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

A Choice-Based Design Approach to Influence Beneficial Use of a Green Space by Family Caregivers at a Tertiary Care Hospital in India

OBJECTIVES, PURPOSES, AND AIMS

Principles of behavioral economics are now being used across fields in changing human behavior toward perceived benefit. We studied the effectiveness of simple, cost-effective design cues based on these principles, in encouraging use of a neglected outdoor space in a hospital.

BACKGROUND

Benefits of access to nature and green spaces are established in healthcare; however, we found utilization of an outdoor space to be suboptimal. Presenting choices in different ways is known to influence user choice.

METHODS

We designed four design interventions based to nudge relative-caregivers waiting outside the operation theater toward utilizing an adjoining outdoor balcony. These included making the terrace prominent, reducing indoor sensory stimulation, adding stereotypical elements, and improving usability. We measured usage via video camera data and satisfaction using questionnaires.

RESULTS

The number of users and average time per person spent on the balcony increased over the consecutive intervention periods as compared to baseline (trend p < .01 for both), mainly driven by the addition of stereotypical elements. There were no adverse events in the balcony. There was no difference in the satisfaction related outcomes on questionnaire; a larger percentage of positive comments tended to be related to the balcony in the final intervention.

CONCLUSIONS

Cost-effective design cues nudged patient-caregivers toward spending more time with nature, thus changing behavior toward that with perceived benefits.

Hierarchy of Evidence: An Appraisal Tool for Weighting the Evidence in Healthcare Design Research Based on Internal Validity

PURPOSE

This inquiry aims to develop an appraisal tool to offer greater granularity in weighing evidence in the field of healthcare design research.

BACKGROUND

In evidence-based design (EBD), the goal is to implement interventions that result in a meaningful and optimal effect based on current best evidence. Although multiple appraisal tools (many adopted from medical disciplines) have been instrumental in evaluating studies in the field of healthcare design research to identify the best evidence, they do not necessarily consider the unique contexts of healthcare design research, and methodologies appropriate to the field.

METHODS

Five basic types of studies are ranked based on the level of confidence that they offer regarding the estimate of an effect: (1) meta-analysis studies, (2) causal studies, (3) correlational studies, (4) descriptive studies, and (5) anecdotal evidence. Causal studies are further divided into four levels based on the interaction of two factors: (1) type of intervention and (2) groups' equivalency and extraneous variable control.

RESULTS

An eight-level hierarchy of evidence for healthcare design research is proposed that is expected to improve upon previous hierarchies in three major ways: (a) including research methods that are more relevant to healthcare design research, (b) enhancing evaluation accuracy and reliability by providing a clearer definition of studies based on their key components rather than using study labels alone, and (c) distinguishing different levels of evidence, particularly in causal studies.

CONCLUSIONS

The proposed appraisal tool is developed specifically for EBD by reflecting on the unique context of healthcare design research and practice.

Caregivers' perspectives on the social and physical environmental factors associated with the play of their children with palliative care needs: A Q methodology study

Children living with palliative care needs are less engaged in play, despite its importance in their lives. The environment may have a crucial role in supporting these children's play. Understanding the importance and impact of environmental factors on children's play is essential to being able to support their participation in play. Data were collected from caregivers (mostly parents) of children living with life-threatening/limiting conditions, who were between 5 and 11 years old. Thirty-nine participants were recruited from two children hospitals and two hospices in Kuwait and in the United Kingdom. The participants' perspectives were explored using Q methodology. By-person factor analysis was used to explore the ranking of each statement. Content analysis was used to analyse the participants' verbal comments. The most important environmental factors were the need for others to share play and get assistance to facilitate play. However, this is not always possible as these conditions, the life-threatening/limiting conditions, may be socially isolating. Children also experience limitations in accessing play resources that match their abilities and meet their play needs. Being aware and responsive to children's play needs is essential for building appropriately supportive play environments for children living with life-threatening/life-limiting conditions.

The Environmental Factors Associated With Fatigue of Frontline Nurses in the Infection Disease Nursing Unit

The workload in the Infection Disease Nursing Unit (IDNU) is increasing dramatically due to COVID-19, and leads to the prevalence of fatigue among the frontline nurses, threatening their health, and safety. The built environment and design could fundamentally affect the fatigue of nurses for a long-term perspective. This article aims to extract the environmental factors of IDNU and explore nurses' perceptions of these factors on the work-related fatigue. It would produce evidences for mitigating the fatigue by environmental interferons. A cross-sectional design was employed by combination of focus group interview and written survey. Environmental factors of IDNU were collected from healthcare design experts (n = 8). Nurses (n = 64) with frontline COVID-19 experiences in IDNU were recruited to assess these factors individually. Four environmental factors were identified as: Nursing Distance (ND), Spatial Crowdness (SC), Natural Ventilation, and Light (NVL), and Spatial Privacy (SP). Among them, ND was considered as the most influential factor on the physical fatigue, while SP was on the psychological fatigue. Generally, these environmental factors were found to be more influential on the physical fatigue than the psychological fatigue. Technical titles were found to be associated with the nurses' perceptions of fatigue by these environmental factors. Nurse assistant and practical nurse were more likely to suffer from the physical fatigue by these factors than senior nurse. The result indicated that environmental factors of IDNU were associated with the nurses' fatigue, particularly on the physical aspect. Environmental interventions of design could be adopted to alleviate the fatigue by these factors such as reducing the ND and improving the spatial privacy. The accurate interventional measures should be applied to fit nurses' conditions due to their technical titles. More attention should be given to the low-ranking nurses, who account for the majority and are much vulnerable to the physical fatigue by environmental factors.

Views of Greenery and Psychological Well-Being in Residential Aged Care Facilities: Longitudinal Associations

OBJECTIVES

This study examined associations of objectively measured views of greenery in residential aged care facilities (RACFs) with changes in multiple psychological well-being measures among residents who were newly admitted to RACFs.

METHODS

Data were collected from 52 residents (mean age: 84, 73% women) of 13 RACFs, located in Melbourne, Australia. The outcomes were changes in depression, stress, anxiety, and quality of life (QoL) between baseline and 8-week follow-up. The exposure measures were the amount and presence of greenery visible from participant's bedroom and common areas (lounge, dining). Greenery was categorized as being either within or beyond the RACF perimeter.

RESULTS

Regression analyses found that greenery visible from participant's bedroom was not associated with any outcomes. The amount of greenery visible from common areas within the RACF perimeter was adversely related to stress, unexpectedly: Each additional 1 m² of greenery was associated with a greater increase in stress (b = 0.05; 95% CI [0.07, 0.94]). However, greenery visible from common areas beyond the perimeter contributed favorably to stress and QoL. The presence of such greenery was associated with a lower increase in stress (b = -3.99; 95% CI [-7.75, -0.23]; reference: no greenery), and a 1 m² increment was associated with a greater increase in QoL (b = 0.07; 95% CI [0.02, 0.11]).

CONCLUSION

Views of greenery outside of the RACF from lounge and dining areas may be protective against residents' stress increase and improve their QoL. Locating residents in areas with such outdoor views may prevent their psychological condition from worsening.

Functional Settings of Hospital Outdoor Spaces and the Perceptions from Public and Hospital Occupant during COVID-19

Hospital outdoor spaces play an important role for the safety and well-being of users (patients, visitors, and staff), particularly during a pandemic. However, the actual needs of these spaces are often overlooked due to the design and management process. This study investigates the perceptions of the public and occupants on the functional settings of outdoor spaces, and provides evidence for building a safe and resilient hospital during (and after) COVID-19. A multi-method approach of web content analysis (WCA) and a web-based survey was employed. Reports were collected from three mainstream websites; keywords were extracted and then categorized, pertaining to the functional settings of outdoor spaces. Three groups of occupants from Southwest Hospital (staff n = 47, patients n = 64, visitors n = 73) participated in the survey to identify their perceptions of these functional settings. Based on the 657 reports and 33 keywords selected, 7 functional settings were identified: health check (HC), quarantine and observation (QO), food and delivery (FD), healing and restoration (HR), waiting and rest (WR), transportation and parking (TP), load and unload (LU). From all users, HC (4.13) was thought to be the most expected function setting while FD (2.61) was the least. Regarding the satisfaction level, most users were satisfied with HC (3.22) while WR (2.16) was the least satisfying. The users also showed significant differences regarding expectation and satisfaction pertaining to their groups. The results indicate that the current outdoor space could not fully meet the needs of users, regarding the emerging functional setting, due to the pandemic. Users showed significant different perceptions on the functional setting due to their roles. The mismatch between the outdoor space and the users’ needs on emerging functional settings resulted in low satisfaction and high expectation in the survey. Environmental interventions with adaptive and flexible strategies should be adapted for these functional settings. The differences of users should be fully recognized by administrators, decision-makers, and designers.

Hospital Outdoor Spaces: User Experience and Implications for Design

OBJECTIVES

This article aims to describe users' perspectives about the impact of hospital outdoor spaces on the patient experience in a postacute setting.

BACKGROUND

Hospital outdoor space is an important element in healthcare facility design. There is growing evidence that access to green space within hospital outdoor spaces facilitates healing. However, limited studies have explored the users' perspective regarding how hospital outdoor spaces impact the patient experience.

METHODS

As part of a hospital preoccupancy evaluation, users (patients, family, and staff) were invited to participate in a semi-structured interview to describe their experiences in the hospital's outdoor spaces. Data were analyzed using inductive thematic analysis.

RESULTS

Seventy-four individuals participated in this study: 24 inpatients, 15 outpatients, 11 family, 23 staff, and one volunteer. Three themes were identified: (1) outdoor space benefits healing by helping patients focus on life beyond their illness, (2) design of healthcare spaces facilitates patients' access to outdoor space to benefit healing, and (3) programming in the outdoor space promotes healing and recovery.

CONCLUSIONS

This study describes the users' perspective regarding the value of outdoor spaces and the design elements that influence the patient experience.

Resilience and Equity in a Time of Crises: Investing in Public Urban Greenspace Is Now More Essential Than Ever in the US and Beyond

The intersecting negative effects of structural racism, COVID-19, climate change, and chronic diseases disproportionately affect racial and ethnic minorities in the US and around the world. Urban populations of color are concentrated in historically redlined, segregated, disinvested, and marginalized neighborhoods with inadequate quality housing and limited access to resources, including quality greenspaces designed to support natural ecosystems and healthy outdoor activities while mitigating urban environmental challenges such as air pollution, heat island effects, combined sewer overflows and poor water quality. Disinvested urban environments thus contribute to health inequity via physical and social environmental exposures, resulting in disparities across numerous health outcomes, including COVID-19 and chronic diseases such as cancer and cardiovascular diseases (CVD). In this paper, we build off an existing conceptual framework and propose another conceptual framework for the role of greenspace in contributing to resilience and health equity in the US and beyond. We argue that strategic investments in public greenspaces in urban neighborhoods impacted by long term economic disinvestment are critically needed to adapt and build resilience in communities of color, with urgency due to immediate health threats of climate change, COVID-19, and endemic disparities in chronic diseases. We suggest that equity-focused investments in public urban greenspaces are needed to reduce social inequalities, expand economic opportunities with diversity in workforce initiatives, build resilient urban ecosystems, and improve health equity. We recommend key strategies and considerations to guide this investment, drawing upon a robust compilation of scientific literature along with decades of community-based work, using strategic partnerships from multiple efforts in Milwaukee Wisconsin as examples of success.

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.