HERD: Health Environments Research & Design Journal

During the COVID-19 pandemic, the Centers for Disease Control and Prevention (CDC) and ASHRAE provided infection control recommendations for the built environments and ventilation systems of nursing homes (NHs). The level of adoption of the suggested strategies is unknown, as little information has been obtained from NHs identifying the strategies that were implemented.

The primary goal of our study was to characterize the built environments of Colorado NHs during the COVID-19 pandemic to assess the level of adoption of CDC and ASHRAE recommendations. Our secondary goal was to identify opportunities and barriers that NHs face as they work to create health-protective built environments in the future.

We used the Nursing Home Built Environment survey to obtain data related to three main categories of CDC and ASHRAE recommendation for Colorado NHs: Resident Isolation, Improved Indoor Air Quality, and Staff Separation/Support.

Key findings included: (1) On average, NHs had 34% of their beds located in single-occupancy rooms; (2) seven (9%) NHs had designated COVID-positive “neighborhoods”; (3) 14 (20%) NHs had common area ventilation systems that were utilizing filters with a minimum efficiency reporting value 13 rating, or higher.

Most Colorado NHs did not fully implement the COVID-19 built environment strategies recommended by CDC and ASHRAE. While there are barriers to the adoption of many of the strategies, there are also opportunities for immediate improvements that can support the health of vulnerable NH populations as we continue to see high rates of aerosolized infectious disease spread in NH facilities.

This study investigates preference for five different seating arrangements (e.g., rows, clusters) in a doctor’s office waiting room, whether these reduce stress and improve judgments of medical care, and how such choices may have changed over the pandemic (2013 vs. 2021).

What is called the doctor’s office layout, with chairs lining the perimeter of the waiting room, is criticized by designers, yet little empirical evidence exists to support that assessment.

Data collected in 2013 and 2021 used sketches of five different seating arrangements; people saw just one of these. The study examined the effect of time and seating arrangement on anxiety, need for privacy, situational awareness, evaluation of the environment, and perception of the doctor.

There was no significant impact of the seating arrangement on any of the dependent variables, but ratings were higher for situational awareness, need for privacy, evaluation of the environment, and aspects related to the physician in 2021. In addition, seating preferences favored end, not middle seats, and chair selections with the chair back to a wall.

In this study, no evidence exists that the doctor’s office layout is less preferred than four other seating arrangements, but seat choice shows people prefer end seats (not middle seats) across arrangements. The doctor’s office layout may offer a supportive familiarity to people; also, given the percentage of people who visit the doctor unaccompanied, layouts designed to encourage social interaction may not always be appropriate.

We aimed to identify how the COVID-19 lockdown affected changes, including the potential for longer term sustained changes, in physical activity, as compared to immediately prior to the pandemic.

Physical activity’s significant role in overall health is known to be influenced by the surrounding environment, such as one’s neighborhood, prompting this study of physical activity and its relationship with individual-level and neighborhood-level factors within the pandemic timeline.

A statewide online survey assessed adults’ self-reported weekly minutes of moderate-to-vigorous physical activity (MVPA) comparing a typical week immediately prior to the pandemic and during the pandemic (prewidespread vaccination) using negative binomial models.

Overall, MVPA decreased during the pandemic, though the decrease was driven largely by the reduction in MVPA outside one’s neighborhood. In contrast, MVPA done within one’s neighborhood increased over time. This change in MVPA done within one’s neighborhood was not uniform across several characteristics including income level favoring those with the highest income (p < .05) and race/ethnicity favoring those self-reporting as non-Hispanic White (p < .05). While several factors, including higher Walk Scores, were associated with higher levels of MVPA without evidence of change over time, evidence of a differential effect over time was seen for other key indicators of social and structural determinants of health including income and race/ethnicity.

This study can add to the existing literature surrounding not only COVID-19 but also neighborhood built environmental research seeking to identify factors associated with changes in MVPA, a known indicator of overall health and health-related outcomes.

Aimed to explore more practical interventions for handwashing compliance (HWC) and protect the minor’ health with the pandemic background, this study tested whether micro architectural interventions would promote HWC of adolescents through active experience.

Despite the well-documented benefits of handwashing (HW), low compliance is common among adolescents. HW space in schools has always been treated as attached spaces of little matter, which is unfavorable to public health. According to environment behavior perspective, personal motivation of HWC may be motivated by active environment.

A school-based investigation and a 30-week environmental behavior experiment were conducted when students returned to school after the COVID-19 pandemic closure in 2020 in China to evaluate the effects of active environment interventions selected by previous survey on promoting adolescents’ HW rate. Digital infrared counters were used to unobtrusively document their behavior.

Results in summer revealed a positive effect on all intervention groups. The effects of combined interventions were higher than the effect of any single intervention. However, HW rates of all groups declined sharply in the coldest month and the between-group differences decreased. Significant correlations were found between HW rates and satisfaction with the intervention schemes.

Findings suggest that architectural environmental intervention may potentially be a positive, friendly, and one-time investment mean to expand the HWC intervention scope from passive policies to positive experience, and HW space design for adolescents should be treated as a public health strategy.

To investigate which spaces stroke patients visit in their free time while undergoing inpatient recovery in rehabilitation centers, what activities they engage in, and what kind of spaces they want.

Research studies consistently show that stroke patients are highly inactive during rehabilitation. Much remains unknown about what patients do in their free time and how the built environment might affect their behavior and activities.

Patients’ free-time activities were recorded via patient shadowing (n = 70, 840 hr), and their spatial preferences were collected using a survey (n = 60) in seven rehabilitation centers. Each participant was observed over one typical day (12 consecutive hours). Their activities, durations, and locations were recorded using floor plans and time log sheets.

Six main themes emerged from the analysis of shadowing data and patient surveys: (1) spending most free time in their room, (2) corridor as the overlooked activity hub, (3) food and beverage stations as triggers of activity, (4) wanting to socialize, (5) variety of common spaces for different activities is desired, and (6) common room’s atmosphere, comfort, style, and view are important. Even though socializing with other patients was mentioned as a primary reason for visiting common spaces in the survey, patients spent most of their free time alone.

Corridor emerged as a space with great potential to motivate and support various activities of patients. Patients’ free-time activities could contribute to their recovery, and the built environment may play a role in facilitating and supporting these activities.

This exploratory mixed methods experiment aimed to determine whether the application of wayfinding aids (colored doors, shapes on the floor, and signage) as an intervention could help children with autism spectrum disorder (ASD) find their way to a destination to promote independence.

Several individuals with ASD have described the difficulties they experienced finding their way in the environment. This is especially relevant to complex environments like healthcare.

Participants with ASD aged 8–11 (n = 9) were randomly assigned to control or treatment groups. The test location was an empty school corridor unfamiliar to participants. Each participant was shown the way to a destination using a script pointing out existing cues (control group) or applied wayfinding aids (treatment group). Participants were taken back to the start and then asked to lead the way to the destination. Afterward, they were interviewed about their experience. Data collection included observation, behavioral mapping, and video recording.

The variable of wayfinding scripts helped all participants find their way to the destination, but those in the treatment group found their way directly compared to 75% of the control group. Wayfinding aids made the environment more memorable to those in the treatment group. Some children were distracted by environmental stimuli, and some noticed surprising elements that helped them wayfind.

Study results suggest that wayfinding instruction could be used as an intervention in environments with and without the application of wayfinding aids. This needs further testing in other environments. Issues included recruitment and random assignment.

This study examined the influences of healthcare facility interior features on users’ wayfinding performance and the relationship between stress and wayfinding.

General hospitals in China always present significant wayfinding problems due to their sizes and complexity. Poor wayfinding often leads to a frustrating and stressful user experience. It has not been fully understood how hospital indoor features affect wayfinding and whether an individual’s stress levels are associated with wayfinding performance.

We conducted an experiment in which 117 college students, aged 18–33 (M = 21.88, SD = 3.01), performed two tasks in virtual reality environments of outpatient clinics. Stress (skin conductance response) and wayfinding performance (distance ratio and time ratio) were measured. Participants’ sense of orientation, navigation ability, distance estimation, and spatial anxiety were captured by a survey.

Male participants reported a significantly better sense of orientation and less spatial anxiety than females. Participants’ stress levels were lower with outdoor window views compared to those without outdoor views. With more environmental features (landmarks and outdoor window views) added to the environments, participants showed significantly better wayfinding performance. No significant relationship was found between wayfinding performance and participants’ stress levels in this study.

While individual environmental factors might not have a significant influence, combining multiple elements such as window views and landmarks could lead to better wayfinding performance. More research is needed to examine the relationship between stress and wayfinding.

This article proposes a method for evaluating the design affordances of primary care exam rooms from the perspectives of users using functional scenario (FS) analysis.

This study aims to develop quantifiable criteria and spatial metrics for evaluating how exam room design supports the needs of different users. These criteria and metrics can be used in the early stages of the design process to choose between alternatives.

The primary care exam room is an essential space in healthcare, as it is the first point of contact between the healthcare provider and the patient. However, there is a lack of rigorous evaluation metrics for exam room design that supports improved user experiences and better health outcomes.

A total of nine primary care exam rooms were analyzed using FS analysis. We identified three key user groups involved in the clinical examination process—providers, patients, and care partners—and translated their needs into FSs. We developed spatial metrics for each FS to quantify the extent to which the needs were spatially supported.

We developed 11 FSs in total: three from the providers’, five from the patients’, and three from the care partners’ perspectives. The results revealed possible design strategies for improved user experiences.

We quantitatively measured the affordance of primary care exam room design for multiple stakeholders. We expect that the criteria and metrics presented in this article will improve the understanding of different users’ perspectives and provide new design guidance for improved user experiences.

The field study was to understand older adults’ reactions to and use of different low-light conditions while walking to bathrooms in the dark in their homes. Low-light conditions included participants’ usual nightlights and a destination-based LED strip lighting system.

Older adults encounter fall accidents while going to bathrooms at night due to low illuminance levels. They also fear falling due to previous fall histories or visual impairments. This field study tested and compared a destination-based LED strip lighting system with their usual nightlights on their movement and fear of falls.

Fifteen older adults from an independent living facility participated in the within-subject design experiment, walking under two scenarios in random order: with usual nightlights turned on or with the destination-based LED strip lighting system turned on. Body-worn sensors were used to collect participants’ movement behaviors, and subjective questionnaires were used to understand participants’ anxiety under the two low-light conditions. Further, semi-structured interviews were conducted to understand their nightlight usage patterns and their evaluations of the destination-based LED strip lighting system.

Participants walked more smoothly under the destination-based LED strip lighting system scenario. However, the anxiety states were not statistically different between the two scenarios.

Visual cues in the dark can benefit older adults’ safe movement. However, the application of the lab-effective LED strip lighting system in home settings should consider older adults’ floor plans and their furniture layout, both indoor and outdoor ambient lighting sources, and their lifestyles.

This article provides a conceptualization and an index of the multidimensional concept of maternity healthscapes (MHS).

Healthscape has emerged as a potential key aspect to improve patient experience. Surprisingly, there has been little effort to delineate the concept of MHS from a design perspective, while maternity wards have unique characteristics and particular challenges. Indeed, patients in maternity wards are usually not acutely ill but can feel highly vulnerable due to the pain, stress, and the many uncertainties surrounding labor and delivery—which can heighten patients’ need for intimacy, supporter comfort, and additional supporting services. Thus, healthscapes need to be designed to account for the specificities of childbearing and needs of those patients and their family.

A multidisciplinary literature review and 39 in-depth interviews were conducted with various stakeholders—mothers, midwives, heads of midwives, and chief executives.

The authors develop a conceptualization to establish a comprehensive understanding of the dimensionality of MHSs. Based on that comprehensive conceptualization, the authors develop an index providing a census of the aspects in the MHS that various stakeholders—such as healthcare providers, designers, and architects—should take into account when conceiving MHS.

Healthcare providers, designers, and architects can use this conceptualization and index to closely monitor and measure for evaluations and further improvements of the MHS, thereby enhancing patient experience in maternity wards.

This article investigates how the physical birth environment is perceived by the users (women and midwives) in different settings, a midwife-led unit and an obstetric-led unit, placed in Italy.

In the field of birth architecture research, there is a gap in the description of the spatial and physical characteristics of birth environments that impact users’ health, specifically for what concerns the perception by women.

The study focuses on multi-centered mixed methods design, employing both quantitative and qualitative research methods (questionnaire, spatial analysis) and covering different disciplines (architecture, environmental psychology, and midwifery).

The results revealed significant differences between the two settings and some associations between perceived and spatial data concerning: calm atmosphere, greater intimacy, spacious birth room, clarity of service points, clarity in finding midwives, sufficient space for labor, noise, privacy, and the birth room adaptability.

The findings confirm the importance of the spatial layout and indicate documented knowledge as an input to consider when designing birth spaces in order to promote user well-being.

The purpose of this study was to understand how specific evidence-based design strategies are related to aspects of nurse wellness.

Addressing burnout among the healthcare workforce is a system-level imperative. Nurses face continuous and dynamic physical and emotional demands in their role. Greater insight into the role of the physical environment can support efforts to promote nurse wellness.

This exploratory qualitative study was conducted at new Parkland Hospital in Dallas, TX. We conducted five focus groups with nursing staff in July 2018. These sessions covered five topics related to nursing work in the facility which had been redesigned nearly 3 years earlier: (1) professional and social communication, (2) workflow and efficiency, (3) nurses’ tasks and documentation, (4) ability to care for patients, and (5) nurses’ overall health. We conducted a thematic analysis and first identified different aspects of wellness discussed by participants. Then, we examined how nurses related different design elements to different aspects of their wellness.

Participants included 63 nurses and nurse managers. They related environmental factors including facility size, break rooms, and decentralized workstations to social, emotional/spiritual, physical, intellectual, and occupational aspects of wellness.

It is critical to inform and integrate nurses at all levels into planning, design, and activation of new healthcare environments in order to ensure the well-being of nurses and, therefore, their ability to effectively support patients.

This article aims to complement the historical literature on the evolution of hospital buildings via a holistic analysis of the contextual factors triggering hospital design innovation over the past 100 years.

Innovation in hospital building design should be considered as a complex ecosystem with a heterogeneous set of actors.

A novel hybrid research design to the Mixed Grounded Theory methodology, with Charmaz’s constructivist paradigm, was developed to explore, construct, and interpret concepts and the interconnections between them.

Six hundred seventeen interconnections between 146 factors, classified across 14 categories, were developed to explain the individual and combined impacts of all components of the design innovation ecosystem.

This study provides hospital building designers, researchers, policy makers, and stakeholders with a systemic understanding of the innovation ecosystem and their potential role in this system. This knowledge suggests the need for interdisciplinary education to address complex and quickly evolving real-world building design problems.

The goal of this research was to understand the use of decentralized nursing stations (DNS), corridors, and huddle stations as places for teamwork and multidisciplinary care in the neonatal intensive care unit (NICU).

This article shares outcomes from a pre- and post-occupancy evaluation that assessed a NICU moving from an open-bay model to a new single-family room (SFR) unit comprised of six, 12-bed neighborhoods. This interdisciplinary research team draws upon the practical expertise of a NICU Patient Care Manager and researchers in Design and Communication to illuminate the research process, results, and lessons learned.

A multi-methodological design, approved by the institutional review board, was employed that utilized an electronically distributed pre- and post-move survey of staff and observational counts of face-to-face interactions.

Survey results indicate NICU staff have statistically significant higher perceptions of job satisfaction, stress and well-being, and design satisfaction among a variety of professionals after moving to a SFR, decentralized unit design. Consistent with the literature, staff did not have significantly higher perceptions of the decentralized NICU relative to teamwork. Observations revealed frequency of conversations primarily at DNS followed by corridors and huddle stations. When examining the multidisciplinary makeup, outcomes were reversed with huddle spaces holding the largest percentage of conversations. On average, there were 2.72 individuals involved in these interactions, with the corridor seeing the largest average of group sizes.

The outcomes of this study demonstrate that neutral spaces such as corridors and centralized huddle stations should be considered as locations for strategic collaboration and multidisciplinary care.

The purpose of this article is to review available literature for evidence-based impact of the built environment upon the prevention and management of COVID-19 with a view to emphasizing lessons learned for future infection control of pandemics.

This is urgently needed given the devastation brought upon long-term care residents worldwide. Long-term care (LTC) facilities face a battle to protect their residents. Previous studies of infection control design issues have focused generally on Fomites: that is, contaminated objects and surfaces. As COVID-19 has been shown to be largely spread through the air, this article will broaden the focus to include engineering controls that effect this type of transmission.

A literature search was conducted using key words such as long-term care facilities, built environment, COVID-19, infection control, and nursing homes.

Results were sorted using an engineering controls pyramid developed by the author to stratify approaches to LTC infrastructure. Basically, six elements were supported: ventilation, spatial separation, physical barriers, hand hygiene stations, resident room zones, and private rooms.

Conclusions were that the built environment has a major impact on infection control that can be deleterious or beneficial. Substantial changes need to be made to protect the very vulnerable LTC population from future pandemics and infectious diseases.

The purpose of this scoping review is to synthesize and map available evidence on the design of “housing with care” (HWC) schemes to inform design decisions built on objective data from previous research, which is key to ensuring such schemes are fit for purpose for older people.

HWC is becoming increasingly recognized as a model for developing housing schemes for older people and balances independent living with elevated levels of care. However, as this scheme is still relatively novel, there are currently no established theoretical frameworks to inform design.

Scoping review, thematic analysis, and mapping methods were used to comprehensively search for and synthesize evidence that links design with assessments of quality-of-life data for HWC schemes. Study findings for each included paper were subject to data extraction for inductive analysis, and the quality of each study was assessed using a modified critical appaisal skills programme (CASP) checklist.

Our searches yielded 821 unique references, of which 18 unique articles met the inclusion criteria. The outcomes of interest were the design considerations or features in HWC schemes and their impact on the residents. The main themes identified were related to design element, accessibility, maneuverability, views, design procedure, and quality of life (QOL). Further subthemes identified across papers were identified to create a comprehensive map of the key features to consider in designing HWC schemes.

This review provides an initial framework for designers and architects to (1) understand the effect of each design element of HWC and (2) inform design to ultimately improve the QOL of aged people.

This article seeks to develop a context-based management system focusing on assessing key operational and design problems and affecting wayfinding in dementia residential care homes.

Dementia is multifaceted neurocognitive impairments largely attributed to cognitive deterioration manifested in memory loss and visuospatial deficit which have wider practical implications to both environmental safety and wayfinding and navigation of dementia user. Two key questions were addressed in this context: (1) How can cognitively facilitating assistive technology (AT) be made more user-focused to mitigate the impacts of cognitive impairments on environmental safety and wayfinding? (2) How can design intervention and changes in design topology, colors and texture, and internal finishing aid wayfinding, navigation, and orientation in dementia residential care homes?

A systematic literature review and analysis was undertaken to assess the efficacy of key cognitively-related AT to support activities of daily living and environmental safety of dementia sufferers in a care home and aid wayfinding, navigation, and orientation.

Several key design variables to facilitate wayfinding and spatial orientation were identified which include design topology, floor finishing, signposting, and use of color and texture strengthened by meaning, emotional connection to places and cognitively focused intervention via memory cueing and objects-centered recognition.

Key operational and design guidelines were proposed to assist built environment, care home developers, clinicians and healthcare professionals, and care services providers. There is a need to move toward a dementia-centered design to address the challenges facing people living with dementia in care homes. This should be based on the interrelated behavioral, cognitive, and communication factors.

The COVID-19 pandemic has impacted healthcare systems worldwide. Although this disease has primarily impacted general medicine intensive care units, other areas of healthcare including psychiatry were modified in response to corona measures to decrease the transmission of the disease. Reflecting on the modifications to the environment provides an opportunity to design psychiatric environments for future pandemics or other demands for healthcare.

The therapeutic environment of psychiatric wards was modified in Friesland, the Netherlands, in response to COVID-19. During this time, an interdisciplinary team met consistently to contribute to the preliminary design of a new psychiatric hospital.

During the first 18 months of the pandemic, clinical reflections were made to describe the impact of COVID-19 on the psychiatric care environment. Architects have created a preliminary design of a new psychiatric hospital based on these reflections, monthly collaborative design discussions based on virtual mock-ups and evidence-based design based on theoretical concepts and research.

This theoretical and reflective study describes how an inpatient psychiatric environment was restructured to manage infection during COVID-19. The therapeutic environment of the psychiatric ward and patient care changed drastically during COVID-19. The number of patients accessing care decreased, patient autonomy was restricted, and the function of designated behavioral support spaces changed to manage the risk of infection. However, these challenging times have provided an opportunity to reflect on theories and consider the design of new hospital environments that can be adapted in response to future pandemics or be restructured for different care functions.

The pediatric intensive care unit (PICU) is an environment where seriously ill children receive complex care, delivered mostly by specialty-trained nurses (registered nurses [RNs]) who must perform multiple high-level tasks. With stressors on healthcare systems at an all-time high, design that optimizes RN workflow has taken on a renewed imperative.

To employ a multimodal approach (1) to identify environmental factors in the PICU patient room that contribute to caregiver workflow inefficiencies, (2) to optimize safety by identifying high-touch surfaces that cause hospital-acquired infections, (3) to develop human-centered design recommendations.

This mixed-method case study was conducted in a 23-bed urban hospital PICU. The activities, movements, and workflows of 13 RNs were recorded using spatial movement mapping, behavioral mapping, and clinical activity mapping. Frequency of RN contact with surfaces was documented to assess relative infection transmission risk. Face-to-face interviews were conducted with RNs to elicit their views on care delivery and their physical work environment.

Direct patient care occupied 50% of RNs’ time. Of the direct patient care workflow activities recorded, 26% were to prepare for care around the bedside, while 27% were for random travel between clean and soiled areas. The surfaces most frequently touched were (1) patient bedrails, (2) intravenous pumps and poles, (3) tubing and medical equipment, and (4) vital sign monitors.

Value-added tasks account for only about 20% of nurses’ work. Combining technology and strategic interior design to streamline workflow and enhance infection prevention optimizes efficiency and empowers frontline providers to maximize their time at the bedside performing value-added tasks.

This study checked the effects of landscape types and complexity along path in urban green spaces on perceived restorativeness, so as to provide guidance for path landscape design.

Paths in urban green spaces are not only the connections between places but also places for visitors reducing mental stress and seeking psychological well-being. However, there is a lack of evidence-based research on the effects of landscape composition along the path on restorative quality, failing to provide a cohesive guideline for practice.

Fourteen videos representing the popular path landscapes in urban green spaces were produced using computer software by adding or/and deleting elements and controlling environmental components. The restorative quality of these videos was measured by Short-version Revised Restoration Scale (SRRS). Statistical analysis was employed to treat the data and checked the effects of different landscape types and complexity on restorative quality.

(1) A significant difference in restorative quality between 14 path landscapes was found, comparatively, the path containing lawn or(and) forest was much better than that containing bamboo and waterscape, and bamboo was a negative predictor of restorative quality; (2) waterscape generally reduced the restorative quality of vegetated path landscape, especially when the landscape possessed higher restorative quality; (3) path landscape complexity had a weak influence on restorative quality.

This study explains how path landscapes affect mental restoration of users, and these findings contribute to enhancing the restorative quality of urban green spaces and have applications for path landscape design.