How does the built environment affect patient safety in relation to physical activity? Experiences at a rehabilitation center

Physical activity benefits patients in rehabilitation yet comes with various safety issues. The built environment impacts on both safety and physical activity. We aim to explore the role of the built environment in safety issues related to being physically active in rehabilitation. We conducted a case study at a free-standing rehabilitation center for patients with Multiple Sclerosis, neurologic, or locomotor issues. Patients participated in two interviews supported by activity tracking data. Care professionals participated in focus group interviews respectively with two therapists and four head nurses. Accessibility and physical barriers, visual connections and (in)dependence, and spatial familiarity are important themes when identifying aspects of the built environment in relation to reducing safety issues patients encounter during physical activity. Raising awareness about each of these among care and design professionals could help them to balance safety issues in relation to physical activity and to communicate about them in a nuanced way.

Housing Accessibility at Home and Rehabilitation Outcomes After a Stroke: An Explorative Study

PURPOSE

To explore if aspects of the physical home environment are related to rehabilitation outcomes among community-living persons poststroke.

BACKGROUND

Research demonstrates that healthcare environments are important for high-quality care and that the design of the physical environment is associated with improved rehabilitation outcomes. However, relevant research focusing on outpatient care settings, such as the home, is sparse.

METHODS

In this cross-sectional study, data on rehabilitation outcomes, physical environmental barriers, and housing accessibility problems were collected during home visits of participants (N = 34), 3 months poststroke. Data were analyzed with descriptive statistics and correlation analysis.

RESULTS

Few participants had adapted their homes, and the relevance of the physical environment was not always discussed with the patient during discharge from the hospital. Accessibility problems were associated with suboptimal rehabilitation outcomes such as worse perceived health and recovery after stroke. Activities most restricted by barriers in the home concerned hand and arm use. Participants who reported one or more falls at home tended to live in houses with more accessibility problems. Perceived supportive home environments were associated with more accessible dwellings.

CONCLUSIONS

Many face problems adapting their home environments poststroke, and our findings highlight unmet needs that should be considered in the rehabilitation practice. These findings could be used by architectural planners and health practitioners for more effective housing planning and inclusive environments.

Challenging Behavior in Context: A Case Study on How People, Space, and Activities Interact

AIM

We aim to gain insight into the interaction between challenging behavior as shown by individuals with an intellectual impairment, and space, and to explore the possibilities of using routinely collected data to this end.

BACKGROUND

Research on challenging behavior shown by intellectually impaired individuals links their behavior to context, which includes space. Unfortunately, research about this link is hard to conduct, since these individuals may have difficulties expressing themselves verbally and react extremely to sensory stimuli.

METHOD

We conducted a single-case study, focusing on a Dutch very-intensive care facility. We analyzed data routinely collected by the healthcare organization in search of time-space configurations that provide insights into the resident-space interaction. As sensitizing concepts, we used three different contexts the residents interact with-space, people, and activities.

FINDINGS

The study exemplified reported interactions that were direct, for example, between the residents and the spatial context, and indirect, for example, through other contexts (people and activities). Space impacts on residents' senses intensely and acts as a lightning rod for their perceived stress. People also influence residents substantially. Caregivers may both have positive or adverse effects, for example, absenteeism or schedule change. Co-residents may trigger challenging behavior directly by a mere presence or transfer of their stress. Transitions between activities cause unpredictability and are triggers for residents, which interact with space.

CONCLUSIONS

Living environments providing choice in nearness to the caregiver and distance to co-residents "high in tension," lowering thresholds for transitions, and facilitating predictability would be beneficial for intellectually impaired individuals showing challenging behavior.

What affects physical activity in a rehabilitation centre? Voices of patients, nurses, therapists, and activity trackers

PURPOSE

In the context of rehabilitation, research shows a close connection between patients' physical activity, care culture, and the built environment. As these three impact on patients' rehabilitation process, we aim to understand what affects physical activity in a particular rehabilitation centre.

MATERIALS AND METHODS

We combine insights from literature with a qualitative study informed by quantitative data. Semi-structured and walking interviews with 16 patients were informed by output from activity trackers. Two focus-group interviews with respectively four nurses and two therapists provided extra perspectives.

RESULTS

We found that patients interpret physical activity rather narrowly, equating it with therapy. Yet, the data of the activity trackers show that daily activities are often as active as therapy, as confirmed by nurses and therapists. Motivation to be physically active was found in setting clear goals, social interaction, allowing choice and control to achieve a sense of normality, and the built environment. How patients act in and interact with the built environment are closely related to how staff approaches and communicates care.

CONCLUSIONS

The focus on what affects - defines, hampers, or supports - physical activity in a rehabilitation centre allowed developing a better understanding of how care culture and the built environment interrelate.Implications for rehabilitationHow physical activity is perceived by patients reflects the goals they like to achieve through rehabilitation.The built environment is a third factor in the relation between care culture and patients' physical activity.Fully supporting patients to be physically active with respect to their personality and capabilities requires differentiating between patients both in how they are approached (patient- or person-centred) and in how they are spatially facilitated.

How does architecture contribute to reducing behaviours that challenge? A scoping review

BACKGROUND

Behaviours that challenge might prevent intellectually impaired individuals from experiencing a good quality of life (QoL). These behaviours arise in interaction with the environment and can be positively or negatively affected by architecture.

AIM

This scoping review explores how architecture contributes to the QoL of individuals engaging in such behaviours. It aims to identify possible gaps in the existing literature and map areas of future research.

METHOD

Four databases were searched using four concepts: architecture, intellectual impairment, challenging behaviour, and QoL. Since only one source covered all concepts, the search criteria were widened to include sources integrating only two or three concepts, nonpeer-reviewed sources, and autism. Eighteen papers, were analysed in terms of their contribution to relations between QoL, behaviours that challenge, and architecture.

RESULTS

This review shows that architecture, QoL, intellectual impairment, and behaviours that challenge have not yet been studied jointly.

CONCLUSIONS

The contribution of architecture to the QoL of these individuals should be subject of future research, together with the similarities and differences between their needs and those of individuals with autism.

Re-grounding the concept of liminality by foregrounding spatial aspects in experiences of cancer care

Liminality captures the passing stages in transitioning from one sociocultural status to another. As its spatial dimension remains under-examined, we analyse this in experiences of people affected by cancer. We review liminality in cancer-related literature and juxtapose this with empirical material. Analysing interview data (with eight patients) and participant-made photos highlights why places may be experienced differently throughout a period of illness and how places of diagnosis and care 'stretch' across locations. We conclude that exploring liminality's spatial dimension has implications for people 'living beyond' cancer, advances sociological understandings of (cancer) illness, and may inform healthcare facility design.

Building scale and well-being in a hospice: a qualitative exploration

Objective

This study explored how built space plays out in palliative care, focusing on spatial aspects that could support or hamper patients’, relatives’ and caregivers’ well-being.

Methods

This study was conducted in a freestanding small-scale hospice combining a residential part for eight guests with a day-care part for groups of about five persons. Observations were combined with semistructured, individual interviews with eight guests (sometimes accompanied by relatives) and three focus-group interviews with staff, volunteers and relatives. All interviews were audio-recorded and transcribed verbatim. Data were analysed based on the Qualitative Analysis Guide of Leuven.

Results

The most important spatial aspects that impact on physical and social well-being in palliative care turned out to be the building scale and physical proximity. The small-scale setting counters the (often negative) association of palliative care with hospital environments. When the medical condition of the guest allows, it makes communal or outdoor spaces reachable, which enhances emotional and social well-being. In worse conditions, it still makes that care and nature are always nearby. The compactness of communal spaces intensifies social contacts.

Conclusions

The building scale and physical proximity play out in the relationship between the building and its surroundings, between the residential and the day-care parts and among people within the building. Future research could investigate to what extent these spatial aspects are relevant in more conventional palliative care units or even in general hospital wards.

Foregrounding the built environment in the experience of cancer care: A qualitative study of autobiographical cancer narratives

BACKGROUND

For cancer patients, exposure to cancer care facilities entails confrontation in multiple ways. The value ascribed to these places grows over time and can be expected to affect the experience of care.

OBJECTIVE

The purpose of this study was to foreground the role of the built environment in this experience.

METHODS

This qualitative study is based on seven autobiographical narratives written by cancer patients being treated in Belgium or in neighbouring countries.

RESULTS

The thematic analysis of these accounts raises awareness of architecture's role in the experience of cancer patients. Their radius of action is typified by the contrasting adventurous undertakings and shrinking lifeworlds. The built environment furthermore provides leads to metaphors for patients to reformulate their experiences of illness and care.

CONCLUSIONS

Deterritorialised landscapes of cancer care include multiple, geographically dispersed places of care, rather than a single prominent care facility. Simultaneously, exposure to buildings where formal cancer care takes place is intense and meaningful. Metaphors are linked to the built environment and can be seen, through their use in the narratives, to support coping. Further research could look into the potential of metaphors to enhance understanding between stakeholders collaborating around design for cancer care.

The Importance of the Built Environment in Person-Centred Rehabilitation at Home: Study Protocol

Health services will change dramatically as the prevalence of home healthcare increases. Only technologically advanced acute care will be performed in hospitals. This-along with the increased healthcare needs of people with long-term conditions such as stroke and the rising demand for services to be more person-centred-will place pressure on healthcare to consider quality across the continuum of care. Research indicates that planned discharge tailored to individual needs can reduce adverse events and promote competence in self-management. However, the environmental factors that may play a role in a patient's recovery process remain unexplored. This paper presents a protocol with the purpose to explore factors in the built environment that can facilitate/hinder a person-centred rehabilitation process in the home. The project uses a convergent parallel mixed-methods design, with ICF (International Classification of Functioning, Disability and Health) and person-environment theories as conceptual frameworks. Data will be collected during home visits 3 months after stroke onset. Medical records, questionnaires, interviews and observations will be used. Workshops will be held to identify what experts and users (patients, significant others, staff) consider important in the built environment. Data will be used to synthesise the contexts, mechanisms and outcomes that are important to support the rehabilitation process at home.

Researching and Designing Health Care Environments: A Systematized Review of Creative Research Methods

In research and design, Creative Research Methods (CRMs) are useful to gain insight into user perspectives. Reviews suggest that CRMs offer potential to engage people, yet little detail is available regarding their use in relation to built health care environments. Consider environments for cancer care, where patients are confronted with particular physical and emotional challenges. This review aims to synthesize what is known from existing literature about CRMs exploring user experience when researching and designing (cancer) care environments. Based on 16 items, we evaluate the potential of CRMs, offering insight into why, how, where, and when they are employed. Generally little consideration is shown for participants' abilities and limitations. Our analysis further emphasizes the importance of reflecting on visual methods, and the need to report research approaches transparently including where CRMs are used. A sophisticated research approach can leverage CRMs' potential to study experience and carry artifacts forward to inform design(ers).

"It's Lonely": Patients' Experiences of the Physical Environment at a Newly Built Stroke Unit

Objective:

The aim of this study was to explore patients’ experiences of the physical environment at a newly built stroke unit.

Background:

For a person who survives a stroke, life can change dramatically. The physical environment is essential for patients’ health and well-being. To reduce infections, a majority of new healthcare facilities mainly have a single-room design. However, in the context of stroke care, knowledge of how patients experience the physical environment, particularly their experience of a single-room design, is scarce.

Method:

This study used a qualitative design. Patients (n = 16) participated in semistructured individual interviews. Data were collected in December 2015 and February 2017 in Sweden; interviews were transcribed verbatim and analyzed using content analysis.

Results:

Two main themes were identified: (i) incongruence exists between community and privacy and (ii) connectedness with the outside world provides distraction and a sense of normality. In single rooms, social support was absent and a sense of loneliness was expressed. Patients were positively distracted when they looked at nature or activities that went on outside their windows.

Conclusions:

The physical environment is significant for patients with stroke. This study highlights potential areas for architectural improvements in stroke units, primarily around designing communal areas with meeting places and providing opportunities to participate in the world outside the unit. A future challenge is to design stroke units that support both community and privacy. Exploring patients’ experiences could be a starting point when designing new healthcare environments and inform evidence-based design.

How Enclosure and Spatial Organization Affect Residents' Use and Experience of a Dementia Special Care Unit: A Case Study

AIM:

We aim to gain insight into how a dementia special care unit is used and experienced by its residents and what design aspects are important therein.

BACKGROUND:

In Flanders, housing for people with dementia evolves toward small-scale, homelike environments. As population aging challenges the affordability of this evolution, architects and other designers are asked to design dementia special care units that offer the advantages of small scaleness within the context of large-scale residential care facilities. How these units are used and experienced is not systematically evaluated.

METHOD:

A case study was conducted in a recently built residential care facility where a dementia special care unit was foreseen on the ground floor, yet after a few months was moved to the top floor. The case study combined architectural analysis, participant observation, and qualitative interviews with residents and care staff.

RESULTS:

Comparing the original situation on the ground floor with the new situation on the top floor highlights how enclosure (physical and visual access to outside and the rest of the facility) and spatial organization affect how residents use and experience a dementia special care unit.

CONCLUSIONS:

Depending on the type and stage of dementia, residents may have different needs for space to move, sensory stimuli, and social contact. In order to meet these different needs, confining residents to a dementia special care unit to the top floor should be avoided unless it is carefully designed, providing sufficient freedom of movement and connection with the outside world.

The physical environment and patients' activities and care: A comparative case study at three newly built stroke units

AIM

To explore and compare the impact of the physical environment on patients' activities and care at three newly built stroke units.

BACKGROUND

Receiving care in a stroke unit instead of in a general ward reduces the odds of death, dependency and institutionalized care. In stroke units, the design of the physical environment should support evidence-based care. Studies on patients' activities in relation to the design of the physical environment of stroke units are scarce.

DESIGN

This work is a comparative descriptive case study.

METHOD

Patients (N = 55) who had a confirmed diagnosis of stroke were recruited from three newly built stroke units in Sweden. The units were examined by non-participant observation using two types of data collection: behavioural mapping analysed with descriptive statistics and field note taking analysed with deductive content analysis. Data were collected from April 2013 - December 2015.

RESULTS

The units differed in the patients' levels of physical activity, the proportion of the day that patients spent with health professionals and family presence. Patients were more physically active in a unit with a combination of single and multi-bed room designs than in a unit with an entirely single-room design. Stroke units that were easy to navigate and offered variations in the physical environment had an impact on patients' activities and care.

CONCLUSIONS

Patients' activity levels and interactions appeared to vary with the design of the physical environments of stroke units. Stroke guidelines focused on health status assessments, avoidance of bed-rest and early rehabilitation require a supportive physical environment.

The Role of Space in Patients' Experience of an Emergency Department: A Qualitative Study

INTRODUCTION

Nurses are increasingly involved in the design of health care facilities. Although their experience differs from that of patients, they are often expected to represent patients in design processes. Especially in the context of an emergency department, patients' states of mind alter their experiences. Knowledge about the role of space in ED patients' experience is limited. Our study aims to gain insight into this role and thus provide ED nurses with information to better represent ED patients' perspectives in design.

METHODS

We conducted qualitative interviews with 22 patients. The interviews were supported by visual material collected through ethnographic methods to facilitate participants' reflections on the role of space in their experience. Participants were selected during their stays at the emergency department by convenience sampling. Interviews were audio-recorded, transcribed, and analyzed in combination with the visual material through open and axial coding.

RESULTS

We found that the role of space in ED patients' experiences is affected by their altered sensory awareness and shaped by material, social, and time-related aspects. These aspects are intertwined and influenced by the transient character of the emergency department.

DISCUSSION

The study indicates that paying attention to the role of space yields a nuanced understanding of ED patients' experiences. The challenge for hospital designers and staff lies in taking into account patients' altered sensory awareness and in designing interventions that support staff in emphasizing a human approach without counteracting the medical-technical aspect of emergency care.

Design Quality in the Context of Healthcare Environments: A Scoping Review

OBJECTIVE

We explored the concept of design quality in relation to healthcare environments. In addition, we present a taxonomy that illustrates the wide range of terms used in connection with design quality in healthcare.

BACKGROUND

High-quality physical environments can promote health and well-being. Developments in healthcare technology and methodology put high demands on the design quality of care environments, coupled with increasing expectations and demands from patients and staff that care environments be person centered, welcoming, and accessible while also supporting privacy and security. In addition, there are demands that decisions about the design of healthcare architecture be based on the best available information from credible research and the evaluation of existing building projects.

METHOD

The basic principles of Arksey and O'Malley's model of scoping review design were used. Data were derived from literature searches in scientific databases. A total of 18 articles and books were found that referred to design quality in a healthcare context.

RESULTS

Design quality of physical healthcare environments involves three different themes: (i) environmental sustainability and ecological values, (ii) social and cultural interactions and values, and (iii) resilience of the engineering and building construction. Design quality was clarified herein with a definition.

CONCLUSIONS

Awareness of what is considered design quality in relation to healthcare architecture could help to design healthcare environments based on evidence. To operationalize the concept, its definition must be clear and explicit and able to meet the complex needs of the stakeholders in a healthcare context, including patients, staff, and significant others.

How architectural design affords experiences of freedom in residential care for older people

Human values and social issues shape visions on dwelling and care for older people, a growing number of whom live in residential care facilities. These facilities' architectural design is considered to play an important role in realizing care visions. This role, however, has received little attention in research. This article presents a case study of a residential care facility for which the architects made considerable effort to match the design with the care vision. The study offers insights into residents' and caregivers' experiences of, respectively, living and working in this facility, and the role of architectural features therein. A single qualitative case study design was used to provide in-depth, contextual insights. The methods include semi-structured interviews with residents and caregivers, and participant observation. Data concerning design intentions, assumptions and strategies were obtained from design documents, through a semi-structured interview with the architects, and observations on site. Our analysis underlines the importance of freedom (and especially freedom of movement), and the balance between experiencing freedom and being bound to a social and physical framework. It shows the architecture features that can have a role therein: small-scaleness in terms of number of residents per dwelling unit, size and compactness; spatial generosity in terms of surface area, room to maneuver and variety of places; and physical accessibility. Our study challenges the idea of family-like group living. Since we found limited sense of group belonging amongst residents, our findings suggest to rethink residential care facilities in terms of private or collective living in order to address residents' social freedom of movement. Caregivers associated 'hominess' with freedom of movement, action and choice, with favorable social dynamics and with the building's residential character. Being perceived as homey, the facility's architectural design matches caregivers' care vision and, thus, helped them realizing this vision.

Offering architects insights into experiences of living with dementia: A case study on orientation in space, time, and identity

Due to memory loss, people with dementia are increasingly disorientated in space, time, and identity, which causes profound experiences of insecurity, anxiety, and homesickness. In the case study presented in this article, we explored how architecture can support people in coping with this challenge. We took a novel approach to offer architects insights into experiences of living with dementia. Starting from a critical realist and constructionist approach, we combined ethnographic techniques with an architectural analysis. This case study offers insights into the experiences and activities of a woman living with dementia within the architectural context of her home. We describe how the physical and social environment provided her guidance through sequences of day-to-day activities. This study highlights how architecture can support people with dementia in orientating by accommodating places for (1) everyday activities and (2) privacy and togetherness.

Evaluating the inclusivity of hospital wayfinding systems for people with diverse needs and abilities

OBJECTIVES

Wayfinding in hospitals is a complex problem since patients, who are likely to be under stress, may have to navigate their way to multiple locations in the course of a single visit. While good wayfinding design can reduce stress, poor wayfinding can not only increase individuals' anxiety but also generate additional costs for the hospital due to: lost time among staff members who need to direct patients rather than concentrate on their designated task; missed appointments or delayed meetings; and additional security staff to ensure that patients do not enter restricted areas. We investigated to what extent a questionnaire, developed by collecting data about the subjective experiences of wayfinders with diverse needs and abilities, could uncover wayfinding problems in hospitals.

METHODS

The methodology we developed involved four steps: creating an initial questionnaire based on the literature; customizing the questionnaire to a hospital environment; validating and verifying the questionnaire; and evaluating the questionnaire's added value at nine other hospitals.

RESULTS

The questionnaire's generality and added value were demonstrated since many types of wayfinding problems were uncovered at the nine hospitals that other methods had overlooked or regarded as relatively unimportant. The research emphasizes the centrality and uniqueness of the wayfinder rather than that of the institute in determining what people need.

CONCLUSION

Our findings can contribute to understanding wayfinding issues in hospitals and to sensitize designers to the needs and knowledge levels of wayfinders when designing hospitals.

Being Wheeled or Walking

Objective:

In this article, we explore what a different way of moving—being wheeled versus walking—means for the spatial experience of day surgery patients.

Background:

Day surgery centers can be conceived in very different manners. Some are organized similar to traditional hospital admittance; others are located in a specifically designed part of the hospital and receive patients as guests who walk through the entire procedure.

Methods:

We conducted semistructured interviews with 37 patients at two distinct day surgery centers.

Results:

Despite the different managerial concepts and corresponding spatial designs, in both centers, patients’ spatial experience is shaped by the interrelation of material, social, and time-related aspects. However, the chosen concept results in a different experience throughout patients’ journey.

Conclusions:

Based on an analysis of the different journeys, we conclude that patients’ interpretation of a hospital’s care vision is influenced not only by what the hospital communicates explicitly or how it educates its staff but also by what is implicitly told by the built environment.

Mary's Little Worlds: Changing Person-Space Relationships When Living With Dementia

With the case study presented in this article we explore how people with dementia experience and use their environment to expand our understanding of how architectural environments can improve their well-being. We focus on how relationships between people and spaces change for people with dementia. Using a qualitative analysis of three in-depth interviews with a woman living with dementia, we obtained an insider's perspective and a rich account of the changes in her life, including her lived experiences and interventions in her home environment. We contend that looking at people with dementia in relation to and interaction with their environment, combined with an explorative research approach, might reveal multiple and innovative possibilities in designing for people with dementia. To that end, and to build on existing architectural expertise, we suggest focusing on architectural ordering principles across different cases.