Positive Distractions and Play in the Public Spaces of Pediatric Healthcare Environments: A Literature Review

Abstract

Background:

A positive distraction is a significant environmental feature that introduces positive feelings by diverting attention from stress or anxious thoughts. Existing research has deemed the application of positive distractions in pediatric environments to be significant. This study investigated the essential positive distractions and the associated health benefits.

Aims:

The aims of this study were to validate and extend evidence on positive distractions and play opportunities in the design of the public spaces in pediatric healthcare environments, translate existing evidence into design suggestions, and identify research gaps in this realm.

Methods:

A four-phased literature review method was employed in the study, including literature search, literature screening and selection, literature appraisal, and thematic analysis and in-depth discussion. Eventually, 27 peer-reviewed publications were reviewed and discussed in detail.

Results/Conclusions:

The gathered materials were grouped into six themes of positive distractions: (1) art and environmental aesthetics, (2) spatial arrangement and atrium, (3) considerations of socialization patterns, (4) play and interactive technologies, (5) sound and lighting interventions, and (6) access to nature. The research indicated that positive distractions in the pediatric healthcare environment provide a series of health benefits for patients, including improved behavioral and emotional well-being, reduced stress and anxiety, enhanced healthcare experience and satisfaction, and facilitated medical procedures and recovery. Yet significant research gaps emerged between positive distractions and play in garden spaces and spatial design to accommodate interactive technology and socialization in the public areas of pediatric healthcare environments. This study organized the understanding on the components of supportive environments and its outcomes for pediatric healthcare design.

Keywords

public spaces play hospital garden socialization evidence-based design

Research Background

Positive Distractions in Healthcare Environment

Since the 1970s, healthcare environmental research and design has shifted its focus from the reduction of negative effects of the physical environment to the creation of supportive environments that reinforce positive experiences (Shepley, 2006). The uninviting interiors and institutional organization of traditional hospital buildings isolated and disoriented their occupants, causing more damage to their psychological health, as such characteristics generated anxiety and stress (Ulrich, 1999). Following patient-centered care principles, increasing research on stress impacts within healthcare spaces led to the coining of the design concept of positive distraction (Ulrich, 1991, 1999). A positive distraction is an environmental feature or situation that evokes positive feelings, holds attention and interest, and eventually fosters beneficial psychological and/or physiological changes (Ulrich, 1991). Providing positive distractions in healthcare environments can reduce people’s stress and enhance their mood, thereby facilitating the healing process (Andrade et al., 2017; Ulrich et al., 1991).

Positive distractions have been shown to have a beneficial impact on patients’ well-being, both psychologically and physiologically (Ulrich et al., 2008). This concept is highly applicable to shared spaces such as waiting rooms, as they serve as an area of relief and recollection (Jiang et al., 2017). Therefore, positive distraction design features that allow and calm occupants can be effectively incorporated into the development of design processes, deviating from results of bare walls and little windows. Incorporating positive distractions could offer comfort and a perception of a supportive environment for patients and their families (Ulrich, 1997). Various types of positive distractions that are effective in general healthcare environments have been identified, such as color and artwork with positive meanings, nature, and technology intervention (Lankston et al., 2010; Nanda et al., 2011). Specifically, utilizing nature as therapeutic devices can soothe and encourage healing, reduce people’s stress, change their mood, and relieve their perceived level of pain in various healthcare situations (Cooper Marcus & Sachs, 2013; Jiang et al., 2017; Vincent et al., 2010).

Pediatric Healthcare Facilities and Patient Experience

Pediatric healthcare facilities are institutions dedicated to patients requiring sensitive care and unique needs. The influence of pediatric therapeutic environments on children—the healthcare facility’s most delicate patents—has been shown to be significant in the past research and practices (Sherman, Shepley, et al., 2005; Silvis, 2013). According to Piaget’s theory of children development, children think and process information from the physical environments differently than adults (Singer & Revenson, 1997). Frequently, visiting healthcare facilities for wellness check, acute care, medical procedures, and hospitalization can be emotionally and psychologically traumatizing for pediatric patients because they lack control of their environment (Lerwick, 2016). Children’s experience of helplessness, loss of identity and control, lack of social support, and accompanying fear and pain can delay important medical treatments, take more time to complete, and reduce patient satisfaction (Lerwick, 2016). Various psychological challenges during hospitalization could limit children’s cognitive development, which may result in the dysfunction of dealing with stress and anxiety in the long run (Eisen et al., 2008).

Play as Positive Distraction in the Public Spaces of Pediatric Healthcare Facilities

Play is essential to child development because it contributes to the cognitive, physical, social, and emotional well-being of children and youth (Ginsburg, 2007). By examining positive distractions through the lens of leisure psychology, play could provide exemplary positive distractions as such distractions share similar engaging experiences, such as relaxation, pleasure, enjoyment, and even the optimal experience of flow (Csikszentmihalyi et al., 2014). Various play opportunities in pediatric healthcare environments could help strengthen patients’ sense of control, reduce their stress, and promote their mood and positive experience while facilitating their healing and recovery from diseases. For pediatric patients’ healthy siblings, design features and settings for recreation play can ease boredom and calm their behaviors. Parents’ stress and anxiety could be alleviated through relationships with others, the ability to share emotions, and more relaxed interactions with other children (Corsano et al., 2015).

Public spaces of pediatric healthcare environments, such as waiting rooms, hallways, and hospital gardens, serve as spaces for mere occupation, bringing to attention the necessity for constant sensory stimulation and entertainment for cognitive development in children. In the public areas of pediatric healthcare facilities, health professionals consider “play” to be an activity that helps children make better use of waiting times, decrease their anxiety and nervousness, and enhance interactions and communication with health professionals during the clinical visit, which is known as humanizing children’s healthcare (Corsano et al., 2015, p. 1067). Play and recreation can be therapeutic by giving children the opportunity to explore, express, and process their healthcare experiences in a safe, nonthreatening environment (Children’s Hospital of Philadelphia, 2017). Therefore, it is critical to design public spaces wherein children and youth can maintain a sense of identity and control through self-directed play activities. In particular, outdoor gardens could nurture and assist the healing process of ill children by enabling them to experience biotic, physical and climatic factors in nature and the diversity of forms, colors, textures, and shapes of landscape elements (Said, 2003).

A Brief Overview of Similar Studies

Yet studies conducted on the topics of pediatric healthcare design under the theoretical framework of positive distractions and play are limited. Compared with studies about the design of patient rooms, there is a particular dearth of documentation of positive distractions and the design of healthcare public spaces, such as shared hallways and gardens (Sherman, Shepley, et al., 2005). In an earlier literature review study, Sherman and colleagues (2005) identified 15 papers directly related to pediatric healthcare environmental design between 1997 and 2004, but the majority of the review papers were related to the newborn intensive care unit or pediatric intensive care unit. A few other literature reviews focused on games as distractions for distress among pediatric patients, but the spatial design features of the care facilities were insufficiently discussed or were not systematically reviewed (MacLaren & Cohen, 2005). Norton-Westwood (2012) reviewed the literature on the design parameters of pediatric healthcare environments published between 1980 and 2010, which did not include studies about emerging technology and ambient environment as a trend in current pediatric healthcare design. Given the importance of the topic and the lack of studies and documentation of the data, the current project aimed to systematically review studies conducted within the recent 20 years that are closely related to the design of positive distractions in the public spaces of pediatric healthcare environments.

Research Objective and Questions

This literature review study aimed to validate and extend evidence on positive distractions in order to determine the best methods and practices of incorporating positive distractions and play opportunities in the public spaces at pediatric healthcare facilities, including the overall facility aesthetics, and the sharable interior and exterior spaces such as the atrium, waiting areas, and gardens. In this study, “play opportunities” was used as a broad concept that included playful objects, places where recreational activities could happen, and design features that could arouse leisure experiences in a built environment. The following questions outline the goals of the literature review: (1) How do users perceive various environmental design features and play opportunities as positive distractions in the public spaces of pediatric healthcare environments? (2) What health benefits might positive distractions and play opportunities provide to occupants in pediatric healthcare environments?

Research Method and Procedures

A four phased literature review was conducted to identify and select relevant studies about positive distractions and play in the design of public spaces at pediatric healthcare facilities. The four phases included (1) literature search, (2) literature screening and selection, (3) literature appraisal, and (4) thematic analysis and in-depth discussions.

Literature Search

A combination of key words was used to search existing literature using mainstream medical and architectural databases. Key words groups included (1) pediatric, neonatal, children, youth, young patient, adolescent, and teenager; (2) hospital, healthcare environment/setting/facility, clinic, and pediatric center; (3) public space/area, waiting room/area, hallway, playground, playroom, and garden; (4) stress, emotion, anxiety, mood, behavior, perception, pain, distress, experience, and satisfaction; and (5) art, color, toy, play, image, video, game, distraction/distractor, and technology. A wide variety of databases were utilized, including the Applied Science and Technology Source, Art Abstracts, Avery Index to Architectural Periodicals, Incites Journal Citation Reports, Journal Storage, ProQuest Database, Springer Publishers, PubMed’s search engine, MEDLINE, CINAHL Nursing Journal Databases, Cochrane Library, PsycINFO database by the American Psychological Association, and Google Scholar. The Center for Health Design research repositories and International Academy for Design and Health resource library were also searched.

Literature Screening and Selection

Initial review results were screened by the investigator and two research assistants; irrelevant publications were eliminated after checking the titles and abstracts of the publications, which resulted in 49 publications, one book (Komiske, 2013), and two research reports (Almon et al., 2018; National Association of Children’s Hospitals and Related Institutions & The Center for Health Design, 2008) as candidates for the next round of review. The investigator further developed a series of selection criteria. Twenty-eight peer-reviewed publications were kept for the following round of review. The selection criteria were as follows:

publication year/date between 2000 and June 2019,

peer-reviewed publications in English language,

studies focused only on private patient rooms and intensive care units were excluded,

distractions not directly related to spatial design (e.g., handheld games/toys, parent/staff coaching programs) were excluded, and

due to the high specialty in the research topic, studies focused on infection control in the pediatric healthcare environment were excluded, although some mentioned toys in a shareable space.

Literature Appraisal

It has been discussed recently in the field of evidence-based design that existing evidence should be appraised regarding the strength of recommendation for healthcare design. Stichler (2010) suggested a hierarchical strategy to rank six levels of evidence (Figure 1). The purpose of such critical appraisals was “not to develop a value judgment about the quality of the study or its findings, but rather to provide a tool to assist designers and healthcare leaders in determining whether statements about the effect of specific design features on outcomes are based on credible, reliable, and valid evidence” (Stichler, 2010, p. 6). Marquardt and Motzek (2013) developed two flowcharts to appraise and rank publications following Stichler’s framework, which was employed in the phase of literature appraisal (Figure 1). It was found that overall the 28 studies showed medium to high level of strength as evidence for healthcare design, with 19 publications ranked at Level 3, 6 ranked at Level 2, and 2 ranked at Level 1. One publication was excluded from this study since it ranked at Level 4 and discussed professional guidelines with studies and experts’ opinions to support such recommendations (Stichler, 2010, p. 7). Eventually 27 publications were reserved for the final round of review, thematic analysis, and in-depth discussions. Information about each publication’s level and citation frequency can be found in Table 1.

Figure 1.

Research appraisal flowchart following Stichler’s (2010) framework, adapted from Marquardt and Motzek’s (2013) figure.

Table 1.

Detailed Content Review and Appraisal of the Level of Evidence for Healthcare Design of the 27 Peer-Reviewed Publications Included in This Study.

Publication	Type of Facility/Space	Participant (N)	Research Method	Positive Distraction	Benefits	Major Findings	Level of Evidence	Citation Frequency
Theme 1: Art and environmental aesthetics
Tivorsak et al. (2004)	Pediatric physicians’ offices (waiting areas)	Adolescents with chronic illness aged 11–19 years (N = 29) and healthy adolescents (N = 25)	Focus group	Interior design and decorations; interesting diversions (e.g., magazines, television [TV], games)	Perception to the interior design; waiting experience	Adolescents preferred less childish, more teen-oriented, neutral color, more comfortable furniture, and home-like interior designs. Adolescents preferred that artwork portray realistic images and medical equipment be hidden. Modifying interior decor, constructing smaller subwaiting areas, and incorporating diversions that are teen-oriented may help promote positive healthcare experiences and utilization by adolescents	3	37
Varni et al. (2004)	A long-term, skilled nursing facility for medically fragile children with complex chronic conditions in the United States (facility aesthetics and overall structures)	Pediatric patients’ parents (N = 40); staff members at the facility (N = 72)	Focus group	Aesthetics appearance of the facility, natural light through windows, decoration, and furniture	Healthcare satisfaction and perceived quality of life	Higher parent satisfaction to the built environment was associated with higher healthcare satisfaction	3	79
Eisen et al. (2008)	Pediatric units of two hospitals in Texas, US (facility aesthetics)	Young patients aged 5–17 years (N ₁ = 129, N ₂ = 48, and N ₃ = 48)	Three-phase, multimethod approach: Focus group, randomized study, and quasi-experimental study	Imagery art	Stress reduction, perception, and preference to the artwork	Representational nature art was the highest preferred art image by young patients for all age-groups. Children’s cognitive development stage appeared to have no impact on art preference	1	71
Norton-Westwood (2011)a	Inpatient or outpatient facility, clinic, or dental office, various private and public spaces in the healthcare facility (facility aesthetics, various private and public spaces)	Pediatric patients aged 1–18 years; 20 peer-reviewed studies were included	Systematic literature review	(1) Interior design using color, texture, and furnishings and art; (2) elimination of environmental stressors using lighting, sound, and scent interventions; (3) wayfinding aids; (4) access to social support and choice; and (5) connection to nature	Anxiety relief, stress reduction, patient satisfaction	The design of the built environment does have the ability to positively or negatively impact the level of anxiety and fear that children experience in a healthcare setting. Design implications summarized as (1) the use of color, texture, and age-appropriate design; (2) design to enable patients’ control of privacy or socialization; (3) spatial arrangement to cohort similar age-groups to increase the sense of security and reduce loneliness; and (4) careful choice of artwork and design to hide “scary” medical equipment/supplies	3	5
Coad and Coad (2018)	An acute care hospital children’s unit in the UK (facility aesthetics)	Children and young patients aged 3–18 years (N _phase1 = 40); current and retrospective inpatients and well school students (N _phase2 =140)	Interviews (Phase 1) and questionnaire (Phase 2)	Colors, textures, and thematic designs for the entrance, reception, outpatient areas, corridors, and the ward	Environmental preference and experience	Overall, a single-color scheme was preferred, the most popular color preference was the mid blue-green colors, not bright colors but rather pale to mid color ranges. All age-groups expressed strong preferences for designs and textures, and the top ranked design themes were (1) ocean; (2) metal, glitter or shiny; and (3) nature	3	81
Bishop (2012)	Children’s Hospital at Westmead in Sydney, Australia (facility aesthetics)	Children and young people aged 7–18 years involved in four stages of the study (N = 55 in total)	Participatory qualitative case study, interview procedures including questionnaires and game tasks	Art and art-related activities	A series of positive healthcare experiences	Art was a key environmental attribute positively impacted children’s hospital experience through providing (1) a rich source of aesthetic variation, entertainment, distraction, engagement and identity; (2) indications of a “child-friendly” environment; (3) an opportunity for children to feel supported by others who had been involved in the creation of the environment; (4) a rich source of color; (5) a sense of familiarity and “not looking like a hospital”	3	15
Theme 2: Spatial arrangement and atrium
Adams et al. (2010)	“SickKids”—The Hospital for Sick Children in Toronto, Ontario (atrium)	The original architecture firm and children/youth inpatients (N = 35) and outpatients (N = 45), aged 5–18 years	Historical, visual, and interview data from the original architect; survey to patients	A glass atrium that housed imagery and sculptural art, landscaping, murals, furniture, a cafeteria, and other activities	Improved levels of comfort, enhanced socialization, wayfinding, contact with nature and diurnal rhythms	Architectural scale of spatial design impacts young patients’ perceived sense of intimacy of the space. A public atrium enhanced opportunity to socialize. It is a place to see, be seen, and be involved in the social life of the hospital. A central atrium with memorable features could ease navigation and improve wayfinding experience. An atmosphere of consumption (i.e., shopping mall) of the atrium provided distractions to patients and families	3	88
Ghazali et al. (2013)	Three pediatric wards in the Klang Valley area, Malaysia (various exterior and interior spaces)	Patients (N = 80) and staff members (N = 80) in the pediatric wards	Case study, on-site observation, and evaluation, questionnaires, and archival data analysis	The design of a supportive pediatric ward	Perception and satisfaction about the physical environment	Design of pediatric healthcare facilities should focus on improving character and innovation, use, and access. Extra design attentions included (1) patient’s privacy; (2) external views; (3) the need for patients dealing with the natural, nature, and outdoor world; (4) patient comfort and control over the environment; (5) understandable healthcare buildings and spatial arrangement; (6) interior appearance and design; and (7) facilities for the users in the healthcare buildings	3	2
Koller and McLaren (2014)	An atrium in a contemporary Canadian pediatric hospital (atrium)	Inpatients and outpatients aged 5–18 years (N = 80)	Survey	An atrium consists of a main lobby with high windowed ceiling, brightly color, water feature, commercial venues	Emotional status, perception, and satisfaction	Children and youth reported a range of emotional responses associated with the atrium, under the following themes: (1) choice of colors, artwork, and interior plants; (2) size and suitability; (3) opportunities for play and recreation; and (4) safety and protection versus fear and entrapment. Children have the ability to identify multifaceted issues related to hospital design and affirm their rights to participate in decision-making during the design of pediatric healthcare environments	3	7
Theme 3: Consideration to socialization pattern
Lambert et al. (2013)	The inpatient, outpatient, and emergency departments of three children’s hospitals in Ireland (overall facility structure)	Children aged 5–8 years with various acute and chronic illness (N = 55)	Semistructured individual/group interviews, purposeful sampling.	Social spaces and art-based activities/field work using verbal and visual mediums	Positive hospital experience, enriching choice, and control; reduced isolation, enhanced socialization	Social spaces in hospital should design to provide (1) leisure and entertainment and (2) social connectivity. Young children desire a diversity of readily available, independently accessible, age, gender, and developmentally appropriate leisure and entertainment facilities seamlessly integrated throughout the hospital environment. Children desire social connection to the internal hospital community as well as to the outside world. Technology can assist to broaden the spectrum of children’s social connectivity when in hospital	3	46
Lambert et al. (2014)	The inpatient, outpatient, and emergency departments of three children’s hospitals in Ireland (overall facility structure)	Children aged 5–8 years with various acute and chronic illness (N = 55)	Semistructured interviews and participatory design	Ideal physical design features for hospital built environments	Social support, self-control, positive hospital experience	Thematic findings related to the design of physical features of pediatric healthcare environments from children’s perspectives included (1) physical environments—creative use of space, imaginative décor, bringing the outside in; (2) access—first impressions in the entrance regions, orientation, and movement; and (3) personal space—individual and family space, privacy, storage, noise, and light. Hospital environments need to be designed not just to be child friendly but to also respect children’s right to dignity, privacy, family support, and self-control	3	51
Corsano et al. (2015)	A day hospital of a pediatric hematology and oncology ward of an Italian hospital (waiting area)	Children and adolescents aged 7–15 years and their family members (a total of 50 families)	Mixed methods: Survey using questionnaires and children’s drawings; semistructured interview	The existing waiting room of the day hospital	Children and their parents’ emotional states and anxiety level during waiting	Young patients displayed a low level of anxiety and negative emotion during waiting in a day hospital. In contrast, the adults’ experience of waiting in entailed boredom, anxiety, and concern for the emotional state of their children. Socialization and sharing emotions with other adults can alleviate negative emotions. Hospital waiting rooms should be designed as relational spaces by adults and children	3	13
Theme 4: Play and interactive technologies
Wolitzky et al. (2005)	The pediatric oncology unit in a children’s hospital in a major metropolitan city (procedure room)	Pediatric patients aged 7–14 years (N = 20)	Experimental study: Survey and heart rate measurement	A virtual reality (VR) system to simulate children exploring gorilla habitat at Zoo Atlanta	Reduced pain and distress	A VR system was an effective, immersive distractor in alleviating children’s distress and pain during the invasive medical procedure	2	100
Chau et al. (2006)b	Two pediatric rehabilitation hospitals in Canada.(experimental site not specified)	Children aged 3–12 years from a rehab center (N = 50) and adolescents aged around 15 years (N =15) with acquired brain injury from the other rehab facility	Controlled trials, pilot study	Two types of computer-mediated, augmented environments (AEs); one for music playing and the other for relearning community mobility skills	Enhanced rehabilitation outcomes	Study 1 indicated that AEs may promote the development of targeted visuo-perceptual and motor planning skills. Study 2 indicated that AEs can be easily tailored for training specific community mobility tasks and that participants seem to be engaged by the practical relevance of the tasks, the natural movement-based interface, and the realism of the visual and auditory feedback	2	25
Pati and Nanda (2011)	A dental clinic and a cardiac clinic in a pediatric hospital in the United States (waiting areas)	Pediatric patients (N = 158)	Quasi-experimental study and observational study	Five visual-auditory sensory stimuli displayed on the TV monitor including nature, aquarium, and virtual Ambient Art	Calm behaviors and improved waiting experience	Positive distractions were attention grabbers that associated with more calm behaviors and less fine and gross movement of patients during waiting	2	42
Lee et al. (2012)	Chonbuk National University Hospital in South Korea (Preoperative holding area)	Children aged 3–7 years undergone outpatient surgery (N = 130)	Randomized study	Favorite toys the patients brought from home or patient-selected animated cartoon	Reduced anxiety pre-and during operating of a surgery	Children playing their favorite toys showed the lowest level of anxiety in the pre-anesthetic holding room, and children watching self-selected animated cartoon showed the lowest level of anxiety in the operating groom. Both toys and cartoon chosen by the children themselves were effective positive distractions in different stage of an outpatient surgery	2	86
Biddiss et al. (2013)	Children’s rehabilitation hospital in an urbanized area in North American (waiting area)	Staff members (N = 10), children/young patients (N = 11), and parents (N = 6)	Questionnaires, focus groups, and observations	ScreenPlay—an interactive media display in the waiting space composed of a big screen and sensors in floor tiles	Anxiety relief and improved waiting experience	ScreenPlay provided a positive, engaging experience without the use of contact surfaces through which infections can be spread. It was accessible to patients of all motor abilities. Positive distractions in pediatric waiting environments should design to consider (1) enhancing the waiting experience, (2) protects safety, (3) affords universal accessibility, (4) ensures comfort of clients and staff, (5) longevity/durability, (6) offers and affordable solutions, and (7) blends aesthetically with the existing space	3	23
Biddiss et al. (2018)	Ambulatory pediatric rehabilitation clinic in Toronto, Ontario (waiting area)	Young patients aged 5–19 years with diverse neurodevelopmental conditions (N = 271)	Observational Study and survey	A shared interactive media, a silent nature video, and an aquarium	Anxiety relief	Young people engaged more with shared opportunities for distraction than personal items brought from home. Interactive media and aquarium significantly reduced anxiety while the nature video appeared to increase anxiety. Shared, hands-free interactive media engaged individuals of diverse age and mobility	3	1
Theme 5: Sound and lighting interventions
Sherman, Shepley et al. (2005)c	Children’s healthcare settings; a broader children’s environment (various private and public areas)	N/Ad	Literature review	Sound intervention (reduced noise, music); lighting condition; temperature; access to nature and garden	Stress and physiological arousal; sleep	(1) Noise in pediatric healthcare environments is associated with increased stress and physiological arousal. (2) Music positively impacted hospitalized children in comfort and stress levels and positively impacted infant developments in newborn intensive care units (NICUs). (3) Reduced lighting levels and cycled lighting in NICUs were associated to positive infant development. (4) Having access to nature provided “get away” opportunities	3	48
Robinson and Green (2015)	Two pediatric emergency departments (EDs) in Florida, US (waiting area)	A total of pediatric patients and parents/accompanying adults (N = 70)	Natural experiment, between-group comparisons	Ambient environment	Stress reduction, pain relief, improved patient satisfaction	Patients and adults experienced less stress, less pain, and higher satisfaction levels in the ambient ED environment than a traditional ED environment.	2	7
Quan et al. (2016)	An orthopedic department at a major pediatric outpatient facility in the United States (radiography rooms)	Pediatric patients aged averagely 9–10 years and their parents (N = 182 total)	Randomized study, between-group comparisons	Colorful lighting distraction; and both colorful lighting and wall projection of child-friendly animations	Facilitating medical procedures, enhanced patient satisfaction, and sense of control over the environment	Lighting and animation interventions helped shorten the time of radiographic scans for patients, enhance parental and patient satisfaction and pleasantness, and could potentially reduce patients’ stress	2	8
Watts et al. (2016)	Bradford Student Health Service near the University of Bradford campus, England (waiting room)	College students who visited the clinic for treatments (N = 162)	Experimental study with matched pairs of participants	Large images of natural landscapes and natural sounds such as water sounds	Improved tranquility and reduced anxiety	Waiting room with auditory and visual interventions improved patients’ waiting experience. Levels of reported tranquility were significantly improved but smaller change in reduced anxiety	2	15
Theme 6: Access to nature
Whitehouse et al. (2001)	The Leichtag Family Healing Garden at Children’s Hospital and Health Center, San Diego, US [garden]	Garden visitors were observed (N = 200); participants were surveyed/interviewed (N _adult = 83; N _children = 22).	Post-occupancy evaluation using the following methods: visual analysis, behavioral observations, surveys, and interviews	Healing garden	A sense of restoration and healing, increased patient satisfaction	The healing garden was perceived as a place of restoration, healing, and mood change. Garden use was accompanied by increased consumer satisfaction. However, the garden was not utilized as often or as effectively as intended. Increasing the visibility and accessibility of the garden could promote the garden use. More trees and greenery and more “interactive things for kids to do” were desired by children, parents, and staff members.	3	371
Sherman, Varni, et al. (2005)	Three healing gardens surrounding a pediatric cancer center in Southern California, US (garden)	A total of 1,400 garden-users were observed; N = 22 participants as the present functioning pilot data	Observational study	Healing gardens	Reduced emotional distress and pain; garden usage and stay in outdoor spaces	The largest garden with most direct patient access was most used. Despite patient and child-friendly designs, staff and adults were the overwhelming majority of garden users who mostly engaged in sedentary activities. Children who did use the gardens interacted with garden features significantly than adults. There was an inverse relationship between the use of windows of ground-level patient rooms and the number of people in the gardens. Distress and pain are lower for all groups of users when in the gardens than when inside the hospital	3	232
Pasha (2013)	Five green outdoor spaces in three pediatric hospitals in east Texas, US (garden)	Hospital visitors/family members (N = 76) and staff members (N = 70)	Survey	Green outdoor spaces and gardens	Gardens provided a “get away” place as replied by hospital staff members	Significant barriers to garden visitation included (1) a lack of knowledge about existence of the garden, visibility, and accessibility to the garden spaces and (2) insufficient quality/availability of seats and poor shade in the garden spaces. Playful features could encourage children’s usage of the gardens, and staff members seek separate space from patients and visitors during their break time	3	20
Pasha and Shepley (2013)	Five green outdoor spaces in three pediatric hospitals in east Texas, USA (garden)	Hospital staff (N = 82), children (N = 32 patients; N = 21 visitors), and adult family members (N = 49) were observed	Garden assessment using audit tools, analysis of shade data, observational study, and survey	Green outdoor spaces and gardens	Levels of physical activity and duration of stay in the garden space	Staff exhibited more sedentary behavior in the gardens and other groups of users more physically active. Gardens have more planting design, better layout and pathways, and attractive amenities for children (e.g., play features, sculptures, and child-scale furniture) encouraged higher levels of physical activity and longer duration of stay	3	12
Reeve et al. (2017)	Four healing gardens at the Lady Cilento Children’s Hospital in Brisbane, Australia (garden)	Garden visitors, not known sample size, 59 garden-related comments were made	Qualitative methods, analysis of archival visitors’ notes—“Bench Diaries”	Four healing gardens	Emotional respite to visitors	Visitors appreciated the following features and benefits provided by the healing gardens, including (1) places for time out, (2) dose of nature, (3) restorative experience, (4) fresh air, (5) views, (6) familiarity, (7) sunshine/warmth, (8) fun/play, (9) new perspective, and (10) engage the senses	3	17

^aNorton-Westwood (2011) paper was a literature review that mentioned multiple themes of positive distractions in pediatric healthcare design. It was categorized into Theme 1 in this table because art and environmental aesthetics aspects were the most discussed content in the publication. ^bThis article included multiple studies and measurements. However, since the article only introduced two studies without meta-synthesis of the results, it was categorized as Level 2 evidence. ^c Sherman, Shepley et al. (2005) paper was a literature review project that mentioned more than one theme of positive distractions in pediatric healthcare environment. It was categorized into Theme 5 because sound and lighting interventions were the most discussed content that were directly related to pediatric healthcare environment in the publication. ^dN/A means not applicable.

Thematic Analysis

The primary researcher (author of the manuscript) scrutinized the publications included in the final round of review and further categorized them according to the focused theme of positive distraction in each publication. Analytic notes were taken along the scrutinization, and codes and themes emerged from the concepts used in the publications. Conceptually similar themes were grouped together using the domain analysis as suggested by Spradley (1980): a series of themes were further grouped according to a semantic relationship such as “is a component of” or “is a type of” (Colorafi & Evans, 2016, p. 19).

Research Results and Findings

Six themes of positive distractions were identified: (1) art and environmental aesthetics, (2) spatial arrangement and atrium, (3) considerations of socialization patterns, (4) play and interactive technologies, (5) sound and lighting interventions, and (6) access to nature. The six themes were sequenced from interior features to outdoors, from general design features of the built environment, to design details and sensory stimulations. These themes of positive distractions were found to be associated with a variety of health benefits, including stress, anxiety, physiological arousal, pain and distress, levels of comfort and calm behaviors, emotional status, medical procedures and recovery, a sense of control or familiarity, socialization and social support, diurnal rhythms and sleep, waiting experience, levels of physical activities and contact with nature, patients’ perceptions of the environment, patient satisfaction, and the overall healthcare experience. Table 1 summarizes the details of the reviewed publications. Some publications examined more than one theme of positive distraction but were only categorized according to the original research intent and main research focus. Many publications explored more than one health benefit in association with certain positive distraction. Figure 2 illustrates the themes discussed in the publications and the associated health outcomes.

Figure 2.

Themes discussed in the publications and the associated health outcomes.

Theme 1: Art and Environmental Aesthetics

Existing studies found that patients’ perceived quality of care is positively correlated to the perceptions of their physical environments. The makeup of an aesthetically pleasing environment could reduce patients’ stress and anxiety and improve patients’ healthcare experience and satisfaction. Six papers addressed the theme of art and environmental aesthetics, including interior design style and art work as decorations. Art work depicting nature and in a realistic style has proved to be more favorable than abstract art among adult patients (Nanda et al., 2011; Ulrich, 1999), and this finding is consistent among pediatric patients as well, regardless of their cognitive development stages (Eisen et al., 2008). Specifically, the thematic design of nature, such as ocean and beach views, was a universal desire in hospital designs for children (Coad & Coad, 2018; Pearson et al., 2019). In Varni and colleagues’ (2004) study aimed at developing an evaluation tool kit of the built environment of children’s hospitals, it was found that facility aesthetics (e.g., the overall appearance and the decoration of the interior of the facility, color of the walls and pictures in the hallways, visual and sensory stimuli, the windows and daylight, and room furniture) were closely associated with the pediatric quality of life and parent and staff satisfaction.

Pediatric patients’ preference for environmental aesthetics vary among age-groups; childish decorations were actually disliked by adolescent patients who had already developed mature personalities (Tivorsak et al., 2004). However, the “fear” of medical equipment seemed to exist among all age-groups of pediatric patients, who had a desire to hide it (Norton-Westwood, 2012; Tivorsak et al., 2004). Some controversial conclusions about the color range pediatric patients preferred emerged: Children and young patients preferred pale to mid color ranges and mid blue-green colors (Coad & Coad, 2008; Tivorsak et al., 2004), although previous studies had suggested bright colors were preferred (Redshaw & Smithell, 2000). In general, pediatric patients preferred a rich variety of color, age-appropriate thematic artworks, and a sense of “not looking like a hospital” (Bishop, 2012, p. 83). Bishop (2012) further explored whether adding interactive art activities/tasks in the public pediatric spaces may promote the therapeutic effect of art, meaning it is not simply a graphic treatment but also functions in the ways that young patients “identified as being valuable in their experience of hospitalization” (p. 81). It is worth noting that using participatory design strategy and a children’s advisory group during the design of aesthetically appealing healthcare environments seemed to be an efficient approach for revealing children’s special needs and preferences (Coad & Coad, 2008; Koller & McLaren, 2014).

In general, pediatric patients preferred a rich variety of color, age-appropriate thematic artworks, and a sense of “not looking like a hospital” .

Theme 2: Spatial Arrangement and Atrium

Three publications addressed programming and spatial arrangement issues in pediatric healthcare environments, and two publications studied the same hospital atrium spaces in a contemporary Canadian pediatric hospital that has color, art, a water feature, and commercial venues as distractions. Adams et al. (2010) interviewed young participants about their perceptions of the central atrium spaces of a children’s hospital. The authors concluded that the architectural scale of spatial design impacts young patients’ perceived sense of the intimacy of the space. The public atrium enhanced opportunities to socialize and was associated with young patients’ emotional status. It was a place to see, be seen, and be involved in the social life of the hospital. The central atrium, with its memorable features, could ease navigation and improve wayfinding experiences. The atrium’s atmosphere of consumption (i.e., shopping mall) provided distractions for patients and families (Adams et al., 2010; Koller & McLaren, 2014). Ghazali et al. (2013) concluded that the design of pediatric healthcare facilities should focus on improving character and innovation, use, and access; understandable healthcare buildings and spatial arrangement could improve patient experience. Koller and McLaren (2014) also reported the absence of specialized spatial design for children, especially environments where play should occur, in the public open spaces within a children’s hospital.

Theme 3: Consideration of Socialization Patterns

Only three publications addressed the opinion that the design needed to include social spaces for young children in healthcare facilities, and two of them were by the same research team. Lambert et al. (2013) found that 5- to 8-year-old patients expressed a strong sense of isolation during hospitalization. They wanted to feel socially connected to the internal hospital community as well as the outside world. The authors concluded that there is a need to include “a diversity of readily available, independently accessible, age, gender and developmentally appropriate leisure and entertainment facilities seamlessly integrated throughout the hospital environment” (p. 203). Lambert and colleagues also stressed that today’s technology offers many opportunities to support children’s psychosocial well-being when in confined healthcare spaces; however, the implementation and operation of such services and systems require much further research in the areas of ethnics, facilitation, organizational impact, and evaluation (p. 195). In another study about waiting experience among young patients (7–15 years old) and their families, the young patients displayed a low level of anxiety and negative emotion (excluding boredom), whereas adults’ experience of waiting entailed boredom, anxiety, and concern for the health status of their children (Corsano et al., 2015). Pediatric waiting areas should be experienced by adults and patients as relational spaces (p. 1066). Design features and activities should support patients’ sense of control over their emotions and fears for the uncertainty. Patients and parents would like a waiting area with the presence of positive social and spatial distractions and entertainment activities. Adult parents’ stress and anxiety could be alleviated through relationships with others by sharing emotions and engaging in more relaxed interactions with the children (Corsano et al., 2015).

Patients and parents would like a waiting area with the presence of positive social and spatial distractions and entertainment activities. Adult parents’ stress and anxiety could be alleviated through relationships with others by sharing emotions and engaging in more relaxed interactions with the children .

Theme 4: Play and Interactive Technologies

The theme of play and interactive technologies has attracted an increasing number of researchers’ attention in recent years. Previous studies criticized that traditional toys, whether plastic or metal, could be contaminated with potentially dangerous bacteria and might provide unnecessary risks for nosocomial infection in certain pediatric healthcare environments (Avila-Aguero et al., 2004; Bocchini et al., 2007; McKay & Gillespie, 2000). Therefore, positive distractions provided through digital displays (e.g., television [TV] screens) and nontouchable medium, virtual reality, and ambient environment emerged in the design of pediatric settings. Health benefits associated with play and interactive technologies included reduced pain and distress during medical procedures, reduced anxiety, reduced arousal, and calm behaviors and tranquility among pediatric patients. Pati and Nanda (2011) found that multisensory stimuli displays and ambient art could help calm pediatric patients’ behaviors and effectively hold their attentions when waiting. Virtual reality could be an efficient distraction during painful medical procedures (Wolitzky et al., 2005). Computer-mediated, augmented environments could efficiently assist with young patients’ rehabilitation process related to visuo-perceptual and motor planning skills (Chau et al., 2006). Furthermore, nature-themed content (e.g., nature, aquarium, animals, and zoo) positively distracts young patients’ attention and relieves anxiety relief (Biddiss et al., 2018; Pati & Nanda, 2011; Wolitzky et al., 2005). However, most existing studies examined the positive distractions as objects, and the spatial designs used to accommodate these play opportunities were rarely mentioned.

Theme 5: Sound and Lighting Interventions

Noise can arouse stress. Noise in pediatric healthcare environments has been shown to be associated with increased stress and physiological arousal among neonatal patients (Sherman, Shepley, et al., 2005). Natural sound intervention has been found to be therapeutic by reducing noise, enhancing tranquility, and calming adolescent patients’ behaviors in waiting areas (Watts et al., 2016). Watts and colleagues (2016) also compared music and natural sound and found that music could play a role in well-being, but personal choice was an important factor that impacted the level of effectiveness of music as a positive distraction. In contrast, natural sounds, especially water sounds, were generally regarded as positive distraction (p. 140).

Technology has enriched the opportunities for sound and lighting interventions in the design of healthcare environments, such as using colorful ambient lighting to match the theme of animation and art. Quan and colleagues (2016) found that ambient lighting and animation interventions in a radiographic scan environment could help shorten the time of medical procedures, enhance parental satisfaction, and potentially reduce patients’ stress. Patients and adults experienced less stress, less pain, and higher satisfaction levels in ambient emergency departments with colorful lighting distractions and child-friendly animations projected on the wall (Robinson & Green, 2015).

Theme 6: Access to Nature

Five publications explored hospital gardens and user behaviors in pediatric healthcare environments. Three studies were post-occupancy evaluations (POEs) that employed methods including on-site observations and behavior mapping/tracing, interviews, and surveys. Whitehouse and colleagues’ (2001) seminal POE study brought the topic of healing gardens in pediatric healthcare environments to researchers’ attention. They found that the garden space was perceived as a place of restoration and healing, and garden use was accompanied by increased consumer satisfaction, enhanced emotional respite for visitors, and reduced pain and distress (Reeve et al., 2017; Sherman, Varni, et al., 2005; Whitehouse et al., 2001). Visitors who used the garden spaces appreciated the features and benefits provided by healing gardens, such as a place to get away, restorative experience, fresh air, sunshine, views, and fun and play (Reeve et al., 2017). However, the garden was not utilized as frequently and effectively as planned due to the low visibility (Whitehouse et al., 2001). Sherman, Varni, and colleagues’ (2005) study found that the largest garden in a pediatric cancer center with the most direct patient access was the most used space. Pasha’s (2013) study further revealed that a lack of knowledge about the existence of the garden, low visibility, and limited accessibility to the garden spaces were major barriers to garden visitation in a Children’s hospital.

Despite the child-friendly design of most pediatric gardens, staff and adult family members were the overwhelming majority of garden users, and only around 5% of the total garden users were children (Sherman, Varni, et al., 2005; Whitehouse et al., 2001). Adults mostly engaged in sedentary activities or simply walked through the garden whereas children engaged in significantly more interactive activities with play structures and natural elements (Pasha & Shepley, 2013; Sherman, Varni, et al., 2005; Whitehouse et al., 2001). Sherman, Varni, and colleagues (2005) also discovered an inverse relationship between the number of people in the gardens and the use of windows in ground-level patient rooms: As the number of people increases, fewer patients are likely to keep their window blinds open. The most popular garden was most likely to have closed windows, and the least populated had the most open windows (Sherman, Varni et al., 2005, p. 178). Design features that could potentially encourage garden usage by children included (1) a variety of high-quality seats and child-scaled furniture; (2) improved accessibility and circulation; (3) more trees, greenery, and shade; (4) a pleasant microclimate; (5) playful features that encourage play activities; and (6) security and privacy (Pasha, 2013; Pasha & Shepley, 2013; Sherman, Varni, et al., 2005; Whitehouse et al., 2001).

Discussion

Answering Research Questions

This article reviewed studies about the design of public spaces in pediatric healthcare environments, positive distractions, and the associated health outcomes by analyzing 27 peer-reviewed publications published in recent 20 years to answer the research questions stated earlier in the paper. The results indicated that environmental design features that young patients and family members in a pediatric healthcare environment perceived as positive distractions could be categorized to six themes: art and environmental aesthetics, spatial arrangement and atrium, play and interactive technologies, considerations of socialization patterns, sound and lighting interventions, and access to nature. A wide range of health benefits could be provided by appropriate positive distractions in the care environment, including physiological, psychological, emotional, behavioral, and social benefits. Young children and adolescents were found capable of perceiving their surrounding environments as well as expressing their preferences for and needs related to the design of the physical features of a healthcare facility. However, many publications reviewed in this study were passive observations of children’s behaviors or survey with adults. There is still insufficient knowledge about what constitutes a child-friendly hospital environment from young children’s perspectives.

The age factor played a role in understanding children’s perceptions about various design features. Preliminary evidence indicated that spatial designs and features should accommodate different age-groups’ developmental stages (Tivorsak et al., 2004); infants need intimacy and loving personal contact, while the desire to have independent spaces, purposeful activities, and social interaction increased as children grew older (Olds, 1981). Including subspaces for different age-groups with age-appropriate thematic designs and decorations may fulfill different users’ needs (Zabloudil, 2017). Using a waiting room space as an example, Figure 3 compares a traditional waiting room to a humanized pediatric waiting room as adapted from previous theories (Olds, 1981). Designs to encourage social interactions are important for both young patients and their families. Hospital environments need to be designed not just to be child friendly in environmental aesthetics but to also respect children’s right to dignity, privacy, cognitive development, social support, and self-control.

The age factor played a role in understanding children’s perceptions about various design features .

Figure 3.

Comparison between a traditional waiting room and a humanized pediatric waiting room as adapted from Olds’ (1981) study.

Nonenvironmental Positive Distractions

This study included positive distractions that are directly related to the physical environment of pediatric healthcare facilities. However, it is worth to point out that many nonenvironmental resources could also provide positive distractions to pediatric patients and families, especially to alleviate pain and distress associated with medical procedures. Through a meta-analysis, Kleiber and Harper (1999) confirmed that distractions had a positive effect on children distress behaviors and perceived level of pain. Nonenvironmental positive distractions examined by Kleiber and Harper (1999) included music/story via earphones, distraction with party blower, imagery, breathing pattern, toy, and nonprocedural talk by a professional. Koller and Goldman (2012) conducted a systematic review and summarized two domains and several subdomains of distraction techniques for children undergoing procedures to control pain, including active distraction (i.e., interactive toys, virtual reality, controlled breathing, guided imagery and relaxation), passive distraction (i.e., music and TV), and a mixture of active and passive distractions.

Organizations and nonenvironmental programs also play significant roles in providing positive distractions, such as the child life profession whose original goals were to improve healthcare experiences through providing play, preparation, family participation and educational programs (Association of Child Life Professionals, n.d.). Music therapy programs have expanded the wide acceptance of the practice in the pediatric healthcare delivery system. Resources such as the American Music Therapy Association and Journal of Music Therapy have documented a substantial amount of empirical studies about the various health benefits of music therapy in pediatric settings (Gooding et al., 2015; Millett & Gooding, 2017). Horticultural therapy programs, as an effective therapeutic modality that involves plants and horticulture to support an established treatment plan (American Horticultural Therapy Association, n.d.), have been implemented in a few pediatric healthcare settings, including the indoor garden suite at the UH Rainbow Babies & Children’s Hospital in Cleveland (Marolf, 2016).

Play therapy is a psychotherapeutic approach primarily used to help children with social or emotional deficits to explore their lives, solve problems, and freely express repressed thoughts and emotions through play (Association for Play Therapy, n.d.). Researchers promoted therapeutic play activities as far back as 1919 (Schaefer & O’Connor, 1983) in order to reduce children’s stress, express feelings of anger, cry, and ask questions (Erikson, 1963; Linn et al., 1986). For young patients who stay in a hospital longer, play can promote normal life experiences while maintaining and supporting the developmental, cognitive, social, and emotional health of the children thereby facilitating the development of hardiness and resiliency as well as the ability to master critical experiences (Bolig et al., 1986; Bratton et al., 2005). Usually such alternative therapy programs need dedicated spaces and specialties to assist with the process. However, it remains unclear that how spatial design and features could facilitate various therapy programs in a pediatric healthcare facility.

Research Gaps and Future Directions

To identify current research strengths and the knowledge gaps, Figure 4 demonstrated the themes of positive distractions, number of publications, and the different types of facilities/public spaces studied in the publications. Significant research gaps were identified through this literature review. There seemed to be a universal preference of nature among children; however, the garden spaces in many pediatric healthcare environments were not effectively used as intended by young patients (Pasha, 2013; Sherman, Varni, et al., 2005; Whitehouse et al., 2001). Gardens and nature are the ideal places to stimulate and nurture ill children’s senses as they can experience diversity of forms, colors, shapes of landscape elements, and dynamism of climatic factors (Said, 2003). With proper design and implementation, the hospital garden spaces can be made into therapeutic platforms for the children and their healthy siblings to play, rest, and socialize (Said, 2003). Future research should focus on how to promote longer stay in a garden space and how to engage children more actively with playful features.

Gardens and nature are the ideal places to stimulate and nurture ill children’s senses as they can experience diversity of forms, colors, shapes of landscape elements, and dynamism of climatic factors .

Figure 4.

Themes of positive distractions, number of publications, and the different types of facilities/public spaces studied in the publications.

Play is the child’s language and toys are the child’s words (Association for Play Therapy, n.d.). Play could be an ideal positive distraction among children and young patients; however, existing studies examined the play device/opportunity only as an object, and very few discussed the spatial design to accommodate various play programs in a pediatric healthcare environment. Socialization patterns among pediatric patients require attentions when designing the physical environments of pediatric healthcare facilities. In-patient pediatric patients desire internal connections to the healthcare community, as well as external connections to their friends, the school, and a normal life. Such bonding between patients, family members, and caregivers could be promoted through play. Play in the realm of public health has consistently remained a research interest among researchers (Almon et al., 2018), yet play and spatial design for play seem to have been less studied in recent years, leaving a significant research gap in the realm of pediatric healthcare design.

Attracting children’s attention could be considerably more challenging than those of adults, especially those children with neurobehavioral development disorders and attention problems (Pati, 2010, para. 13). Interactive technology could effectively hold pediatric patients’ attentions. Ambient environment with multisensory stimulations and immersive virtual realities could calm behaviors, relieve anxiety, and enrich children’s enjoyable experiences during hospitalization. Technology is developing rapidly, but updates to physical features and spaces in a healthcare facility may not catch up in time. Designing flexible spaces that can easily be transferred to accommodate new technology may be a future direction in both practice and research.

Interactive technology could effectively hold pediatric patients’ attentions. Ambient environment with multisensory stimulations and immersive virtual realities could calm behaviors, relieve anxiety, and enrich children’s enjoyable experiences during hospitalization .

Implications for Practice

A rich source of natural and thematic decorations should be integrated in the design of pediatric healthcare environments.

Spatial design should promote occupants’ play behaviors and hide “scary” medical equipment/supplies.

Strengthen social connectivity and provide opportunities for both children and adults to socialize in a shared space.

Interactive technologies, sound, and lighting interventions could be effective play opportunities and positive distractions.

Hospital gardens should be visible and accessible to all. Attractive landscape features, abundant shade, comfortable seating, choices of socialization or privacy, and guaranteed safety could enhance the usage of the garden spaces.

Children have the ability to identify multifaceted issues related to hospital design. Including a “children advisory board” could be an efficient strategy to understand the needs from young patients’ perspectives and involve patients in decision-making during the design of pediatric healthcare environments.

Supplemental Material

Supplemental Material, sj-pdf-1-her-10.1177_1937586720901707 - Positive Distractions and Play in the Public Spaces of Pediatric Healthcare Environments: A Literature Review

Supplemental Material, sj-pdf-1-her-10.1177_1937586720901707 for Positive Distractions and Play in the Public Spaces of Pediatric Healthcare Environments: A Literature Review by Shan Jiang in HERD: Health Environments Research & Design Journal

Footnotes

Acknowledgment

I thank my research assistants, Krisha Redillas, Yasmeen Juma, and Udday Datta, from West Virginia University, who provided assistance in the early phase of the manuscript development.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was partially funded by 2017–2018 U.S. Play Coalition Research Seed Grant and West Virginia University Research Apprenticeship Program.

ORCID iD

Shan Jiang, PhD

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