search for academic theses for the period 2000 to 2012. Recurrent themes and subthemes were identified and numerical data that emerged from quantitative studies was tabulated.

RESULTS

Key themes that emerged were nursing stations, light, therapeutic milieu, security, privacy, designing for the adolescent, forensic facilities, interior detail, patients' rooms, art, dementia, model of care, gardens, post-occupancy evaluation, and user engagement in design process. Of the 165 articles (including conference proceedings, books, and theses), 25 contained numerical data from empirical studies and 7 were review articles.

CONCLUSIONS

Based on the review results, especially the growing evidence of the benefits of therapeutic design on patient and staff well-being and client length of stay, additional research questions are suggested concerning optimal design considerations, designs to be avoided, and the involvement of major stakeholders in the design process.

KEYWORDS

Evidence-based design, hospital, interdisciplinary, literature review, post-occupancy.

Restorative Design Features for Hospital Staff Break Areas

Objectives:

The study investigated the main restorative components of staff break areas in healthcare facilities, by assessing usage patterns, verbal/visual preferences, and perceived restorative qualities of specific design features found in break areas for hospital staff.

Background:

Nurses are extremely important to the healthcare industry, and maintaining the quality of nursing care is a central concern for healthcare administrators. While healthcare leaders are concerned about improving nurses’ satisfaction, performance, and job retention, they may overlook the importance of respite for nurses and underestimate the value of designing staff break areas to maximize their restorative potential.

Methods:

A multi-method approach combined qualitative explorations (focused interviews and narrative survey questions) with quantitative measurements (discrete survey questions and a visual ranking of break-room spaces), and the results were compared and triangulated.

Results:

It was found that staff break areas are more likely to be used if they are in close proximity to nurses’ work areas, if they have complete privacy from patients and families, and if they provide opportunities for individual privacy as well as socialization with coworkers. Having physical access to private outdoor spaces (e.g., balconies or porches) was shown to have significantly greater perceived restorative potential, in comparison with window views, artwork, or indoor plants.

Conclusions:

The results of this empirical study support the conclusion that improvements in the restorative quality of break areas may significantly improve nurses’ satisfaction and stress reduction, potentially leading to improved care for the patients they serve.

Rooftop Hospital Gardens for Physical Therapy: A Post-Occupancy Evaluation

Objective: The goal of this study was to understand successes and weaknesses of a rooftop hospital garden used primarily for physical therapy.

Background: Literature on the healing benefits of nature and designed outdoor spaces in healthcare contexts continues to become more focused on specific patient populations. This study contributes to the knowledge of rooftop hospital gardens and gardens for physical rehabilitation.

Methods: A post-occupancy evaluation was conducted using interviews with a lead therapist and landscape architect, behavior mapping, a staff survey, and a patient questionnaire.

Results: The designer and administrative staff perceived high accessibility while patients and staff reported low accessibility. Patients reported high satisfaction with the garden while staff reported little time for garden use. Poor maintenance decisions resulted in decreased functional and aesthetic value.

Conclusions: Garden elements take on added layers of meaning and value to users seeking to escape the indoor environment, placing increased importance on evidence-based site design. Multiple perspectives must be considered in facility and garden master planning. Finally, designers and horticultural therapists must be retained in garden management to preserve and enhance garden functionality.