Purpose: The purpose of this inquiry was to explore how nurses envision and benefit from restorative built environments in acute care hospitals. Background: The Covid-19 pandemic has resulted in alarming rates of occupational stress and attrition in front-line clinicians, which has made inquiry into how to promote well-being in nurses particularly timely, and salient. Much of the existing design literature is functionalist in tenor, foregrounding how to improve the efficiency and productivity of staff. Provided this, little is known about how nurses experience hospital environments and what restorative features they imagine within these spaces to attenuate stress. This insight is necessary for an improved articulation of supportive and restorative architectural affordances. Methods: Informed by interpretive description, a qualitative study using photo-elicitation was employed to solicit the experiences of 4 frontline registered nurses working in acute care hospitals in Canada. Data was triangulated from three sources; (1) Photographs; (2) Narrative notes; (3) Semi-structured interviews. Results: Iterative and thematic analysis revealed that nurses recognize the power of good design to promote staff retention and promote well-being, although participants largely regard their present work environments as pathogenic and perpetuating harm. Nurses visually and narratively envisioned enriched environments through the use of adaptable space, visual and associative references to nature, a creative atmosphere, inclusive spaces, a civic presence, and the provision of spaces to enable rituals of (self)care. Conclusions: Nurses have considerable tacit and embodied knowledge which can improve the hospital built environment, but further research is needed to capture and solicit these holistic experiences.

Progressive efforts within the healthcare design community have led to a call for architects to use relevant scientific research in design decision making in order to provide facilities that are safe, efficient, and flexible enough to accommodate evolving care processes. Interdisciplinary design project teams comprising architects, interior designers, engineers, and a variety of consultants struggle to find ways to deal with the challenge of incorporating the evidence base into the projects at hand. To date there has been little research into how these interdisciplinary teams operate in the real world and especially how they communicate and attempt to integrate evidence coming from different sources into the architectural design that is delivered. This study presents an investigation of a healthcare design project in situ by using methods of ethnographic inquiry, with the aim of developing an enhanced understanding of actual collaborative healthcare design practices. A major finding is that ‘evidence’, as used in practice is a richly textured notion extending beyond just the scientific research base. The description and analysis of the observed practices is presented around two core chapters involving the design process of 1) the emergency department and 2) the inpatient unit. Each design episode, which depicts the complex socio-cognitive landscape of architectural practice, introduces how evidence, with its various types and representational forms, was generated, represented, evaluated, and translated within the interdisciplinary design team. Strategically utilizing various design media, including layout drawings and mock-ups, the architects represented and negotiated a set of physical design attributes which were supported by differing levels of scientific research findings, anecdotes, successful precedents, in-house experimental findings, and intuition, each having different affordances and constraints in solving design problems over time. Individually, or combined into larger “stories” which were collectively generated, the set of relevant evidence provided a basis for decision making at various scales, ranging from minor details within rooms to broader principles to guide design work over the course of the project. Emphasizing the role of the architects in translation of evidence, the design episodes provide vivid examples of how various forms of evidence shape the design of healthcare environments. The case observed in this research demonstrated that the participants formulated and explained their design ideas in terms of mechanistic arguments where scientific research, best practices, and anecdotal evidence were integrated into segments that formed causal links. These mechanistic models, as repositories of trans-disciplinary knowledge involving design, medicine, epidemiology, nursing, and engineering, expand the scope of traditional understanding of evidence in healthcare design. In facilitating design processes architects are required not only to become knowledgeable about the available evidence on healthcare, but also to use their meta-expertise to interpret, translate (re-present), and produce evidence in order to meaningfully engage in interdisciplinary exchanges. In re-presenting causal models through layouts or mock-ups, architects play a critical role in evidence-based design processes through creating a platform that displays shortcomings of available evidence and shows where evidence needs to be created in situ.

An ageing population is demanding more of healthcare services worldwide, particularly for long-term conditions. In the UK, the challenge of limited healthcare service resources and the influence of the Equality Act on services have increasingly led to the consideration of people's access to community rehabilitation services. These present a potential opportunity for Inclusive Design. The literature suggests that Inclusive Design and its associated tools have been widely applied to the accessibility of buildings and public transport, as well as consumer products and services, but there is little evidence of their application to healthcare services. A review of the literature highlights the importance of improving people's access to community-based rehabilitation by providing care at or closer to home which has become an increasingly prevalent option to meet the healthcare demand for long-term conditions in an ageing population. Therefore, this thesis investigates how Inclusive Design can be applied to healthcare delivery services to improve patients' experiences of accessing these services. It accomplished this through two case studies: community-based rehabilitation services of back pain and chronic obstructive pulmonary disease (COPD). The case studies involved online surveys and interviews with healthcare professionals and patients in understanding the patients' care journeys and challenges in accessing these services. The impact of services demands on patients' capability and their access to services was analysed using an Inclusive Design tool, the Exclusion Calculator. An inclusive approach integrating tools and procedures was summarised to facilitate the understanding of patients' capability-related needs both for the recipients of care and for the providers of care. This research provides a novel contribution by filling the gaps in the literature on the application of Inclusive Design to healthcare delivery services, i.e., community-based rehabilitation. It demonstrates that an Inclusive Design approach can be used to improve people's access to healthcare services and the tools applied can make a useful contribution to understanding service provision and hence service improvement. The Inclusive Design approach focuses on identifying the demands that healthcare services make of their users' capability and in estimating services' exclusion. The process of applying Inclusive Design in this research may be used to improve other healthcare services.

Researchers have studied the positive effect of healing outdoor environments on hospitalized children, their family members and staff's health and mood. Consequently many modern hospitals dedicate portions of their space to healing outdoor environments. However, these amenities are underutilized due to various design barriers. This research aimed to identify barriers to garden visitation and introduce design guidelines that encourage garden visitation in pediatric hospitals for all groups. Five Texas pediatric hospital gardens were selected to examine the impact of availability of shade, quality and availability of seats, and presence of the healing nature on user satisfaction and garden use. Behavioral observation, surveys, interviews, and site evaluations were conducted. Gardens were ranked based on design qualities, user satisfaction, and frequency and duration of garden visitation. The primary conclusion of this study was that garden visitors' satisfaction with design is positively correlated with presence and quality of hypothesis variables. Duration and frequency of garden visitation also increased in gardens with better shading, seating options, and planting. Other factors identified as influential in increasing garden use included availability of amenities for children and playfulness of design layout. The research findings were instrumental in introducing new design guidelines for future hospital garden design projects. In addition, they served to statistically support design guidelines suggested by previous researchers.

At the heart of this thesis research lies the theory of biophilia which describes the innate affinity that humans have for nature and suggests a scientific hypothesis for environmental behavioral responses within the creative fields of architecture and design. Natural environments afford healing and restorative benefits in the form of positive shifts in cognitive, physical, and social functioning. Stress relieving benefits of natural environments are also widely recognized for their ability to provide a sense of control or privacy, a means for social support and interaction, opportunities for physical exercise and movement, and positive distractions through connection to nature. By creating verdant environments that are sensory-rich and accommodate physical experiences with nature beyond the passive experience of simply viewing it from the interior, a garden can provide healing benefits that extend past the architectural walls of the healthcare building. Through the introduction of guidelines and considerations, the field of healing landscape architecture has been able to design for positive environmental responses to create successful exterior healing environments. However, the same supportive characteristics, preferences, and stress relieving benefits of a natural healing environment need to be considered for the interior healthcare environment. To further facilitate well-being, the built spaces need to be environments that reconnect the body and mind and foster a sense of place. These healing effects can be achieved through biophilic and sensory encounters within the facility. By focusing more on the human-environmental response research from environmental psychology, the methods for healing landscape architecture, and expanding on the principle of connection to nature in evidence-based healthcare design, healing interior environments can begin to be redefined. Using concepts of biophilic design to guide decisions for the built environment, spaces are designed to support healing through biophilic responses and connection to natural elements and systems. This thesis is meant to be viewed as a contribution towards developing evidence-based biophilic interior design solutions for healthcare environments. The interdisciplinary research and proposed guidelines are hypotheses for how to further design with nature for human well-being. They offer support and design considerations for psychological responses to nature within the interior healthcare environment. / text

abstract: Over the past century, the relationship between the built environment and people’s health and well-being has become central to the discussion and critique of healthcare design. The concept of such a relationship is not new; more than a century ago, Florence Nightingale promoted a particular vision for hospital design. Her concerns with naturalism, acoustics, ventilation, and aesthetics in the healthcare environment are as relevant today as they were in the mid-19th century. This dissertation examines Nightingale’s contributions to the development of the nascent field of healthcare interiors by: identifying major developments of healthcare interiors through the centuries; investigating Nightingale’s life, work, and principles on the healthcare environment; and examining whether certain contemporary hospital design approaches support, expand upon, or negate her principles. The research integrates material culture analysis of extant objects and content analysis of documents within the framework of a case study of two healthcare facilities in Tucson, Arizona. Findings show that the Nightingale era was seminal in the evolution of the healthcare environment, with key developments towards healthful interiors for the sick. Wide adoption of hospital design guidelines suggested by Nightingale—emphasizing physical elements such as ventilation, natural light, view, sanitization, and ambiance—occurred in various types of healthcare facilities, including military and tuberculosis sanatoria around the world. Additionally, analysis of the case study shows just how welcoming and supportive a 1920s healthcare facility, like the Desert Sanitarium, can be. The facility successfully adapts Florence Nightingale’s principles to the local climate and context, including indigenous pueblo architecture, traditional Southwestern materials, Native American artifacts, desert views, and even the traditional courtyard plan used by Spanish colonial settlers. This successful adaptation suggests that Nightingale’s principles may be valuable to and relevant within different places and times, even today. Thus, Nightingale contributed to the emerging field of healthcare interiors by: 1) functionally organizing the built environment affecting patients’ healing, 2) preventing healthcare-associated infection in the physical environment, and 3) supporting psychological health with aesthetic amenities. The findings advance interior design scholarship, education, and practice; and further the documentation and explication of Arizona’s history in the healthcare environment. / Dissertation/Thesis / Doctoral Dissertation Design 2015

In his classic book, Experiencing Architecture, Rasmussen (1959) noted that architects inspired by addressing problems in built environments created buildings with a special spirit: a distinctive stamp. Recent problems in healthcare facilities, specifically those related to reducing stress and anxiety, have inspired designers to create positive, uplifting distractions to redirect a patient's attention from a sterile environment and/or noxious event. In doing so, healthcare facilities have become special environments with a caring spirit. This study examined a specific aspect of creating a caring environment: determining whether or not a positive distraction, a child's art-light mosaic movie developed by the researcher, would lower pain and distress in children 4, 5, and 6 years old during an immunization procedure. The researcher conducted a randomized controlled study in two locations using a child's self-report pain scale, heart rate, parent/guardian report, and nurse report measures. After collecting and analyzing data from 76 well-participants receiving one to five immunizations, the researcher found no statistically significant difference between the conditions for any of the measures. Thus, the null hypothesis, the art-light mosaic image would not assist in lowering pain and distress in pediatric patients, 4 to 6 years old, during an immunization procedure, was not rejected. From these results, the researcher recommended future studies incorporate training the parent and child on how to use the distraction, combine the distraction with a topical analgesic, provide a clear understanding of pain and distress from the child's point of view, and develop more sensitive self-report measures of pain for children. / Ph. D. / In his classic book, Experiencing Architecture, Rasmussen (1959) noted that architects inspired by addressing problems in built environments created buildings with a special spirit. Recent problems in places that provide healthcare, specifically those related to reducing stress and anxiety, have inspired designers to create positive, uplifting distractions to redirect a patient’s attention from an unfriendly environment and/or unpleasant event. In doing so, healthcare facilities have become special places with a caring spirit. This study investigated one area in creating a caring environment: determining whether or not a positive distraction, a child’s art-light mosaic movie developed by the researcher, would lower pain and distress in children 4, 5, and 6 years old receiving a vaccination. The researcher conducted a study in two locations using proven measures to determine the child’s anxiey. After collecting and analyzing information from 76 well-children receiving one to five vaccinations, the researcher found no difference between the children’s anxiety watching or not watching the positive distraction during a vaccination. Therefore the researcher stated the positive distraction, an art-light mosaic image, would not help lower pain and distress in children, 4 to 6 years old, during a vaccination. From these results, the researcher recommended future studies include training the parent and child on how to use the distraction, combine the distraction with a cream designed to rub on the skin to relieve pain, provide a clear understanding of pain and distress from the child’s point of view, and develop better measures to determine pain in children.

Since the 1960s, researchers have been exploring how the design of the built environment impacts the health and well-being of occupants and users. By the 1980s, further research began to focus on healthcare facilities in particular and how design could influence patient healing and medical staff performance (Alfonsi, 2014). Evidence-Based Design (EBD) is "the process of basing decisions about the built environment on credible research to achieve the best possible outcomes" (CHD, 2016). The desired outcomes of Evidence-Based Design recommendations include improvements in the following: patient healing, patient experience and comfort, medical staff performance, and medical staff job satisfaction (CHD, 2017). Extensive research has been done on the subject of EBD; however, the question remains whether or not the latest research findings are being utilized by the design and construction industries in practice. The purpose of this research is to determine whether or not the latest scientific knowledge and research findings are being implemented into hospital renovation projects by the healthcare design and construction industries. A list of recommendations from existing EBD literature was compiled. Construction documents from 30 recent healthcare facility renovation projects across the United States were then obtained and analyzed. The findings indicate that EBD recommendations are being adopted in practice at consistently high levels. These findings also reveal that there are still areas of potential improvement which could inform those who influence or determine building and design codes, standards, and guidelines. The results are instructive to owners, designers, and contractors by providing a glimpse into how well the industry is recognizing and implementing known best practices. The findings likewise open up new opportunities for further research which could lead to additional improvement in the healthcare facilities of the future.

Doctor of Philosophy (PhD) / This study was conducted to increase our understanding of children and young people’s experience of a hospital environment and to identify the salient attributes of the physical environment in their experience. There were three specific aims: to describe children and young people’s experience of a hospital environment and identify what constitutes a supportive paediatric environment; to examine the role of the physical environment in patients’ feeling of well-being; and to highlight the capacity of participatory research with children and young people to inform evidence-based paediatric design. At this stage, there has been very little healthcare design research carried out with populations of children and young people. Well-being research with children and young people in paediatric environments that identifies the potential supportive attributes in this environment is also very limited. Historically research on children’s health and well-being has been dominated by a focus on the prevalence of disorders, problems and disabilities. More recently, in response to the change to health promotion, positive attributes have been included in well-being and satisfaction measures. At this stage, there are still many fewer positive measures. Within the body of literature that exists in healthcare, healthcare design research, and well-being research, there are only a small number of participatory studies that focus on children and young people’s experience of hospitalisation, and an even smaller number that include children and young people’s experience of hospital environments. The picture that is created by the research that exists is patchy. There is a need for a more holistic understanding of children and young people’s experience of hospitalisation and of hospital environments from their own perspectives. Based on these gaps in current knowledge, two research questions were developed. The first was concerned with describing children and young people’s experience of the sociophysical environment of a paediatric hospital. The second question was concerned with understanding the role of the physical environment in children and young people’s feeling of well-being in a hospital environment. In addressing these questions, the intention was to identify attributes within the hospital setting which collectively comprise a supportive environment for children and young people and which contribute to children and young people’s feeling of well-being in a paediatric setting. The current study was conducted as an exploratory qualitative case study and carried out at the Children’s Hospital at Westmead, in Sydney, Australia. Using participatory research techniques, the sequence of the study included two pilot studies and the main study. The focus was on understanding the experiences of longer-term patients of a paediatric hospital environment. In the main study 25 children and young people, aged between 9-18 years, who had been in hospital for at least a week completed semi-structured interviews in which they talked about their response to the environment of the hospital and their experience of hospitalisation. Data analysis was completed using a combination of concept mapping and thematic analysis techniques. Preliminary findings were used as the basis of a further member-checking task carried out with a further six children and young people before conclusions were reached. The findings reveal that children and young people’s experience of a paediatric setting involves a number of major areas of influence including their personal situation, their social experience, their interaction with the physical environment, opportunities and characteristics of the organisation, and the effect of time. The findings also reveal that children’s feeling of well-being within this experience is linked to their ability to feel comfortable in the environment, to maintain a positive state of mind, and to remain positively engaged with the experience and the environment. This research reveals a dynamic relationship between children and young people and a paediatric environment that children and young people actively manage and shape. It reveals some of the key considerations in children and young people’s experience of hospitalisation. It also reveals why these considerations are important and what role they play in patients’ experience and feeling of well-being. These findings provide the basis for further research and they have implications for future design and research practice in paediatric healthcare settings.

Primary care clinics play a vital role in the US healthcare system, providing preventative and cost-effective care. New trends in healthcare such as the development of the medical home model for care, the application of electronic medical records (EMRs), the effort to increase access to care, and the need to adhere to the Health Insurance Portability and Accountability Act (HIPAA) will have direct impacts on the work flow and spatial delineation of primary care clinics. To ensure the success of primary care practices, the architectural design of primary care clinics needs to address these changes to satisfy both patients and staff, and to improve efficiency and outcomes of care. There is limited literature on the design usability (efficiency, effectiveness, and user satisfaction) of primary care clinics. This study developed a set of building usability evaluation tools to collect, analyze and interpret the “usability” of a primary care facility. The study used previous literature as well as a case study primary care clinic in Maryland as a basis to develop these tools. In the clinic, data were collected through an initial interview with the head nurse, a forty-hour behavioral observation, and a staff survey. A behavioral observation tool and a survey questionnaire were developed for the data collection. For data analysis, JMP Pro 9 software was used to analyze the data collected through behavioral observation and the staff survey. The literature review developed a “Building Usability Framework” specifically for healthcare design. A data analysis tool, the “Usability Matrix” was created to integrate and understand the analyzed data within the Building Usability Framework. Integrating the analyzed data from the case study within the Usability Matrix, a primary care clinic usability evaluation survey was developed at the end of the study. This survey along with the behavioral observation tool and design analysis tools were compiled together to produce the “Building Usability Evaluation Tool-Kit for Primary Care Clinics.” This tool-kit can be used by architects and researchers interested in designing and analyzing “usable” primary care clinics.