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 However, within most facilities, rehabilitation environments are found to be outdated and undersized compared to other programs or lack the correct adjacencies within the facility.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 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.

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.

The Relationship of Neighborhood Walking Behavior to Duration of Aging in Place-A Retrospective Cohort Study.

The benefits of physical activity on health are widely known. However, the impact of physical activity on aging-in-place at home for older adults is unclear. Focusing on older adults who recently moved from home to a senior-living facility, this research explored the impact of walking on the ability to age-in-place. Data were collected through a questionnaire survey completed by residents in 12 assisted-living facilities in Houston, Texas. Controlling for significant personal factors, ANOVAs were applied. Non-Hispanic White older adults (N = 124) who used canes or no aids and engaged in 30 min to 1 h of walking per occurrence were able to remain in their homes for an average of 17.84 years after age 65, 1.85 years longer than their counterparts who walked less than 30 min per occurrence. Those who walked for more than an hour per occurrence remained at home for 22.71 years on average, 6.72 years longer than their counterparts (p ≤ 0.05). Engaging in neighborhood walking may help older adults maintain more years of aging-in-place at home. The findings have a direct impact on both public health programs and community design and planning strategies promoting aging-in-place.

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 saliency of geographical landmarks for community navigation: A photovoice study with persons living with dementia.

This study uses the photovoice method to explore how persons living with mild-to-moderate dementia perceive neighborhood landmarks and identify characteristics that render these landmarks salient for outdoor navigation. Previous research has highlighted the role of well-designed, stable geographical landmarks in improving the navigability of neighborhoods for persons living with dementia. However, the specific attributes that render landmarks salient have not yet been sufficiently explored, resulting in inadequate evidence-based environmental design guidelines for dementia-friendly communities. To address this gap, a photovoice study was conducted with five community-dwelling persons living with dementia and their care partners, as part of a dementia-friendly neighborhood walking program in the city of Seattle, USA. Photovoice facilitated the exploration of saliency of neighborhood landmarks from an emic perspective by (i) empowering persons living with dementia to identify and take photos of salient landmarks during the group walk and (ii) interpret and reflect on attributes that contributed to saliency using the photos as visual aids in a focus group discussion and survey questionnaire. Participants associated the saliency of landmarks with two groups of attributes: (i) visual distinctiveness, which encompassed physical aspects, such as size, shape, color, texture; and (ii) meaningfulness, which included subjective factors of personal and emotional significance that linked the landmarks to participants' pasts, passions, hobbies, and emotions related to having dementia. Findings suggest that outdoor landmarks should be designed for maximum legibility and noticeability, as well as familiarity, recognizability, and memorability. The evidence from this research also points to the likely positive effect of salient neighborhood landmarks on the community navigation of persons living with dementia.

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.

The Correlation Between Visibility and Medical Staff Collaborative Communication in Emergency Departments.

OBJECTIVES: This study empirically investigates the correlation between visibility and nurses and physicians' collaborative communication in emergency departments (EDs). The researchers hypothesized that higher visibility levels in EDs are associated with higher collaborative communication among nurses and physicians. BACKGROUND: The review of related literature addresses the role of communication in EDs, and more specifically, how visibility has been found to affect nurse and physician behavior in healthcare facilities. METHOD: The visibility levels in four EDs within the same hospital system were quantitatively measured in this study. Also, the communication levels among medical staff were explored by two methods. Data collection included computerized floor plan analyses, observations, and surveys. RESULTS: The researchers found statistically significant relationships between several underlying dimensions of ED visibility and collaborative communication among the medical staff members. CONCLUSION: Understanding the role of visibility provides a critical design principle for future EDs. The enhancement of ED design helps nurses and physicians to benefit from supportive environments.

Evaluation of a Mental and Behavioral Health Patient Room Mockup at a VA Facility.

OBJECTIVE: The primary goal of this research was to evaluate a physical full-scale, high-fidelity mockup of a mental and behavioral health (MBH) inpatient room and bathroom. BACKGROUND: There is minimal research on design for MBH and no published research using mockups to evaluate a MBH design proposal. To address this gap, an interdisciplinary team developed an ideal Patient-Centered MBH Patient Room, which was built as a mockup at a Veterans Administration (VA) facility and evaluated by patients and staff in situ. METHOD: The mock-up was evaluated using a structured mixed methods process that incorporates feedback using Feedback Forms and facilitated Listening Sessions. Our two primary hypotheses were that the design, as represented by the mock-up, would be positively evaluated and that there would be a difference between staff and patient perceptions, with patients rating the design higher than staff. RESULTS: Quantitative analysis confirmed our hypotheses, revealing an overall positive response, with a difference between patients and staff. Contrary to hypothesis, staff consistently rated the design higher than patients. Qualitative analysis found mixed reception of the design and three primary themes: safety, homeyness/deinstitutionalization, and positive distraction/nature. CONCLUSIONS: Physical mock-ups may be an effective tool for evaluation of a proposed design; however, staff perceptions of the environment may differ from those of patients. One drawback of using a physical high-fidelity mock-up is the expectation that the mock-up perfectly represents the proposed design. With this project, even small unfinished details were distracting to the participants and may have negatively affected the evaluation.

The Influence of Visibility on Medical Teamwork in Emergency Departments: A Mixed-Methods Study.

AIM: This mixed-methods study delivers empirical evidence on the influence of visibility on healthcare teamwork in Emergency Departments (EDs). This study researchers hypothesized that with changes of visibility in EDs, teamwork among medical staff members will be impacted. BACKGROUND: Prior research results suggest that visibility can influence health-setting efficacy. Teamwork is one of the components of each healthcare system that can be supported by environmental design. METHOD: Visibility in four subject sites from the same healthcare system was objectively measured by morphology plan analyses. Teamwork among medical staff members was the behavioral variable of interest and explored through field observations, interviews, and surveys. RESULTS: The qualitative outcomes demonstrated that teamwork can be enhanced by improved visibility, while the quantitative findings supported the idea that some specific measures of visibility were correlated with teamwork. CONCLUSION: This study provides a model for future research on the association between healthcare staff behavior and ED plan configuration. The enhancement of ED design, considering the significance of visibility, enhances the perceptions of nurses and physicians in terms of teamwork.

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.

The Impact of Green Space on Violent Crime in Urban Environments: An Evidence Synthesis.

Can the presence of green space in urban environments reduce the frequency of violent crime? To ascertain the evidence on this topic, we conducted an in-depth literature review using the PRISMA checklist. The search parameters included US articles written in English and published since 2000. More than 30,000 potential paper titles were identified and ultimately, 45 papers were selected for inclusion. Green spaces typically comprised tree cover, parks and ground cover. Criminal behaviors typically included murder, assault, and theft. The majority of the research reviewed involved quantitative methods (e.g., comparison of green space area to crime data). We extracted multiple mechanisms from the literature that may account for the impact of green space on crime including social interaction and recreation, community perception, biophilic stress reduction, climate modulation, and spaces expressing territorial definition. Recommendations are made for future research, such as meta-analysis of existing data and the development of grounded theory through qualitative data-gathering methods. By providing evidence that access to nature has a mitigating impact on violence in urban settings, city governments and communities are empowered to support these interventions.