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Evaluating Therapeutic Healthcare Environmental Criteria: Architectural Designers’ Perspectives

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International Journal of Environmental Research and Public Health (IJERPH)
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This study presents architectural designers’ perception of the importance of healthcare environmental criteria in the implementation of user-centered, therapeutic hospital design. Architectural designers with over three years of professional experience (N = 182) in South Korea were surveyed using an empirical questionnaire. The extensive interviews of 15 hospital design experts followed to interpret the survey results and discuss the barriers and suggestions for the successful delivery of therapeutic healthcare design practice. Among the 27 variables selected from the preliminary literature review, factor analyses revealed seven important therapeutic environmental criteria (i.e., management, interior design, spatial quality, service, nature and rest, ambient indoor comfort, and social program and space; χ2 = 1783.088, df = 300, p < 0.001). Analyses of variance revealed the level of importance among these criteria related to respondents’ personal and professional characteristics. Significant differences were found for the variables from the management, interior design, and spatial quality factors in relation to the respondents sex and age. For the successful delivery of therapeutic healthcare design, the design experts highlighted the implementation of evidence-based design practice that integrates local and international knowledge from various hospital users and multi-disciplinary specialists participating in the healthcare design process.
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Int. J. Environ. Res. Public Health 2023, 20, 1540. https://doi.org/10.3390/ijerph20021540 www.mdpi.com/journal/ijerph
Article
Evaluating Therapeutic Healthcare Environmental Criteria:
Architectural Designers’ Perspectives
Minjung Cho
Department of Architecture, Inha University, 100 Inharo, Michuholgu, Incheon 22212, Republic of Korea;
minc@inha.ac.kr
Abstract: This study presents architectural designers’ perception of the importance of healthcare
environmental criteria in the implementation of user-centered, therapeutic hospital design. Archi-
tectural designers with over three years of professional experience (N = 182) in South Korea were
surveyed using an empirical questionnaire. The extensive interviews of 15 hospital design experts
followed to interpret the survey results and discuss the barriers and suggestions for the successful
delivery of therapeutic healthcare design practice. Among the 27 variables selected from the pre-
liminary literature review, factor analyses revealed seven important therapeutic environmental
criteria (i.e., management, interior design, spatial quality, service, nature and rest, ambient indoor
comfort, and social program and space; χ2 = 1783.088, df = 300, p < 0.001). Analyses of variance re-
vealed the level of importance among these criteria related to respondents’ personal and profes-
sional characteristics. Significant differences were found for the variables from the management,
interior design, and spatial quality factors in relation to the respondents sex and age. For the suc-
cessful delivery of therapeutic healthcare design, the design experts highlighted the implementa-
tion of evidence-based design practice that integrates local and international knowledge from var-
ious hospital users and multi-disciplinary specialists participating in the healthcare design pro-
cess.
Keywords: therapeutic healthcare environment; healthcare facility design; architectural designer;
evidence-based healthcare design practice
1. Introduction
1.1. Background
An extensive body of research reports a strong association between physical
healthcare environmental quality and hospital users’ health benefits and well-being [1
7]. Scholars have investigated the elements and attributes of the hospital physical setting
and their physiological and psycho-social impacts on building occupants, which con-
tribute to the therapeutic effects of hospital environments [812]. The essential physical
and psycho-social features of hospitals are studied in relationship to various hospital
inhabitants’ objective and perceptive health outcomes. These environmental features are
interrelated and affect healing [1315]. Substantial scientific evidence has been presented
based on studies of patient and healthcare staff’s post-occupancy experiences (POE),
including those of other hospital inhabitants [16,17]. Such knowledge provides compel-
ling reasons for a user-responsive, evidence-based, healthcare design approach [1820].
Subsequently, a growing number of healthcare design practices have adapted the meth-
ods and processes of user-centric, evidence-based design (EBD) globally [21]. Notwith-
standing the resourceful information that has been accumulated from various hospital
users’ testimonials regarding healing healthcare environments, little is known about the
perception of other stakeholders participating in the decision-making and design pro-
cess. Especially, architectural designers’ perspectives, although playing an essential role
Citation: Cho, M. Evaluating
Therapeutic Healthcare
Environmental Criteria:
Architectural Designers’
Perspectives. Int. J. Environ. Res.
Public Health 2023, 20, 1540.
https://doi.org/10.3390/
ijerph20021540
Academic Editor: Paul B.
Tchounwou
Received: 20 November 2022
Revised: 8 January 2023
Accepted: 12 January 2023
Published: 14 January 2023
Copyright: © 2023 by the author.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license
(https://creativecommons.org/license
s/by/4.0/).
Int. J. Environ. Res. Public Health 2023, 20, 1540 2 of 35
in the implementation of hospital design, are seldom reported concerning crucial envi-
ronmental criteria for the delivery of therapeutic healthcare facilities.
1.2. Healthcare Environmental Attributes and Their Impacts on Hospital Users Healing
Experiences
This literature review examines previous research on the therapeutic healthcare en-
vironment and design in which critical physical and psycho-social environmental attrib-
utes were analyzed in relationship to the key hospital users (i.e., patients, healthcare
staff, and visitors)’ objective and subjective health outcomes and healing perceptions.
1.2.1. Physical Space
Elemental physical attributes are determined during the initial design phases, mak-
ing them difficult to modify afterward. The underlying physical features include spatial
layout, orientation, size, shape, type of room, etc. (e.g., placement and scale of public ar-
ea, access and flow, inpatient/outpatient room, utility and service space, window, etc.)
[9]. The complex arrangement of rooms and movement flows may cause wayfinding and
accessibility problems, raising patients and visitors’ frustration and stress [22,23]. Im-
proper spatial arrangement caused unnecessary trips and flow overlap among hospital
nurses causing delayed treatment, fatigue, and unsatisfactory performance [24,25]. The
layout and shape of patient rooms and corridors that enhance wayfinding, visibility,
safety, access, and efficiency were associated with the healthcare staff’s satisfaction and
work performance in the emergency department [26]. Regarding the size and type of
room, a single-person hospital room had more advantages than a multiple-person occu-
pancy room, in terms of its organizational cost, patient care and management, and ther-
apeutic impacts on patients in terms of privacy, lowered stress, control, lesser infection
risk, and flexibility [27]. A single-family patient room type, compared to the open-bay
room type, improved hospital caregivers’ satisfaction and reduced their stress levels
[28]. A room with a solid wall as opposed to a room with a movable partition provided a
different sense of acoustic and visual privacy for patients in the emergency department
[29]. In an experimental study, the exterior appearance of the hospital building façade
influenced the participants’ judgment on the perceived quality of care and expected
comfort in hospitals [30].
In recent studies, the organizational and structural rigidity of hospital spaces are
pinpointed because of unusually high demands on beds, equipment, and emergency
rooms owing to the global spread of infectious diseases. Flexibility and efficiency of
physical spaces are emphasized to foster adaptation to unexpected emergency situations
[31]; for example, the transformation of empty core, shell spaces, or unfunctional areas to
emergency checkup and treatment spaces, etc. Simultaneously, the physical design of
hospitals needs to provide strategies to create a buffer between wards, a division be-
tween contaminated and uncontaminated areas, and dedicated decontamination spaces
for healthcare workers [32].
1.2.2. Ambient Indoor Comfort
Ambient environmental attributes indicate sensory-evoking features such as light-
ing, noise, temperature, air quality, etc. The ambient environmental quality is empha-
sized, as it influences hospital users’ physiological and psychological reactions including
pain, infection, stress, positive or negative moods, satisfaction, social interaction, work
efficiency, etc. [11,15].
Daylight is a crucial attribute that impacts healthcare environments [33]. Patients
and healthcare staff experiencing daylight reported less depression and anxiety; shorter
average length of stay and improved mood, social interaction, and satisfaction as com-
pared to their counterparts with less daylight exposure [3437]. Noise was paid special
attention, as it affected patients’ negative health-related responses in sleep disruption,
Int. J. Environ. Res. Public Health 2023, 20, 1540 3 of 35
pain perception, cardiovascular response, hospital stay, wound recovery, etc. [38] Un-
wanted noise influenced hospital nurses’ stress, annoyance, miscommunication, im-
paired concentration, risk of errors, etc. [39].
Thermal comfort (i.e., temperature, humidity, air quality and airflow) also impacts
the medical staff’s working conditions, well-being, safety, and health [40]. Comfortable
thermal conditions can assist in stabilizing patients’ moods and improving healing [41].
According to Gola et al. [42], the hospital indoor air quality is associated with various
dimensions including outdoor air and microclimatic factors (temperature, relative hu-
midity, air velocity, air change, etc.), management (heating, ventilation, and air condi-
tioning [HVAC] systems, etc.), design (room dimensions, furniture, finishing materials,
etc.), and human and medical activities (users’ presence, health status, medical activities,
etc.). The indoor air quality (i.e., humidity, air flow and exchange, temperature) is criti-
cal to hospital occupants’ healing because it relates directly or indirectly to discomfort,
occupational disease, and hospital-acquired infection [43].
Especially concerning infection control, recent research has emphasized innovative
ventilation systems catering to different healthcare needs to achieve the desired level of
human comfort and improve the defense capabilities from contaminants [31]. As a solu-
tion, the combination of improved natural ventilation, HVAC systems, personalized
ventilation, and exhaust systems is underscored to enhance the adequate level of indoor
air quality and prevent the air transmission of infectious viruses across the hospital [44].
1.2.3. Interior Design
Interior design features (i.e., furnishing, artwork, color, lighting, materials, etc.) can
improve patients' and visitors’ positive feelings and satisfaction toward the hospital's
physical setting and expected service value and enhance the quality of healthcare work-
ers’ work life [45–47].
According to Chaundhury et al. [48], the suitable arrangement, installation, and
maintenance of furniture and equipment are necessary for healthcare workers’ efficient
and safe handling of patients. Improper furnishing (i.e., bed, chair, toilet, etc.) can in-
crease the potential risk of patients’ falls and fall-related injuries [49]. The interior design
elements such as furniture and finishing in patient rooms were essential parameters to
increase illumination and affect indoor daylight performance [50]. In an experimental
study, participants responded that the way a therapist’s office was decorated influenced
how the therapist’s qualifications and energy were judged [51]. The use of nature-
themed visual artwork improved patients' and visitors’ emergency department waiting
experiences, by distracting patients/visitors from their concerns (i.e., increasing positive
“distraction activities” [52] (p. 175). Specific thematic design types (e.g., ocean, plant, an-
imals, etc.) and color pallets (e.g., blue-green tones and pale to mid-color ranges) were
preferable for children and adolescent patients for the different parts of their hospital
settings [53]. In a POE study of healthcare staff in a mental hospital, Kalantari and Snell
[54] combined a color scheme, graphics, and icons as a part of design innovation strate-
gies for wayfinding improvement. Proper illumination related to healthcare workers’
enhanced care and reduced medical errors, and it contributed to a better quality of life
and job satisfaction [55,56]. The interior finish materials, including the flooring, require
special caution because of the incidence of falls and fall-induced injuries and mainte-
nance reasons [22,57]. In recent studies, innovative materials were recommended be-
cause of their durability, flexibility, and eco-friendliness. Especially, as sanitary-related
issues are emphasized for the bacterial and viral load reduction on the finishing surfac-
es, easily cleanable and replaceable materials are recommended to promote safety and
maintenance efficiency in hospitals [32].
1.2.4. Nature and View
Numerous studies have highlighted the impact of nature on patients' and hospital
staff’s health outcomes, satisfaction, and well-being [9,20,5860]. Natural features in-
Int. J. Environ. Res. Public Health 2023, 20, 1540 4 of 35
clude a view through a window, indoor and outdoor plants and gardens, representa-
tional visual media of nature, etc. [6164].
In Grinde et al.’s review [65] of the empirical studies on indoor and outdoor envi-
ronments, visual access to nature (regardless of environment) provided a higher poten-
tial for improved health benefits such as stress reduction, mental restoration, and mood
enhancement, compared with lesser access to nature. Additionally, a window view of
the outside natural surroundings had positive impacts on patients’ self-reported physi-
cal and mental health recovery in a residential rehabilitation center [66]. According to
Park and Mattson [64], placing indoor plants in patients’ rooms accelerated patients’ re-
covery while also improving satisfaction with their rooms. Hospital gardens provided
stress reduction and psychological relaxation to adult patients, family members, visitors,
and nurses [63,6769] as well as hospitalized children [60]. The visibility and physical
access to the pediatric hospital gardens were examined and design recommendations
were suggested to enhance visitation and physical activities in the hospital garden con-
cerning access, function, visibility, and amenities [70,71]. The nature-inducing visual
media was also reviewed. The patients who were engaged in rehabilitation sessions with
simulated natural environments via virtual reality showed higher psycho-emotional
health improvement than those who participated in regular rehabilitation sessions [72].
During the COVID-19 pandemic, healthcare workers reported experiencing anxiety,
depression, stress, insomnia, etc. [73,74]. To mitigate the experienced distress by medical
staff, a field study was conducted to develop a recharge room with multi-sensory, im-
mersive, and nature-inspired relaxation scenery. Healthcare workers participated in the
15-min recharge room experiment and reported a significant short-term reduction in
their perceived stress and a highly enjoyable experience [75].
1.2.5. Safety
Safety is one of the most emphasized parameters in the healthcare environment
[76]. The hospital built-environment influences hospital occupants’ safety directly or in-
directly, such as through reductions in patient anxiety, patient falls and injuries, medical
errors, and hospital-acquired infections [77]. For example, a safety concern was linked to
patients’ emotional affects in healthcare settings; private patient rooms enabled patients’
feeling of protection and helped the facility be perceived as a safe place [78]. In psychiat-
ric hospital facilities, unfamiliarity was associated with discomfort and insecurity per-
ceived by patients [79]. Hospital nurses preferred visibility of patients and coworkers,
more exits, and locks in case of emergency [80].
The environmental risks contributing to patients’ falls and related injuries are inad-
equate flooring, poor lighting, mobility hazards, suboptimal furniture, and unsuitable
signposting [81]. To prevent medical errors by hospital staff, the improvement of the
physical settings can minimize various problems [48]. In the emergency department, a
poor entry layout, airflow circulation problems in the treatment area, etc., were associat-
ed with security and safety problems [32].
The significance of hospital-acquired cross-infection issues requires attention, as ev-
idence has been reported in clinical environments worldwide [10,82]. Owing to the
COVID-19 pandemic, hospital-acquired infection control is highly emphasized by im-
proving air circulation control systems as well as managing the flow of staff, patients,
and visitors in the entrance, lobby, corridors, etc. [32].
1.2.6. Management and Maintenance
Management, organizational process, and physical design aspects are interrelated
and directly or indirectly affect healthcare workers’ emotional stress, fatigue, work per-
formance, and job satisfaction; for example, the management and organizational deci-
sion (e.g., staff education, communication, workload, and safety concern) and architec-
tural/interior design aspects contribute to nursing staff’s medication errors, mediated by
their physical and emotional stress and dissatisfaction with their work [48].
Int. J. Environ. Res. Public Health 2023, 20, 1540 5 of 35
The enhanced performance functions of the hospital facility management affect cost
reduction and efficiency improvement, and further foster patients’ satisfaction with the
quality and reliability of hospital services [83]. The maintenance of the physical spaces
and indoor environmental systems are also important management parameters to im-
prove the quality of healthcare facilities perceived by medical staff [84].
Monitoring the maintenance and cleaning of indoor surfaces and air circulation sys-
tems is important for effective hospital operation. For example, high-performance sur-
face materials and flexibility in usage and spatial organization help the effective man-
agement of emergency situations. Setting up the rules to operate the HVAC systems and
scheduling for inspection and maintenance are crucial because the overall level of sani-
tary management of a hospital facility relies on the operation strategies of the indoor
surface materials and building systems [43].
Rigidity and obsolescence of spaces and systems found in several hospital facility
settings cause more challenges to hospital management [43]. Therefore, from the design
phase of hospital facilities, identifying the optimal solutions for efficient and sustainable
management is critical for the functional, technical, and economic operations of
healthcare facilities [43].
1.2.7. Service and Social Support
Patients’ perception of hospital service quality affects satisfaction and intention to
choose the hospital [85,86]. According to Rashid and Jusoff [87], patients rely on func-
tional aspects such as the physical facility and equipment, and the appearance of
healthcare staff when evaluating the service quality of a hospital. In addition to the tan-
gible, functional service quality components, scholars noted other attributes such as
communication, accessibility, the relationship between patients and staff, security, con-
venience, etc., in the assessment of the healthcare service quality [88,89].
Arneill and Devlin [90] reported that the nice and warm appearance of the physical
facility and equipment in the hospital setting influences participants’ perception of the
quality of care provision. Patients’ perceived appraisals of the quality of the medical
staff’s care, relationships, and privacy were positively related to perceived quality [8].
Social support and the perceived quality of social relationships among patients,
healthcare staff, and families promoted individuals’ health through the buffering effects
against stress [91,92]. Social support through informational, emotional, and tangible aids
by hospital nurses and counselors helped reduce patients’ fear and anxiety effectively
during pre-operation settings [93]. Nursing staff can benefit from social support pro-
grams that promote coping skills to reduce stress and enhance a supportive work envi-
ronment in hospital settings [94]. To foster social support in healthcare settings, Ulrich
[95] recommended convenient service facilities for comfort, rest, and socialization (e.g.,
waiting rooms, overnight accommodations, accessible gardens, break rooms, etc.) for
families and visitors and healthcare staff.
Communication with healthcare staff has been a critical aspect for patients and fam-
ilies [96]. Communication with medical staff is an important parameter of caring, as pa-
tients often want to be well-informed by and interact and discuss with medical staff [97].
According to Douglas and Douglas [98], patients responded that facilities that are not
usable and accessible hindered a patient-friendly hospital atmosphere.
In the new, technology-driven healthcare environment, patients’ care and treatment
services have been substituted by digital healthcare communication and information
technologies, both in routine and emergency medical situations [99]. For example, tech-
nology impacted the reconfiguring of spatial demands and programming (e.g., replacing
or eliminating paper-based storages, archive rooms, etc.). Owing to the pandemic, tech-
nological advances allowed for remote care of patients, making resource management
more efficient and reducing contact between patients and medical staff [32].
Int. J. Environ. Res. Public Health 2023, 20, 1540 6 of 35
1.3. Research Aim
While hospital users’ perceptions of the physical spaces and healthcare services
have been rigorously studied, scarce information is obtainable from healthcare facility
designers’ perspectives. This research aimed to fill this gap by investigating architectural
designers’ points of view concerning various healthcare environmental criteria to en-
hance the quality of therapeutic healthcare environments. Particularly, this study pre-
sents an empirical examination of various physical and psycho-social environmental fac-
tors to identify significant therapeutic environmental aspects, focusing on the user-
centered perspective as a pivot to healthcare design.
The research questions are as follows:
What are the essential therapeutic environmental factors perceived by architectural
designers for the successful delivery of patient-centered, therapeutic, healthcare de-
sign?
What healthcare environmental factors are perceived most importantly by architec-
tural designers? How do such factors relate to architects’ personal and professional
characteristics?
Why are certain factors considered more important by architectural designers?
Does the priority differ between their personal and firms perspectives?
What are the hurdles in the implementation of such therapeutic healthcare envi-
ronmental factors in hospital design practice? What can be suggested to improve
the quality of therapeutic healthcare environments in the hospital design process?
To answer the aforementioned research questions, this empirical study was con-
ducted by utilizing self-reported surveys among architectural design practitioners and
in-person interviews with healthcare design specialists in South Korea. The data from
the architects’ survey and extensive insights were based on their professional design ex-
pertise and hospital design examples implemented in South Korea.
Architectural design professionals play a key role in the delivery of a physical-
spatial healthcare setting that is relatively permanent throughout the lifecycle of a hospi-
tal. Such physical and spatial features devised by architectural designers can have a crit-
ical impact on building users’ interactions with the physical setting as well as their psy-
cho-social experiences [8]. As exemplified in prior studies, hospital designers integrate
the psycho-social dimension reflecting users’ subjective perceptions and behavioral as-
pects to achieve a more comprehensive delivery of environmental design [21,84]. There-
fore, it is worth considering architectural designers’ critical views concerning the thera-
peutic hospital environmental design criteria and the hurdles to implementing them in
healthcare facility designs. Addressing these issues by obtaining evaluative data and ex-
tensive insights will provide valuable discussions on what can be suggested to tackle
these issues for holistic design approaches. This will ultimately promote successful de-
sign delivery and elevate the quality of the therapeutic healthcare environment.
2. Materials and Methods
This study conducted a survey with architectural design practitioners and inter-
viewed architects who specialized in hospital design. Based on the relevant literature re-
sources, a survey questionnaire was developed to examine architectural design practi-
tioners’ perspectives on the importance of therapeutic environmental variables for the
success of healthcare design delivery. Following the survey, supplementary interviews
with hospital design experts were conducted to interpret and expand the findings from
the survey results. Interview materials were also used to discuss how to successfully in-
tegrate the therapeutic design criteria in the design process as well as the outcome of ac-
tual hospital facilities.
Int. J. Environ. Res. Public Health 2023, 20, 1540 7 of 35
2.1. Instrument and Variables
2.1.1. Survey
A preliminary list of 27 essential therapeutic healthcare environmental variables
was selected from extensive literature materials. These variables include spatio-physical
and psycho-social environmental attributes emphasized during the design delivery and
the post-design delivery stages. Two professional architects who were awarded for the
excellency of their hospital design projects in South Korea were consulted in the selec-
tion of these preliminary variables. The architects confirmed these variables are im-
portant not only in the design delivery stage but also in the post-design delivery for the
successful design and operation of the healthcare facility. The draft survey questionnaire
was then developed and validated by two senior healthcare specialist architects. The
draft questionnaire was then updated based on their input.
The completed survey questionnaire comprised two sections:
Respondents’ personal and professional characteristics: sex, age, education, hospital
design experiences (years), architect licensure, and field of design specialty.
Importance of therapeutic healthcare environmental attributes: 27 variables from
the relevant literature sources (Table 1). Respondents were asked to evaluate the
importance of the 27 variables, considering a user-centric hospital design task. Re-
spondents indicated the degree that they considered it important. A five-point Lik-
ert scale (1 = least important, 2 = not so important, 3 = neutral, 4 = important, and 5 =
very important) was used to assess the level of importance of the 27 variables in the
delivery of therapeutic healthcare facility design.
Table 1. Therapeutic healthcare environmental variables and relevant literature sources.
Variables
Citation(s)
Illumination
[55,100,101]
Air quality
[42,102,103]
Natural daylight
[34,100,101,104]
Thermal comfort
[105107]
Noise
[38,39,108]
Ventilation
[107,109,110]
View
[65,66,111]
Plants and gardens
[9,58,6264]
Rest and recreational space
[98,112]
Color
[62,100,104]
Art image
[113,114]
Furniture
[115]
Maintenance
[83,84]
Safety
[57,76]
Hygiene
[82,116118]
Spatial access
[22,119,120]
Wayfinding
[23,121]
Openness and visibility
[25,122,123]
Location and orientation
[8,124]
Exterior appearance
[8,124]
Privacy
[28,29,125]
Family service and convenience space
[21,98]
Communication and information
[96,97,126]
Socio-cultural support
[93,95,98]
Medical and administrative staff relationship
[8,124,126]
Utilizing the two sections, the relationship between respondents’ personal and pro-
fessional profiles and the assessment of the importance of the variables was exam-
ined. Respondents’ personal and practice profiles may impact architects’ response
Int. J. Environ. Res. Public Health 2023, 20, 1540 8 of 35
patterns on the level of importance of the 27 variables. All 27 variables in the survey
were described in both Korean and English texts to ensure the meanings were clear.
Additional visual aids (e.g., hospital photos, images, or virtual reality) were not
combined because the visual representation may alter the way in which survey re-
spondents judge the meaning of the text description [127,128]. As such, respond-
ents’ evaluations relied on their tacit and explicit architectural knowledge devel-
oped through their professional practice experiences [129].
2.1.2. Interview
The written interview method was utilized owing to the spread of COVID-19 in
South Korea. The interviewees were provided with the questionnaire, which was re-
viewed by the two senior architects who gave feedback for the survey questionnaire. To
ensure item comprehensibility, the two architects provided their insight. The interview
questionnaire comprised four sections. Except for Section I—the interviewees’ personal
and professional characteristics’ questions—the other three sections consisted of open-
ended questions that allowed interviewees to communicate their ideas freely. In Section
II, the list of the 27 therapeutic healthcare environmental variables from the survey ques-
tionnaire is used. However, rather than assessing the degree of importance of each vari-
able, the interviewees were asked to select the most important therapeutic environmen-
tal variables and write their thoughts on the significance of such variables concerning
the successful implementation of the hospital environment.
The four sections of the interview questionnaire are as follows:
Respondents’ personal and professional characteristics: sex, age, education, hospital
design experiences (years), architect licensure, and the size of the firm (number of
employees).
The most important therapeutic environmental attributes among the 27 variables
for the successful project delivery and the explanation of their importance from the
personal point of view as well as from firms’ perspectives: a multiple selection of
the variables is permitted and the reasons for the importance of each selected varia-
ble needs to be described.
The selection of the therapeutic environmental attributes from the 27 variables that
are more or less frequently implemented in the hospital design projects and the ex-
planation of the reasons.
Suggesting the ways to implement the therapeutic environmental attributes holisti-
cally in the healthcare facility design for the success of healing hospital design de-
livery.
2.2. Participants
2.2.1. Survey
Survey participants were recruited by emailing the contact personnel at 32 random-
ly selected architectural design firms in Seoul, South Korea. In the email, the intent, pro-
cedure, and confidentiality of the survey results were described. Twenty-five firms
agreed to participate. The size of these firms varied, ranging from small (≤30 employees)
and mid-size (31100 employees) to large offices (>100 employees). Using their office in-
tranet email systems, the survey questionnaire was circulated along with the written de-
scription of the survey’s goal, voluntary participation, the confidentiality of the data,
and reward. A total of 191 designers voluntarily completed survey questionnaires that
were returned to the author via email. Out of the 191 responses, 182 questionnaires were
used for further analysis owing to significant data omission in the other nine question-
naires. All respondents had at least over three years of professional architectural practice
experience (one’s graduate school years were included if the person held a professional
master’s degree in architectural design), which ensured their understanding of the im-
portance of the examined therapeutic healthcare environmental variables [130]. Based on
Int. J. Environ. Res. Public Health 2023, 20, 1540 9 of 35
the respondents’ validation of the abstract spatial and psychological variables, their
evaluation of the importance of healing in healthcare environmental variables was ex-
amined in relation to their personal and professional characteristics.
2.2.2. Interview
The interview participants were contacted by emailing the contact personnel at the
nine randomly selected architectural design firms in Seoul, South Korea, in which the
healthcare design department or project team is in operation. The size of the firms var-
ied, ranging from mid-size (30100 employees) to large offices (>100 employees), as
healthcare design projects are mostly executed by large architectural design offices in
South Korea. In the email, the intent, procedure, confidentiality of the interview, and
reward were explained. Fifteen healthcare design specialists agreed to participate in the
interview. They had over 10 years of professional practice experience and were all de-
sign managers with at least five years of healthcare design project management experi-
ence. Such experiences are considered adequate to address healthcare design specialties
[131]. The interviews were conducted using an interview questionnaire that was emailed
to each participant. Each participant hand-wrote or typed their answers using the pro-
vided interview questionnaire. The completed interview documents were returned to
the author via email. Additionally, two healthcare design specialists among the 15 inter-
viewees were invited via an online meeting for in-depth discussions on their recent
healthcare design projects that present adaptation of healing design elements in the
course of design development and outcomes. Both specialists are men and from large-
size architectural offices. They hold over 10 years of experience in the healthcare design
field and were in senior project management positions leading the healthcare depart-
ment team at their firms.
2.2.3. Ethical Considerations
This study was approved by the Inha University Institutional Review Board and
conducted in accordance with the Helsinki Declaration. Informed consent was obtained
from all participants.
2.3. Analysis
2.3.1. Survey
The survey data were analyzed using SPSS v. 25 (IBM, Armonk, NY, USA).
First, a basic descriptive analysis was conducted to understand respondents’ per-
sonal and professional characteristics.
Second, a factor analysis and a reliability analysis were conducted to analyze the
validity and reliability of the survey results. The therapeutic environmental factors con-
sisted of 27 variables based on the previous literature review. A principal component
analysis (PCA) was conducted to extract the model. Varimax was used for the rotation
method, which assumes independence between factors. A factor loading value of 0.4 or
higher was selected, and the factors with an eigenvalue of one or more were extracted
[132]. The KaiserMeyerOlkin (KMO) coefficient, which determines the appropriate-
ness of the sample used in the factor category, ranges from 0 to 1. The closer the KMO is
to 1, the more desirable it is. When the KMO is at least 0.5, it is considered suitable for
factor analysis [133]. Bartlett’s test of sphericity was used to test the validity of the PCA
results. To measure the reliability between variables and internal consistency,
Cronbach’s alpha ) coefficient was used. There is no absolute criterion for a measure-
ment tool to be recognized for its reliability; however, it is considered reliable if α is 0.6
or more [134].
Third, to compare the level of significance of the therapeutic environmental factors
and variables, a descriptive analysis was used to examine the mean score of each factor
and variable.
Int. J. Environ. Res. Public Health 2023, 20, 1540 10 of 35
Fourth, a two-tailed t-test and analysis of variance were utilized to examine the re-
lationship between the environmental factors and respondents’ personal and profes-
sional characteristics. The two-tailed t-test was used to reject the hypothesis by which
the mean of a dependent variable (significance of the therapeutic environmental varia-
bles) is the same among the groups in the dependent variable and displays a confidence
interval for the difference between mean values among the groups in the dependent var-
iable. Significance was set at < 0.05.
2.3.2. Interview
The data collected from the interviews were analyzed by scrutinizing participants’
written manuscripts. Through this process of uncovering the meaning behind the texts
in the documents, the similarities and differences in the interpretations of the selected
priori variables and the reasons for such perspectives were carefully examined. In addi-
tion, the interviewees’ views concerning how to improve the implementation of the var-
ious therapeutic healthcare environmental elements for hospital design in practice were
highlighted.
3. Results
3.1. Survey
3.1.1. Respondents Personal and Professional Characteristics
Respondents personal and professional characteristics are shown in Table 2.
Table 2. Survey respondents’ personal and professional characteristics.
Variable
%
Sex
Male
72.0
Female
28.0
Age (years)
20s
19.2
30s
24.2
40s
40.7
50s or older
15.9
Education
Bachelor
47.8
Graduate
43.4
Doctorial
8.8
Experience with hospital
design
(years)
<1
52.2
15
18.7
610
13.7
>10
15.4
Architect licensure ship
Yes
34.1
No
65.9
Field of specialty
Healthcare and welfare
37.9
Commercial and cultural
22.5
Office/workspace
7.1
Housing and urban planning
21.4
Educational, etc.
11.0
Total
100.0
3.1.2. Important Therapeutic Environmental Criteria (Factors and Items)
Each respondent’s perception of the level of importance of the 27 identified thera-
peutic environmental variables was examined using a PCA with varimax rotation. The
factor loadings after rotation in the PCA are presented in Table 3. The KMO measure
was computed to verify the sampling adequacy of the analysis [135]. The KMO coeffi-
cient was 0.835, which is considered high for the PCA [134]. Bartlett’s sphericity test
yielded a significant value (1783.088; p < 0.001), indicating that the PCA is well-suited.
Int. J. Environ. Res. Public Health 2023, 20, 1540 11 of 35
The PCA resulted in seven component factors with eigenvalues over Kaiser’s crite-
rion of one. The explanatory power of the total combined variance was 64.917%. The re-
liability of each factor was examined by Cronbach’s α and was greater than 0.6, indicat-
ing acceptable internal reliability among the items in each factor (Table 3).
Table 3. Principle component analysis and varimax rotation of the important therapeutic envi-
ronmental criteria (factors and items).
Factor and Items
Factor Loading
Eigenvalue
% Variance
Cronbach’s α
Factor 1: Management
2.700
10.801
0.761
Hygiene
0.732
Safety
0.708
Maintenance
0.704
Factor 2: Interior design
2.628
10.513
0.776
Color composition
0.814
Coordinated art and image
0.765
Furniture layout
0.641
Factor 3: Spatial quality
2.571
10.285
0.765
Openness and visibility
0.745
Location and orientation
0.657
Wayfinding
0.653
Accessibility
0.587
Spatial privacy
0.476
Exterior appearance
0.465
Factor 4: Service
2.285
9.141
0.754
Medical staff’s service
0.832
Administration staff’s service
0.825
Family service facility
0.508
Factor 5: Nature and rest
2.085
8.339
0.712
Outdoor view
0.767
Natural daylight
0.674
Green space
0.609
Rest and recreational space
0.572
Factor 6: Ambient indoor comfort
2.046
8.183
0.679
Illumination
0.627
Thermal comfort
0.612
Air quality
0.588
Indoor noise
0.508
Factor 7: Social program and space
1.914
7.655
0.663
Health information program and space
0.789
Socio-cultural program and space
0.693
Total variance explained: 64.917%
Bartlett’s test: chi square = 1783.088, df = 300 (p < 0.001), KaiserMeyerOlkin = 0.835
Note: Two items did not load onto any factor in the factor analysis: ventilation and provision of
convenient facility (e.g., hospital store, cafeteria, etc.).
The seven factors presented in the PCA results are as follows:
Factor one is classified as “management” (eigenvalue = 2.700, variance = 10.801,
Cronbach’s α = 0.761), as it includes variables such as hygiene, safety, and upkeep and
maintenance.
Factor two is classified as “interior design” (eigenvalue = 2.628, variance = 10.531,
Cronbach’s α = 0.776), as it includes variables such as color composition, coordinated art
and image, and furniture layout.
Factor three is classified as “spatial quality” (eigenvalue = 2.571, variance = 10.285,
Cronbach’s α = 0.765), as it includes variables such as openness and visibility, location
and orientation, wayfinding, accessibility, spatial privacy, and exterior appearance.
Int. J. Environ. Res. Public Health 2023, 20, 1540 12 of 35
Factor four is classified as “service” (eigenvalue = 2.285, variance = 9.141,
Cronbach’s α = 0.754), as it includes variables such as friendly medical staff, helpful ad-
ministration staff, and family service facility.
Factor five is classified as “nature and rest” (eigenvalue = 2.085, variance = 8.339,
Cronbach’s α = 0.712), as it includes variables such as outdoor view, natural daylight,
indoor green space, and indoor play and rest area.
Factor six is classified as “ambient indoor comfort” (eigenvalue = 2.046, variance =
8.183, Cronbach’s α = 0.679), as it includes variables such as illumination, temperature,
air quality, and indoor noise.
Factor seven is classified as “social program and space” (eigenvalue = 1.914, vari-
ance = 7.655, Cronbach’s α = 0.663), as it includes variables such as the provision of facili-
tating spaces to run information and communication and socio-cultural programs for
hospital users.
3.1.3. Priority among the Therapeutic Environmental Criteria (Factors and Items)
The level of importance of each therapeutic environmental factor and variable per-
ceived by the respondents was compared by computing the descriptive analysis of the
mean and standard deviation (SD) value of each factor and variable item (Table 4). Re-
spondents perceived that all factors and subsequent variable items were important to ef-
fective hospital design (i.e., the mean values of all items were over 3.0). Factor one,
“management,” yielded the highest importance (mean = 4.52, SD = 0.573); followed by
factor six, “ambient indoor comfort” (mean = 4.26, SD = 0.501); factor four, “service”
(mean = 4.15, SD = 0.606) and factor five, “nature and rest” (mean = 4.04, SD = 0.556).
Concerning the variable items, “air quality” (mean = 4.66, SD = 0.597) yielded the
highest mean value, followed by “hygiene” (mean = 4.65, SD = 0.620) and “safety” (mean
= 4.51, SD = 0.763), “natural daylight” (mean = 4.54, SD = 0.618), and “medical staff’s ser-
vice” (mean = 4.42, SD = 0.691).
Table 4. Mean and standard deviation of important therapeutic environmental criteria (factors
and items).
Factors and Items
Mean
Standard Deviation
Factor 1: Management
4.52
0.573
Hygiene
4.65
0.620
Safety
4.51
0.763
Maintenance
4.42
0.698
Factor 2: Interior design
3.59
0.699
Color composition
3.72
0.850
Coordinated art and image
3.43
0.900
Furniture layout
3.63
0.767
Factor 3: Spatial quality
3.77
0.548
Openness and visibility
3.87
0.746
Location and orientation
3.82
0.829
Wayfinding
3.79
0.782
Accessibility
3.80
0.852
Spatial privacy
3.96
0.761
Exterior appearance
3.37
0.868
Factor 4: Service
4.15
0.606
Medical staff’s service
4.42
0.691
Administration staff’s service
4.18
0.762
Family service facility
3.84
0.767
Factor 5: Nature and rest
4.04
0.556
Outdoor view
3.82
0.797
Int. J. Environ. Res. Public Health 2023, 20, 1540 13 of 35
Natural daylight
4.54
0.618
Green space
3.58
0.855
Rest and recreational space
4.21
0.746
Factor 6: Ambient indoor comfort
4.26
0.501
Illumination
4.18
0.677
Thermal comfort
4.37
0.667
Air quality
4.66
0.597
Indoor noise
3.84
0.844
Factor 7: Social program and space
3.39
0.738
Health information program and space
3.23
0.855
Socio-cultural program and space
3.54
0.851
Note: 1: least important; 2: not so important; 3: neutral; 4: important; 5: very important (n = 182).
3.1.4. Relationship between Important Therapeutic Environmental Criteria and Re-
spondents’ Personal and Professional Characteristics
The three therapeutic environmental factors (i.e., management, interior design, and
spatial quality) were significantly related to respondents’ personal characteristics. How-
ever, the rest of the factors were non-significantly different.
First, the management factor was significantly different according to the respond-
ents’ sex (t = 3.228, p = 0.002). Women (M = 4.71, SD = 0.409) displayed higher scores in
the management factor compared to men (M = 4.45, SD = 0.612; Table 5).
Table 5. Management factors in relation to the respondents’ personal and professional characteris-
tics.
Variable
f(n)
Mean
Standard Deviation
t/F
p
Sex
Male
131
4.45
0.612
3.228
0.002
Female
51
4.71
0.409
Second, the interior design factor was significantly different according to respond-
ents’ age (t = 2.683, p = 0.048). Respondents in their 50s or older (M = 3.85, SD = 0.688)
showed the highest scores in the interior design factor, followed by those in their 40s (M
= 3.63, SD = 0.648), 30s (M = 3.55, SD = 0.705) or 20s (M = 3.37, SD = 0.753; Table 6).
Table 6. Interior design factor in relation to the respondents’ personal and professional character-
istics.
Variable
f(n)
Mean
Standard Deviation
t/F
p
Age (years)
20s
35
3.37 a
0.753
2.683
0.048
30s
44
3.55 ab
0.705
40s
74
3.63 ab
0.648
50s or older
29
3.85 b
0.688
a < b: Duncan’s post-verification.
Third, the spatial quality factor was significantly different according to respond-
ents’ sex (t = 2.608, p = 0.010). Women (M = 3.91, SD = 0.391) showed higher scores in the
spatial quality factor compared to men (M = 3.71, SD = 0.590; Table 7).
Table 7. Spatial quality factor in relation to the respondents’ personal and professional characteris-
tics.
Variable
f(n)
Mean
Standard Deviation
t/F
p
Sex
Male
131
3.71
0.590
2.608
0.010
Female
51
3.91
0.391
Int. J. Environ. Res. Public Health 2023, 20, 1540 14 of 35
3.2. Interview
3.2.1. Participants’ Personal and Professional Characteristics
Participants’ personal and professional characteristics are shown in Table 8.
Table 8. Interview participants’ personal and professional characteristics.
Variables
n
%
Sex
Female
8
53.3
Male
7
46.7
Age (years)
30s
10
66.7
40s
3
20.0
50s or older
2
13.3
Education
Bachelor
7
46.7
Graduate
8
53.3
Doctorial
0
0.0
Experience in hospital design project
management (years)
≤5
2
13.3
610
4
26.7
1115
4
26.7
>15
5
33.3
Architectural licensure ship
Yes
8
53.3
No
7
46.7
Size of firm (persons)
≤100
4
26.7
101300
1
6.7
301600
3
20.0
>600
7
46.7
Total
15
100.0
3.2.2. Priority in Design Implementation
Participants’ judgment of the priority of the therapeutic environmental criteria
when implementing in design was asked both from the interviewees’ personal as well as
their firms’ practice dimensions. Participants were then asked which environmental cri-
teria are more/less frequently implemented in their hospital design practice. For each
question, multiple answers among the given environmental criteria are possible.
Concerning participants’ personal dimensions, interviewees answered that spatial
privacy (n = 6, 40.0%), natural daylight (n = 5, 33.3%), air quality (n = 4, 26.7%), hygiene
(n = 4, 26.7%) and a rest and recreational space (n = 4, 26.7%) were among the top prior
variables. Concerning the firms’ practice dimension, interviewees responded that acces-
sibility (n = 6, 40.0%), exterior appearance (n = 6, 40.0%), natural daylight (n = 6, 40.0%),
hygiene (n = 5, 33.3%), locationand orientation (n = 5, 33.3%), and air quality (n = 5,
33.3%), were critical (Figure 1).
Concerning more frequently (or less) implemented environmental criteria in design
practice, wayfinding (n = 10, 66.7%) was the most common, followed by natural daylight
(n = 7, 46.7%) and a rest and recreational space (n = 6, 40.0%). Contrastingly, the inter-
viewees agreed that facilitating family service space(n = 6, 40.0%), creating a sense of
openness and visibility (n = 6, 40.0%), and introducing green space (n = 5, 33.3%) are
relatively not applied as often in their design projects (Figure 2).
Int. J. Environ. Res. Public Health 2023, 20, 1540 15 of 35
Figure 1. Participants’ personal priority and their firms’ priority in design implementation of the
therapeutic healthcare environmental variables (Appendix A: Table A1).
Figure 2. Frequency of applied variables in design implementation for therapeutic healthcare en-
vironments (Appendix A: Table A2).
3.2.3. Hurdles and Suggestions in Design Practice
The participants addressed existing barriers and suggested ways in which to im-
prove creating therapeutic healthcare environments in the hospital design practice (Fig-
ure 3). Participants (n = 7, 46.7%) strongly advocated for facilitating the design of guide-
Int. J. Environ. Res. Public Health 2023, 20, 1540 16 of 35
lines/manuals or even imposing design restrictions for some fundamental therapeutic
design elements such as the rest area, green space, natural light, access con-
trol/separation for hygienic areas, etc. For example, the provision of a mandatory rest ar-
ea per a hospital’s size, or per the number of total beds, can be one of the ways to apply
healing environmental criteria in the hospital.
Participants (n = 5, 33.3%) pinpointed that clients’ perspective is one of the primary
reasons that hinders the implementation of a therapeutic healthcare environmental.
Providing a healing space is often pushed out of priority from the hospital’s project
budget owing to minimal interest from clients.
Participants (n = 5, 33.3%) strongly emphasized the significance of the evidence-
based healthcare design practice approach integrating POE and case studies. According
to the respondents, access to POE information is often limited in the healthcare facility
precedents in South Korea. The lack of such relevant POE data on the cases of South Ko-
rean hospitals hinders the implementation of certain healing environmental items; the
scarce and nonvague information creates doubts about the effects of such design ele-
ments, which makes them difficult to apply. The lack of domestic studies also challenges
the ability to persuade clients and relying on overseas’ examples has limitations for both
designers and clients.
Consideration of diverse hospital user groups is also emphasized by the inter-
viewed experts (n = 4, 26.7%). The respondents experienced that the medical staff is the
primary source of data during the user consultation process; thus, the staff’s opinion is
usually adopted in the hospital’s spatial program, subsequently impacting the final de-
sign result. Since most of the clients are medical doctors or medical professors, it be-
comes difficult to equally reflect the diverse views of various hospital user groups.
Lastly, design integration among diverse fields in the hospital design process was
highlighted by the participating experts (n = 3, 20.0%). Like other building types, a hos-
pital facility requires a complex and multi-layered design process involving diverse spe-
cialty areas (i.e., architectural design; interior design; structural design; mechanical, elec-
trical, and plumbing engineering; landscape design; accessibility checks; fire egress con-
sulting; the Internet of things (IoT) engineering; service sector consulting, etc.). Howev-
er, the coordination of such fields can be challenging, particularly when focusing on the
healing aspects of hospital design, primarily owing to the limited budget allocation for
such items. In addition, architectural designers are in charge of many tasks from external
building design to medical space arrangement, technical solutions, permitting, etc. As
such, the specificity of each expertise is limited, it becomes difficult to present a well-
orchestrated healing environment.
Figure 3. Hurdles and suggestions in healthcare design practice.
Int. J. Environ. Res. Public Health 2023, 20, 1540 17 of 35
4. Discussion
4.1. Important Therapeutic Environmental Criteria
The factor analysis presented seven environmental factors (i.e., management, spa-
tial quality, ambient indoor comfort, interior design, service, social program and space,
and nature and rest). Though the architects considered the seven factors were all im-
portant assets in pursuit of healing environments in hospital design, they prioritized the
management, indoor comfort, service, and nature and rest criteria. This result highlights
physical design attributes and their relationship with health.
Among the seven factors, the architects ranked the management criterion (i.e., hy-
giene, safety, and maintenance) most important for the hospitals’ healing environments.
According to Reijula et al.’s [136] qualitative study, participants involved in the Finnish
hospital design projects emphasized the building’s adaptability and durability as well as
its aesthetic quality, highlighting both the facility’s design and management characteris-
tics in the design process. Hygiene has been one of the most essential issues highlighted
in the hospital environmental design. Particularly, hospital-associated infection has re-
ceived special attention in evidence-based research and design because the physical built
environment (e.g., room layout, sanitary equipment, furnishing, materials, etc.) reduced
transmission of cross-infection in hospitals and improved hospital users’ wellness and sat-
isfaction [118]. A safety attribute is also one of the most emphasized threads in the studies
of healing healthcare environmental design [76]. Diverse spatial properties such as noise,
lighting, patient room design, unit layout, and interior features (i.e., ergonomics of the fur-
niture, equipment, and facility) were associated directly or indirectly with safety-related
accidents [57]. The maintenance methods, skills, and technology have been studied and
implemented to improve utilization, operational efficiency, and hospital workers’ produc-
tivity and service quality [137]. Ultimately, the goals and strategies of the maintenance
function and performance are linked to hospital users’ satisfaction [83].
The ambient indoor comfort quality criterion (i.e., illumination, air quality, and
thermal comfort) has received special attention in numerous publications, as indoor
comfort attributes affect hospital users’ healing and well-being [10]. The architects’ per-
ception of the significance of indoor comfort features was not exceptional, and only sec-
ond to the management factor. According to Gola et al. [43], architectural design strate-
gies can contribute to improving indoor air quality and its daily management problems
and the exemplary suggestions relate to the building location, room exposure, layout de-
sign, mechanical and air handling unit system, structure, and material performances. In
recent studies, indoor air quality is particularly underlined because of its direct and/or
indirect relationship with hospital-acquired infection prevention and control during the
COVID-19 outbreak. From the design perspective, hospital designers play a key role in
providing preventive design strategies by pursuing environmental comfort, aesthetics,
flexibility, and adaptability to combat the pandemic [116].
The service criterion was valued as an important therapeutic environmental asset
by the architects. Service attributes include supportive service from healthcare workers
and family service-related physical facilities. In previous studies, many different aspects
of facility design were linked to the quality of healthcare service [18]. For example, Meng
et al. [126] reported that service organization and physical facilities influenced patients’
satisfaction in Wuhan public hospitals. The physical design features such as spatial lay-
out, visibility, and accessibility affected the perceived level of collaboration and efficient
communication among healthcare staff [138]. A supportive hospital environment for
family and visitors was emphasized to promote patients’ health and well-being by
providing physical service infrastructure, furniture, and room equipment (e.g., visitor
meeting room, family’s overnight stay facility, play area for kids, drink/tea/coffee ma-
chine for family/visitor, etc. [98]). Additionally, the design of family support facilities
(i.e., location, size, and communication equipment) encouraged family participation in
care by building up social networks among patients and families [139].
Int. J. Environ. Res. Public Health 2023, 20, 1540 18 of 35
The positive impacts of nature on hospital users’ stress reduction, restoration, and
well-being were highlighted in numerous publications [140]. Consistently, the architects
agreed that providing proximity to nature and rest space is an important criterion for
healing healthcare environments. Hospital design that allows access to indoor and out-
door nature promoted positive healthcare effects among hospital users [58,62,95]. For
example, the window placement and orientation in the patient room toward the outdoor
nature and ample natural sunlight contributed to the health benefits of patients and
medical staff [66,95]. Well-designed hospital gardens relieved stress and fostered soli-
tude, privacy, and social support for patients and hospital staff [95]. The design methods
and users’ evaluation of the quality of the healing garden design were examined
[63,68,141], and the strategies to promote the usage of healing gardens were suggested
by improving spatial visibility, accessibility, and functionality [70]. Concerning rest
space in hospitals, an attractive waiting room design influenced patients’ perceived
waiting time and satisfaction with the care service [142]. A simulation study on the lay-
out design of the hospital emergency department examined patients’ and staff’s circula-
tion and workflow and contributed to the reduction in patient waiting time and optimi-
zation of staff allocation [143]. Becker and Parsons [18] cited Iedema et al.’s [144] re-
search and noted that the provision of recreational facilities influenced the level of com-
munication among patients, hospital staff, and visitors.
4.2. Relationship between the Important Environmental Criteria and the Respondents’
Characteristics
Of the four personal variables, respondents’ sex and age explained the differences
in perceiving the importance of the therapeutic environmental criteria such as manage-
ment, ambient indoor comfort, and spatial quality factors, as being more significant.
Contrarily, none of the professional characteristic variables were significant enough to
explain the differences in perception of the important healing environmental criteria.
The female architects’ mean scores on the level of importance of the therapeutic en-
vironmental criterion were higher than those of their male counterparts in all therapeu-
tic environmental criteria, among which the management and spatial quality were sig-
nificant. This result echoes Mourshed and Zhao’s [84] study on healthcare providers’
perspectives concerning healthcare environmental design: female healthcare staff evalu-
ated cleanliness, ease of maintenance, and hygiene as more important than their male
counterparts. Additionally, other studies reported that female healthcare providers often
presented more precautious behavioral performance regarding hospital hygienic issues
(i.e., hand hygiene for hospital-acquired infections [145,146]). Mourshed and Zhao [84]
explained the reason for this by citing Velle’s [147] research, in which women showed
greater sensitivity and physiologic responsiveness to environmental stimuli as com-
pared to male respondents.
The female architects were more perceptive about the spatial quality criterion (i.e.,
wayfinding, accessibility, openness and visibility, location and orientation, spatial priva-
cy, and exterior appearance) compared to their male counterparts. Female architects’
higher awareness of the significance of spatial quality can be further linked to the stud-
ies on women architects’ perceptions and modes of their design practices. According to
Ahrentzen and Anthony [148], who cited Franck’s [149] research, female architects pre-
sent a tendency to connect with others and the world as well as valuing everyday life
and experiences; a desire for inclusiveness; a responsibility for others’ needs and an ac-
ceptance toward subjectivity, complexity, and flexibility. According to Ahrentzen and
Anthony [148], women do not design differently from men. Rather, they are more sensi-
tive to human needs and willing to do more to attend to clients. Although certain studies
on female architects’ characteristics toward their architectural practice and relationship
with clients may have methodological limitations, including sampling, the aforemen-
tioned differences between the perceptions of female and male architects may have been
Int. J. Environ. Res. Public Health 2023, 20, 1540 19 of 35
further associated with the socially constructed, stereotypical projection about women
and men [148].
The architects’ age presented a significant difference among the age groups with
their perception of the ambient indoor design criterion (i.e., color composition, coordi-
nated art and image, and furniture layout). Older adults had higher mean scores com-
pared to their younger counterparts. The order of the mean score from the highest to the
lowest corresponded to the oldest to the youngest age groups. According to Dalke et al.
[100], the improved visual environment provided enhanced patients’ recovery, and
staff’s work productivity, and ultimately promoted a sense of well-being thorough the
appropriate color scheme, display of certain types of artworks, adequate material and
furniture layout, proper illumination, etc. It can be speculated that the architects in the
older (vs. younger) age group were more conscious about the effects of the interior de-
sign criteria as a key to creating the overall ambiance of hospitals [9].
Among the professional characteristics, no variables explained the differences in the
significance of therapeutic healthcare environmental factors. This result may require fur-
ther examination to shed light on the relationship between architects’ professional expe-
riences and the perspectives on the healing effects of healthcare environmental design.
4.3. Implementation in Healthcare Design Practice
4.3.1. Personal vs. Firms’ Professional Dimension
Concerning the healthcare design experts’ viewpoints at the personal level, natural
daylight, air quality, privacy, and rest area were considered critical to enhancing healing
experiences in hospitals. The experts prioritized the quality of the ambient hospital envi-
ronment reinforced by the introduction of ample natural daylight and effective air circu-
lation. Furthermore, psychological attributes such as the protection of personal privacy
and the provision of a place for mental recess via a tranquil and reserved atmosphere
were highlighted. One design expert stated,
Facilitating the good quality daylight and air flow are perhaps, the most fundamental
norms in the design of healthy hospital environment. Introducing natural daylight and
allowing natural ventilation as well as maintaining good indoor air quality, are essen-
tial in the design of inpatient rooms and corridors. Such design principles are also sig-
nificant in outpatient areas (i.e., lobby, hall, lounge, cafeteria, etc.). Hospital facilities
with good quality natural daylight and air movement affect not only building occu-
pants’ physiological health but also their psycho-emotional wellness.
Besides ambient environmental elements, creating a psychologically healing at-
mosphere in hospitals was underlined by providing private, reserved, and tranquil
spaces in patient areas. The spatial aid with screen, noise reduction, and absorption ma-
terials, and rest area with seats and proximity to an outdoor view were emphasized as
fundamental steps to create a healing atmosphere in inpatient areas. Contrastingly, the
hospital design experts responded differently concerning their firms’ perspective, un-
derscoring that wayfinding, exterior appearance, space layout and orientation, and cir-
culation distribution were prioritized. Two design experts stated,
In my personal view, natural elements and ambient atmosphere are primary for heal-
ing environments. However, in my firm’s sphere, physical and spatial properties be-
come priority because spatial organization of rooms and equipment affects the overall
design configuration as well as management performance and cost.”
Functional layout of rooms and equipment is primal in my firms’ design approach,
for the physical built environment impact on the long-term efficiency in usage, opera-
tion, and maintenance of buildings. Moreover, the physical design attributes affect the
overall building aesthetics and for the most, impact on the sustainability of the hospital
building.”
Int. J. Environ. Res. Public Health 2023, 20, 1540 20 of 35
According to design experts, the aesthetic style of the exterior and interior design
appearances is often emphasized by clients. One design expert stated,
As healthcare service becomes a more competitive industry, good quality physical de-
sign is emphasized more importantly as means to establish trustful and reputable im-
age of hospitals.”
The design experts valued the appealing and modernized impression of hospital
buildings because the appearance of internal and external areas and the subsequent
healing through welcoming, engaging, and tranquil images ultimately drew positive re-
sponses from occupants concerning the hospital organization’s overall healthcare service
setting [98,150].
4.3.2. More vs. Less Frequent Implementation
In the hospital design implementation phase, the healthcare design experts pursue
to accommodate the significant environmental criteria perceived by the design project
team in addition to clients’ requests. Particularly, several experts mentioned wayfinding
as the most frequently emphasized attribute, especially for the design of common areas
(i.e., entrance lobby, main circulation, rest lounge, cafeteria, etc.). Natural daylight was
focused on most frequently. Designers achieve wayfinding and natural daylight condi-
tions by introducing key landmark design items such as an atrium, hospital street, light-
well (e.g., air shaft, sky-well, unroofed internal or external area, etc.), skylight, etc.
Providing a rest area was also highlighted in the design of common spacesboth in
outpatient and inpatient areas.
Contrarily, the design specialists agreed that facilitating family service spaces be-
came more challenging owing to the recent COVID-19 pandemic and the need to pre-
vent cross-contamination in hospitals. One design expert stated,
In the past, the motto of family-oriented healthcare service led to facilitation of family
service spaces such as a family lounge, caretaker’s bed, rest area for families and visi-
tors, etc. Since the spread of severe acute respiratory syndrome and COVID-19, family
spaces received lesser attention, but instead moved toward non-caretaker healthcare
service approach. Especially since the COVID-19 pandemic, families and visitors’ ac-
cess is restricted and service spaces for family and visitors are getting eliminated in the
hospital.”
The expert addressed that creating a sense of openness physically and visually is
challenging to achieve because space is often limited. Introducing more daylight and in-
creasing glazed window areas is less cost-effective owing to the tight project budget.
Providing sufficient green space was also considered difficult because of the limited plot
size and interior space. One design expert stated,
In many urban hospital projects, creating a sense of openness and providing sufficient
green space are restricted. The complex list of a space program often requires more
rooms for patients and medical services, compared to the available plot area of the pro-
ject site. To offer green space, my project team used a roof-top garden. We throve to
provide a separate green zone for inpatients from outpatients and visitors because of
COVID-19. However, in many cases, a roof-top garden or an available lot for garden is
not available owing to the complex requirement of rooms and equipment.”
4.4. Barriers and Suggestions in Design Practice
The experts addressed various barriers hindering hospitals’ therapeutic environ-
mental and suggested practical and political recommendations to overcome such hur-
dles in the healthcare facility design.
Int. J. Environ. Res. Public Health 2023, 20, 1540 21 of 35
4.4.1. Reinforcing Design Guideline
The design experts emphasized raising the bar to implement therapeutic design by
reinforcing design guidelines, policies, or restrictions in the hospital design project. Ac-
cording to the experts, although healthcare service policies and standards are consistent-
ly updated, the policy or regulatory attention to the facility design of hospitals is rela-
tively narrow-scoped. For example, the South Korean healthcare accreditation system
does not assess the facility and environmental quality criteria as thoroughly as other au-
ditory dimensions such as service delivery, patient care and safety, infection control and
prevention, and medication management systems [151]. Two design experts stated,
For instance, provision of a mandatory rest area per a hospital’s square area, or per
the number of bed sits can be one of the design rules to improve implementation of the
healing environment in hospitals.”
For an effective design input, I recommend to revise the present healthcare service ac-
creditation system to assess the quality of healing environmental design in hospital. In
most cases, for the user-oriented operation and management of the hospital’s healthcare
service, the South Korean Ministry of Health and Welfare runs healthcare accredita-
tion system to monitor patient safety and hospital’s service quality. In most cases,
larger hospitals or specialized hospital programs participate in the accreditation,
whereas smaller or rural healthcare facilities do not. Under the current healthcare ac-
creditation system, the facility’s spatial and physical environmental quality is a less
concerned criteria.”
4.4.2. Clients’ Perspective
The design specialists pinpointed that clients play an essential role in the process of
providing a successful therapeutic healthcare environment. A project design team needs
to expand clients’ philosophical approach toward creating a healing hospital setting ho-
listically, which can be delivered through a good quality physical facility as well as the
organization’s healthcare service [3]. The experts emphasized that rather than relying on
the low-price-based design bidding system practiced in several healthcare design pro-
jects in South Korea, it is urgent to establish the necessary standards or guidance to as-
sure the physical design quality. However, the costs of this are often disregarded or un-
derestimated in the project budget planning. One design expert stated,
Due to the changes in healthcare service policies and regulatory issues, the design
construction budget and time are often fluctuating to reflect such changes in the de-
sign process. In many cases, clients concern more on the issues of functional require-
ment in facility programming and building operation but are less considerate on the
aspects of the healing effects that can be achieved through the careful orchestration of
the physical and socio-emotional design criteria for building users.”
4.4.3. EBD Practice
The design experts emphasized the necessity and importance of the EBD approach
in the design practice of hospitals. According to the specialists, empirical POE infor-
mation in the healthcare design research field is rare and often difficult to access in
South Korea. The experts commented that the lack of relevant POE data, especially
based on the local information, is due to the internal policy of a hospital organization
against the exposure of the shortcomings of a hospital’s resources, doubts about the ef-
fectiveness of POE, economic reasons, etc. Nevertheless, the specialists addressed that
the POE provides useful testimonials in the decision-making process; for example, in the
remodeling projects of the hospital’s internal and external areas, which takes place fre-
quently in South Korea. Owing to the lack of local research data, hospital design relies
on overseas’ information. In addition, during the consultation with clients, designers of-
ten experienced using data from other building types such as nursing home facilities,
Int. J. Environ. Res. Public Health 2023, 20, 1540 22 of 35
workspaces, etc. The scarcity of domestic POE data becomes a hurdle to convincing the
clients and drawing an aggregable decision. One design expert stated,
In many cases, clients and users are healthcare professionals. They are very specific
about their needs and think they know a lot more than architects in hospital design.
Because of this low credibility on architects, we are often struggled to persuade clients
to draw a better design solution.”
Access to EBD data and the EBD practice permit specialized information and skill-
sets catered to a higher level of design performance. By offering knowledge and reason-
able benchmarks on various hospital settings, design quality can be improved, and cli-
ents can be convinced through a suitable comparison [129]. However, according to the
experts, many architects often do not know what sources are available and where to find
them because of the disclosure of information from hospitals. Even if they find relevant
information, it is often from overseas’ resources that do not fit domestic situations.
4.4.4. Consideration of Diverse User Groups
The design experts commented that medical staff is often a primary source of data
in the design consultation when analyzing and facilitating a hospital’s spatial program;
although, there are multi-level users involved in the design of hospital projects. The de-
sign experts mentioned that they were often faced with medical healthcare practitioners
and/or medical university professors during the design process. As such, it was difficult
to equally reflect the needs and desires of other users such as patients, families, visitors,
etc., and the healthcare staff’s viewpoints impact the overall hospital design outcome.
For example, in the outpatient department, doctors’ treatment rooms are usually located
on the outskirts of a building and thus have an outdoor window view and daylight. The
experts highlighted that it is essential to increase opportunities to consult with various
hospital users including patients, nurses, administrative technicians, etc. One design ex-
pert stated,
Users are knowledgeable of their needs. Particularly, the clients, mostly, healthcare
professionals have very specific desires. However, the access to information on other
facets of healthcare users are extremely limited.”
Therefore, considering the complexity of hospital users and conflicts from diverse
healthcare user groups, it is necessary to work together toward a common goal by re-
sponding to specific knowledge and desires from various hospital users [129]. As such,
collaborative design efforts from intermediate design groups (e.g., clients, designers, re-
searchers, etc.) to end-user groups (e.g., patients, staffs, visitors, and all other users) are
necessary for successful therapeutic hospital design output [152].
4.4.5. Design Integration
The design experts viewed that healthcare facilities demand a complex design pro-
cess involving diverse specialties from various fields (i.e., architectural design, interior
design, mechanical, electrical, and plumbing engineering, landscape design, IoT, etc.).
However, the experts agreed that the coordination of such associative fields is challeng-
ing.
For example, spatial programming, planning for a future space change, technical
knowledge and design skills understanding medical equipment and work processes,
quality checks and control for legal and technical concerns are associated with not only
hospital facility design but also medical issues, permit documentation preparation and
permitting, construction administration, etc. One design expert stated,
In the project design team, architects are responsible and in charge of almost every-
thing from the exterior building design to medical space arrangement, mechanical elec-
trical and plumbing technical solutions, document permitting, design supervision dur-
ing construction, etc.”
Int. J. Environ. Res. Public Health 2023, 20, 1540 23 of 35
As a downfall, a specialty in each expertise may be lacking, making it difficult to
present a well-coordinated healing environment in the range of expected project costs.
As such, a team-based approach that utilizes specific skills and knowledge is highly rec-
ommended. Its advantage is to proceed to a design phase via a higher level of specific
and professional understanding of the function and performance involved in the hospi-
tal facility design. Such expert-based design coordination can help to draw more reason-
able and rational design alternatives when facing various problems in the design phase
[129].
4.5. Design Examples
To conclude the implications on healthcare design practice, two hospital design ex-
amples are case-studied, in which the knowledge of the significant healing design crite-
ria is conveyed in the design outcome. These examples demonstrate how architects’ ap-
proaches to healing design are reflected in the actual design results, any obstacles, and
what possible solutions can be sought to deliver the design team’s promises on thera-
peutic hospital place-making.
The first example is the entrance lounge design at the Shinchon Y. S. Hospital in
Seoul, South Korea, designed by Gansam Co. Ltd. (Figure 4). This project was initiated
to remodel the external space between an existing medical lab building and a newly
built hospital into a healing atrium space. The purpose of the design was to provide an
optimal resting space that is not affected by the season and the external environment
and that benefits various users from inpatients, outpatients, visitors, and hospital staff to
lab users (Figure 4a).
The original space was relatively narrow and an outdoor area between two build-
ings and was used as a passageway with no landscaping. By turning this space into an
indoor space with a natural garden and a rest area with indoor trails, the new space
changed the way people use the existing hospital entrance space. Since the completion of
its constriction in 2016, this lounge has intrigued not only hospital users but also pass-
ers-by to take a walk or rest, regardless of the season or weather conditions.
According to the interviewed project architect, the most emphasized design criteria
were to simulate natural greenery by planting real trees from the Southern part of South
Korea, introducing natural daylight and a rest space and creating a sense of openness
(Figure 4b). This has also helped make the hospital entrance more appealing and pro-
moted wayfinding as a focal point in the midst of the surrounding larger hospital com-
plex. The concept of the lounge design was influenced by various overseas and domestic
EBD information on the impact of nature on health [153,154].
It could have been an abandoned exterior space between the buildings, but I think this
lounge design is a pinpoint at which the client’s consumer-oriented value and the ar-
chitect’s design orientation are aligned. Usually, persuasion of medical clients is not an
easy process because functionality, efficiency, and saving construction costs are the cli-
ents’ primary interests. But, in this case, a consensus was found between the client and
the design team. The clients’ understanding of the healing space was very sophisticat-
ed. I think the most fundamental part in creating a healing environment comes
through the process of finding a common point between the client’s and designer’s val-
ues.”
However, the project architect wished to have access to POE data on the healing ef-
fects of the lounge design for building users. The project architect stated,
We have not found any research information from the hospital’s own investigation or
from any academic research institute on this lounge design. Either such data does not
exist, or even if it does, access to the data, especially if done from the hospital, would be
difficult to obtain. Typically, hospitals restrict disclosure of any kind of user related da-
ta, even when such information is not relevant to their medical record.”
Int. J. Environ. Res. Public Health 2023, 20, 1540 24 of 35
Concerning design guidelines, the Korea Institute for Healthcare Accreditation
provides a rough evaluation standard related to the hospital facility [155]. The architec-
tural guideline studies for healthcare design facilities were released by the Ministry of
Healthcare and Welfare [156]. These guidelines provide a broad perspective for safe and
high-quality medical services by listing the standards for safety management of facility
environments, facility systems, complementary hazardous materials (e.g., medical
wastes, chemicals), convenience and safety facilities. As such, these guidelines are insuf-
ficient to provide the physical and psycho-social environmental aspects to convey heal-
ing hospital design [157]. The project architect mentioned,
Since most hospitals do not have their own facility design guidelines concerning heal-
ing environments, design guidelines are mostly tailored to the specific hospital, which
are suggested by the project architects via consultation with healthcare staff during the
hospital design process. This was an exemplary case in which the clients’ advocation
and hospital users’ satisfaction (although not systematically researched) for the indoor
healing garden were high, and the lesson from this example will allow us to pursue a
similar or an upgraded indoor atrium space in other hospitals.”
(a)
(b)
(c)
Figure 4. (a) The lounge is located in-between two buildings and connects them- the medical re-
search lab building and a new hospital addition; (b) The indoor lounge includes a rest area with
plants, undulating walkways, and benches; (c) Daylight is introduced through the glazed curtain
walls and the overhead skylight in the ceiling) (Source: photos by author; The lounge was de-
signed by Gansam Co., Ltd.).
The second example is the design of inpatient wards at the Songdo Y. S. Hospital in
Incheon, South Korea (Figure 5). This hospital is based on a competition-winning design
proposal by the Samoo Architects and Engineers and the construction started in 2022.
South Korean urban hospitals often have outpatient and inpatient zones stacked
vertically in a single building structure owing to the limited land in the city. In this hos-
pital, the lower floors are dedicated to an outpatient department, central examination
labs, administrative offices, and socio-cultural supportive spaces. The upper tower floors
are composed of inpatient wards (Figure 5a).
Out of the numerous design dedications sought in this hospital proposal, the pro-
ject architect emphasized the inpatient ward design. In tune with the new South Korean
medical law in 2017, the inpatient ward unit design is based on a four-person room [158].
According to the project designer, the healing design concept is to secure privacy and
enhance comfort via natural daylight and view. The design team researched the EBD lit-
erature on patients’ satisfaction and preference for the size, distance, and location of the
patient rooms, beds, and room arrangement [159,160]. In addition, the interviews with
nurses on patients’ stress and discomfort in the typical inpatient unit design were ad-
ministered by the design team when initiating the design project. To provide improved
Int. J. Environ. Res. Public Health 2023, 20, 1540 25 of 35
privacy and daylight condition for each patient’s bed location, the design team expand-
ed the typical unit module of 6.6 m × 9.6 m to an 8.4 m × 8.4 m module, suggested the
outer periphery shape of the unit to be an alcove type, undulating form, and used exten-
sive glazed windows. The layout of each bed allows for a direct window view, daylight,
and increased patients privacy (Figure 5b). According to the interviewed project archi-
tect:
As a trade-off for the wider and expanded unit area, we proposed a more efficient
parking layout module which can reduce dead space in the basement parking floors.
This idea convinced the client because the improved inpatient ward design could im-
prove competitiveness with similar hospitals.”
As another effort to enhance the inpatient ward unit’s natural daylight, the design
team proposed a tower with a square-shaped floor plan instead of a typical, linear floor
plan. The square floor plan can allow direct contact with the outside air in four direc-
tions, which will increase the wards’ receipt of daylight from the outer periphery (Figure
5a).
We collaborated with an overseas design firm that conducts behavior simulation de-
sign through data algorithms. During the design process, our teams were able to create
a scenario based on nurses’ daily routines from the design team’s observational studies
and direct interviews with nurses because such data were not available from the hospi-
tal. By comparing the experimental results of the nurses’ simulated movement distance
according to the daily routine scenario in the square vs. linear floorplan, we confirmed
that the square floorplan shape reduced the nurse’s movement distance by approxi-
mately 38%. With the help of this simulation, we refined the floorplan and adjusted
orientation of the overall building so that there are no wards facing due direct north.
Furthermore, this data-based design collaboration resulted in higher praise from the
medical clients and eventually won the competition via our unique design challenge.”
In this example, a new multi-patient unit design was developed based on the initial
research efforts by the design team’s EBD data search on inpatient satisfaction and pref-
erence with the multi-person units. Furthermore, the unit design was transformed and
confirmed through the data simulation via collaborative study among the design fields.
As with the completion of the hospital in a few years, the design architect wishes to in-
vestigate the impacts of the design on users such as patients’ and nurses’ stress, fatigue,
satisfaction, etc. with the patient ward unit design and floorplan layout. Through this
POE, the project architects expect to obtain the design improvement points which can be
reflected in the follow-up attempts for the healing hospital design.
Int. J. Environ. Res. Public Health 2023, 20, 1540 26 of 35
(a)
(b)
Figure 5. (a) The lower section of the hospital includes an outpatient department, central medical
labs, and administrative department. The upper tower is dedicated to an inpatient department.
Unlike the typical hospitals, the overall shape of the tower is not linear but rectangular to enhance
the daylight condition in the inpatient wards and to reduce the corridor length traveled by nurs-
ing staff; (b) The design of the four-person inpatient unit type is devised to improve the daylight,
view, and privacy for each patient by an extensive exterior glazed window, an alcove-shaped
room, and bed arrangement. (Source: (a) photo by author taken from the construction site, (b) im-
age from Samoo Architects and Engineers; The original competition-winning design was pro-
posed by Samoo Architects and Engineers).
5. Conclusions
Designing a physical hospital environment includes a holistic approach, creating an
aesthetically pleasing and functionally efficient physical setting that is responsive to
human perception and behaviors [84]. In addition, healthcare facility design reflects the
socio-cultural values oriented by a specific healthcare organization [161].
In the design stage, architectural designers play a fundamental role in shaping the
healing hospital environment; the layout and usage of the hospital’s indoor and outdoor
spaces are configured, and the spatial ambiance evolves as a result. After completion,
the physical structure, primary usage, and spatial atmosphere remain relatively perma-
nent [9] and, together, make an immense impact on hospital users’ experiences. Subse-
quent adjustments at a later stage can be challenging particularly considering “the multi-
disciplinary nature” of healthcare facilities involving various participants and stake-
holders [84]. The architect’s role is essential not only in the design stage but also in the
long-term of a building’s lifecycle [162,163]. Considering their critical position in the cre-
ation of healthcare environments, considering architects’ viewpoints concerning the im-
portant therapeutic healthcare environmental criteria is an essential step to investigate a
user-centric healthcare design approach and outcome.
The findings of this study highlight that architects are not only concerned with the
physical place-making but also focus on the management criterion in creating healing
healthcare environments. According to healthcare design specialists, architects scruti-
nize the issues pertaining to the post-occupancy stage during the planning stage of a
building and thrive to reflect these problems in their design outcomes. Another signifi-
cant finding reveals that architects highlight the psycho-social facets of the healthcare
Int. J. Environ. Res. Public Health 2023, 20, 1540 27 of 35
environment concerning hospital users. In particular, the results showcase that the ser-
vice criteria as well as the nature and rest factors are emphasized by the architects. In
many previous studies, the quality of the psycho-social setting of hospitals was linked to
the perceived quality of the performance and delivery of healthcare service. This finding
provides an insight into architects’ awareness of the strength of the human service fac-
tors in healing healthcare place-making and the design’s orientation to accentuate the
human service delivery in the hospital.
In addition, this study sheds light on the significance of the nature and rest aspects
in making a therapeutic hospital environment. Much evidence has noted the value of na-
ture in relation to human health and well-being. The architects also agreed on the power
of nature and rest in the design of healing hospitals. Therapy gardens, rest areas on the
roof-top in urban hospitals, nature-themed art features in the hospital lobby and corri-
dors, etc., exemplify the value of nature as an important asset for hospital users’ healing.
Finally, the concept of humanized healing hospitals was underlined, especially by
female architects and older age designers. This finding may support previous studies, in
which female architects present a tendency to approach their design practices with sensi-
tivity, comprehensiveness, and inclusiveness based on the understanding of and empa-
thy for human needs. The finding from this research may also recall a previous study, in
which personal characteristics such as age and sex were related to the health perception,
behaviors, and activities regarding a sense of well-being among South Korean adults
and elders [164,165].
Methodological and practical implications of this research highlight the human-
centered therapeutic medical facility design as follows:
Avoiding obsolescence and rigidity to allow for flexible spatial reconfiguration for
future expansion and particularly for effective infection control and management.
Fostering socio-cultural service functions in healthcare facility design by integrating
art, new technology, and the organization’s healthcare design and service philoso-
phy.
Suggesting a new design guidance or accreditation system that promotes the im-
plementation of therapeutic healthcare design; for example, regulating a minimum
rest space area per bedsit, or by a certain percentage of patient and staff areas.
Promoting a multi-disciplinary and integrated healthcare design practice, based on
scientific research data. Validated design strategies through case studies and evi-
dence-based evaluation in domestic empirical hospital settings have not been suffi-
ciently linked to healthcare design practices. Through integrated research and de-
sign practice, decision-making in the design and management phases can be more
fluent, leading to successful healthcare design delivery.
The limitations of this study and directions for future research are as follows. In
writing a future survey or conducting interviews on therapeutic hospital design ele-
ments, a questionnaire design needs to be refined in terms of validating the variables in
the examination. As design is a visual field, this study’s text-based questionnaire could
not fully validate the variables in question. Along with the text-oriented questionnaire,
visual 2D, 3D, or real-time virtual reality representational materials can be integrated in-
to the research design to help validation. This may convey a more concrete projection of
the variables, but only if the visual information is situated in a proper healthcare context.
Measuring the level of importance through the variable comparisons may be another
way to refine the questionnaire design. This can help respondents precisely weigh and
judge the significance of the variables. In addition, the respondents’ profiles can be
measured more carefully in future research. Not only architects’ healthcare design prac-
tices but also their personal experiences with healthcare (e.g., hospitalization or visita-
tion) may lead to different response patterns to judging the importance of therapeutic
environmental elements.
Int. J. Environ. Res. Public Health 2023, 20, 1540 28 of 35
In future research, more diverse and refined case studies need to be conducted. As
this study aimed to identify how healing environmental elements are perceived and im-
plemented by healthcare designers in hospital design, profound discussion on what in-
terrupts the design delivery of healing architecture and how to improve the healing
quality of the actual hospital design outcomes is necessary. Information on healthcare
users’ behavioral and psychological responses to medical spaces and facilities is rarely
transparent, hindering the connection between EBD research and practice. Rigorous case
study investigations seeking data from diverse users’ empirical experiences in relation to
actual hospital environments in various sizes and locations across South Korea as well as
other regions are essential. Therefore, future researchers should endeavor to validate
and expand the findings from this study through refined methodologies and further
case studies.
Funding: This research was supported by the National Research Foundation of Korea (NRF) grant
funded by the Korea government (MSIT) (No. 2020R1A2C1012877).
Institutional Review Board Statement: The study was conducted in accordance with the Declara-
tion of Helsinki and approved by the Institutional Review Board of Inha University (no. 210405-2;
approved 12 May 2021).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the
study.
Data Availability Statement: All the data are presented in this study.
Acknowledgments: I express my special thanks to all the participants and especially to Jaeyeon
Seo and Minyeon Kim who assisted in collecting and analyzing the survey data for this study. I al-
so thank Gansam Co., Ltd. and Samoo Architects and Engineers for sharing informative
knowledge on their recent hospital design projects.
Conflicts of Interest: The author declares no conflict of interest. The funders had no role in the de-
sign of this study; in the collection, analyses, or interpretation of data; in the writing of the manu-
script, or in the decision to publish the results.
Appendix A
Table A1. Participants’ personal priority and firms’ priority in design implementation of the ther-
apeutic environmental variables.
Factors and Items
Personal
Firm
n
%
n
%
Factor 1: Manage-
ment
Hygiene
4
26.7
5
33.3
Safety
3
20.0
3
20.0
Maintenance
2
13.3
1
6.7
Factor 2:
Interior design
Color composition
1
6.7
1
6.7
Coordinated art and image
0
0.0
0
0.0
Furniture layout
2
13.3
0
0.0
Factor 3:
Spatial quality
Openness and visibility
3
20.0
3
20.0
Location and orientation
1
6.7
5
33.3
Wayfinding
3
20.0
4
26.7
Accessibility
1
6.7
6
40.0
Spatial privacy
6
40.0
3
20.0
Exterior appearance
0
0.0
6
40.0
Factor 4:
Service
Medical staff’s service
2
13.3
0
0.0
Administration staff’s service
2
13.3
0
0.0
Family service facility
1
6.7
0
0.0
Factor 5:
Nature and rest
Outdoor view
3
20.0
4
26.7
Natural light
5
33.3
6
40.0
Int. J. Environ. Res. Public Health 2023, 20, 1540 29 of 35
Green space
2
13.3
2
13.3
Rest and recreational space
4
26.7
2
13.3
Factor 6: Ambient
indoor comfort
Illumination
3
20.0
3
20.0
Thermal comfort
0
0.0
2
13.3
Air quality
4
26.7
5
33.3
Indoor noise
1
6.7
1
6.7
Factor 7:
Social program
and space
Health information program and
space
0
0.0
0
0.0
Socio-cultural program and space
1
6.7
1
6.7
Table A2. Frequency of applied variables in design implementation for therapeutic hospital envi-
ronment.
Factors and Items
More Frequent
Less Frequent
n
%
n
%
Factor 1:
Management
Hygiene
3
20.0
3
20.0
Safety
5
33.3
0
0.0
Maintenance
0
0.0
1
6.7
Factor 2:
Interior design
Color composition
0
0.0
3
20.0
Coordinated art and image
0
0.0
3
20.0
Furniture layout
0
0.0
3
20.0
Factor 3:
Spatial quality
Openness and visibility
5
33.3
6
40.0
Location and orientation
4
26.7
0
0.0
Wayfinding
10
66.7
1
6.7
Accessibility
4
26.7
0
0.0
Spatial privacy
1
6.7
2
13.3
Exterior appearance
4
26.7
1
6.7
Factor 4:
Service
Medical staff’s service
0
0.0
2
13.3
Administration staff’s service
0
0.0
2
13.3
Family service facility
1
6.7
6
40.0
Factor 5:
Nature and rest
Outdoor view
4
26.7
5
33.3
Natural light
7
46.7
1
6.7
Green space
5
33.3
5
33.3
Rest and recreational space
6
40.0
4
26.7
Factor 6:
Ambient indoor
comfort
Illumination
1
6.7
2
13.3
Thermal comfort
0
0.0
3
20.0
Air quality
2
13.3
3
20.0
Indoor noise
0
0.0
1
6.7
Factor 7:
Social program
and space
Health information program and
space
0
0.0
1
6.7
Socio-cultural program and space
2
13.3
2
13.3
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... For evaluating the success or performance areas of HPs, the key performance indicator (KPI) approach is the most utilized ahead of others such as balanced scorecard and post-occupancy evaluation [7][8][9][10][11][12]. Responsible practitioners define objectives for performance evaluation, select significant KPIs, gather and analyze relevant data, and present performance results to appropriate establishments or persons [13]. ...
... Due to ever-changing performance expectations, there is a need for the several fragmentary KPI frameworks to be consolidated, updated and enhanced to be suitable for multitudes of HPs and organizations in the current industry. In addition, the literature on KPI frameworks is so much focused on the "what" performance areas to measure including cost, time, and quality [11,17]. However, there is limited scholarly progression on "how" these suggested performance areas could be methodically, objectively and reliably evaluated. ...
... These three criteria serve as the most basic and common system for evaluating the performance of construction projects historically. Their relevance is key in this study because HPs are of unique characteristics (e.g., complexity), for handling emergency healthcare situations, and for sustaining lives [5,8,11,19,20,[27][28][29][30][31]. Accidents, injuries and casualties fraught the execution of construction HPs. ...
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The determinants of hospital project or healthcare project (HP) success are divergent and difficult to generalize because of the heterogeneous perceptions of various stakeholders. There is also a paucity of HP life cycle success evaluations from planning to post-construction phases. Meanwhile, the successful delivery and continual functionality of HPs are pivotal for sustainable development, as evident in the United Nations’ Sustainable Development Goal 3 about ensuring healthy lives and promoting wellbeing for all people. To contribute to sustainable development, a novel evaluation framework is essential to define robust metrics of selected key performance indicators (KPIs) for monitoring and controlling HPs at the life cycle phases thereof. Fuzzy set theory, namely the bisector error method (BEM), was applied to questionnaire survey outputs of an expert panel to establish performance metrics of HPs within five grades, namely, poor, average, good, very good and excellent. The novel evaluation framework comprising indexes, indicators and grades are demonstrated on hypothetical HPs to provide objective, reliable and practical outcomes for performance comparison, benchmarking and improvement purposes. The findings show that a high standard is required for excellent planning, execution, and performance in HPs. The life cycle success evaluation framework is foundational in policymaking. Thus, policymakers can track the success of HPs by linking the performance metrics to goals and policy priorities in benchmarking and strategic planning for sustainable development in HPs.
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... Understanding the views of medical doctors on therapeutic architecture is not only important for validating the effectiveness of current design approaches but also for informing future architectural innovations in healthcare (Cho, 2023). As healthcare systems worldwide face growing challenges, including aging populations, increasing demand for services, and rising healthcare costs, creating environments that optimize patient www.afropolitanjournals.com outcomes and operational efficiency is more important than ever (Gu, Andreev & Dupre, 2021). ...
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The environment in healthcare facilities can influence health and recovery of service users and furthermore contribute to healthy workplaces for staff. The concept of therapeutic landscapes seems to be a promising approach in this context. The aim of this qualitative meta-analysis is to review the effects of therapeutic landscapes for different stakeholders in psychiatric care facilities. A systematic literature search was conducted in the four data bases PubMed, PsycInfo, CINAHL, and Web of Science. Thirteen predominately qualitative studies were included in this qualitative meta-analysis. The methodological quality of these qualitative studies was assessed, using an adapted version of the Journal Article Reporting Standards for Qualitative Research, and a thematic analysis was conducted. The results were categorised into the three main themes of the physical (built and natural), social, and symbolic dimensions of the therapeutic landscape. Given the heterogeneity of the summarised data and an overall methodological quality of the included studies that can be rated as medium, the results should be interpreted with caution. Current findings are based almost exclusively on qualitative studies. Therefore, there is a need for quantitative study designs that investigate the relationship between specific environmental elements and mental health outcomes for different stakeholders in psychiatric facilities.
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Objectives The purpose of this scoping review is to identify evidence on how characteristics of healing architecture in clinical contexts impact clinical practice and patient experiences. Based on these insights, we advance a more practice-based approach to the study of how healing architectures work. Background The notion of “healing architecture” has recently emerged in discussions of the spatial organization of healthcare settings, particularly in the Nordic countries. This scoping review summarizes findings from seven articles which specifically describe how patients and staff experience characteristics of healing architecture. Methods This scoping review was conducted using the framework developed by Arksey and O’Malley. We referred to the decision tool developed by Pollock et al. to confirm that this approach was the most appropriate evidence synthesis type to identify characteristics related to healing architecture and practice. To ensure the rigor of this review, we referred to the methodological guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews. Results There are two main findings of the review. First, there is no common or operative definition of healing architecture used in the selected articles. Secondly, there is limited knowledge of how healing architecture shapes clinical and patient outcomes. Conclusions We conclude that further research is needed into how healing architectures make a difference in everyday clinical practices, both to better inform the development of evidence-based designs in the future and to further elaborate criteria to guide postoccupancy evaluations of purpose-built sites.
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Environmental noise has been growing in recent years, causing numerous health problems. Highly sensitive environments such as hospitals deserve special attention, since noise can aggravate patients’ health issues and impair the performance of healthcare professionals. This work consists of a systematic review of scientific articles describing environmental noise measurements taken in hospitals between the years 2015 and 2020. The researchers started with a consultation of three databases, namely, Scopus, Web of Science, and ScienceDirect. The results indicate that for the most part, these studies are published in journals in the fields of medicine, engineering, environmental sciences, acoustics, and nursing and that most of their authors work in the fields of architecture, engineering, medicine, and nursing. These studies, which are concentrated in Europe, the Americas, and Asia, use as reference values sound levels recommended by the World Health Organization. Leq measured in hospital environments showed daytime values ranging from 37 to 88.6 dB (A) and nighttime values of 38.7 to 68.8 dB (A). Leq values for outdoor noise were 74.3 and 56.6 dB (A) for daytime and nighttime, respectively. The measurements were taken mainly inside hospitals, prioritizing more sensitive departments such as intensive care units. There is a potential for growth in work carried out in this area, but research should also include discussions about guidelines for improvement measures aimed at reducing noise in hospitals. Graphical abstract