Exploring health professionals' views regarding the optimum physical environment for palliative and end of life care in the acute hospital setting: a qualitative study

Designing the physical environment for inpatient palliative care: a narrative review

BACKGROUND

It is essential that the physical environments in which inpatient palliative care is provided support the needs of patients and the facilitate the multidimensional delivery of palliative care. This review aims to identify the features and characteristics of inpatient palliative care environments that enhance or detract from the patient experience; and identify opportunities for progress within this field.

METHOD

Three databases were searched: MEDLINE (1946-2020), PsycINFO (1806-2020) and CINAHL (1937-2020). Articles were screened by title and abstract with included studies read in full for data extraction. Data synthesis involved thematic analysis informed by the findings of the included literature. Inclusion criteria were studies with empirical methodology examining adult palliative care in the hospital, hospice or nursing home environment. Studies that examined palliative care delivered within the emergency department, ICU or within the home were excluded, as were those related to paediatric palliative care.

RESULTS

Four main themes were identified: the provision of privacy, facilitating interactions with family, facilitating comfort through homeliness and connections to nature.

CONCLUSIONS

The board acceptance of single rooms as the preeminent design solution for supporting privacy, dignity and family interaction, alongside current conceptions of homeliness that typically focus on matters of interior design, are limiting possibilities for further design innovation within palliative care settings. Research that investigates a broader set of design strategies through which the built environment can support care, alongside enhanced interdisciplinary collaboration, could positively contribute to patient and family experiences of inpatient palliative care.

Beyond homeliness: A photo-elicitation study of the 'homely' design paradigm in care settings

This paper examines perceptions of homeliness in palliative care environments through a photo-elicitation study involving 89 palliative care staff. The study finds that what is perceived as homely tends to exhibit a mutually exclusive relationship with a clinical antithesis. It also finds that antonymous or antithetical understandings of homeliness are as common as those based on actual attributes of homeliness. It is argued that a more nuanced understanding of the spatial and material constituents of homeliness is needed to make it a more realistic objective within the design and procurement of healthcare environments. It is also argued that the inverse relationship of homely and clinical environmental qualities could be translated into a design approach that aims to negotiate rather than negate their apparent mutual incompatibility.

Unburdening expectation and operating between: architecture in support of palliative care

The role of design and materials in the enactment and experience of healthcare has gained increasing attention across the fields of evidence-based design, architecture, anthropology, sociology and cultural geography. Evidence-based design, specifically, seeks to understand the ways in which the built environment can support the healing process. In the context of palliative care, however, the very measure of healing differs vastly. Physicians Mount and Kearney suggest that 'it is possible to die healed', and that such healing can be facilitated through the provision of 'a secure environment grounded in a sense of connectedness' (2003: 657). Acknowledging this critical difference raises important questions around the various ways through which the built environment might support healing, but also about the potential of architecture to impart care. This paper reports on 15 interviews with architects, experienced in the design of palliative care settings, from the UK, USA and Australia, to provide a deeper understanding of the questions being asked within the briefing processes for these facilities, the intentions embedded in the ways that architects respond, and the kinds of compromises deemed allowable (by various stakeholders) within the procurement process. Our findings suggest that palliative care architects often respond to two briefs, one explicit and the other unspoken. Design responses in relation to the first include: formally expressing a differentiation in the philosophy of care (signalling difference), attention to quality, extending comfort and providing 'moments'. The second relates to the unburdening of palliative care facilities from their associative baggage and responding to the tension between the physical and imaginative inhabitation of space. In revealing the presence of this hidden brief, and the relationship between the two, this paper invites a broader discussion regarding the capacity of architecture to support palliative care patients, their families and staff.

Placing Care: The Impact of the Physical Environment on Experiences of Providing and Utilizing Palliative Care

BACKGROUND

Environmental design in palliative and end-of-life care is known to improve care outcomes, service-user satisfaction, and the continuation of service uptake. No study in the literature has investigated the influence of the environment on palliative and end-of-life care in Nigeria or other African contexts.

PURPOSE

This study was designed to explore the impact of the physical environment (i.e., place and people) on staff and service users and how these influence the experiences of providing and using palliative and end-of-life care in a Nigerian hospital context.

METHODS

Ethnographic methodology was employed because this approach facilitates understanding of environmental realities. This study is part of a larger ethnographic research project developed to uncover aspects of organizational complexities related to the provision and use of palliative and end-of-life care in the Nigerian context. Three hundred fifty hours of participant observation was achieved, and semistructured interviews were used to gather data from 26 participants, including 10 patients, 11 members of a palliative care team, and five hospital managers. Informal chats and photographic capture were additional methods used in data collection. Thematic analysis was conducted to identify and analyze patterns within the collected data.

RESULTS

Physical space, equipment, and placing staff were the three primary themes identified. The physical environment was untidy, and the ward layout prevented privacy, dignity, or comfort for patients and families. The equipment was old and inadequate, and the context of care was worsened by insufficient staffing and neglect of the environmental needs of the staff.

CONCLUSIONS

Hospital design for palliative and end-of-life care in Nigeria is "autoinhibitory" (a negative feedback mechanism whereby hospital design detracts rather than promote quality of care), and a physical environment that supports the provision and utilization of care must be implemented to promote palliative and end-of-life care success. Urgent policy action is needed to improve environmental and staffing conditions to advance palliative and end-of-life care in Nigeria.

Designing Palliative Care Facilities to Better Support Patient and Family Care: A Staff Perspective

OBJECTIVE

To contribute staff perspectives on the design of palliative care facilities to better align with the philosophy of palliative care, in support of patient, family, and staff well-being.

BACKGROUND

The receipt of palliative care differs from other inpatient experiences owing to its distinct philosophy of care, longer lengths of stay, a greater presence of family members, and more frequent end-of-life events. While research regarding the optimal design of palliative care environments recognizes these differences, this knowledge has been slow to exert change on the guidelines and procurement processes that determine the design solutions possible within these settings. Sustained research attention is required.

METHODS

An online survey, comprising a series of open-ended questions, elicited the perceptions of palliative care staff regarding the relationship between the physical environment and the distinct philosophy of palliative care.

RESULTS

Responses from 89 Australian-based palliative care professionals confirmed the high value that staff place on environments that offer privacy, homeliness, safety, and access to gardens to assist the delivery of optimum care.

CONCLUSIONS

Our findings illustrate that the implications of privacy and homeliness extend far beyond the patient room and that homeliness is about more than an aesthetic of comfort. This highlights a broader capacity for design to better support the philosophy of palliative care. Importantly, the data reveal a key relationship between staff well-being and the environments in which they work; environments that are unable to match the quality of care that staff aspire to deliver can engender frustration and distress.

Interior Environments in Long-Term Care Units From the Theory of Supportive Design

AIM

This study was designed to examine how residents in long-term care (LTC) units perceive their living environment based on the theory of supportive design.

BACKGROUND

Healthcare environments may cause a significant level of stress mainly due to patients' lack of familiarity with such environments and patients' poor health conditions. According to the theory, the healthcare environments providing a sense of control, social support, and positive distraction can promote wellness. This study was designed to learn how LTC residents perceive their current living environments.

METHOD

This study collected data through qualitative interviews. A total of 48 residents living in two LTC units were asked the three interior environments they liked and they wanted to improve. Only the residents who lived in the current space for 1 month and communicate without any cognitive disabilities were able to participate. Most residents were female and lived in a private room.

RESULTS

The participants' responses indicated the importance of perceived control, social support, and positive distraction in the environment. The most frequently mentioned interior environment that the residents liked was "window and view," followed by "pictures and photos" and "TV," while they wanted "bigger room and space," followed by "improved privacy" and "more options for food." In addition to the three elements, the participants considered other elements as important for them which can benefit the participants.

CONCLUSION

More studies must be carried out to expand the theory, so that it can be applied to future studies with inclusive perspectives.

Palliative care environments for patient, family and staff well-being: an ethnographic study of non-standard design

OBJECTIVE

There is an increased expectation that contemporary hospital design will improve clinical outcomes and patient experiences and support staff well-being. In response, this study examined innovative approaches in the design of in-patient palliative care facilities.

METHODS

An ethnographic study comprised the identification and analysis of 30 architectural precedents, 24 qualitative, semistructured interviews with key stakeholders and 11 site visits, during which field notes and photographs were taken. Data were analysed using the framework approach, to identify design solutions that move beyond standard practice, to offer insight into the possibilities and challenges of processes of design or refurbishment in palliative care settings.

RESULTS

Three thematic areas of focus were derived from the analysis: (1) planning solutions that support privacy plus connection; (2) enhancing comfort through the use of non-standard materials-and managing the risks associated with those and (3) shaking off tradition in hospital design.

CONCLUSIONS

Myriad constraints resist innovation within the contemporary construction of hospital and hospice facilities. Drawing on a series of real-world examples, our findings point to the value of broad consultation and collaboration throughout the design process in achieving design solutions that go beyond standard practice for the benefit for patients, families and staff.

The Physical Hospital Environment and Its Effects on Palliative Patients and Their Families: A Qualitative Meta-Synthesis

AIM

To review the latest qualitative literature on how the physical hospital environment affects palliative patients and their families.

BACKGROUND

People with a life-limiting illness may receive palliative care to improve their quality of life in hospital and may have multiple admissions as their illness progresses. Yet, despite a preference for a death at home, more than half of the dying population will receive end-of-life care in hospital. The physical hospital environment consists of ambiance, aesthetics, and architectural factors, and it is well known that the hospital's acute wards are not a homely environment. Demand is increasing for the physical environment to be improved to better meet the needs and demands of palliative and end-of-life patients and their families.

METHOD

Combining thematic analysis and meta-ethnography methodologies, 12 international qualitative papers were analyzed and synthesized by the three authors.

RESULTS

Findings resulted in the development of the SSAFeR Place approach that incorporates the concepts that are important to palliative and end-of-life patients and their families by describing an environment within the acute or palliative care units that feels safe, is private, customizable, and accommodates family; is a space to share with others, is homelike in ambiance and aesthetics, and is conducive for reflection. The concepts of identity, belonging, and safety are connected to the notions of home.

CONCLUSIONS

To provide person-centered care and to move the focus toward the palliative approach of comfort and quality of life, attention to room size, layout, aesthetics, and ambiance is needed.

Deployable designs to temporarily convert subacute hospital rooms into palliative care rooms

OBJECTIVE

To explore the design of deployable articles that can turn subacute hospital rooms into palliative care rooms to provide better patient-centred care and to meet the shortage of dedicated palliative care spaces in Australia.

METHODS

Clinicians and a design researcher collaborated to review the literature, obtain clinical/practitioner feedback on needs and use design research methods to produce design concepts and prototypes for use in the subacute care hospital setting.

RESULTS

A design solution that included: (a) A guest-bed module for improved family togetherness and room personalisation; and (b) A digital connectivity module designed to provide family togetherness virtually.

CONCLUSIONS

Informed design solutions for palliative care spaces were derived from clinical feedback and literature evidence. Clinicians expressed great interest and support for further development and implementation in Victorian hospitals. This exploratory concept also provides insights for future research and innovation in the design of palliative care environments.

Palliative Care Professionals' Message to Others: An Ethnographic Approach

INTRODUCTION

Palliative care continues to be misunderstood within the world of healthcare. Palliative care professionals are key agents for promoting a greater understanding of their field. This study aims to examine the messages, both implicit and explicit, that palliative care professionals transmit about themselves and their work within their teams and to other health professionals.

METHODS

Focused ethnographic secondary analysis, exploring the interactions of palliative care professionals as it happens at everyday work. An inductive thematic analysis was developed from 242 h of observation of the daily work practices of palliative care professionals, focusing on their interactions with others. The data was coded without predefined categories, and the analysis was performed independently by two researchers.

RESULTS

Palliative professionals communicate that they are part of an active team working in an organized manner. They value and feel proud of their work. Despite the intensity of their work, these professionals are always available to others, to whom they demonstrate a clear professional identity. They convey their expertise in alleviating suffering, respectful behavior and collaborative ability.

CONCLUSION

Professionals, in their daily work, communicate through their messages the essence of palliative care. It is essential that palliative care professionals perceive themselves as potential influencers and explicitly transmit the reasons for their intervention. Otherwise, others will perpetuate the myths, misunderstandings, and lack of a positive reputation for palliative care.

Environmental Design for End-of-Life Care: An Integrative Review on Improving the Quality of Life and Managing Symptoms for Patients in Institutional Settings

CONTEXT

The environment in which end-of-life (EOL) care is delivered can support or detract from the physical, psychological, social, and spiritual needs of patients, their families, and their caretakers.

OBJECTIVES

This review aims to organize and analyze the existing evidence related to environmental design factors that improve the quality of life and total well-being of people involved in EOL care and to clarify directions for future research.

METHODS

This integrated literature review synthesized and summarized research evidence from the fields of medicine, environmental psychology, nursing, palliative care, architecture, interior design, and evidence-based design.

RESULTS

This synthesis analyzed 225 documents, including nine systematic literature reviews, 40 integrative reviews, three randomized controlled trials, 118 empirical research studies, and 55 anecdotal evidence. Of the documents, 192 were peer-reviewed, whereas 33 were not. The key environmental factors shown to affect EOL care were those that improved 1) social interaction, 2) positive distractions, 3) privacy, 4) personalization and creation of a home-like environment, and 5) the ambient environment. Possible design interventions relating to these topics are discussed. Examples include improvement of visibility and line of sight, view of nature, hidden medical equipment, and optimization of light and temperature.

CONCLUSION

Studies indicate several critical components of the physical environment that can reduce total suffering and improve quality of life for EOL patients, their families, and their caregivers. These factors should be considered when making design decisions for care facilities to improve physical, psychological, social, and spiritual needs at EOL.

A qualitative study on oncology nurses’ experiences of providing palliative care in the acute care setting

Background:

With the renewed emphasis on palliative care in Singapore, coupled with a dearth of studies on provision of palliative care in acute services, it is timely to explore the experiences, barriers and challenges faced by oncology nurses in the acute care setting.

Aim:

This study aimed to explore nurses’ experiences of providing palliative care in the acute oncology care unit.

Method:

An exploratory descriptive research methodology was adopted. Focus group interviews, involving a total of 24 nurses, were conducted. Interviews were audio-taped and transcribed verbatim. Data was analyzed using an inductive content analysis approach.

Results:

Five key themes emerged from the analysis: (1) nurses’ perceptions of palliative care; (2) multiple roles of nurses in palliative care; (3) emotional burden of providing palliative care; (4) misconceptions of palliative care; (5) challenges in providing palliative care.

Conclusion:

The provision of palliative care in the acute care setting remained challenging. This is partly due to the attitudes of patients, families and healthcare workers, as well as organizational factors such as lack of training. Nurses play an important role in giving and facilitating palliative care for patients in the hospitals. Future studies can explore interventions to help overcome the challenges that are impeding nurses from providing high-quality palliative care in the acute care setting.

The impact of the environment on patient experiences of hospital admissions in palliative care

OBJECTIVE

To explore the impact of environment on experiences of hospitalisation from the perspective of patient's with palliative care needs.

METHODS

A qualitative study design using longitudinal semistructured, face-to-face interviews were used to elicit the views of patients with palliative care needs admitted to hospital in 1 large urban acute hospital in New Zealand. The sample comprised of 14 patients admitted to hospital between July 2013 and March 2014 who met one of the Gold Standard Framework Prognostic Indicators for palliative care need.

RESULTS

Almost all participants described a range of factors associated with the environment which impacted negatively on their experiences of hospitalisation. This included challenges with the physical surroundings, the impact on social relationships with other patients, families and health professionals and the influence of the cultural milieu of the hospital setting.

CONCLUSIONS

Emulating the 'ideal' environment for palliative care such as that provided in a hospice setting is an unrealistic goal for acute hospitals. Paying attention to the things that can be changed, such as enabling family to stay and improving the flexibility of the physical environment while improving the social interplay between patients and health professionals, may be a more realistic approach than replicating the hospice environment in order to reduce the burden of hospitalisations for patients with palliative care needs.

The meaning of home at the end of life: A video-reflexive ethnography study

BACKGROUND

While 'home' is cited most frequently as being the preferred place of death, most people will die in institutions. Yet, the meaning and significance of home for people nearing the end of life has not been fully explored.

AIM

The aim of this article is to critically examine the meaning of home for dying patients and their families.

DESIGN

The qualitative study used video-reflexive ethnography methods. Data were collected and analysed over an 18-month period.

SETTING/PARTICIPANTS

Participants were recruited from two Australian sites: a palliative care day hospital and an acute hospital. Participants included patients with a prognosis of 6 months or less (n = 29), their nominated family member(s) (n = 5) and clinicians (n = 36) caring for them. Patients and families were 'followed' through care settings including the palliative care unit and into their own homes.

RESULTS

Whether or not participants deemed space(s) safe or unsafe was closely related to the notion of home. Six themes emerged concerning this relationship: 'No place like home'; 'Safety, home and the hospital'; 'Hospital "becomes" home'; 'Home "becomes" hospital'; 'Hospital and "connections with home"'; and 'The built environment'.

CONCLUSION

Home is a dynamic concept for people nearing the end of life and is concerned with expression of social and cultural identity including symbolic and affective connections, as opposed to being merely a physical dwelling place or street address. Clinicians caring for people nearing the end of life can foster linkages with home by facilitating connections with loved ones and meaningful artefacts.

Preference for a single or shared room in a UK inpatient hospice: patient, family and staff perspectives

OBJECTIVE

This study investigated the preferences of patients, family and staff for single or shared rooms in a UK hospice.

METHOD

Semistructured interviews were conducted with patients, informal carers and staff at a hospice, focusing on room type preference.

RESULTS

14 current and former hospice inpatients, 15 patients attending the hospice day centre, 23 carers of current and former inpatients and 10 hospice staff were interviewed. Patients most often stated a preference for a shared room, especially if they had experience of being in this room type at the hospice. The main reason for this preference was the company of others. Patients preferring single rooms cited the benefits of increased privacy, reduced noise and private facilities. Other patients said their room preference would depend on how ill they were. Carers valued the social contact and increased staff presence in shared rooms, but felt that single rooms were easier for visitors and more appropriate when patients reached the end of life. Staff found it easier to observe patients in a shared room, and to maintain privacy and confidentiality in a single room.

CONCLUSIONS

The study concludes that single and shared rooms should be available in a hospice. Innovative planning can enable the social benefits of shared rooms to be maintained without compromising patients' privacy and dignity.

The acute hospital setting as a place of death and final care: a qualitative study on perspectives of family physicians, nurses and family carers

While the focus of end-of-life care research and policy has predominantly been on 'death in a homelike environment', little is known about perceptions of the acute hospital setting as a place of final care or death. Using a qualitative design and constant comparative analysis, the perspectives of family physicians, nurses and family carers were explored. Participants generally perceived the acute hospital setting to be inadequate for terminally ill patients, although they indicated that in some circumstances it might be a 'safe haven'. This implies that a higher quality of end-of-life care provision in the acute hospital setting needs to be ensured, preferably by improving communication skills. At the same time alternatives to the acute hospital setting need to be developed or expanded.