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Original Paper
I
Indoor
and
and B
uilt
uilt
Environment
Healing environment correlated with
patients’ psychological comfort:
Post-occupancy evaluation of
general hospitals
Fouad Jalal Mahmood and Abdullah Yosif Tayib
Abstract
Modern hospital indoor environment aims at fulfilling the psychological needs and preferences of the
people who use it. Nowadays, physical and non-physical and healing environments are perceived as
potential contributors to recovery processes. Unlike curing, healing relates to aspects of health that are
psychological and spiritual. This study aims at tracing the relationship between the qualitative level of
the healing environment and patients’ psychological comfort. Therefore, a 43-item questionnaire was
distributed among 148 respondents to obtain patients’ opinion; a total of 117 valid questionnaires were
received. The results showed that the quality of the healing environment can be considerably related to
the fulfilment of patients’ satisfaction. The patients at tested hospitals were generally satisfied with their
healing environments. The findings revealed four crucial factors, Interior appearance,Comfort and
control,Views and Privacy, to create a satisfying healing environment. A negative correlation between
demographic information, such as age and education, and patient satisfaction was revealed.
Additionally, this study suggests that post-occupancy evaluation is a relevant tool for evaluating the
quality of indoor environment and a useful technique to inform designers that variations in the indoor
physical design may positively influence the patients’ level of satisfaction.
Keywords
Indoor environment, Healing environment, Psychological comfort, Interior design, Hospital wards, POE
Accepted: 21 October 2019
Introduction
In the last couple of decades, modern hospital design
has considered medical staff’s needs, health technology
requirements and new movements in medical care, pro-
viding a patient with medical care in best possible ways.
Psychological needs (safety, love and belonging, esteem
and comfort) are considered one of the basic human
needs. Studies show that some indoor physical elements
of a hospital can influence the wellbeing of patients and
their families.
1–3
The presence or absence of any ele-
ments of physical environment may positively or neg-
atively affect the psychological state (mood and stress
levels) of a person, and this may be manifested in the
form of actions or behaviours. Nowadays, healthcare
facilities are considered among the most complex
institutional constructions, regarding not only compli-
cated medical supplies but also some subtle concerns,
like the psychological requirements of users.
4,5
An increasing number of evidences exist showing the
influence of indoor environment on curing. Ulrich
6
set
up controlled experiments in a health centre proving
Department of Architecture Engineering, College of
Engineering, University of Sulaimani, Sulaimani, Kurdistan,
Iraq
Corresponding author:
Fouad Jalal Mahmood, Department of Architecture
Engineering, College of Engineering, University of Sulaimani,
Sulaimani, Kurdistan, Iraq.
Email: fouad.mahmood@univsul.edu.iq
Indoor and Built Environment
0(0) 1–15
!The Author(s) 2019
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DOI: 10.1177/1420326X19888005
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that patients recovered from surgical treatment more
quickly and took fewer pain relievers when they could
see a view through a window, rather than merely
having bare walls. The conditions of hospital setting
design that promote the development of a patient’s
health and wellbeing should include safety, ergonom-
ics, colour, artwork, appropriate lighting, external
good view, adequate furniture and a homely environ-
ment.
7–11
Studies point out that if the healthcare
design is changed more in accordance with patients’
psychological needs, it will positively affect the
outcomes for patients, improving healing and decreas-
ing the length of stay at hospitals. This has resulted in a
new perspective called the salutogenic perspective.
2,12,13
According to Dilani,
14
salutogenic perspective
focuses on the following factors: (i) social support;
(ii) user’s control in regulating daylight, artificial and
soft lighting, ambient temperature and sound; (iii) quiet
and private accommodation and (iv) a nice view with
access to nature. Along with salutogenic perspective,
Ulrich introduced the theory of supportive design,
15
which included elements such as perception of control,
social support and positive distraction, emphasizing the
importance of creating indoor environments that
encourage healing. Both these theories consider some
indoor environment aspects of patient’s treatment,
such as thermal comfort, privacy, lighting, social sup-
port and view of nature; however, they differ in pro-
viding positive distractions in the hospital, especially
the company of animals and space for mild exer-
cise.
14,15
Both salutogenic perspective and theory of
supportive design have an important role in creating
healing environments. Therefore, healing environment
not only provides medical treatment to patients but
also ensures the fulfilment of patients’ physical, psycho-
logical, spiritual and social needs.
16,17
The healing environment takes into consideration
the provision of privacy, thermal comfort, air quality,
colours, daylight and access to nature, view of nature,
visual stimulation and serenity, access to social sup-
port, providing green areas and positive distractions.
18
Hence, the integration between these elements creates
an indoor healing environment. However, each of those
elements alone does not create this environment.
19–21
Mostly, the wards catch the public attention, as the
patients spend most of their time in wards. Usually,
patients are weak and vulnerable in wards; they expe-
rience a lesser amount of control upon their setting,
which magnifies the role of a ward’s design on their
wellbeing and the recovery time.
22,23
Post-occupancy evaluation (POE) principally
includes gathering data about users and buildings
using questionnaires, interviews, visiting sites and
field remarks.
24,25
POE evolved out of practices of
architectural programming in the late 1950s and the
beginning of the 1960s in the UK, France, Canada
and the USA.
26
POE is defined by Watson
27
as a reg-
ular assessment of the attitude concerning occupied
constructions from the standpoint of the people using
them. Preiser et al.
28
define POE as ‘the process of
evaluating buildings in a systematic and rigorous
manner after they have been built and occupied
for some time’. Therefore, it is possible to assume
POE as a multidimensional instrument adopted for
problem-solving as well as a method of systematically
collecting data and evaluating buildings and facilities’
performance.
29–31
For POE, user’s needs and requests
are placed at three levels of the main concerns, which
are (i) health, safety and security; (ii) performance and
effectiveness and (iii) psychological comfort and
satisfaction.
32
User satisfaction has different definitions from dif-
ferent standpoints according to the context of the
research.
33,34
It may refer to the relation between the
user’s satisfaction and indoor environment quality
(thermal, visual, acoustic and air quality) in addition
to the place of work and characteristics of the interior
spaces (i.e. size, aesthetic appearance, furniture
and cleanliness).
35
Patient satisfaction is frequently
described as the subjective experience of patients
through their opinions of the healthcare environment.
It reflects the fulfilment of their opinions and expect-
ations of services with the ones that are provided by
the facilities.
36–41
Also, demographic factors, such as
gender, age and educational attainment, affect patient
satisfaction with their indoor environment of the hos-
pital wards and their psychological comfort.
19
The term POE, like a regular approach to data col-
lection on occupied constructions, does not have exten-
sive usage in relation to healthcare buildings in the
Kurdistan Region of Iraq.
31
There is a shortage of
existing research to recommend evidence-based design
guidelines for the provision of psychosocially support-
ive space within general hospitals. This article high-
lights the difficulties to overcome this knowledge
deficit, and those are the specific needs for this study.
This study emphasizes the evaluation of the wards in
the hospitals as groups of single and multiple beds in
rooms for patient accommodation based on the discus-
sions conducted with the senior staff of hospitals.
It seems that POE studies were never applied on the
wards at Sulaimani general hospitals. Accordingly, this
study aims at bridging this research gap. The key aim
of this study is to investigate patients’ level of satisfac-
tion with the quality of indoor environment of the
hospital wards to understand how patients experience
room space (physical environment). The second objec-
tive is to develop a questionnaire that evaluates and
represents inpatients’ expectations of the hospital
wards’ interior design process.
2Indoor and Built Environment 0(0)
The analysis was based on survey responses gathered
directly from patients in two hospital wards. The criteria
and qualifications, however, sometimes did not comply
with changeable requirements and anticipations of
patients due to various factors, such as culture, religion
and education. Sociocultural perspectives differentially
affect how people react to elements in the physical envi-
ronment.
42
In Kurdish culture, privacy is important,
especially for women who have higher expectation of
privacy than men, similar to other religious societies.
The beauty of Kurdish interior designs is enriched by
the use of variety in colours, natural textures and local
materials (brick, stone and wood); artwork and relations
to nature. Moreover, the society is strengthened by the
spirit of healing one another, strong family relations and
solid familial fabric, social interaction and higher con-
tinuum of collective values compared to individualism.
43
Thus, the findings of this study provide insights on how
inpatients in the Kurdistan Region of Iraq perceive their
indoor environment. The importance of this study lies in
determining the shortages that may affect the interior
design of wards that can make them more supportive.
The findings would contribute to current information
about the perceived satisfaction of inpatients at health-
care facilities.
Research method
This study was based on patient’s surveys adopting the
methodological steps to accomplish the research objec-
tives. To have a hospital environment that can function
at its best, design evaluation toolkits for healthcare
facilities were specifically promoted worldwide.
17
Questionnaire surveys, personal visits to sites and
observation of the wards were added to the toolkits’
evaluations. Before visiting the site, consents were taken
from hospitals’ directors, recognized via formal
applications. Given primary briefings about the hospitals’
arrangement, representatives from the hospitals came for
the site visits offering answers to spontaneous general
questions while exploring the wards’ physical setting.
Case studies
This research used a multiple case study approach to
assess two general hospitals in Sulaimani City, Iraq.
The hospital wards selected for the research included
Educational General Hospital (EGH) (renovated in
2005) and Shar General Hospital (SGH) (constructed
in 2013). The two hospitals were chosen for the study
because of their differences (newly built versus renovat-
ed). The first hospital (EGH) is in New Sulaimani
District on the Qanat road of Sulaimani City and was
built on 4400 square metres and accommodates 320
patient beds, including 12 operating rooms, one ICU
with 6 beds. The indoor environment was designed in a
way that enables all patients and their relatives to easily
access various areas of the hospital as shown in Figure 1.
The second hospital, SGH, is located on the Malik
Mahmood Circle road, Kurdsat District, Sulaimani
City. It is a General Hospital that provides healthcare
for all specialties and consists of 400 beds, 12 ICU units
and 23 operating suites, Figure 2. The hospital’s policy
is to provide the best care possible for patients and
their families. Therefore, great attention is paid to
every detail, not only to the medical treatment but
also to the patient’s psychological health, Table 1.
Questionnaire surveys
Questionnaire surveys have been identified as an
important element of any building functioning assess-
ment research, and POE studies are the most significant
part of any study of building assessment as the con-
structions that do not fulfil the needs of the occupants
Figure 1. Educational General Hospital EGH patients’ room.
Mahmood and Tayib 3
cannot be judged to function in a good way, even if the
physical criteria of those buildings are found to be sat-
isfying.
44,45
The approach of gathering information
implemented the assessment of the physical environs
using UK’s NHS AEDET Evolution (Achieving
Excellence Design Evaluation Toolkit),
46
which repre-
sents a significant development of the original AEDET
tool, and questionnaire adapted from ASPECT (A
Staff and Patient Environment Calibration Toolkit),
47
as POE tools make the users capable of assessing the
design by producing a design evaluation profile. The
questionnaire survey was used due to the nature of
the current study; as a result, two questionnaire surveys
were used.
The first one, The Achieving Excellence Design
Evaluation Toolkit (AEDET),
46
was developed by
The Centre for Healthcare Design. The AEDET
Evolution is a tool to assess the design quality in
healthcare constructions, providing a profile indicating
the strengths and weaknesses of a design or an avail-
able construction.
17
The tool assesses a design through
a sequence of expressions covering the three aspects as
illustrated in Table 2. This tool is especially targeted at
attaining quality in design rather than guaranteeing
conformity with law or regulations, and it has been
designed to be useable by whoever that may deal with
commissioning, producing and the use of healthcare
constructions.
49
This study used AEDET Evolution
in its original form. Therefore, the scale’s range was
kept how it was found in the tool without any change
from ‘Virtually complete Agreement (VcA)’ to
‘Virtually no Agreement (VnA)’. For each assessed sec-
tion, three choices were presented, the options were
zero (0) weight for the statements that were not rele-
vant to the study topic, which were excluded from the
calculation, one (normal) weight for pertinent state-
ments and using a two (high) weight for the most sig-
nificant factors. The researcher decided which option to
choose according to the study topic and the availability
of a similar item in the second questionnaire, which was
important for finding the relationship between the
quality of physical environment and patients’ level of
satisfaction regarding similar items. For discussion, the
analysed scores were classified in this way: a maximum
score of 6 points as VcA, score of 5 points as Strong
Agreement (SA), score of 4 points as Fair Agreement
(FA), score of 3 points as Little Agreement (LA), score
of 2 points as Hardly any Agreement (HaA) and score
of 1 point as VnA. AEDET Evolution had three main
sections: impact, build quality and functionality, which
were split into 10 assessment sections. Scoring these
sections helped in assessing how well a healthcare
building complied with best practices. This study
involved the analysis of three sections (Staff and
Figure 2. Shar General Hospital (SGH) patients’ room.
Table 1. Information about the selected hospitals.
Hospitals Type
Building area
in m
2
No. of
floors
Multi-bed rooms Single-bed rooms
No. of
rooms
No. of beds
in room
No. of
rooms
No. of beds
in room
Education General Hospital General 9783 3 33 8 – –
Shar General Hospital General 50,507 6 74 2–6 63 1
4Indoor and Built Environment 0(0)
Patient Environment, Performance and Space).
The rest of the seven sections, were Character and
innovation, Form and Materials, Urban and Social
Integration, Engineering, Construction, Use and
External Access were excluded because they did not
deal with the evaluation of the physical elements of
indoor environment.
46
The second questionnaire for patients at the hospital
wards was developed specifically for this study. The
questionnaire comprised of a set of questions identified
based on a Staff and Patient Environment Calibration
Tool (ASPECT), which was designed by the British
Healthcare Design Centre based on a database with
data from over 600 studies. This has been used by the
UK’s NHS since 2008 to assess the influence of health-
care indoor physical environment on staff and patient
satisfaction and patients’ recovery.
47
Based on UK’s
NHS ASPECT tool and healing environment theories
(salutogenic perspective and supportive design), the
questionnaire contained several indoor elements and
features influencing the psychological comfort of
the patients summarized in six factors with grouped
sub-factors, that is, Privacy,Views,Comfort and con-
trol,Interior appearance,Family support and
Facilities.
14,15,47,50–54
This questionnaire was divided
into two main sections. The first section consisted of
demographic information, such as age and gender of
patients. In the second section, which was the main
feature of the questionnaire, patients were asked to
rate their level of satisfaction with the ward environ-
ment features on a five-point Likert scale ranging from
‘very dissatisfied’ to ‘very satisfied’. This section of the
survey included 43 questions regarding hospital ward.
The first group of questions (five questions) focused on
patients’ privacy. The second group (six questions) was
related to the views (availability of adequate windows
Table 2. A scoring layer of included sections of the AEDET Evolution toolkit.
46,48
Aspect Section Focuses on
1. Impact Staff and
patient
environment
-Privacy and dignity of patient and staff (patients should be able to have private con-
versations and to be alone if they wish, and it should be easy for them to find a
company and to be with others).
-Internal and external good views (rooms where patients or staffs spend significant
amounts of time should have windows which afford good, pleasant and interesting
views).
-Good outdoor access.
-Control of comfort (the temperature should be comfortable all year round and be
capable of easy local control. Patients and staff should be able to exclude sunlight and
darken spaces when patients wish to sleep. Artificial light should be easily controllable
offering patterns suitable for day and night and for winter and summer. The windows
and doors should be easily opened for fresh air. The places should be quiet and free
from noise).
-Attractive interior (Spaces where patients spend significant amounts of time should be a
stimulating variety of appropriate colours and textures. Ceilings should look inter-
esting especially where patients are likely to be on beds.
-Good facilities for patients & staff (Places for religious observance and live performances
are important. They should have the option of a relative/friend being able to stay
overnight and to make drinks.
2. Building
quality
Performance
-Building technical performance.
-Easy to clean (surfaces should have finishes that enable simple and quick methods of
cleaning especially those that require to be clean for clinical reasons. Access to win-
dows for cleaning both externally and internally should be as easy as possible given the
nature of the building).
-Durability of finishing materials (The materials should be able to last for their predicted
lifespans. These lifespans should be as long as possible).
3. Functionality Space
-The amount of space in the building in relation to its purpose (all general spaces must be
adequate to meet normal demand comfortably and peak demand at least adequately).
-Minimizing circulation distances.
-Gender segregation.
-Adequate storage space (Storage needs to be adjacent to places where it will be needed
to ensure items are appropriately stored in actual use. The design should avoid creating
storage spaces which can easily be eliminated).
Mahmood and Tayib 5
with a view of nature). The third group (10 questions)
was associated with the patient’s comfort and control
(accessibility to control lighting, temperature, minimiz-
ing unwanted noise and closing/opening windows). The
fourth group (fourteen questions) was designed to cap-
ture patients’ experience with the interior design ele-
ments of the ward (safety and security, feeling at
home, colours, art, plants and furniture). The next
group (three questions) dealt with the patients’ social
supports. Finally, the last group of questions (eight
questions) assessed patient satisfaction regarding
ward facilities. Overall, groups and questions were
important elements of the satisfaction index in the eval-
uation of patients’ psychological comfort.
Respondents were selected at random to participate
in the questionnaire. The participation was voluntary
and they were informed that the confidentiality of data
would be maintained. The length, structure and design
of the questionnaire were short and straightforward so
that respondents could complete it easily without any
fatigue. This significantly motivated and encouraged
the respondents to participate in the survey and
indirectly increased the response rate. A total of 148
questionnaires were distributed and 117 valid question-
naires signifying around 79% of the distributed ques-
tionnaires were retrieved. Thus, the results of this study
were based on 117 responses from patients at the wards
of the two hospitals as shown in Table 3.
Statistical analysis
Descriptive analysis was conducted on the results of
questionnaires distributed to patients of the two gener-
al hospitals in Sulaimani City as mentioned in Table 3.
The analysis was performed by applying the statistical
software program IBM SPSS (Statistical Package for
Social Sciences, version 22) to scrutinize the data and
find the percentage and Mean Satisfaction Score
(MSS). The last part demonstrated the correlational
analysis between (1) the quality of the indoor environ-
ment of hospital wards and patients’ level of satisfac-
tion and (2) between psychological comfort factors and
patients’ level of satisfaction at the wards. The last cor-
relation was between patient demographic information
and their level of satisfaction according to the
statements contained within the evaluation tools of
the two hospitals.
Results
The AEDET tool sections and the questionnaire were
explained to ensure that the patients understood the
questions involved before filling out the questionnaires.
The results were derived from questionnaires (evalua-
tion toolkits) that were distributed to the patients of the
targeted general hospitals, Table 1. The responses were
used to develop and offer this study’s definite results
and conclusions.
Personal characteristics of the
respondents
The analysis of the Personal characteristics of respond-
ents as shown in Table 4 includes gender, age, educa-
tional attainment and duration of stay. The result of
this survey showed that majority of respondents were
men 53.8%, while 46.2% were women. Of this propor-
tion, 49.6% of respondents were between 18 and
30 years of age against 33.3% of respondents who
were between 31 and 45 years of age. Regarding the
educational attainment, 41% of respondents had sec-
ondary education, while 35% of them had BSc
Degrees, 6.9% had MSc degrees or higher and 17.1%
of the respondents had less than primary education.
The results also revealed that a large number 63.2%
of respondents stayed in the ward less than three days,
while 22.3% stayed between four and seven days and
14.5% of the respondents stayed more than eight days.
Results of AEDET Evolution
On the basis of AEDET Evolution, evaluation of the
physical qualities of the three wards is summarized in
Tables 5 and 6 and Figure 3.
Patient environment. This section included Privacy
for the patient, Internal and external views, Control of
Comfort, Attractive interior and Good facilities for
patients. The results showed that majority of respond-
ents, 44.2% and 36%, were virtually in no agreement
with scores (1.10) and (1.02) for items Privacy of patient
Table 3. Hospitals involved based on the year built or renovated and the number of respondents.
Hospitals
Year of built or
*Renovation No. of Beds
Distributed
questionnaires
Respondents
(patients)
Educational General Hospital 2005*R 320 67 52
Shar General Hospital 2013 400 81 65
Total 148 117
6Indoor and Built Environment 0(0)
and Good facilities for patients at EGH, respectively.
Regarding Internal and external views, the majority of
respondents, 36.2%, were virtually in complete agree-
ment with the mean score of 2.40, and 34.5% were
Hardly in Agreement with score of 1.50 for Control of
Comfort, and 35.3% of the respondents were in little
agreement with the mean score of 1.65 at EGH. The
findings of SGH revealed that most respondents,
43.6% with a mean score of 2.15, 55.7% with a mean
of 3.24, 41.6% with a score of 3.75, 63.2% with a mean
of 4.20 and 43.5% of respondents with a mean score of
2.50 were virtually in complete agreement with Privacy,
Internal and external views, Control of Comfort,
Attractive interior and Good facilities for patients,
respectively. This result showed the achievement of the
degree of satisfaction in a newly built hospital in com-
parison to the renovated hospital.
Performance. This section was related to Easy to
clean and Durability of finishing materials. The find-
ings reported that 48.7% of respondents with a score of
3.15 and 45.4% with a mean score of 3.62 were virtu-
ally in complete agreement with Easy to clean and
Durability of finishing materials at EGH. Also, the
Table 4. Demographical information of the respondents.
Item Classification
EGH number of
respondents (n ¼52)
SGH number of
respondents (n ¼68)
Total number of
respondents (n ¼117)
Frequency Frequency Frequency Per cent
Gender Male 28 35 63 53.8
Female 24 30 54 46.2
Total 117 100
Age (years) 18–30 27 31 58 49.6
31–45 18 21 39 33.3
46–59 10 6 16 13.7
>60 1 3 4 3.4
Total 117 100
Educational attainment Less than primary 12 8 20 17.1
Secondary 26 22 48 41
BSc 19 22 41 35
MSc and above 2 6 8 6.9
Total 117 100
Duration of stay 3 Days or less 31 43 74 63.2
4–7 days 14 12 26 22.3
8 Days or more 3 14 17 14.5
Total 117 100
Source: Fieldwork (2018).
Table 5. Results of the AEDET for Educational general hospital (EGH).
Section AEDET-related item (indoor attributes)
Response (%)
Mean
1 2 3456
VnA HaA LA FA SA VcA
Patient environment Privacy of patient 44.2 39.2 9.2 5.1 2.3 0 1.10
Internal and external good views 2.5 7.2 10.7 14.2 29.2 36.2 2.40
Control of comfort 12.1 34.5 26.4 11.4 7.6 8 1.50
Attractive interior 9.3 16.5 35.3 10.1 14.2 14.6 1.65
Good facilities for patients 36 32.4 12.6 8.1 10.9 0 1.02
Performance Easy to clean 0 4.7 6.2 11.6 28.8 48.7 3.15
Durability of finishing materials 0 4.5 9.2 10.2 30.7 45.4 3.62
Space The amount of space in relation to its purpose 18 42.2 23.2 7.7 8.9 0 1.41
Adequate storage space 16.1 28.3 14.6 20.2 16.2 4.6 1.72
VnA: virtually no agreement; HaA: hardly any agreement; LA: little agreement; FA: fair agreement; SA: strong agreement; VcA: virtually
complete agreement.
Mahmood and Tayib 7
results showed that majority of respondents, 74.6%,
with a mean score of 4.10 were virtually in complete
agreement with Easy to clean an item, while 42.1% of
them were in strong agreement with a mean score of
3.53 for Durability of finishing materials at SGH. This
finding displayed developments in indoor environmen-
tal quality in the newly built hospital.
Space. This section was associated with the Amount
of space and Adequate storage space. The space section
revealed that 42.2% and 28.3% of the respondents with
a mean score of 1.41 and 1.72, respectively, were hardly
in Agreement with this section at EGH. Furthermore,
findings indicated that 28.2% were virtually in com-
plete agreement with a mean score of 3.55 with
Amount of space, although 39.2% of respondents
with a mean score of 3.21 were in Strong Agreement
regarding Adequate storage space at SGH. This result
reflected the effect of achieving a new design for the
hospital on the quality of the indoor environment.
Satisfaction levels of respondents
In general, patients from the newly built hospital
(SGH) were more satisfied than patients in the reno-
vated one (EGH) in terms of the quality of the indoor
environment. Analysis was conducted to assess inpa-
tient’s level of satisfaction with the two hospitals’
wards, and the results are summarized in Figure 4,
where the patients’ level of satisfaction are as follows.
Privacy. The factor included single-bed accommoda-
tion, visual privacy, private conversation, isolation from
others and close relation gathering. The results showed an
increase in the mean score from dissatisfied (2.15) at EGH
to a recorded mean score of neutral (2.90) at SGH. This
result indicated the need to enhance the privacy factor by
using only single-bed rooms in the newer hospital.
Views. This factor was associated with having win-
dows, seeing the sky and the ground, calming and
Table 6. Results of the AEDET for Shar general hospital (SGH).
Section AEDET-related item (indoor attributes)
Response (%)
Mean
1 2 3456
VnA HaA LA FA SA VcA
Patient environment Privacy of patient 0 0 8.7 18.6 29.1 43.6 2.15
Internal and external good views 0 2.7 7.2 9.1 25.3 55.7 3.24
Control of comfort 5.8 4.9 1.5 8.6 37.6 41.6 3.75
Attractive interior 0 0 5.8 9.5 21.5 63.2 4.20
Good facilities for patients 0 0 9.8 17.8 28.9 43.5 2.50
Performance Easy to clean 0 0 0 4.1 21.3 74.6 4.10
Durability of finishing materials 0 0 0 18.3 42.1 39.6 3.53
Space The amount of space in relation to its purpose 1.2 13.2 9.4 21.6 26.4 28.2 3.55
Adequate storage space 0 0 10 14.9 39.2 35.9 3.21
VnA: virtually no agreement; HaA: hardly any agreement; LA: little agreement; FA: fair agreement; SA: strong agreement; VcA: virtually
complete agreement.
Figure 3. The AEDET analysis – Summary of finding for the two hospitals.
EGH: Educational General Hospital; SGH: Shar General Hospital.
8Indoor and Built Environment 0(0)
interesting outside, availability of plant and nature.
There was a significant change in the recorded mean
score from dissatisfied (2.29) at EGH to neutral (3.27)
at SGH. The result revealed that the designers were
aware of this point, and the view of the newer hospital
recorded a better level of satisfaction.
Comfort and control. These factors were related to
proximity to nursing, cleaning, excluding sunlight, con-
trolling and variety of lighting, temperature, minimiz-
ing noise, positive sound and odour. The results
showed a slight increase in the mean score from dissat-
isfied 2.46 at EGH to satisfactory with a mean score of
4.02 at SGH. This significant change indicates the role
of comfort level in creating a satisfying indoor environ-
ment in the hospital ward.
Interior appearance. This section included safety and
security, falling, feeling at home, variety of colours,
suitable covering, adequate and pleasant furniture
and comfortable seating. The section increased from
dissatisfied with a mean score of 2.06 at EGH to satis-
factory with a mean score of 4.17 at SGH. This result
revealed an enhancement in the interior appearance at
the newer hospital that used different colours and fin-
ishing materials.
Family support. This factor comprised of easy access,
adequate accommodation and seating area for visitors.
This section increased slightly from dissatisfied with
mean scores of 2.40 at EGH to neutral with mean
scores of 2.85 at SGH, which showed the possibility
of improving the quality of the indoor environment
by providing adequate area for seating and accommo-
dation and variety in colours.
Facilities. This factor was characterized as having an
easy table, a place to make a drink, a space for religious
and entertainment purposes and facilities for relatives
to stay. Lower changes were seen in the facilities factor
that increased slightly from very dissatisfied with a
mean score of 1.66 in EGH to a mean score of 1.80
of SGH, which reflected the influence of the facility in
achieving patient satisfaction at the hospital wards.
The patient satisfaction audit illustrated that a major-
ity of patients were satisfied with the quality of the
indoor environment, followed by very satisfied with
44%atSGH,8%atEGHandneutralwith28%at
SGH and 4% at EGH. Surprisingly, the dissatisfied
and very dissatisfied to be rated as the lowest at SGH
were 1% and 0%, respectively, as illustrated in Figure 5.
The findings also revealed that male patients were
more satisfied than females in general; they had a mean
score of 2.80 for privacy, 3.22 for views,3.56forcomfort
and control,3.67forinterior appearance,2.72forfamily
support and 1.79 for facilities,asshowninTable7.While
female patients had a mean score of 2.30 for privacy,2.38
for views,3.06forcomfort and control,3.25forinterior
appearance,2.56forfamily support and 1.69 for facilities.
Correlation between perceived
indoor environment quality and
patient satisfaction
The fourth analytical section explored the presence of a
relationship between the indoor environment quality,
Figure 4. Patients’ satisfaction means of the factors for the two hospitals.
EGH: Educational General Hospital; SGH: Shar General Hospital.
Mahmood and Tayib 9
factors and demographic information, with the
patients’ level of satisfaction at the two hospital
wards. The correlational analysis was conducted by
applying Kendall’s tau correlation. The significance
value for the correlation of this study was (p<0.01).
The first correlation matrix was between indoor
environment quality and patients’ level of satisfaction.
The correlation test investigated the existence of a
strong relationship between the indoor quality level
and patient satisfaction at the hospitals as demonstrat-
ed in Table 8. The findings revealed strong positive
correlation with Attractive interior (r ¼0.802,
p¼0.01), Internal and External views (r ¼0.732,
p¼0.01), the Amount of space (r ¼0.675, p¼0.01),
Easy to clean (r ¼0.637, p¼0.01) and Control of com-
fort (r ¼0.631, p¼0.01) at hospital wards.
Furthermore, a positively moderate correlation was
found with Adequate storage space (r ¼0.445,
p¼0.01) and Good facilities (r ¼0.438, p¼0.01).
Privacy of patient recorded positively weak correlation
(r ¼0.012, p¼0.01) and negatively weak correlation
regarding Durability of finishing (r ¼0.247, p¼0.01)
with patients’ level of satisfaction at hospital wards.
These findings showed that the patients were satisfied
with most of the items of indoor environment quality
and explained that the better indoor quality, the higher
the level of patient satisfaction.
The second correlation matrix was between the six
substantial factors, Privacy,Views, Comfort and control,
Interior Appearance, Family Support and Facilities,with
patients’ level of satisfaction, shown in Table 9. There
was a positive significant correlation between Interior
Appearance (r ¼0.817, p¼0.01), comfort and control
(r ¼0.732, p¼0.01), Views (r ¼0.618, p¼0.01) and
Privacy (r ¼0.577, p¼0.01), in relationship with overall
patient satisfaction. The correlation for Facilities factor
demonstrated a positive moderate correlation (r ¼0.353,
p¼0.01) at hospital wards. Hence, the results indicated
that the patients were strongly satisfied with the four
factors, and the patients’ psychological comfort
increased when they were strongly satisfied with the
Interior Appearance,Comfort and control,Views and
Privacy at the hospital wards.
The third correlation matrix was between demo-
graphic information and patient satisfaction as illus-
trated in Table 10. The findings showed a significant
negative correlation (r ¼0.281, p¼0.01) between
educational attainment of the patients and their overall
level of satisfaction and negatively low (r ¼0.277,
p¼0.01) in relation with patients’ age. However, the
result did not find any relationship between patients’
overall level of satisfaction and duration of stay at
wards. An overall correlation indicated a more negative
trend. In other words, the patient satisfaction decreased
when the patients were older and their educational
attainment higher.
Findings and discussion
Considering the difficulty of collecting data from
patients, the questionnaire items were written in both
Figure 5. Patients’ satisfaction to overall indoor environment quality at the wards.
EGH: Educational General Hospital; SGH: Shar General Hospital.
Table 7. Patients’ satisfaction level according to gender.
Factors
Mean
Male Female
Privacy 2.80 2.30
Views 3.22 2.38
Comfort and control 3.56 3.06
Interior appearance 3.67 3.25
Family support 2.72 2.56
Facilities 1.79 1.69
10 Indoor and Built Environment 0(0)
English and Kurdish language, and necessary instruc-
tions and explanation were given to participants who
were unfamiliar with this type of evaluation tools. The
procedure took more time and the ratio of retrieved
questionnaires was influenced. In perspective of the
study’s key objective, it can be concluded that the
users’ psychological comfort level relied on the quality
of the healing environment within hospital wards. The
study findings revealed the feasibility of POE as an
assessment tool in evaluating the physical qualities of
the building, including healthcare facilities, and it was
possible to explore users’ perception of the factors in
their psychological comfort in order to stimulate best
practices for the designers to create an indoor healing
environment. This result was in line with the findings of
the previous studies.
17,29,31,48,55
The study also indicated that respondents were gen-
erally satisfied with the indoor environment quality of
the newly built hospital as compared to that of the
renovated one. They suggested that the interior appear-
ance of the hospital wards met their psychological
aspects and expectations. In general, the wards’
design quality saw huge enhancements in all sections
within the newly built hospital SGH compared to that
of the EGH. The most remarkable progress was in the
Interior appearance that increased from No Agreement
Table 8. Correlation between the indoor environment quality and patients’ satisfaction for the two hospitals.
Overall
satisfaction
Privacy of
patient
Internal and
external views
Control of
comfort
Attractive
interior
Good
facilities
Easy to
clean
Durability
of finishing
The amount
of space
Adequate
storage
space
Overall satisfaction 1 0.012
a
0.732
a
0.631
a
0.802
a
0.438
a
0.637
a
0.247
a
0.675
a
0.445
a
Privacy of patient 0.012
a
1 0.245
a
0.351
a
0.111 0.234
b
0.361
a
0.259
a
0.115 0.321
a
Internal and external views 0.732
a
0.245
a
1 0.125 0.326
a
0.425
a
0.231
a
0.221 0.124 0.352
a
Control of comfort 0.631
a
0.351
a
0.125 1 0.238
a
0.216
a
0.128 0.238 0.346
b
0.361
a
Attractive interior 0.802
a
0.111 0.326
a
0.238
a
1 0.329
a
0.235
a
0.195 0.213
a
0.125
Good facilities 0.438
a
0.234
b
0.425
a
0.216
a
0.329
a
1 0.425
a
0.125 0.265
a
0.212
a
Easy to clean 0.637
a
0.361
a
0.231
a
0.128 0.235
a
0.425
a
10.321
a
0.256
a
0.135
Durability of finishing 0.247
a
0.259 0.221 0.238 0.195 0.125 0.321
a
10.135 0.274
The amount of space 0.675
a
0.115
a
0.124 0.346
b
0.213
a
0.265
a
0.256
a
0.135 1 0.214
a
Adequate storage space 0.445
a
0.321
a
0.352
a
0.361
a
0.125 0.212
a
0.135 0.274 0.214
a
1
a
Correlation is significant at the 0.01 level (2-tailed).
b
Correlation is significant at the 0.05 level (2-tailed).
Table 9. Correlation between the factors and patients’ satisfaction for the two hospitals.
Correlation matrix
Overall
Satisfaction Privacy Views
Comfort and
control
Interior
appearance
Family
support Facilities
Overall satisfaction 1 0.577
a
0.618
a
0.732
a
0.817
a
0.198
a
0.353
a
Privacy 0.577
a
1 0.595
a
0.483
a
0.481
a
0.120 0.317
a
Views 0.618
a
0.595
a
1 0.533
a
0.514
a
0.148
b
0.389
a
Comfort and control 0.73
a
0.483
a
0.533
a
1 0.619
a
0.051 0.293
a
Interior appearance 0.817
a
0.481
a
0.514
a
0.619
a
1 0.200
a
0.282
a
Family support 0.198
a
0.120 0.148
b
0.051 0.200
a
1 0.144
b
Facilities 0.353
a
0.317
a
0.389
a
0.293
a
0.282
a
0.144
b
1
a
Correlation is significant at the 0.01 level (2-tailed).
b
Correlation is significant at the 0.05 level (2-tailed).
Table 10. Correlation between demographic information and patients’ satisfaction for the two hospitals.
Correlation matrix Overall Satisfaction Patient age Educational attainment Duration of stay
Overall satisfaction 1 0.277
a
0.281
a
0.00
Patient age 0.277
a
1 0.159 0.155
Educational attainment 0.281
a
0.159 1 0.085
Duration of stay 0.00 0.155 0.085 1
a
Correlation is significant at the 0.01 level (2-tailed).
Mahmood and Tayib 11
at EGH to Strong Agreement at SGH. In other words,
it appears that the architects and interior designers
were aware of the findings of previous studies and the
new trends in healthcare interior designs and used
updated theories and new finishing materials to
enhance the quality of the indoor environment. This
result appeared to be in support of studies,
16,53,56
which found that the users of the newly built hospital
were most satisfied with the indoor environment qual-
ity of the facilities.
When comparing the patients’ level of satisfaction in
the two hospitals, the study found strong differences in
Views,Comfort and Control and Interior appearance
factors and slightly different values for the rest of the
factors (Figure 4). Therefore, the patients at SGH were
more satisfied than patients at EGH, given the reason
that great attention was paid to the interior design at
SGH, and the hospital had more single-bed accommo-
dation than the other hospital, which provided
Comfort and Control like home. Also, to reduce lone-
liness, single-bed rooms should be designed to allow
patients to visit communal areas where they have
access to a stimulating environment that includes, for
example, books, games and computers and can experi-
ence social interactions. Among the indoor environ-
ment quality items correlated with patient satisfaction
at hospital wards (Table 8), Attractive interior had a
strong positive relationship (r ¼0.802), followed by
Internal & external views (r ¼0.732), The amount of
space (r ¼0.675), then Easy to clean and Control of
comfort with strong positive correlation (r ¼0.637)
and (r ¼0.631), respectively. These findings suggested
that inpatients were more concerned about indoor
environmental items (Attractive interior and Internal
and external views) than the Space item (The amount
of space) and Performance item (Easy to clean).
The findings reported that when patients were rating
the six factors, they considered four factors to be more
important than the others for achieving their psycho-
logical comfort (Table 9). Overall, Interior appearance
was considered to be the most important factor in
having a significant positive correlation (r ¼0.817)
with overall patient satisfaction. This may be due to
Kurdish patients’ sociocultural nature, which is char-
acterized by precise senses of beauty (a strong relation-
ship to nature, artwork and use of different colours).
The role of interior design in patient satisfaction has
been indicated in many studies.
1,15,52
Comfort and con-
trol was ranked as the second most important factor
with a significant positive correlation (r ¼0.732) with
overall patient satisfaction. The effect of this factor on
patients was conducted in some studies.
31,33,34,52
Then,
Views was rated as the third most important factor with
a significant positive correlation (r ¼0.618) with overall
patient satisfaction. The role of views in increasing the
level of satisfaction in patients has been conducted in
some studies.
15,19,50,51
Privacy was rated as the fourth
most important factor with the significant positive cor-
relation (r ¼0.577) with overall patient satisfaction.
This result was, to some extent, expected, as previous
studies
50–52,57
suggested a generally positive effect of
privacy in raising the level of satisfaction in patients
at hospital wards.
This study did not find significant differences in
patient satisfaction between male and female when
considering gender variables. In general, the male
patients were more satisfied than female patients for
privacy factors (2.80 vs. 2.30). This may be due to the
cultural preference of Kurdish women, as women have
a higher expectation for privacy than men. In other
words, women expected more isolation from strangers
in a healing environment. However, this difference is
not noticed in the findings of the studies conducted in
some western countries.
19,42,50–52
This is also true for
factors: Views (3.22 vs. 2.38), Comfort and control
(3.56 vs. 3.06) and Interior appearance (3.67 vs. 3.25).
Moreover, the findings from demographic information,
such as age and educational attainment, showed a neg-
ative relationship with overall patient satisfaction. The
significant negative correlation (r ¼0.281, p¼0.01)
was between overall patient satisfaction with educa-
tional attainment; the well-educated patients possibly
expected indoor environments of best quality. This
result was in line with the other studies that reported
that the patients who had a university degree were less
satisfied than the other patients.
58,59
Regarding patient
age (r ¼0.277, p¼0.01), this finding was in accor-
dance with previous studies,
56,59
which showed that
the satisfaction level decreased with the increase in
patients’ age. Although findings of studies conducted
in some western countries explored the link between
longer hospital stays and decrease in patients’ satisfac-
tion level,
60–62
in this study, the results did not find any
relationship between patients’ overall level of satisfac-
tion with the duration of the stay at wards (Table 10).
This may be due to the family support factor that
decreased the effect of a long stay at a hospital on
patients’ overall level of satisfaction, especially in
Kurdish society, strengthened by the spirit of
healing one another, strong family relations and solid
familial fabric, social interaction and higher continuum
of collective values compared to individualism.
This result is in line with a previous study conducted
in Dutch hospital wards, which revealed no correlation
between length of stay and patient satisfaction level.
63
Furthermore, Farmahini Farahani et al.
64
pointed
out that the range of impact of these characteristics
was not equal in all countries. This study confirmed
the existence of a positive correlation, from Kurdish
perspective, between overall patients’ level of
12 Indoor and Built Environment 0(0)
satisfaction and the quality of the indoor environment
at hospital wards.
All people, including engineers, designers, develop-
ers and healthcare facility managers, who are directly
involved in designing healing environment need to be
aware of factors identified in the study. The findings of
this study were limited to assessing two hospitals,
which were constructed and renovated after 2005,
and the wards only. The term POE is still new in the
Kurdistan Region of Iraq, and many building practi-
tioners are still unfamiliar with this approach in eval-
uating building performance. Therefore, this study
introduces this new discipline to the local academic
and professional communities, recommending them
to conduct further studies using POE and its results
as a means to build designs compatible with Kurdish
culture. For future studies, this study suggests the
results of this research be compared with AEDET
data from other hospitals in other countries to validate
these findings. Also, the findings emphasize the neces-
sity for further studies to be conducted in general and,
in particular, in Iraq on factors, such as culture and
considerations included in the questionnaire to confirm
their consistency with the users’ level of satisfaction.
Further studies are important to confirm and validate
these findings in different geographic regions.
Conclusion
In the last couple of decades, a few main theories aimed
to reveal the relation between the healing environment
and the patients’ level of satisfaction to create an
indoor environment that is stress free and helps
patients to not only receive medical care but also cre-
ates a friendly environment without any additional
stress. Using POE tools to identify various psycholog-
ical comfort factors can be crucial to ensure that the
quality of the designed indoor environments would
effectively meet the design goals and satisfy the needs
of the users. This study suggests that six factors play a
role in achieving patients’ psychological comfort at
hospital wards. According to respondents’ perspective,
among these factors, Interior appearance,Comfort and
control,Views and Privacy had the greatest impact on
their level of satisfaction and fit the psychological
aspects and expectations of patients and their families,
resulting in an increased level of satisfaction toward the
indoor environment. Thus, appropriate interior design
along with the tested factors improve patient satisfac-
tion and wards’ performance, leading to an increase
in the quality of the indoor environment not only
for designing new wards but also to develop the
existing hospital wards in Kurdistan Region of Iraq.
Furthermore, a relatively good response rate
indicated that the questionnaire could be used for
extracting inpatients’ views on the importance of inte-
rior design indicators.
According to the results, the overall physical quali-
ties and design of the wards during the last decade
seemed to be positive toward creating a comfortable
healing environment in the hospital wards built in
Kurdistan Region of Iraq. Furthermore, a negative
correlation between demographic characteristics, such
as age and educational attainment, with the overall
patient satisfaction was found. Patients’ experiences
of the physical environment are essential and could
be valuable in the design process when enhancing the
physical environment to attain quality of care at wards.
Consequently, the results of this study would inform
the architects and interior designers to consider the
overall balance between the biological, medical and
psychological needs of patients and provide an
evidence-based design for future healthcare facilities,
considering the role of psychological comfort factors
in improving the quality of healing environment in
ways that would contribute to the future interior
design solution. When designing new wards, designing
components that include natural elements in the phys-
ical environment and permit patients to view the out-
side world should be considered. Moreover, this study’s
findings may familiarize designers with AEDET
Evolution and questionnaire as POEs of indoor envi-
ronments, which, when combined, lead to more
dependable assessments of the indoor healing environ-
ment. A broader disciplinary approach that assimilates
knowledge from environmental psychology and sociol-
ogy with evidence-based design will improve under-
standings of how social spaces are utilized and
appreciated by patients and their families and how
these social provisions contribute to wellbeing.
Authors’ contribution
All authors contributed equally in the preparation of this
article.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Fouad Jalal Mahmood https://orcid.org/0000-0002-2766-
9666
Mahmood and Tayib 13
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