The Role of the Built Environment in Supporting Older Adults' Engagement: A Narrative Literature Review

OBJECTIVE

This literature review aimed to summarize the existing knowledge surrounding the role of the built environment in supporting older adults' physical and social engagement and identify opportunities for future research and design that facilitates older adults' engagement at multiple environmental scales: from interior spaces to neighborhoods.

BACKGROUND

Physical environments can support or impede older adults' physical and social engagement: willful, motivated involvement in meaningful activity or occupation. Research shows that engagement is a core component of health and well-being and relates to positive health outcomes, including reduced disease risk, better mental health, and improved physical and cognitive function. Thus, designing supportive built environments for engagement can yield significant, positive health and well-being impacts.

METHODS

A systematized search of five databases, a hand search, and an iterative screening process identified 55 studies for inclusion in this review. Through inductive thematic analysis, this review summarizes findings regarding the built environment's role in physical and social engagement in older age and design strategies to facilitate engagement and support health and well-being.

RESULTS

Evidence indicates that built environment characteristics can influence older people's physical and social engagement in homes, neighborhoods, and care settings. The thematic analysis of the included studies identified three key themes concerning the relationships of built environment characteristics to older adults' engagement across multiple environmental scales: connection, access, and security.

CONCLUSIONS

Built environments influence older people's physical and social engagement, significantly affecting their health, well-being, abilities, and longevity. Numerous design strategies can support older adults' engagement, but more research is needed.

Developing Resilient Community Spaces in Healthcare Facilities: An Exploratory Study of a Public Health Crisis

OBJECTIVES

This exploratory study aimed to investigate the impact of the COVID-19 pandemic on the design of healthcare facilities, particularly those featuring communal spaces. It sought to identify strategies that were implemented, learned, or recognized when adapting to the limitations imposed by protective measures during the pandemic.

BACKGROUND

Third places are social gathering places outside of home and work. Over time, these community-centric places evolved from free-standing getaways to more integrated niches in diverse contexts including healthcare. Their numerous advantages for users include enhancing community bonds and collaboration among healthcare workers. The onset of the COVID-19 pandemic resulted in a need to rethink the design of such spaces to make them more adaptable and resilient.

METHODS

An exploratory qualitative study was conducted through in-depth semi-structured interviews with sixteen practitioners involved in healthcare architecture and design projects during the pandemic. Data were analyzed using a thematic analysis approach.

RESULTS

Findings indicate that the design of shared spaces in healthcare facilities for pandemic-like situations requires a special focus on modifiability and multifunctionality, achievable through strategies such as the use of movable, unconnected, and rearrangeable furniture or partitions that could swiftly change the function of a space. Other strategies include the capacity for compartmentalization of spaces, fostering indoor-outdoor connections, integrating advanced technology, and implementing effective infection control measures. Detailed emergent themes and examples of experienced constraints are discussed.

CONCLUSIONS

Insights gained from our findings can be applied to new and ongoing healthcare design projects to ensure resiliency during normal and pandemic conditions.

Exploring the Association Between the Healthcare Design Elements and Physician Well-Being: A Scoping Review

PURPOSE

To evaluate the association between elements of the built environment and physician well-being using a scoping review.

BACKGROUND

Physicians currently report low work satisfaction, high burnout and depression. The built environment has been shown to affect well-being in the general population, but its relationship to physician well-being is not well understood. Gaining a better understanding of this relationship will allow for better evidence-based design for physician well-being.

METHODS

A scoping review of the literature was conducted of Scopus and PubMed databases using key words for (1) environmental variables such as "environmental design"; (2) physician terms, such as "doctor"; and (3) outcome measures of well-being, such as "burnout." Studies were included if they had at least one measure of the built environment and one measure of physician well-being. Of 1,723 abstracts screened, 146 full-text articles were reviewed, leaving 16 articles to be included for data extraction.

RESULTS

Included studies were from all around the world, except for, notably, the United States. Robust interpretation of the data was challenging because of the lack of standardization in the assessment of environmental factors and physician well-being. Excessive noise was the variable most linked to well-being. Suitable surroundings, including lighting, furniture, and art, were also linked with satisfaction, but it was unclear whether there was an association with well-being.

CONCLUSION

Understanding how environmental factors affect physician well-being is paramount but considerably understudied. Standardization of research approach should be developed in order to produce more robust research to create evidence-based designs for physician well-being.

Retaining Healthcare Workers: A Systematic Review of Strategies for Sustaining Power in the Workplace

The shortage of healthcare workers is a growing concern. The COVID-19 pandemic and retirement wave have accelerated turnover rates. This systematic review aimed to identify and analyse the existing interventions for job retention of healthcare workers, in terms of nurses and physicians, in a hospital setting. A comprehensive search was conducted within three electronic databases, guided by the preferred reporting items for systematic review and meta-analyses (PRISMA) and synthesis without meta-analysis (SWiM) guidelines, this resulted in 55 records that met the inclusion criteria. The intervention outcomes are categorized into substantial themes: onboarding, transition program to a different unit, stress coping, social support, extra staffing, coping with the demands of patient care, work relationships, development opportunities and department resources, job environment, work organization, recruitment approach, and technological innovations. Considering the literature, onboarding programs and mentoring for nurses and physicians are recommended. Additionally, other interventions described in this review could positively affect the retention of nurses and physicians. When selecting an intervention for implementation, managers and human resources should consider the intervention that matches the determinant of intention to leave of their healthcare workers and the hospital's mission, vision, and values. Sharing the success stories of implemented interventions may benefit healthcare organizations.

The Role of Healthcare Facility Design on the Mental Health of Healthcare Professionals: A Literature Review

OBJECTIVE

This study aims to review and synthesize the empirical evidence about the connection between healthcare facility design and the mental health of healthcare professionals by reviewing the relevant literature.

BACKGROUND

Mental exhaustion of healthcare professionals is becoming a critical issue in healthcare, especially during the pandemic. The physical design of healthcare facilities has significant potential to reduce and prevent the mental exhaustion of healthcare professionals by removing environmental stressors and providing restorative experiences. However, the built environment is not fully utilized as an intervention to support healthcare professionals.

METHODS

Relevant articles were identified from the Medline, PsycINFO, PubMed, and Web of Science databases using a combination of search terms representing environmental design factors and health outcomes. Identified articles were reviewed by their titles, abstracts, and full texts using the inclusion and exclusion criteria.

RESULTS

The search yielded 27 empirical articles investigating the relationships between environmental design factors and staff mental health outcomes, including stress, fatigue, job satisfaction, burnout, and well-being. Healthcare design aspects that were investigated in the identified articles include overall facility and perception (e.g., aesthetic appeal and impression, belonging to the surroundings, safety), specific spaces (e.g., patient area, staff workspace), intangible elements (e.g., exterior view, light, sound), and interior space and ergonomics (e.g., material finishes, furniture).

CONCLUSIONS

Through the synthesis of the current literature regarding the relationships between healthcare facility design and the mental health of healthcare professionals, this study provides implications for supporting healthcare professionals through the design of the healthcare facility.

Investigating the Influences of Healthcare Facility Features on Wayfinding Performance and Associated Stress Using Virtual Reality

OBJECTIVE

This study examined the influences of healthcare facility interior features on users' wayfinding performance and the relationship between stress and wayfinding.

BACKGROUND

General hospitals in China always present significant wayfinding problems due to their sizes and complexity. Poor wayfinding often leads to a frustrating and stressful user experience. It has not been fully understood how hospital indoor features affect wayfinding and whether an individual's stress levels are associated with wayfinding performance.

METHOD

We conducted an experiment in which 117 college students, aged 18-33 (M = 21.88, SD = 3.01), performed two tasks in virtual reality environments of outpatient clinics. Stress (skin conductance response) and wayfinding performance (distance ratio and time ratio) were measured. Participants' sense of orientation, navigation ability, distance estimation, and spatial anxiety were captured by a survey.

RESULTS

Male participants reported a significantly better sense of orientation and less spatial anxiety than females. Participants' stress levels were lower with outdoor window views compared to those without outdoor views. With more environmental features (landmarks and outdoor window views) added to the environments, participants showed significantly better wayfinding performance. No significant relationship was found between wayfinding performance and participants' stress levels in this study.

CONCLUSION

While individual environmental factors might not have a significant influence, combining multiple elements such as window views and landmarks could lead to better wayfinding performance. More research is needed to examine the relationship between stress and wayfinding.

The Healthcare Workspace: Understanding the Role of Decentralized Nursing Stations, Corridors, and Huddle Spaces as Locations for Teamwork in a Neonatal Intensive Care Unit

OBJECTIVE

The goal of this research was to understand the use of decentralized nursing stations (DNS), corridors, and huddle stations as places for teamwork and multidisciplinary care in the neonatal intensive care unit (NICU).

BACKGROUND

This article shares outcomes from a pre- and post-occupancy evaluation that assessed a NICU moving from an open-bay model to a new single-family room (SFR) unit comprised of six, 12-bed neighborhoods. This interdisciplinary research team draws upon the practical expertise of a NICU Patient Care Manager and researchers in Design and Communication to illuminate the research process, results, and lessons learned.

METHODS

A multi-methodological design, approved by the institutional review board, was employed that utilized an electronically distributed pre- and post-move survey of staff and observational counts of face-to-face interactions.

RESULTS

Survey results indicate NICU staff have statistically significant higher perceptions of job satisfaction, stress and well-being, and design satisfaction among a variety of professionals after moving to a SFR, decentralized unit design. Consistent with the literature, staff did not have significantly higher perceptions of the decentralized NICU relative to teamwork. Observations revealed frequency of conversations primarily at DNS followed by corridors and huddle stations. When examining the multidisciplinary makeup, outcomes were reversed with huddle spaces holding the largest percentage of conversations. On average, there were 2.72 individuals involved in these interactions, with the corridor seeing the largest average of group sizes.

CONCLUSION

The outcomes of this study demonstrate that neutral spaces such as corridors and centralized huddle stations should be considered as locations for strategic collaboration and multidisciplinary care.

Staff participation in design with multiple tools: Impact on design and POE results

OBJECTIVE

This is a concluding part of an action research study to evaluate the impact on healthcare staff participation in the design of a new intensive care unit (ICU). Staff participated with multiple tools in the design; during the predesign phase utilizing co-design and virtual mock-ups, and also participating in the predesign evaluation (PDE) and postoccupancy evaluation (POE). Both the ICU design and evaluations were based on the principles of evidence-based design studies.

METHOD

Staff satisfaction was evaluated with an online survey comprising 116 statements on 13 different topics used both in PDE and POE. There was space for open-ended comments after each topic.

RESULTS

There was a statistically significant difference (<.001) between PDE and POE results. There were considerable improvements in privacy, accessibility, safety and security, and acoustics. It was assumed that participation in the predesign phase would positively influence POE results, but there were no statistical differences in any topics. However, as a result of collaborative predesign phase, the staff was satisfied with these jointly designed patient rooms. Open-ended questions revealed the importance to continue functional and technical support for staff after commissioning and ensure that technical solutions are practical and well-functioning.

CONCLUSION

The use of PDE and POE assists to set predetermined criteria and evaluate the success of design. Healthcare providers should see POE as a valuable part of design and commissioning process. Additionally, the use of POE should be made more effortless and the results more easily accessible to promote increased interest and usage.

Ways to harness the built environment of ambulatory cancer facilities for comprehensive patient support: A review of the literature

OBJECTIVE

To review patient experiences of the architectural elements conducive to a supportive or healing-promoting environment in the context of ambulatory oncology care.

DESIGN

A comprehensive review of original peer-reviewed qualitative studies conducted to reveal the meaning and significance of patient experience in this context was undertaken.

DATA SOURCES

Studies were identified through electronic databases including Ovid MEDLINE, CINAHL, PubMed and Embase. No time limit was applied and language was restricted to English.

REVIEW METHODS

The generated records were screened at the titles and abstracts level by the first reviewer, with full text assessment conducted by both authors. Main themes were extracted in an excel file and a narrative synthesis strategy was used to systematically gather evidence and explain the findings. The guidelines of the Centre for Reviews and Dissemination have been followed in the searching and reporting of the essential matters relevant to this review.

RESULTS

Eleven original studies were selected; in addition to these, fourteen other studies that did not fully meet the selection criteria, however held important information relevant to the scope of the review, were considered to expand the discussion with relevant information to ambulatory cancer facilities. The findings of these studies were synthesized into five major themes: stimulating and homely environments; flexibility and environmental enrichment; social support; complementary support and engagement; and physical and sensory support.

CONCLUSION

The paper identified key architectural design qualities that have the potential to support treatment and empower patients, with particular reflection on patients undergoing intravenous anti-cancer treatment within ambulatory settings. It provides examples in which designing the built environment with people in mind and providing tailored solutions to meet their actual needs and preferences may help cancer patients cope with the emotional and physical challenges of the disease and its treatment and support a general experience of patient-centred care. A conceptual framework that articulates the principal constituents of a supportive environment is tentatively proposed, extending existing theoretical propositions to facilitate further investigation of this context.

Healthy and Sustainable Hospital Evaluation—A Review of POE Tools for Hospital Assessment in an Evidence-Based Design Framework

Hospitals are complex, high-performance systems that demand continuous quality improvement. Several instruments evaluate the organizational or clinical qualities but very few focus on the built environment. The purpose of this paper is to compare and review the recent tools able to assess the hospital built environment and test how they measure health, sustainability, or both through Post Occupancy Evaluation (POE). A literature review has been conducted in the field of hospital quality assessment and 13 POE instruments have been included and analyzed through Ulrich’s Evidence-Based Design (EBD) framework. The percentage and the content of health or sustainability-related criteria have been compared and further discussed. Health related criteria the most recent tools are used three times more than in the tools developed in the nineties. The most used EBD criteria are safety enhancement (n = 131; 14%) and visual environment (n = 119; 13%). Although sustainability remains a relevant issue, today, growing attention is dedicated to the impact of built environment on occupant’s health. Further investigation is needed to understand the effectiveness of those instruments in practice.

A reason to renovate: The association between hospital age of plant and value-based purchasing performance

BACKGROUND/PURPOSE

Value-based purchasing (VBP) is increasing in influence in the health care industry; however, questions remain regarding the structural factors associated with improved performance. This study evaluates the association between age of hospital infrastructure and VBP outcomes.

METHODOLOGY

Data on 1,911 hospitals from three sources (the American Hospital Association Annual Survey Database, the American Hospital Association DataViewer Financial Module, and the Centers for Medicare & Medicaid Services Hospital VBP Total Performance Scores data set) were evaluated. Age of health care facilities was represented by the "average age of plant" financial ratio. VBP performance was measured by an aggregate Total Performance Score composed of four equally weighted domains, including Efficiency and Cost Reduction, Clinical Care, Patient- and Caregiver-Centered Experience, and Patient Safety. We hypothesize that average age of plant is negatively correlated with each of these measures.

RESULTS

Hospitals within the lowest quartile of average age of plant (0-8.13 years) were found to have a total Performance Score of 2.35 points higher than hospitals with a an average age of plant in the fourth quartile (14.63 years and above; R = 21.5%; p < .001) while controlling for hospital ownership, size, teaching status, geographic location, service mix, case mix, length of stay, community served, and labor force relative cost. Comparable results were found within the VBP domains, specifically for Clinical Care (β = 4.09, p < .001) and Patient Experience (β = 3.41, p < .001). Findings for the Patient Safety and Efficiency domains were not significant. A secondary and more granular examination of capitalized assets indicates organizations with higher building asset accumulated depreciation per bed in service were associated with lower total performance (β = -.25, p < .001), Clinical Care (β = -.31, p < .05), and Patient Experience scores (β = -.45, p < .001).

CONCLUSIONS

The results of this study provide evidence of an inverse association between a hospital's age of plant and specific elements of VBP performance.

PRACTICE IMPLICATIONS

To date, no studies have investigated the relationship between hospital age of plant and value-based care. The results of our study may serve as supportive foundational evidence for health care leaders to target future capital investments to improve VBP outcomes.

Health care quality from the patients' perspective: a comparative study between an old and a new, high-tech hospital

Purpose

Previous studies show that the hospital environment and the behavior of health care personnel may predict patients’ perceptions of care quality. The aim of the study was to explore changes in perceived care quality from the patients’ perspective (QPP) when hospital services are relocated from an old to a new high-tech hospital and to describe what is important for patients in the high-tech hospital.

Patients and methods

A comparative cross-sectional design was used. The questionnaire QPP, which is based on a theoretical model of the quality of care comprising four quality dimensions, was used. Data were collected in 2015 (old hospital) and 2016 (new hospital), with 253 and 324 respondents, respectively, by consecutive sampling. Comparative statistics was used to test differences between patients’ care quality perceptions (perceived reality [PR] and subjective importance [SI]) (P≤0.05).

Results

The patients rated PR of all four quality dimensions (the care organization’s physical-technical conditions and sociocultural approach and the caregivers’ medical-technical competence and identity-oriented approach) higher in the new hospital. However, only the two quality dimensions concerning the care organization were rated significantly more highly. On an item level, five of the 27 items scored significantly higher on patients’ SI than on patients’ PR of the care in the new hospital, indicating a quality deficiency from the patients’ perspective. This comprised receiving effective pain relief, receiving examination and treatment within an acceptable waiting time, receiving useful information on self-care, receiving useful information on which doctors were responsible for their medical care, and having a comfortable bed.

Conclusion

The increase in care QPP was associated with improved environmental conditions, and no significant improvement in care quality was associated with the health care personnel. The results indicate that being in a high-tech environment does not improve patients’ perceptions of care quality provided by health care personnel. The results gave valuable information for quality improvement in clinical practice, based on the patients’ perspective.

Can the physical environment itself influence neurological patient activity?

PURPOSE

To evaluate if a changed physical environment following redesign of a hospital ward influenced neurological patient physical and social activity.

METHODS

A "before and after" observational design was used that included 17 acute neurological patients pre-move (median age 77 (IQR 69-85) years Ward A and 20 post-move (median age 70 (IQR 57-81) years Ward B. Observations occurred for 1 day from 08.00-17.00 using Behavioral Mapping of patient physical and social activity, and location of that activity. Staff and ward policies remained unchanged throughout. An Environmental Description Checklist of each ward was also completed.

RESULTS

Behavioral Mapping was conducted pre-/post-move with a total of 801 Ward A and 918 Ward B observations. Environmental Description Checklists showed similarities in design features in both neurological wards with similar numbers of de-centralized nursing stations, however there were more single rooms and varied locations to congregate in Ward B (30% more single-patient rooms and separate allied health therapy room). Patients were alone >60% of time in both wards, although there was more in bed social activity in Ward A and more out of bed social activity in Ward B. There were low amounts of physical activity outside of patient rooms in both wards. Significantly more physical activity occurred in Ward B patient rooms (median = 47%, IQR 14-74%) compared to Ward A (median = 2% IQR 0-14%), Wilcoxon Rank Sum test z = -3.28, p = 0.001.

CONCLUSIONS

Overall, patient social and physical activity was low, with little to no use of communal spaces. However we found more physical activity in patient rooms in the Ward B environment. Given the potential for patient activity to drive brain reorganization and repair, the physical environment should be considered an active factor in neurological rehabilitation and recovery. Implications for Rehabilitation Clinicians should include consideration of the impact of physical environment on physical and social activity of neurological patients when designing therapeutic rehabilitation environments. Despite architectural design intentions patient and social activity opportunities can be limited. Optimal neurological patient neuroplasticity and recovery requires sufficient environmental challenge, however current hospital environments for rehabilitation do not provide this.

Using a Discrete Choice Conjoint Experiment to Engage Stakeholders in the Design of an Outpatient Children’s Health Center

Objectives:

To engage users in the design of a regional child and youth health center.

Background:

The perspective of users should be an integral component of a patient-centered, evidence-based approach to the design of health facilities.

Methods:

We conducted a discrete choice conjoint experiment (DCE), a method from marketing research and health economics, as a component of a strategy to engage users in the preconstruction planning process. A sample of 467 participants (290 staff and 177 clients or community stakeholders) completed the DCE.

Results:

Latent class analysis identified three segments with different design preferences. A group we termed an enhanced design (57%) segment preferred a fully featured facility with personal contacts at the start of visits (in-person check-in, personal waiting room notification, volunteer-assisted wayfinding, and visible security), a family resource center with a health librarian, and an outdoor playground equipped with covered heated pathways. The self-guided design segment (11%), in contrast, preferred a design allowing a more independent use of the facility (e.g., self-check-in at computer kiosks, color-coded wayfinding, and a self-guided family resource center). Designs affording privacy and personal contact with staff were important to the private design segment (32%). The theme and decor of the building was less important than interactive features and personal contacts.

Conclusion:

A DCE allowed us to engage users in the planning process by estimating the value of individual design elements, identifying segments with differing views, informing decisions regarding design trade-offs, and simulating user response to design options.

Territories of Engagement in the Design of Ecohumanist Healthcare Environments

Background:

Increasingly, architectural and allied designers, engineers, and healthcare facility administrators are being challenged to demonstrate success in adroitly identifying and contextualizing ever-shifting and expanding spheres of knowledge with respect to the role of energy conservation and carbon neutrality in healthcare treatment environments and their immediate exterior environs.

Aim:

This calls for making sense of an unprecedented volume of information on building energy usage and interdigitizing complex and at times contradictory goals with the daily requirements of building occupants. Ecohumanist Design Strategies: In response, a multidimensional framework is put forth with the aim of advancing theory and practice in the realm of designers’, direct caregivers’, and administrators’ engagement with ecohumanist design strategies in the creation of ecohumanist healthcare environments.

Conclusions:

Ten territories for engagement are presented that both individually and collectively express salient themes and streams of inquiry in theory and practice, within an operative framework placing the patient, the patient’s significant others, and the caregiver at the center of the relationship between the built environment and occupant well-being.