A Structured Literature Review on the Research and Design of Rehabilitation Environments.

AIM: This literature review is conducted to identify knowledge gaps and shape a framework for the development of guidelines and future research on programming and design of rehabilitation environments. BACKGROUND: Patients suffering from trauma, stroke, neurological or cardiopulmonary conditions, or recovering from surgery or cancer treatment require rehabilitation services. A comprehensive rehabilitation program can support continuum of care for inpatient and outpatient groups. However, within most facilities, rehabilitation environments are found to be outdated and undersized compared to other programs or lack the correct adjacencies within the facility. Unfortunately, this deficiency is echoed by limited guidelines on programming, planning, and design of these environments. General guidelines derived from healthcare environments research is not adaptable to rehabilitation environments, because the paradigm used in most healthcare environment research does not address specific needs of rehabilitation patients in regaining confidence or relearning daily life skills. METHOD: We conducted a structured literature review, using Preferred Reporting Items for Systematic Reviews and Meta-Analyses as a basis for reporting the available body of work on evidence-based research in rehabilitation environments. RESULT AND CONCLUSION: Through analysis of the limited literature, specific mediators such as patient confidence and motivation were identified. An environment that creates a balance between privacy and social interaction can promote these mediators. Creating enriched environments through elements that engage the senses and encourage more social and physical interaction is essential for recovery. Finally, accessibility and wayfinding are of great importance in these environments due to potential limited mobility or cognitive impairments of patients.

How Visibility May Reduce Security Issues in Community Hospitals' Emergency Departments.

This research explored the relationship between visibility and the level of security risks as perceived by nurses and physicians in emergency departments (EDs). Security in EDs has been reported as a major global concern, and visibility has been identified as a design factor impacting behavior. However, few previous studies have rigorously investigated the role of visibility in reduction of ED security risks with evidence-based design approach. There is a lot of significant questions about how visibility impacts the reduction of security issues in EDs. METHODS: How visibility may influence ED security was explored via qualitative methods in five EDs using semi-structured one-on-one interviews with 17 clinical staff and 48 hr of field observations. The coding process for both interviews and observational notes followed the principles of naturalistic inquiry. RESULTS: The findings suggest security risks can be decreased by improving visibility. Medical staff (registered nurses and physicians) felt more secure in the EDs with higher visibility. DISCUSSION: This study provides a framework to identify preferable levels of visibility in EDs and proposes design strategies to minimize security issues. Registered nurses and physicians can improve their team's sense of security by considering visibility throughout their daily practices.

Reimagining the NICU: a human-centered design approach to healthcare innovation.

Design charettes have been utilized in architectural and design practice to generate innovative ideas. The Reimagining Workshop is a version that combines practical and blue-sky thinking to improve healthcare facility design. The workshop engages diverse stakeholders who follow a human-centered design framework. The Reimagining the Neonatal Intensive Care Unit workshop sought to generate ideas for the future, optimal NICU without specific site or client constraints. Key themes include family-centered care, technology-enabled care, neighborhood and village design and investing in the care team. Recommendations include a supportive physical environment, celebrating milestones, complementary and alternative medicine, enhancing the transition of care, aiding the transition period, and leveraging technology. The workshop showcased the potential for transformative change in NICU design and provided a roadmap for future advancements. These findings can inform regulatory standards for NICU design and drive improvements in family-centered care, patient experiences, and outcomes within the NICU environment.

Color and NICU Design.

PURPOSE: The appropriate use of color in healthcare settings has been a topic of interest for designers and researchers, and the need for evidence-based standards evident. The purpose of this article is to summarize recent research on color as applicable to neonatal intensive care units and to propose standards for color in these settings. BACKGROUND: Research on this topic is limited due to difficulties associated with constructing research protocols, challenges in setting parameters for the independent variable (color), and the need to simultaneously address infants, families, and caregivers. METHODS: For our literature review, the following research question was developed: Does the use of color in the design of the neonatal intensive care units (NICUs) impact health outcomes in newborn infants, families, and/or staff? Using Arksey and O'Malley's framework for conducting a structured literature review, we (1) identified the research question, (2) identified relevant studies, (3) selected studies, and (4) collated and summarized the results. Only four papers were found regarding NICUs, so the search was expanded to include related healthcare and authors reporting on best practice. RESULTS: Overall, the primary research focused on behavioral or physiological outcomes including the role of wayfinding and art, the impact of lighting on color, and tools for evaluating the impact of color. Best practice recommendations sometimes reflected the primary research but occasionally provided contradictory advice. CONCLUSIONS: Based on the reviewed literature, five topics are addressed: palette malleability; the use of the primary colors, blue, red, and yellow; and the relationship between light and color.

Color and newborn intensive care unit design: executive summary.

Research on color in the design of healthcare settings is minimal. This paper provides an executive summary of a recent review on this topic, focusing on application to newborn intensive care units. The review focuses on the following question: Does the use of color in the design of the newborn intensive care units impact health outcomes in infants, families, and/or staff? We employed a structured review process, resulting in four studies involving the use of color in NICUs. The search was expanded to include general research on responses to color and studies in other healthcare settings. The literature clustered around preferences and psychobiological impact of color on infants and adults in NICUs, the interaction of color and light, and the impact of color on adults in general medical settings. Recommendations are made regarding the importance of modifiability and flexibility in the use of color in NICUs and colors that are associated with stress reduction and stimulation.

Time Outdoors in Nature to Improve Staff Well-Being: Examining Changes in Behaviors and Motivations Among University Staff in the Use of Natural Outdoor Environments Since the Emergence of the COVID-19 Pandemic.

Background: Work-related stress is of growing concern to employers because of its significant implications for employee dissatisfaction, reduced productivity, and lowered emotional and physical health. Job-related stress is particularly acute among staff members in higher education, negatively impacting the professional work and personal welfare of staff. During the COVID-19 pandemic, stress levels increased, due to work- and non-work-related factors. Work expectations and environments shifted, as did new non-work responsibilities, such as care of dependents. As a result, many people were forced to spend much more time at home. Given the anticipated levels of stress (higher) and the change in time spent at home (increased), we sought to explore if adults were spending more time outdoors, as compared to pre-pandemic times, and if so, for what purposes. We hypothesized that people would be spending more time outdoors in nature during the pandemic, and that they would be doing so to achieve some of the well-documented benefits including managing stress, and bolstering mental health and wellbeing. We further hypothesized that some staff would experience barriers to spending time outdoors in natural outdoor environments (NOEs), potentially limiting their ability to experience these beneficial effects. Materials and Methods: This study surveyed 507 staff from a large United States university to examine the degree to which staff were spending time in natural outdoor environments (NOEs) during the pandemic (two time-points, compared to pre-pandemic), and whether and how nature-based routines changed as a result of its emergence. The study also examined whether staff were motivated to spend time in nature to improve their mental health and/or wellbeing. Results: The majority of respondents reported spending more time in NOEs since COVID-19 emerged, particularly early in the pandemic. Respondents reported doing so for restorative purposes, including stress relief, improved mental health, and improved physical health. Relative accessibility of NOEs, both in terms of proximity and number of barriers to access, significantly impacted both time outdoors and the number of NOEs used. Access to safe, high-quality NOEs was not experienced equally across staff respondents; barriers to access tended to be higher among staff living with dependents or others in their household, and for staff who identify as non-White. Conclusion: Spending time outdoors may have served as a protective factor for many university staff against some of the potentially detrimental effects of the pandemic, particularly reduced mental health and well-being. Universities can contribute to the ongoing well-being of their staff by supporting access to safe, high-quality NOEs on or adjacent to campus. This may also serve to reduce disparities in access to nature and experience of its benefits. Universities may also consider alternative work arrangements for staff to allow for more time for health and wellness self-care during the work day, including spending time outdoors in nature.

Reimagining Workshops.

Design charettes have been a mainstay in architectural and design practice. Although they are relatively common, research studies on their effectiveness and methods are rare. Recently, an approach has been introduced in the format of Reimagining Workshops (RWs), a charette characterized by both practical and blue-sky thinking, training in empathy, and multi-stakeholder input. In spring of 2021, two RWs were held to explore ideal neonatal intensive care environments. The RWs were born out of a desire to provide a source of information for the Facility Guidelines Institute Guidelines. To date, there have been four RWs: Reimagining the ED, Reimagining Childbirth Facilities, Reimagining Critical Care, and Reimagining the NICU (virtual). This experience enables participants to operate outside of their comfort zone, an important step toward achieving innovation. They are unique in the following ways: (1) the assignments are broad, (2) participants are encouraged to think radically, (3) there are no constraints, (4) participants receive empathy training, and (5) multiple facilities and stakeholders are brought together rather than focusing on a single facility. This article describes the history of design charettes, the history of the RWs, the methodology associated with RWs, and the specific findings from the NICU and the other workshop events.

Using Virtual Reality to Systematically Examine Impacts of Noise and Visual Clutter on Message Elaboration and Cognitive Capacity.

This study used virtual reality to examine how environmental attributes interact with health communication to influence psychiatric help-seeking behavior, using the example of a subway station. We used a 2 × 2 factorial design crossing two noise conditions (high noise [75 dB] or low noise [30 dB]) and two visual clutter conditions (low clutter [a tidy trash can and orderly construction materials] or high clutter [scattered trash and construction materials]). We found that participants in the high (vs. low) visual clutter condition reported lower cognitive capacity levels, and there was a significant correlation between cognitive capacity and message elaboration. However, we found no effects of noise conditions. Serving as a proof-of-concept study to investigate the contexts in which environmental stressors may influence information processing, this study contributes to the field of health communication environmental design research. Clinical Trial Registration: https://osf.io/rsa48.

Assessing Preferences and Perceived Restorative Qualities of Break Spaces for Nurses in China.

OBJECTIVE: This study investigated Chinese nurses' preferences for (a) proximity of break areas, (b) functionality of break areas, (c) amenities, and (d) nature-related environmental features. BACKGROUND: While nurses in China need support to adequately perform their jobs, little is known about how restorative spaces impact their mental and physical health. METHODS: Data were collected through interviews (N = 12), survey questionnaires (N = 88), and visual assessments (N = 88) from nurses who worked in inpatient settings in China. RESULTS: Nurses preferred the break room to be close to nursing stations; to have visual privacy from patients; and to provide space and facilities for drinking, taking naps, dining, and chatting with colleagues. Balconies and windows were shown to have a significant restorative effect. Well-designed break areas were perceived to have positive impacts on nurse perceived levels of well-being and increase nurses' satisfaction levels with their work environment. CONCLUSION: The study outcomes emphasize the importance of restorative spaces for inpatient nurses and recommend including natural elements in the break rooms.

The Potential Correlation Between Nature Engagement in Middle Childhood Years and College Undergraduates' Nature Engagement, Proenvironmental Attitudes, and Stress.

INTRODUCTION: Nature engagement (NE) provides myriad psychological and physiological benefits, many of which begin in childhood and continue into adulthood. Research suggests children who have positive experiences with nature are more likely to continue engaging with nature and have more proenvironmental attitudes (PEAs) as adults. Among the benefits of NE are reduced stress, improved sleep, and improved cognitive performance, all essential criteria for healthy undergraduate life. College students in particular, because of high levels of stress, may benefit from NE, and the frequency and type of their engagement may be impacted by childhood experience. OBJECTIVE: This study aimed to better understand the potential correlation between university undergraduates' past NE in their middle childhood years (MCYs) and current NE; past NE and undergraduate PEA; and undergraduate NE and stress levels. We chose to examine the middle childhood and undergraduate years because little research has been conducted on the relationship of NE between these two age groups. METHODS: We used a survey of undergraduate students (n = 309) enrolled at a US university to explore the frequency and types of NE during MCYs, their family and neighborhood demographics, and current levels of NE, PEA, and stress in their undergraduate lives. RESULTS: Although results indicated a large decrease in NE from middle childhood to undergraduate years for most participants, we found a significant positive correlation between NE during MCYs and undergraduate NE. We found a positive correlation between MCYs NE and undergraduate PEA as well as undergraduate NE and undergraduate PEA. Contrary to other studies and to our hypothesis, we did not find a correlation between undergraduate NE and reduced stress levels. CONCLUSION: This study looked specifically at US undergraduate students to compare their current engagement with and attitudes toward nature and the environment with their nature experiences during their formative MCYs. Our results suggest that it is important for people to have positive experiences with nature in childhood, both for continued NE and to inculcate PEAs in adulthood. These results can help in formulating approaches to improving student well-being at institutions of higher learning.

Physical environments that support the mental health of staff and families in the NICU.

INTRODUCTION: The number of individuals suffering from mental and behavioral health disorders and the lack of access to treatment and appropriate facilities for these individuals are among the most pressing issues of our time. The purpose of this study is to describe the psychological challenges of staff and families in a neonatal intensive care unit (NICU), apply the outcomes of a study on mental health environments to the NICU setting, and make recommendations for the design of NICUs in support of mental health therapy and care. MATERIALS AND METHODS: This study involved the translation of a previous study in mental and behavioral health facilities to the NICU setting. The original study involved interviews (N = 19) and online surveys (N = 134) investigating the importance and presence of particular environmental amenities intended to support mental and behavioral health settings. Data analyzed using Mann-Whitney U tests suggested that the "importance" scores of specific environmental qualities and features were significantly higher than the "effectiveness" scores. An analysis using the Dunn-Bonferroni correction revealed that some environmental qualities and features were rated as significantly more important or more effective than others. For the purposes of this paper, the variables were reexamined for applicability to NICU settings. RESULT: Twenty of the original 26 design goals for mental health units were applicable to NICUs. These goals and how they might be implemented are summarized. DISCUSSION: Guidelines identified as being important in therapeutic environments can be applied to NICU settings.

Comparative Study of the Social Interactions of Two Differently Designed Long-Term Care Facilities for Individuals With Acquired Brain Injury.

AIM: This study focused on long-term care (LTC) settings for individuals with acquired brain injury (ABI). The goals were (1) to assess the impact of facility configuration on social interactions between residents and staff and (2) obtain a better understanding of staff and resident perceptions of the built environment. BACKGROUND: A few studies have explored the relationship between the built environment and social interaction in LTC facilities, but there is little empirical data about ABI-specific LTC facilities. METHODS: A literature review was conducted on the impact of the built environment on the LTC of brain injury survivors. Via a questionnaire, staff and residents in two settings, one with patient rooms off corridors and the other with patient rooms surrounding a common space, rated the effectiveness of the built environment in promoting social interaction. Behavioral observation was conducted on 18 residents for a duration of 4 hr per resident. RESULTS: Via questionnaires, staff rated the corridor facility as more effective in promoting social interaction, but no significant differences were found between the assessments of the two resident populations. Contrary to staff questionnaire results, residents in the open configuration facility exhibited more social behaviors. CONCLUSIONS: Building configuration may impact social interaction between staff and residents in ABI-specific LTC facilities and potentially impact staff and resident quality of life. However, configuration cannot be viewed in a vacuum; residents' physical and mental limitations, demographic information, and staff engagement must be also considered.

Mental and behavioral health environments: critical considerations for facility design.

OBJECTIVES: The purpose of the study was to identify features in the physical environment that are believed to positively impact staff and patients in psychiatric environments and use these features as the foundation for future research regarding the design of mental and behavioral health facilities. METHODS: Pursuant to a broad literature review that produced an interview script, researchers conducted 19 interviews of psychiatric staff, facility administrators and architects. Interview data were analyzed using the highly structured qualitative data analysis process authored by Lincoln and Guba (1985). Seventeen topics were addressed ranging from the importance of a deinstitutionalized environment to social interaction and autonomy. RESULTS: The interviewees reinforced the controversy that exists around the implications of a deinstitutionalized environment, when the resulting setting diminishes patient and staff safety. Respondents tended to support open nurse stations vs. enclosed stations. Support for access to nature and the provision of an aesthetic environment was strong. Most interviewees asserted that private rooms were highly desirable because lower room density reduces the institutional character of a unit. However, a few interviewees adamantly opposed private rooms because they considered the increased supervision of one patient by another to be a deterrent to self-harm. The need to address smoking rooms in future research received the least support of all topics. CONCLUSION: Responses of interviews illustrate current opinion regarding best practice in the design of psychiatric facilities. The findings emphasize the need for more substantive research on appropriate physical environments in mental and behavioral health settings.

Space Syntax Analysis: Tools for Augmenting the Precision of Healthcare Facility Spatial Analysis.

AIM: This article reviews and addresses various spatial measures that provide and facilitate accurate descriptions of different layout typologies with particular focus on healthcare facilities. BACKGROUND: Evidence-based design is a field of study that emphasizes the importance of using credible data in order to influence the design process. It addresses whether/how the design and operation of buildings support positive health outcomes through a growing collection of solutions informed by research and practical knowledge. In order to acquire this knowledge, we must consider the environment in a very precise and measurable way, which can then be investigated quantitatively with regard to various human behaviors and cognitive processes. TOPICAL HEADINGS: Space Syntax theory and methods are concerned with understanding how spaces are arranged and connected to one another. It provides quantitative measures of individual spaces and of the entire layout, thereby achieving great accuracy. Space Syntax researchers have used graph theory to define spatial measures and have produced computer tools to quantify the relational properties of spaces and to provide numerical and display values for each. Moreover, they have developed more precise tools that can be embedded within basic Space Syntax concepts in order to augment the credibility of the acquired data. CONCLUSION: The study elaborates on the effectiveness of Space Syntax and its newly developed measures for the field of healthcare facility design and research. We present a comprehensive model that brings together these measures with their correlated behavioral and perceptual consequences, thereby providing a point of departure for further investigation and exploration.

The Role of Daylighting in Skilled Nursing Short-Term Rehabilitation Facilities.

OBJECTIVE: The aim of this study is to investigate the best placement of windows in short-term rehabilitation facilities in terms of daylighting and outdoor views by exploring the impact of windows on resident perception of stress, mood, activities, and satisfaction. BACKGROUND: The physiological and psychological benefits of daylighting have made it an increasingly important topic in multidisciplinary research. Although multiple studies have been written about the impact of daylight on physiological responses, few investigations have been made into the nonvisual effects related to resident mood, satisfaction, and stress level. In addition, researchers typically propose recommendations for quantitative aspects of illuminance, rather than addressing the behavioural outcomes. METHODS: A combination of qualitative and quantitative methodologies were used to address the research questions. Thirty-four participants, who were living temporarily in the inpatient rehabilitation units of two skilled nursing facilities, were subjects in semistructured interviews and a 7-question 5-scale survey. While residents expressed the need to have direct visual access to the outdoors, they indicated that daylight was of even higher benefit. Additionally, they noted that size and location of windows impacted their stress levels, moods, and activities. More than half of the facility residents reported changing their postures for either better outdoor views or less light disturbance while sleeping. CONCLUSIONS: The results of this study emphasize the importance of daylighting for residents in rehabilitation units. Architects should acknowledge the role of daylighting and window views in the design of rehabilitation facilities.

The impact of windows and daylight on acute-care nurses' physiological, psychological, and behavioral health.

OBJECTIVE: To investigate the physiological and psychological effects of windows and daylight on registered nurses. BACKGROUND: To date, evidence has indicated that appropriate environmental lighting with characteristics similar to natural light can improve mood, alertness, and performance. The restorative effects of windows also have been documented. Hospital workspaces generally lack windows and daylight, and the impact of the lack of windows and daylight on healthcare employees' well being has not been thoroughly investigated. METHODS: Data were collected using multiple methods with a quasi-experimental approach (i.e., biological measurements, behavioral mapping, and analysis of archival data) in an acute-care nursing unit with two wards that have similar environmental and organizational conditions, and similar patient populations and acuity, but different availability of windows in the nursing stations. RESULTS: Findings indicated that blood pressure (p < 0.0001) decreased and body temperature increased (p = 0.03). Blood oxygen saturation increased (p = 0.02), but the difference was clinically insignificant. Communication (p < 0.0001) and laughter (p = 0.03) both increased, and the subsidiary behavior indicators of sleepiness and deteriorated mood (p = 0.02) decreased. Heart rate (p = 0.07), caffeine intake (p = 0.3), self-reported sleepiness (p = 0.09), and the frequency of medication errors (p = 0.14) also decreased, but insignificantly. CONCLUSIONS: The findings support evidence from laboratory and field settings of the benefits of windows and daylight. A possible micro-restorative effect of windows and daylight may result in lowered blood pressure and increased oxygen saturation and a positive effect on circadian rhythms (as suggested by body temperature) and morning sleepiness. KEYWORDS: Critical care/intensive care, lighting, nursing, quality care, work environment.

Positive distraction and the rehabilitation hospitals of joão filgueiras lima.

OBJECTIVE: This article discusses the use of positive distraction, an evidence-based design approach, in rehabilitation hospitals in Brazil through the work of João Filgueiras Lima ("Lelé"). BACKGROUND: In many parts of the world architects may not formally incorporate theories of positive distraction and evidence-based design, but there are multiple international examples of health facility architects and designers that use nature, daylighting, art, and social interaction to enhance the healing experience. The work of the Brazilian architect João Filgueiras Lima is a particularly salient example. Lima has been a dominant figure in 20th and 21st century Brazilian architecture and the architect of several rehabilitation facilities. METHODS: First positive distraction is defined as it relates to nature and art, and in the context of rehabilitation hospitals. Second, rehabilitation facilities are defined. The discussion then focuses on awareness of evidence-based design in Latin America. Next, Brazilian healthcare architecture is discussed along with the history of the Brazilian Sarah rehabilitation hospitals designed by Lelé and Lelé's role in the history of Brazilian architecture. Last we look at Lelé's use of positive distraction. RESULTS: Despite Lelé's recognition in Brazil, his work has not gained much international exposure. Lelé played a critical role in the design of the Sarah facilities and served on the board of directors for the Technological Center of the Sarah Network (CTRS) in Brazil from 1992 to 2009. Based on our review of his work it was clear that Lelé used positive distraction as a tool for creating healing environments. CONCLUSIONS: In spite of the lack of formal integration of evidence-based design in healthcare architecture in Latin America, many of its basic tenets have been incorporated in Brazilian rehabilitation hospitals. Lelé's projects are a clear example of this phenomenon and demonstrate an alignment between research and practitioner objectives. The presence of nature, art, and natural light in his rehabilitation hospitals serves as a model for evidence-based design in facilities throughout the world and presents an opportunity to measure the benefits of positive distraction on rehabilitation patient outcomes.

Design research and the globalization of healthcare environments.

OBJECTIVE: Global healthcare practice has expanded in the past 20 years. At the same time the incorporation of research into the design process has gained prominence as a best practice among architects. The authors of this study investigated the status of design research in a variety of international settings. We intended to answer the question, "how pervasive is healthcare design research outside of the United States?" METHOD: The authors reviewed the international literature on the design of healthcare facilities. More than 500 international studies and conference proceedings were incorporated in this literature review. A team of five research assistants searched multiple databases comparing approximately 16 keywords to geographic location. Some of those keywords included: evidence-based design, salutogenic design, design research, and healthcare environment. Additional articles were gathered by contacting prominent researchers and asking for their personal assessment of local health design research studies. RESULTS: While there are design researchers in most parts of the world, the majority of studies focus on the needs of populations in developed countries and generate guidelines that have significant cost and cultural implications that prohibit their implementation in developing countries. Additionally, the body of literature discussing the role of culture in healthcare environments is extremely limited. CONCLUSION: Design researchers must address the cultural implications of their studies. Additionally, we need to expand our research objectives to address healthcare design in countries that have not been previous considered.