Hospital design for inpatient psychiatry: A realistic umbrella review

The evaluation of the effects of architecture and design in psychiatric hospitals primarily focuses on final outcomes, such as disease progression, and is made from the perspective of evidence-based medicine. Meanwhile, the evidence-informed, realist approach addresses how the intervention works. Understanding the underlying action mechanisms of the intervention is needed to facilitate its scaling-up and adaptation in new environments. This umbrella review reports in which ways architecture and design have an effect on patients' and staff experience in inpatient psychiatric hospital. The search was constructed around three key concepts (psychiatric hospital, design, and staff and patient outcomes) and was conducted across three reference databases (Embase, Medline, and PsychINFO). Academic and gray literature was analyzed. Information on design and architectural features in psychiatric hospitals, their effects on patients and staff experience, and the acting mechanisms enabling these effects were extracted. From 951 original references, 14 full texts were included in the analysis. Design and architectural features (e.g., aesthetic appeal of places, home-like environment) in psychiatric hospitals address patients' stress, boost social interaction, foster patients' autonomy and feelings of control, ensure respect for patient's privacy and dignity, and prevent under-and overstimulation. Using theory-driven evaluation may facilitate future hospital renovation and the evaluation of its effect.

Design of Pediatric Outpatient Procedure Environments: A Pilot Study to Understand the Perceptions of Patients and Their Parents

OBJECTIVE

To understand parent and child perception of spaces experienced during outpatient procedures and to measure their anxiety in these spaces.

BACKGROUND

Same-day procedures are becoming prevalent among children in the United States. While studies conducted in different types of healthcare settings show that the physical environment influences healthcare experiences of patients, there is a lack of research on patient and family perceptions of the physical environment of the outpatient centers where such procedures are conducted.

METHODS

This study used ecological momentary assessment to collect patient experience and anxiety data at different points during the patient's journey through an ambulatory surgical center where pediatric gastrointestinal (GI) procedures were performed. Objective and subjective measures of anxiety were collected. A Qualtrics survey asked participants' perceptions about four spaces-waiting, preprocedure, procedure, and recovery.

RESULTS

Child participants reported liking murals, double chairs, patient beds, wall color, and access to a television. They disliked medical equipment and lack of child-friendly furniture. Most parents liked the murals, access to a television, and nature photos, while disliking the lack of privacy, lack of toys in waiting areas, and lack of child-friendly furniture. On average, both children and parents experienced the highest anxiety levels before and during the procedure and the lowest during recovery. Between the four spaces, no significant differences were observed in the heart rate variability and skin conductance responses for both groups.

CONCLUSIONS

Despite the outpatient nature of the procedures, participants experienced anxiety before the GI procedure. Comfortable design features that provide distractions are preferred by children and their parents.

Nurses' perceptions of the transition to 100% single-occupancy patient rooms in a university hospital in the Netherlands: an uncontrolled before and after study

BACKGROUND

To improve patients' privacy, comfort and infection control, newly built hospitals increasingly offer 100% single-occupancy patient rooms. Our study examines how nurses perceived the transition from a hospital with multi-bedded patient rooms to one with solely single-occupancy patient rooms designed according to principles of a healing environment.

METHODS

In a single-centre, before-after survey study, nurses completed a questionnaire of 21 items in three domains: perceived patient safety and monitoring, nurses' working conditions and patient environment. Before-measurements (n = 217) were compared with two after-measurements in the new hospital, respectively after one (n = 483) and two years (n = 191).

RESULTS

Nurses considered the single rooms in the new hospital worse for visibility and monitoring but this had improved somewhat after two years. In either setting, the majority perceived working conditions (walking distances and designated rest area) as unfavourable. The patient environment in the new hospital was generally perceived as much better than in the former hospital.

CONCLUSION

The transition to solely single-occupancy patient rooms was largely considered positive by nurses in terms of patient environment. However, monitoring of patients and working conditions remain a concern. When designing new hospitals, attention should be paid to optimal working conditions for nurses. To improve monitoring of patients, we recommend the use of remote-sensoring.

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.

Family members´ experiences of the end-of-life care environments in acute care settings - a photo-elicitation study

PURPOSE

This article explores experiences of the acute-care environment as a setting for end-of-life (EoL) care from the perspective of family members of a dying person.

METHOD

We used participant-produced photographs in conjunction with follow-up interviews with nine family members to persons at the EoL, cared for in two acute-care settings.

RESULTS

The interpretive description analysis process resulted in three constructed themes-Aesthetic and un-aesthetic impressions, Space for privacy and social relationships, and Need for guidance in crucial times. Aspects of importance in the physical setting related to aesthetics, particularly in regard to sensory experience, and to a need for enough privacy to facilitate the maintenance of social relationships. Interactions between the world of family members and that of professionals were described as intrinsically related to guidance about both the material and immaterial environment at crucial times.

CONCLUSION

The care environment, already recognized to have an impact in relation to patients, is concluded to also affect the participating family members in this study in a variety of ways.

Analyzing the heterogeneity of labor and delivery units: A quantitative analysis of space and design

This study assessed labor and delivery (L&D) unit space and design, and also considered correlations between physical space measurements and clinical outcomes. Design and human factors research has increased standardization in high-hazard industries, but is not fully utilized in medicine. Emergency department and intensive care unit space has been studied, but optimal L&D unit design is undefined. In this prospective, observational study, a multidisciplinary team assessed physical characteristics of ten L&D units. Design measurements were analyzed with California Maternal Quality Care Collaborative (CMQCC) data from 34,161 deliveries at these hospitals. The hospitals ranged in delivery volumes (<1000–>5000 annual deliveries) and cesarean section rates (19.6%-39.7%). Within and among units there was significant heterogeneity in labor room (LR) and operating room (OR) size, count, and number of configurations. There was significant homogeneity of room equipment. Delivery volumes correlated with unit size, room counts, and cesarean delivery rates. Relative risk of cesarean section was modestly increased when certain variables were above average (delivery volume, unit size, LR count, OR count, OR configuration count, LR to OR distance, unit utilization) or below average (LR size, OR size, LR configuration count). Existing variation suggests a gold standard design has yet to be adopted for L&D. A design-centered approach identified opportunities for standardization: 1) L&D unit size and 2) room counts based on current or projected delivery volume, and 3) LR and OR size and equipment. When combined with further human factors research, these guidelines could help design the L&D unit of the future.

Association Between Room Location and Adverse Outcomes in Hospitalized Patients

OBJECTIVE

To investigate whether a patient's proximity to the nurse's station or ward entrance at time of admission was associated with increased risk of adverse outcomes.

METHOD

We conducted a retrospective cohort study of consecutive adult inpatients to 13 medical-surgical wards at an academic hospital from 2009 to 2013. Proximity of admission room to the nurse's station and to the ward entrance was measured using Euclidean distances. Outcomes of interest include development of critical illness (defined as cardiac arrests or transfer to an intensive care unit), inhospital mortality, and increase in length of stay (LOS).

RESULTS

Of the 83,635 admissions, 4,129 developed critical illness and 1,316 died. The median LOS was 3 days. After adjusting for admission severity of illness, ward, shift, and year, we found no relationship between proximity at admission to nurse's station our outcomes. However, patients admitted to end of the ward had higher risk of developing critical illness (odds ratio [ OR] = 1.15, 95% confidence interval [CI] = [1.08, 1.23]), mortality ( OR = 1.16, 95% CI [1.03, 1.33]), and a higher LOS (13-hr increase, 95% CI [10, 15] hours) compared to patients admitted closer to the ward entrance. Similar results were observed in sensitivity analyses adjusting for isolation room patients and considering patients without room transfers in the first 48 hr.

CONCLUSIONS

Our study suggests that being away from the nurse's station did not increase the risk of these adverse events in ward patients, but being farther from the ward entrance was associated with increase in risk of adverse outcomes. Patient safety can be improved by recognizing this additional risk factor.

The Reality of Well-Being-Focused Design in Dementia Care: A Case Study of Acute Dementia Wards in the United Kingdom

OBJECTIVE:

The study explored design for well-being within dementia care by investigating the adoption of well-being-focused design in real-world practice, through observing National Health Service (NHS) wards.

BACKGROUND:

Design for well-being is an approach that considers the psychological and physiological effects of architecture to improve health and well-being. The high psychological care requirement for dementia patients makes them a significant group to study in the evaluation of current hospital facilities.

METHODS:

A literature review was conducted to frame the current theoretical perception of the key characteristics of a good environment for dementia care. A framework was generated to summarize and used as an assessment tool in a series of observational visits to NHS wards. Interviews with clinical staff focused on care outcomes and practicalities of implementing well-being-focused design, considering the historical and economical context. Key findings from the observations and interviews were analyzed for recurring themes.

RESULTS:

The ward observations and interviews provided insight into the current progression of well-being-led design in NHS hospitals in England. The research highlights key areas of success and factors that inhibit further progression.

CONCLUSIONS:

The case studies showed a good degree of ambition to utilize well-being-focused design, with belief among staff that the physical environment has a substantial role in the health and well-being of patients. Staff also felt that this approach is most effective for those in the less advanced stages of dementia. Despite the high level of support, the current degree of implementation appears to be varied.

A qualitative investigation of hospital visitors' experiences using the analytic lens of liminality: Informing nursing practice and policy

This research aimed to inform nursing practice and policy by identifying satisfying and problematic experiences of hospital visitors during the hospitalisation episode of a significant other. An extensive contextual review revealed that healthcare systems in advanced economies face multiple pressures and that in England, the government leaves the determination of hospital visiting rules to individual trusts. The analytic lens of liminality provides rich interpretations of visitors' accounts and demonstrates the importance to visitors of structure (hospital rules and systems) and communitas (social bonding among liminal personae). Supportive hospital structures reduce the challenges of liminality and increase satisfaction. The data further suggest an extension to current understandings of liminality. Strong structure and successful communitas permit a safe exit from liminality after the hospitalisation episode for visitors with a close emotional bond with the patient.

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.

Single-room usage patterns and allocation decision-making in an Australian public hospital: a sequential exploratory study

AIMS AND OBJECTIVES

The aims are to (1) measure occupancy rates of single and shared rooms; (2) compare single room usage patterns and (3) explore the practice, rationale and decision-making processes associated with single rooms; across one Australian public health service.

BACKGROUND

There is a tendency in Australia and internationally to increase the proportion of single patient rooms in hospitals. To date there have been no Australian studies that investigate the use of single rooms in clinical practice.

DESIGN

This study used a sequential exploratory design with data collected in 2014.

METHODS

A descriptive survey was used to measure the use of single rooms across a two-week time frame. Semi-structured interviews were undertaken with occupancy decision-makers to explore the practices, rationale decision-making process associated with single-room allocation.

RESULTS

Total bed occupancy did not fall below 99·4% during the period of data collection. Infection control was the primary reason for patients to be allocated to a single room, however, the patterns varied according to ward type and single-room availability. For occupancy decision-makers, decisions about patient allocation was a complex and challenging process, influenced and complicated by numerous factors including occupancy rates, the infection status of the patient/s, funding and patient/family preference. Bed moves were common resulting from frequent re-evaluation of need.

CONCLUSION

Apart from infection control mandates, there was little tangible evidence to guide decision-making about single-room allocation. Further work is necessary to assist nurses in their decision-making.

RELEVANCE TO CLINICAL PRACTICE

There is a trend towards increasing the proportion of single rooms in new hospital builds. Coupled with the competing clinical demands for single room care, this study highlights the complexity of nursing decision-making about patient allocation to single rooms, an issue urgently requiring further attention.