Facilitating play in hospitalized handicapped children: the design of a therapeutic play environment

Impact of the physical environment in paediatric hospitals on health outcomes: a systematic review

BACKGROUND

Nesmith identified two roles for the physical settings in which health care is provided. One is as a tool to support productivity and effectiveness and the second is as healer: "… they are an end in themselves - aiding in the healing and wellness process through psychological and physiological effect…" (p. 671). Research to confirm this statement has been slowly accumulating over the last two decades, but primarily in the area of adult care. Although there are a plethora of articles describing the various creative and innovative approaches to physical design in paediatric hospitals, very few of these innovations have been evaluated in terms of their impact on the health outcomes of children and their families.

OBJECTIVES

The objective of this review was to determine from the available evidence the impact of the physical paediatric hospital environment on health outcomes of children and adolescents.

SEARCH STRATEGY

Using a defined search and retrieval method, a wide range of indexes of periodical articles were accessed for the period 1980 to 2008 including both health and architectural databases. Unpublished studies from 1991 were sought using a variety of sources including Dissertation Abstracts, Index to Theses, conference proceedings, research and clinical trials registers and web sites of relevant professional associations.

INCLUSION CRITERIA

The review considered studies using either quantitative or qualitative methodologies or mixed methods that assessed the impact of physical design elements of a paediatric hospital environment including architectural, interior design, ambient features and /or features that supported patient and family centred care. The primary outcomes of interest were clinical or psychological, with other outcomes of interest being patient - family perceptions, including safety and security.

METHODOLOGICAL QUALITY

Each study was assessed independently by two reviewers prior to inclusion in the review using standardised critical appraisal instruments developed by the Joanna Briggs Institute. As both assessors were in agreement on all studies a third reviewer was not required.

DATA EXTRACTION AND SYNTHESIS

Data was extracted independently from each of the included studies by two reviewers using standardised critical appraisal instruments developed by the Joanna Briggs Institute. Again there were no disagreements between the reviewers in relation to the data extracted from the quantitative studies. Agreement was reached on the synthesis of the findings from the two qualitative studies through discussion. Given the differences in study design, interventions and outcome measures in the quantitative studies, statistical pooling of the results was not possible and the findings are presented in a narrative form.

RESULTS

Eight studies were included in the review with five elements of physical design addressed. In the sub-topic of physical building structures, single room design for paediatric intensive care units significantly reduced nosocomial infections as did the addition of negative pressure ventilation to single rooms in an isolation unit. The one study on the effect of specially designed gardens found very low usage rates but children who did visit them were actively engaged with both natural and structural features. On the same theme of active engagement a play centre designed to encourage symbolic play generated statistically significantly more total play and less unoccupied time or wandering as well as the type of play it was designed to encourage. The one study on art did not demonstrate that nature art was effective in reducing stress in hospitalised children. In regard to adolescents, the two themes that emerged in regard to physical facilities from the two qualitative studies were ways of maximising normal life and ways of supporting coping with the illness through ward design.

CONCLUSION

Given the small number of studies addressing five sub-topics, no firm conclusions can be drawn from the review. However the results suggest positive elements of physical design that could be considered for implementation to support a healing environment within paediatric hospitals or paediatric wards in general hospitals.

IMPLICATIONS FOR RESEARCH

The review clearly illustrates the need for more research in this area assessing the health outcomes of innovations in physical design in paediatric hospitals or units. There are numerous opportunities for multidisciplinary studies and in varying cultural contexts.

IMPLICATIONS FOR PRACTICE

This review suggests a number of aspects of physical design that can be implemented although cost and cultural appropriateness are a consideration in several cases. These include the use of single rooms with negative pressure ventilation to control cross infection; the provision of both private and 'public' space for adolescent inpatients with 'public' spaces including spaces for interaction just with other peers; the incorporation of interactive gardens, however small, designed for families and their use encouraged by staff; and specially designed play structures to encourage symbolic play.

The use of a playroom as a nursing intervention with the early adolescent age group

Most interventions for adolescents have relied upon a group format. Early-age adolescents who demonstrate hyperactivity, cognitive impairment, or regressive behavior often find the "talk" format of groups difficult. This article advocates the use of a classic playroom equipped with materials for the early adolescent as an adjunct intervention to individual and milieu therapy modalities. Two case examples illustrate the use of a playroom as an intervention.