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Citation: Feng, H.; Liu, Y.; Liu, Z.; Chi,
Z.; Osmani, M. Sustainable Healing
and Therapeutic Design Driven
Well-Being in Hospital Environment.
Buildings 2024,14, 2731. https://
doi.org/10.3390/buildings14092731
Academic Editor: Antonio Caggiano
Received: 22 July 2024
Revised: 25 August 2024
Accepted: 28 August 2024
Published: 31 August 2024
Copyright: © 2024 by the authors.
Licensee MDPI, Basel, Switzerland.
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4.0/).
buildings
Article
Sustainable Healing and Therapeutic Design Driven Well-Being
in Hospital Environment
Haoran Feng 1, †, Yi Liu 1, *,† , Zhen Liu 2, * , Ziyuan Chi 3and Mohamed Osmani 4
1School of Innovation, Guangzhou Academy of Fine Arts, Guangzhou 510261, China;
fenghaoran@gzarts.edu.cn
2School of Design, South China University of Technology, Guangzhou 510006, China
3Innovation and Entrepreneurship College, Guangzhou Xinhua University, Dongguan 510520, China;
ziyuanchi@outlook.com
4
School of Architecture, Building and Civil Engineering, Loughborough University, Loughborough LE11 3TU,
UK; m.osmani@lboro.ac.uk
*Correspondence: liuyi@gzarts.edu.cn (Y.L.); liuzjames@scut.edu.cn (Z.L.)
†These authors contributed equally to this work.
Abstract: Despite the growing awareness of healing hospitals, they are still far from being globally
widespread, and traditional hospital building models are increasingly unable to address the seri-
ous resource constraints and environmental stresses that we face today. In addition, sustainable
development concepts have become key driving forces in the construction process of healing build-
ings. Currently, while research on healing hospital design continues to grow, there is relatively little
that specifically addresses the integration of sustainable development concepts. Hence, this paper
aims to explore the current state of development and knowledge structure of sustainable healing
and therapeutic design (HTD) in hospital scenarios using a systematic methodology that integrates
macro-quantitative bibliometric analysis and follow-up micro-qualitative content analysis methods
based on data from the Web of Science (WOS) database, which investigates eight research objectives,
including the background, current state, hotspots, high-frequency words, integration with sustainable
development goals (SDGs), particularly SDG3, “Ensure healthy lifestyles and promote well-being of
people of all ages”, and the challenges posed by public health emergencies, such as the COVID-19
era, for sustainable HTD in hospitals. This paper identified six main clusters: the environment of
a hospital, mental health, quality of life, illness and care, COVID-19, and wound healing. These
clusters were taken from keyword network visualization analysis, emphasizing key terms focused
on wound healing, mental health, quality of life, nursing, children, and evidence-based design via
high-frequency keyword analysis. These have been further grouped into three categories: strategy,
approach, and method. Subsequently, this paper further explores how hospital HTD relates to SDG 3
targeted on reducing child mortality (SDG 3.2), promoting mental health and physical health (SDG
3.4), and achieving universal health coverage (SDG 3.8) to explore wound healing, mental health,
quality of life, nursing, and children, which are stressed in the results of both macro-quantitative
bibliometric and follow-up micro-qualitative content analyses. In addition, it is shown that more
changes should be made to sustainable hospital HTD in the context of the pandemic era to cope with
unpredictable crises. Finally, the expression HTD is discussed to justify the keywords. The results of
this study complement sustainable hospital HTD and provide assistance to future architects, policy
makers, and healthcare professionals.
Keywords: hospital; sustainability; healing; therapeutic; design; health; well-being; sustainable
development goals (SDGs)
1. Introduction
Hospitals are not only just places for providing medical services but also are complex
entities whose operations are deeply rooted in health concepts, welfare, ethical considera-
Buildings 2024,14, 2731. https://doi.org/10.3390/buildings14092731 https://www.mdpi.com/journal/buildings
Buildings 2024,14, 2731 2 of 26
tions, and environmental protection. They are intricate and complex places, encompassing
multiple dimensions and interconnected elements [
1
]. In this context, medical practice not
only aims to cure diseases but also focuses on the overall well-being of patients, adheres to
medical ethical norms, and strives to create a sustainable development environment [
2
].
Therefore, the existence and development of hospitals are multi-dimensional and all-round
processes that intend to promote the comprehensive enhancement of human health. In or-
der to provide high-quality healthcare services to citizens, hospital design should take more
consideration of health and psychological needs [
3
]. The concept of healing architecture
focuses on using the built environment to promote the physical and mental well-being of pa-
tients, which has significantly changed in the field of spiritual health services [
4
]. However,
there is still much to learn about how specific design details affect clinical outcomes and
patient recovery. Its importance lies in unveiling the possible links between building design
and health results, providing a key entry point for improving medical environments.
Healing and therapeutic design (HTD) for hospitals is a patient-centered design
approach that aims to promote the physical and mental health of patients by creating
a comfortable and serene environment [
5
]. This design approach not only focuses on
the layout and function of physical spaces but also considers the emotional needs and
psychological states of patients and how environmental factors can assist in treatment and
accelerate the healing process [
4
]. For example, the New Herlev Hospital in Denmark is
designed based on the healing effects of nature and sunlight [
6
]. This approach is realized
through lush gardens, green roofs, and a large central green area, creating an environment
that facilitates rapid patient recovery. Additionally, in the outdoor environment of the
Tiantan Hospital of Beijing Medical University in Anhui China, the river design is used
as an axis to connect the river walk, roof garden, landscape retreat, resting balcony and
central courtyard, creating a five-dimensional green eco-healing space for patients [
7
]. The
above examples demonstrate the focus on the efficient and flexible use of space in hospitals,
as well as human-centered space design, to provide a high-quality environment to enhance
patient treatment experiences.
Despite the growing awareness of healing hospitals, they are still far from being
globally widespread, and traditional hospital building models are increasingly unable to
address the serious resource constraints and environmental stresses that we face today [
8
].
In this context, sustainable development concepts have become key driving forces in the
construction of healing buildings. Currently, while research on healing hospital design
continues to grow, relatively little specifically addresses the integration of sustainable
development concepts. The majority of existing research focuses on the impact of healing
hospitals on the quality of life of patients or healthcare workers [
9
,
10
], as well as their mental
health [
11
,
12
] and physical health [
13
,
14
]. Extra attention is paid to outdoor landscape
design [
15
,
16
] and specific areas within hospitals, such as children’s wards [
17
–
19
], and
intensive care units [
20
,
21
]. Therefore, the aim of this paper is to explore sustainable HTD in
hospitals. Initially, an overview of the existing studies on the utilization of HTD in hospitals
is provided. Additionally, future trends and challenges in sustainable HTD in hospitals in
response to the sustainable development goals (SDGs), particularly SDG3, “Ensure healthy
lifestyles and promote well-being of people of all ages”, are explored.
2. Materials and Methods
This paper explores the current state of development and the knowledge structure of
sustainable HTD in hospital scenarios using a systematic methodology based on data from
the Web of Science (WOS) database, with the aim of comprehensively and systematically
collecting, integrating, and appraising the existing published studies to answer research
questions and to explore the current status, trends, and issues [
22
]. This methodology has a
wide range of applications in healthcare, offering a valuable means for assessing the effec-
tiveness and safety of healthcare interventions, as well as the quality and effectiveness of
healthcare services [
23
]. As shown in Figure 1, the research process of this paper consists of
six phases: (1) defining the research question, (2) searching databases, (3) defining selection
Buildings 2024,14, 2731 3 of 26
and quality standards, (4) performing macro-quantitative data analysis, (5) conducting
micro-qualitative content analysis, and (6) discussing the findings.
Buildings 2024, 14, x FOR PEER REVIEW 3 of 27
questions and to explore the current status, trends, and issues [22]. This methodology has
a wide range of applications in healthcare, offering a valuable means for assessing the
effectiveness and safety of healthcare interventions, as well as the quality and effectiveness
of healthcare services [23]. As shown in Figure 1, the research process of this paper con-
sists of six phases: (1) defining the research question, (2) searching databases, (3) defining
selection and quality standards, (4) performing macro-quantitative data analysis, (5) con-
ducting micro-qualitative content analysis, and (6) discussing the findings.
Figure 1. The flowchart of the research methodology (generated by the authors).
2.1. Phase 1: Defining the Research Questions
The purpose of this paper is to explore “sustainable HTD in hospitals”, for which the
following eight objectives were addressed:
Q1: What is the research background of hospitals and HTD?
Figure 1. The flowchart of the research methodology (generated by the authors).
2.1. Phase 1: Defining the Research Questions
The purpose of this paper is to explore “sustainable HTD in hospitals”, for which the
following eight objectives were addressed:
Q1: What is the research background of hospitals and HTD?
Q2: What is the current state of research on hospitals and HTD?
Q3: What are the hotspots in research on hospitals, sustainability, and HTD?
Q4: What are the high-frequency keywords and classifications in research on hospitals,
sustainability, and HTD?
Q5: What are hospital, HTD and SDG 3.2 reducing child mortality?
Buildings 2024,14, 2731 4 of 26
Q6: What are hospital, HTD and SDG 3.4 promoting physical and mental health?
Q7: What are hospital, HTD and SDG 3.8 achieve universal health coverage?
Q8: What are COVID-19 era warnings for sustainable hospital HTD?
2.2. Phase 2: Searching the Database
In this research, the WOS Core Database (WOSCC), which is known as the most
important data source for bibliometric analyses, was used as the data collection source. The
keywords “hospital”, “healing and therapeutic design”(HTD), “sustainable”, and “health”
were applied.
Table 1illustrates the keyword screening phrases that were searched and the number
of documents that were subsequently identified. In total, there were 8827 (1932 + 6749
+ 146) articles on the topics “hospital” and “HTD”. However, the number of articles
retrieved through the “title”-searching process was reduced to 27 (19 + 8). The three
keywords “hospital”, “HTD”, and “sustainability” appeared together in 24 (16 + 8) articles.
However, when “hospital”, “HTD”, and “health” are considered together, the number
of articles rises to 2118 (1671 + 447). Considering the close relationship between health
and the concepts of “hospital” and “HTD”, the keyword “health” was shown to be of
significant importance. Concurrently, as “sustainability” represents a common objective
across numerous industries, and with the current paucity of interdisciplinary research,
there is a compelling opportunity to investigate the integration of sustainability with the
design of hospitals and healthcare facilities. The aforementioned considerations are based
on keyword searching and document counting.
Table 1. Keyword terms and number of searches for data collection (generated by the authors).
Keywords Number of Documents Searched
(TOPIC (hospital) AND TOPIC (healing design)) 1932
(TOPIC (hospital) AND TOPIC (therapeutic design)) 6749
(TOPIC (hospital) AND TOPIC (healing and
therapeutic design)) 146
(TITLE (hospital) AND TITLE (healing design)) 19
(TITLE (hospital) AND TITLE (therapeutic design)) 8
(TITLE (hospital) AND TITLE (sustainability)) 181
(TOPIC (hospital) AND TOPIC (healing design) AND
TOPIC (sustainability)) 16
(TOPIC (hospital) AND TOPIC (therapeutic design) AND
TOPIC (sustainability)) 8
(TOPIC (hospital) AND TOPIC (therapeutic design) AND
TOPIC (health)) 1671
(TOPIC (hospital) AND TOPIC (healing design) AND
TOPIC (health)) 447
2.3. Phase 3: Defining Selection and Quality Standards
A large number of studies were retrieved in the above phase, and there were duplicates
and results of little relevance or irrelevant to the research questions, which needed to be
filtered in line with the following criteria:
(1) Filtering duplicate documents;
(2) Excluding publications that are not relevant to the research topic of hospitals;
(3) Excluding research that did not mention design;
(4) Excluding non-English texts;
(5) Adopting articles collected from high-quality databases;
(6) Preference was given to articles that were widely cited in their field;
(7) Adoption of peer-reviewed journal or conference papers;
(8) Preference for articles related to sustainability and HTD.
A total of 2210 texts were retained for macro-quantitative analysis, and the most
relevant 100 articles were identified for micro-qualitative analysis.
Buildings 2024,14, 2731 5 of 26
2.4. Phase 4: Macro-Quantitative Bibliometric Analysis
The main tools used for this phase are the VOSviewer 1.6.15 software and the Citespace
6.3.1 software tools, which were used to analyze the data taken from the WOSCC database.
VOSviewer is a tool used to construct and visualize bibliometric networks, with a clustering
display that analyses the co-occurring relationships between keywords and indicates the
topics represented by clusters [
24
]. Citespace is citation visualization and analysis software
that helps to analyze potential knowledge and illustrate hotspots and trends within related
fields [
25
]. Therefore, this paper employed these two software tools to help understand the
current state of research and hotspots in sustainable HTD in hospital scenarios.
This stage is carried out in three steps. Firstly, descriptive statistics on the annual
publication volume and journal sources of the research topic were carried out, which
can be used to obtain data through the analysis tools provided by WOSCC to obtain the
background and research trends in the field; secondly, keyword co-occurrence analysis
was carried out using VOSviewer, from which the keywords within the obtained clusters
and the relationships between the clusters and inter-clusters were examined to reflect the
current status of “hospital”, “HTD”, “sustainability”, and “health”; the third step was to
analyze keyword burst detection through VOSviewer high-frequency words and Citespace
to confirm research hotspots and trends. The combination of these two tools yields an
objective and comprehensive understanding of the current developmental situation as well
as the research hotspots and trends encompassed.
2.5. Phase 5: Micro-Qualitative Analysis
Based on the results of the macro-quantitative analysis, the key themes are categorized
into three parts: strategy, approach, and method. These themes are centered around
“wound healing”, “mental health”, “quality of life”, “nursing”, “children”, and “evidence-
based design” to explore the current development of HTD in hospitals in detail.
2.6. Phase 6: Discussion
Based on the macro- and micro-analyses, there are fewer studies that mention “sus-
tainability”. This section explores how SDG 3 can be applied to hospital HTD, as well as
warnings about sustainable hospital HTD in the context of public health emergencies, such
as the COVID-19 pandemic. The limitations of this paper are discussed, particularly the
ways in which the terms “healing design and therapeutic design” are defined and whether
the collection of texts may have influenced the results.
3. Results
3.1. Results of Macro-Quantitative Bibliometric Analysis
3.1.1. Descriptive Statistics
•Number of publications
Changes in the annual number of publications and citations can reflect the overall
research trends in the research topic, which can be used to find out whether the topic is
popular or has recently been receiving more attention. This method is a way of presenting
citations and publications together with the literature obtained from all the keyword
combinations. However, due to the limitations of the WOS analysis, it is not possible to
analyze the search results of multiple combinations; only one keyword combination can be
analyzed at a time. Therefore, this paper started with a visual analysis of all the keyword
combinations, as shown in Table 1, the results of which suggested that the research intensity
of the subject matter is on the rise. The keywords “hospital” and “HTD” were chosen to
present the literature published on the topic, as shown in Figure 2. The search includes
both the research background “hospital” and “therapeutic design” for treating psychology
and disability as well as “healing design” for restoring health and becoming healthy. As
shown in Figure 2, relevant published studies have appeared since 1997. Fluctuations
have occurred in the number of publications each year, and this persisted until 2016.
Beginning in 2017, there has been a continuous increase, maintaining an average of more
Buildings 2024,14, 2731 6 of 26
than 10 publications annually. The citation frequency of this topic also grew from two times
in 1998 to more than a hundred times in 2014, reaching 279 citations in 2022. In recent years,
the number of publications and citations of the research topic, “hospital”, and “HTD”, has
shown an obvious growth trend, becoming a hot topic in recent years and receiving greater
recognition and attention.
Buildings 2024, 14, x FOR PEER REVIEW 6 of 27
combinations, as shown in Table 1, the results of which suggested that the research inten-
sity of the subject maer is on the rise. The keywords “hospital” and “HTD” were chosen
to present the literature published on the topic, as shown in Figure 2. The search includes
both the research background “hospital” and “therapeutic design” for treating psychol-
ogy and disability as well as “healing design” for restoring health and becoming healthy.
As shown in Figure 2, relevant published studies have appeared since 1997. Fluctuations
have occurred in the number of publications each year, and this persisted until 2016. Be-
ginning in 2017, there has been a continuous increase, maintaining an average of more
than 10 publications annually. The citation frequency of this topic also grew from two
times in 1998 to more than a hundred times in 2014, reaching 279 citations in 2022. In
recent years, the number of publications and citations of the research topic, “hospital”,
and “HTD”, has shown an obvious growth trend, becoming a hot topic in recent years
and receiving greater recognition and aention.
Figure 2. The number of articles and citations on “hospital” and “healing and therapeutic design
(HTD)” published annually in the Web of Science Core Collection (WOSCC) database from the first
related publication from 1997 to 2024 (28 years) (generated by the authors).
• Sources of publications
From data of the past 28 years (1997 to 2024) in the WOSCC database, a total of 69
studies have been published related to “hospitals” and “HTD”. Table 2 shows the top ten
publications in terms of volume and percentage, with their topics mainly being centered
on medical-related topics, accounting for 73.759% of all the published studies.
Among them, the top theme “Surgery” was present in most studies (14.184%), fol-
lowed by “Public Environmental Occupational Health” (11.348%) and “Medicine General
Internal” (10.638%), “Dermatology” (6.383%), “Integrative Complementary Medicine”
(6.383%), “Nursing” (6.383%), “Orthopedics” (5.674%), “Architecture” (4.255%), “Envi-
ronmental Sciences” (4.255%), and “Medicine Research Experimental” (4.255%). Thus, the
research themes of “hospital” and “HTD” are mainly centered around surgery, public en-
vironments, occupational health, medicine, nursing, and architecture.
Table 2. Top 10 most productive sources of studies on “hospital” and “HTD” from 1997 to 2024
(generated by the authors).
Ranking Publication Titles Record Count % of 141
Top 1 Surgery 20 14.184
Top 2 Public Environmental Occupational Health 16 11.348
Top 3 Medicine General Internal 15 10.638
Top 4 Dermatology 9 6.383
Figure 2. The number of articles and citations on “hospital” and “healing and therapeutic design
(HTD)” published annually in the Web of Science Core Collection (WOSCC) database from the first
related publication from 1997 to 2024 (28 years) (generated by the authors).
•Sources of publications
From data of the past 28 years (1997 to 2024) in the WOSCC database, a total of
69 studies have been published related to “hospitals” and “HTD”. Table 2shows the top
ten publications in terms of volume and percentage, with their topics mainly being centered
on medical-related topics, accounting for 73.759% of all the published studies.
Table 2. Top 10 most productive sources of studies on “hospital” and “HTD” from 1997 to 2024
(generated by the authors).
Ranking Publication Titles Record Count % of 141
Top 1 Surgery 20 14.184
Top 2 Public Environmental
Occupational Health 16 11.348
Top 3 Medicine General Internal 15 10.638
Top 4 Dermatology 9 6.383
Top 5 Integrative Complementary
Medicine 9 6.383
Top 6 Nursing 9 6.383
Top 7 Orthopedics 8 5.674
Top 8 Architecture 6 4.255
Top 9 Environmental Sciences 6 4.255
Top 10
Medicine Research Experimental
6 4.255
Among them, the top theme “Surgery” was present in most studies (14.184%), followed
by “Public Environmental Occupational Health” (11.348%) and “Medicine General Internal”
(10.638%), “Dermatology” (6.383%), “Integrative Complementary Medicine” (6.383%),
“Nursing” (6.383%), “Orthopedics” (5.674%), “Architecture” (4.255%), “Environmental
Sciences” (4.255%), and “Medicine Research Experimental” (4.255%). Thus, the research
themes of “hospital” and “HTD” are mainly centered around surgery, public environments,
occupational health, medicine, nursing, and architecture.
Buildings 2024,14, 2731 7 of 26
3.1.2. Network Analysis
•Keyword network visualization
The obtained data were imported into VOSviewer for keyword co-occurrence analysis,
with keywords used as the unit for analysis, resulting in 5335 keywords. Since the number
of keywords was too large, the minimum number of co-occurrences was set to 5, from
which a total of 374 keywords met the requirements after the elimination of 27 meaningless
keywords.
Network visualization in the VOSviewer software tool shows the text, circles, connect-
ing lines, and color blocks to present the associated keywords, where larger circles assigned
to the text indicate the higher occurrence frequency of the expressed keyword; the thicker
the connecting line between two circles, the stronger their direct affinity; the shorter the
connecting line (the closer it is), the higher the correlation; and the colors represent different
clusters that also reveal relationships within and between clusters. As shown in Figure 3,
there are six clusters, i.e., blue, yellow, green, red, purple and orange, on “hospital”, “HTD”,
“health” and “sustainability” in the WOSCC database.
Buildings 2024, 14, x FOR PEER REVIEW 7 of 27
Top 5 Integrative Complementary Medicine 9 6.383
Top 6 Nursing 9 6.383
Top 7 Orthopedics 8 5.674
Top 8 Architecture 6 4.255
Top 9 Environmental Sciences 6 4.255
Top 10 Medicine Research Experimental 6 4.255
3.1.2. Network Analysis
• Keyword network visualization
The obtained data were imported into VOSviewer for keyword co-occurrence analy-
sis, with keywords used as the unit for analysis, resulting in 5335 keywords. Since the
number of keywords was too large, the minimum number of co-occurrences was set to 5,
from which a total of 374 keywords met the requirements after the elimination of 27 mean-
ingless keywords.
Network visualization in the VOSviewer software tool shows the text, circles, con-
necting lines, and color blocks to present the associated keywords, where larger circles
assigned to the text indicate the higher occurrence frequency of the expressed keyword;
the thicker the connecting line between two circles, the stronger their direct affinity; the
shorter the connecting line (the closer it is), the higher the correlation; and the colors rep-
resent different clusters that also reveal relationships within and between clusters. As
shown in Figure 3, there are six clusters, i.e., blue, yellow, green, red, purple and orange,
on “hospital”, “HTD”, “health” and “sustainability” in the WOSCC database.
Figure 3. Keyword network visualization of “hospital”, “HTD”, “health”, and “sustainability” in
the WOSCC database using VOSviewer (generated by the authors).
Cluster 1 (yellow) centers around terms relating to the environment of a “hospital”,
including keywords such as “healthcare”, “healing environment”, “pain”, “patient
safety”, “well-being”, “healthcare facilities”, “architecture”, “design”, “hospital design”,
“interior design”, “biophilic design”, and “satisfaction”. This indicates that relevant re-
search focuses on discussing the impact of hospital architecture and interior and exterior
environments on healthcare. The design of these environments is closely related to patient
recovery and medical experience [5]. This is not just relevant for hospitals, therapeutic
architecture has now become a discipline within medical building design, highlighting
Figure 3. Keyword network visualization of “hospital”, “HTD”, “health”, and “sustainability” in the
WOSCC database using VOSviewer (generated by the authors).
Cluster 1 (yellow) centers around terms relating to the environment of a “hospital”,
including keywords such as “healthcare”, “healing environment”, “pain”, “patient safety”,
“well-being”, “healthcare facilities”, “architecture”, “design”, “hospital design”, “interior
design”, “biophilic design”, and “satisfaction”. This indicates that relevant research focuses
on discussing the impact of hospital architecture and interior and exterior environments on
healthcare. The design of these environments is closely related to patient recovery and med-
ical experience [5]. This is not just relevant for hospitals, therapeutic architecture has now
become a discipline within medical building design, highlighting the significant positive
interventions that architectural design can have on patient treatment and recovery [
26
]. In
addition, as an evidence-based design approach, “evidence-based design” is widely used
to achieve sustainable healthcare services, including the importance of service landscapes
in rehabilitation environments [
27
], post-occupancy evaluations [
28
], and medical intensive
care environments [
29
]. Evidence-based design helps to better understand patient needs
and preferences, allowing for the creation of healthcare products and services that meet
patient demands while also improving the effectiveness and safety evaluation of these
products and services. Meanwhile, the population of “children” should not be overlooked,
especially because “children” frequently appears as a keyword. Relevant HTD research fo-
Buildings 2024,14, 2731 8 of 26
cuses on the design of “healing gardens” in pediatric or children’s hospitals. Garden plants
provide a multisensory comfort experience through visual and olfactory stimuli [
30
], and
their medicinal properties also contribute to healing [
31
]. It is known that the therapeutic
effects of nature can alleviate patients’ pain and depression. Therapeutic landscape design
has a positive impact on promoting children’s mental health [
32
], and the introduction
of biophilic design patterns plays a practical role in patient recovery [
33
]. Further, the
keyword “sustainability” is very close to “hospital.” Sustainability in this field is reflected
in the design of sustainable healthcare buildings using natural elements or sustainable
finishing materials [
4
,
34
], with attention to improving indoor environmental quality [
35
],
such as air and heating systems [36].
Cluster 2 (green) shows that “mental health” is one of the most important keywords
for the research theme, followed by “nurses”, “nursing”, and “depression”. Treatment
design interventions are not only about physical health but also about mental health,
not only for patients but also visitors and staff. Therapeutic environments play crucial
roles in recovery from mental illness, expressed in the form of external landscapes, interior
decorations, light, art, and sound [
12
,
37
]. In addition, “suicide” and “hypertension” are also
described as major research areas where “mobile health” is involved. In order to provide
more convenient health services, mobile medical interventions have been developed and
promoted in many hospitals to provide psychological counseling and treatment for mental
health conditions, which are especially appropriate support for young people facing suicidal
crises [
38
]. This is also relevant for lifestyle-centered text messaging for cardiovascular
disease patients in terms of mitigating the impact of risk factors [
39
]. Further, mobile
healthcare allows for the treatment environment to be no longer confined to hospitals but
rather enables remote diagnostic monitoring and universal access at home, reducing patient
waiting times and improving the quality of services [40].
Cluster 3 (red) focuses on “quality of life”, involving a high proportion of nurses and
critically ill patients, as well as in-patients and physicians. There are more references to
quality of work life and analyses of how people experience their work, such as nurses
and other healthcare professionals [
41
]. Nursing positions are subject to a high level of
turnover [
42
,
43
]. In general, the most disabled patients have the poorest quality of life and
care in hospitals [
44
], and subjective quality of life scales should be developed for different
condition domains [
45
]. In addition, keywords such as “rehabilitation”, “anxiety”, “cancer”,
“public health”, “palliative care”, and “health services” receive more attention. Apart from
hospitals, clinics, community health service centers, schools, and other places are important
venues for the provision of public health services, providing disease prevention, especially
relating to cancer, health education, and healthcare services to improve public health and
reduce disease morbidity and mortality. Further, “older adults” are the main population
that appeared in this cluster, and more studies have been dedicated to improving the health
and quality of life of older adults via examinations of the organizational factors that affect
hospital services [
46
], assistive devices for older adults [
47
], and spatial accessibility [
48
] to
improve older people’s hospital and service satisfaction.
The main keywords in Cluster 4 (purple) concern illness and care: “mortality”, “critical
care”, “intensive care”, “pediatrics”, “prognosis”, and “critical illness”. Mortality rates
are influenced by a variety of factors, including age, gender, race, geographic location,
lifestyle, environmental factors, and level of healthcare. In general, mortality rates increase
gradually with age. This is due to the gradual decline in physical function and immunity
with age, making this population more susceptible to various diseases, such as heart disease,
cancer, and diabetes. Mortality in older adults in intensive care units is associated with
changes in the characteristics of intensive care unit (ICU) care that can have implications
for patient prognostic strategies [
49
,
50
]. In reference to critical care, pediatric intensive
care is an important part of reducing global mortality, providing a conducive treatment
environment, equipment and expertise, and appropriate intensive care services to reduce
pediatric morbidity and mortality [
51
]. Hence, mortality is a key indicator when measuring
the effectiveness and social equity of interventions.
Buildings 2024,14, 2731 9 of 26
Cluster 5 (blue) is related to “COVID-19”, and “healing”, “surgery”, “treatment”,
“randomised controlled trial”, “fracture”, and “infection” are associated. COVID-19 is
highly contagious and resulted in a pandemic that involved large numbers of infected
people who traveled to hospitals or medical isolation sites for treatment. During this period,
multiple studies were produced with the aim of improving cure rates. For example, the risk
of infection was reduced by designing resilient hospitals, improving the layout of hospital
buildings, and altering patient pathways [
52
,
53
]. Research also looked into designing
outdoor spaces, such as gardens and green spaces, to provide resting places for healthcare
workers to alleviate work stress and anxiety [11,54].
Cluster 6 (orange) contains “wound healing” as the core term, with keywords such
as “pressure ulcer”, “wound care”, “telemedicine”, “postoperative complications”, and
“wound infection”. The presence of the keyword “wound healing” is both unexpected
and justified. Wound healing and HTD are interconnected in promoting patient recovery
and comfort in healthcare environments. Studies have focused on how to accelerate
wound recovery through various therapeutic means and whether the level of wound
healing is good at different sites, whether it is delayed or not, and the environment;
further, randomized controlled trials have been conducted to determine optimal healing
methods [55–57].
The above cluster analysis was used to analyze the main keywords in the field, as-
sisting our ability to understand the research hotspots in the field. Concerning the SDGs,
the keywords mainly focus on SDG 3. Good health and well-being, as achieved through
designs that create a comfortable and peaceful healing environments, promote the physical
and mental health of patients and improve the effectiveness of patient treatment and the
speed of recovery.
•High-frequency keyword analysis
Table 3shows the top 12 keywords from 1997 to 2024, with co-occurrence seen in
studies focusing on “hospital”, “HTD”, “sustainability”, and “health”; here, the influence is
positively correlated with the intensity and frequency of connections. In addition, Table 4
lists the top 24 most-cited keywords derived when using Citespace on related studies from
1997 to 2024. Further, the main keyword themes presented in Table 3is supplemented by
the high-frequency keyword analysis detailed in Table 4. Citespace burst detection can be
used to identify and explore the research frontiers and latest trends in a particular field,
which are usually considered to have been the research hotspots in a field during that
period of time [58].
Table 3. High-frequency keywords from published articles regarding “hospital”, “HTD”, and
“sustainable” from 1997 to 2023 created using VOSviewer network visualization (generated by
the authors).
Cluster Keyword Occurrence Total Link Strength
1 Hospital 110 212
6 Wound Healing 102 160
3 Quality of Life 78 134
5 COVID-19 71 122
2 Mental Health 49 120
2 Nursing 45 84
1 Healing Environment 44 67
3 Rehabilitation 43 58
1 Children 41 60
1 Sustainability 40 59
2 Qualitative Research 35 67
1Evidence-based
Design 31 62
Buildings 2024,14, 2731 10 of 26
Table 4. Top 24 keywords with the strongest citation bursts on “hospital”, “HTD”, and “sustainable”
from 1997 to 2024 created using Citespace (generated by the authors).
Keywords Year Strength Start End 1997–2024
Quality of life 1997 7.86 1997 2014 ␖␖␖␖␖␖␖␖␖␖␖␖␖␖␖␖␖␖
Controlled trial 1997 6.7 1997 2014 ␖␖␖␖␖␖␖␖␖␖␖␖␖␖␖␖␖␖
disease 1997 6.19 1997 2014 ␖␖␖␖␖␖␖␖␖␖␖␖␖␖␖␖␖␖
Complications 2001 7.58 2001 2014 ␖␖␖␖␖␖␖␖␖␖␖␖␖␖
Children 2004 6.82 2004 2017 ␖␖␖␖␖␖␖␖␖␖␖␖␖␖
Reliability 2006 6.73 2006 2014 ␖␖␖␖␖␖␖␖␖
Validity 2006 6.73 2006 2014 ␖␖␖␖␖␖␖␖␖
Evidence-based Design 2008 5.95 2008 2017 ␖␖␖␖␖␖␖␖␖␖
Prevalence 2007 7.25 2007 2014 ␖␖␖␖␖␖␖␖
Pain 2008 8.24 2008 2018 ␖␖␖␖␖␖␖␖␖␖␖
Randomized controlled trial 2008 5.51 2008 2013 ␖␖␖␖␖␖
Injury 2009 5.66 2009 2013 ␖␖␖␖␖
Qualitative research 2017 3.84 2020 2021 ␖␖
Healing environments 2013 6.17 2013 2014 ␖␖
Mortality 2007 5.51 2013 2016 ␖␖␖␖
Services 2017 6.09 2017 2019 ␖␖␖
Program 2013 6 2017 2020 ␖␖␖␖
Nurses 2018 4.21 2018 2021 ␖␖␖␖
Public health 2020 5.94 2020 2024 ␖␖␖␖␖
Wound healing 2011 7.97 2021 2024 ␖␖␖␖
Carbon footprint 2022 9.29 2022 2024 ␖␖␖
Climate change 2022 8.87 2022 2024 ␖␖␖
Environmental sustainability 2019 7.46 2022 2024 ␖␖␖
Sustainable development 2022 5.5 2022 2024 ␖␖␖
The most frequently occurring keyword shown in Table 3is “wound healing”, and
the increasing concentration of this keyword from 2021 onwards can be noted in Table 4.
The keyword “healing” is dominant in this setting. Since the concept of HTD is directly
related to wound healing in the medical field, “healing” is the relief of mental and physical
symptoms, and wound healing is the recovery of physical wounds, which is a kind of
“healing”. As such, the “wound healing”-centered Cluster 6 concerns physical healing.
Cluster 2, which focuses on “mental health”, relates to psychological healing. The
importance of mental health and psychological healing is further discussed in a later
micro-qualitative analysis section in this study. “Quality of life”, as the third most fre-
quent keyword in Table 3and the keyword with the highest intensity in Table 4, refers
to the standard of living and the degree of well-being that a person enjoys over a certain
period of time, including their material life, spiritual life, social relationships, health, and
environmental quality. Therefore, Cluster 3 is associated with both physical healing and
mental healing and emphasizes happiness, social values, and SDG, which will be further
investigated as the third element of this research.
The outbreak of COVID-19 defined the broader context of this period, and its spread
put enormous pressure on global health systems and social security systems. During
the COVID-19 period, most research existed within the context of pandemic research,
with relevant research being produced concerning this global crisis. In the future, HTD
can be applied as a new way of coping with similar sudden crises by drawing upon
past experiences.
Additionally, as presented in Figure 2and Tables 3and 4, the keywords “nursing”,
“healing environment”, and “rehabilitation” are related to healing with the intention of
providing treatment and cure. Both nursing and rehabilitation are important aspects
of healthcare, with nursing emphasizing the care and support provided by healthcare
professionals to patients, and rehabilitation focusing on the restoration of physical and
cognitive functioning after an illness or injury. Additionally, healing environments are a
means of providing HTD that promote the physical and psychological recovery of patients
Buildings 2024,14, 2731 11 of 26
by providing comfortable environments for recovery with safe facilities and supportive
healthcare staff. Thus, these keywords will be further explored in the follow-up micro-
qualitative analysis section.
Moreover, “children” is the only word in the keywords presented in Table 4to show
consistently strong concentrations since the start of the research period. Children are
psychologically immature, more prone to fear, and require a more sensitive healing envi-
ronment to restore their health. The relevance of children as the main population addressed
in studies concerning hospital HTD is also intriguing to explore, and this will be further
investigated in the follow-up micro-qualitative analysis section.
Furthermore, “sustainability” is one of the main focuses of this paper, which is pre-
sented in Table 4as “environmental sustainability” and “sustainable development”. A
few studies have looked into the integration of “sustainability” and “HTD”, especially
in the context of “hospitals”. In contrast, sustainability emphasizes the balanced and
coordinated development of economic, social, and environmental aspects. In addition, the
concept of sustainable design emphasizes a natural, healthy, and comfortable environment,
which is beneficial to the physical and mental health of patients. It not only promotes the
physical and mental health of patients, improves the quality of medical services, reduces
environmental pollution, and improves resource utilization but also brings economic and
social benefits to hospitals. Therefore, sustainability should fill every cluster in order to
explore how it is applied and what its role is. Interestingly, the use of research methods
such as “qualitative research” and “evidence-based design” is also presented. Most of
the studies used qualitative research, the most prominent of which is the evidence-based
design methodology, as shown in Table 4, which appeared centrally from 2008 to 2017 and
has also been used in recent years. In particular, these methods can be used to help create
environments that are conducive to patient recovery, improve healthcare staff productivity,
and promote sustainable hospital development.
3.2. Results of the Micro-Qualitative Content Analysis
The results of the network analysis shown in Section 3.1.2 yielded high-frequency,
important keywords relating to the field. As shown in Figure 4, in the literature visualiza-
tion with “hospital”, “HTD”, “sustainable”, and “health” as the initial words, the other
keywords that appeared clearly were “wound healing”, “quality of life”, “mental health”,
“nursing”, “rehabilitation”, “children”, “COVID-19”, and “evidence-based design”. These
are precisely the main keywords that appeared in the high-frequency keyword analysis,
leading to the continuation of the following subsection: high-frequency keyword analysis
for the micro-qualitative content analysis. These keywords are divided into three parts,
strategy, approach, and method, for the follow-up micro-qualitative content analysis.
3.2.1. Strategy
•Wound healing
In healthcare environments, HTD assists patients to recover better. Wound healing
is a natural process involving recovery after an injury, which is related to the quality of
recovery and quality of life of patients and is an important issue in the field of medicine. In
the process of wound healing, HTD is present in a number of aspects, including material
selection, technology applications, and treatment strategies. For instance, traditional dress-
ings, particularly gauze, often cause secondary damage to wounds and surrounding tissues,
offsetting the healing effects of the dressings when establishing a physical barrier between
the wound and the external environment to accelerate healing [
13
,
59
]. Modern wound
dressings, such as hydrogels, provide a moist environment for the wound, absorbing exu-
date, forming a physical barrier and accelerating wound healing [
60
,
61
]. Thus, personalized
treatment strategies are formulated according to the different stages and characteristics of a
wound. This has led to the development of heat-sensitive smart hydrogels that respond
to minor temperature changes in the environment [
61
], hydrogels that form in situ for
diabetic high-glucose environment wounds [
60
], bacterial cellulose for infected wounds,
Buildings 2024,14, 2731 12 of 26
acute trauma, burns, and diabetic wounds [
62
], and bio-inspired hydrogels that mimic
wound healing in the oral mucosa [
63
]. These dressings offer various healing strategies
and show potential applications in chronic wound repair, acute repair, cosmetic surgery,
and commercial fields [59,62,63].
Buildings 2024, 14, x FOR PEER REVIEW 12 of 27
analysis, leading to the continuation of the following subsection: high-frequency keyword
analysis for the micro-qualitative content analysis. These keywords are divided into three
parts, strategy, approach, and method, for the follow-up micro-qualitative content analy-
sis.
Figure 4. The rationalization of the keyword network visualization shown in Figure 2 for follow-up
micro-qualitative content analysis (generated by the authors).
3.2.1. Strategy
• Wound healing
In healthcare environments, HTD assists patients to recover beer. Wound healing is
a natural process involving recovery after an injury, which is related to the quality of re-
covery and quality of life of patients and is an important issue in the field of medicine. In
the process of wound healing, HTD is present in a number of aspects, including material
selection, technology applications, and treatment strategies. For instance, traditional
dressings, particularly gauze, often cause secondary damage to wounds and surrounding
tissues, offseing the healing effects of the dressings when establishing a physical barrier
between the wound and the external environment to accelerate healing [13,59]. Modern
wound dressings, such as hydrogels, provide a moist environment for the wound, absorb-
ing exudate, forming a physical barrier and accelerating wound healing [60,61]. Thus, per-
sonalized treatment strategies are formulated according to the different stages and char-
acteristics of a wound. This has led to the development of heat-sensitive smart hydrogels
that respond to minor temperature changes in the environment [61], hydrogels that form
in situ for diabetic high-glucose environment wounds [60], bacterial cellulose for infected
wounds, acute trauma, burns, and diabetic wounds [62], and bio-inspired hydrogels that
mimic wound healing in the oral mucosa [63]. These dressings offer various healing strat-
egies and show potential applications in chronic wound repair, acute repair, cosmetic sur-
gery, and commercial fields [59,62,63].
• Mental health
Hospital HTD is a design concept that focuses on the psychological needs and emo-
tional experiences of patients with the goal of creating a healthcare environment that
meets the functional needs of healthcare while providing psychological comfort and well-
Figure 4. The rationalization of the keyword network visualization shown in Figure 2for follow-up
micro-qualitative content analysis (generated by the authors).
•Mental health
Hospital HTD is a design concept that focuses on the psychological needs and emo-
tional experiences of patients with the goal of creating a healthcare environment that meets
the functional needs of healthcare while providing psychological comfort and well-being.
This design concept posits that during treatment, patients need not only physical treatment,
such as wound healing but also mental support through emotional communication and
social interaction. Hence, mental health is crucial for improving patients’ quality of life and
promoting their recovery, relating to the well-being obtained via psychological, emotional,
and behavioral aspects that are characterized by stability, adaptability, and positivity.
Hospitals are primary providers of mental health services and are used by patients to
cope better with the psychological stress brought about by illness through the creation of a
positive therapeutic environment and comfortable rest and social spaces, reducing anxiety
and unease and enhancing treatment outcomes and patient satisfaction. Current studies on
how HTD in hospitals improves mental health often focus on external environmental design,
particularly green interventions provided by nature for psychological healing. In addition,
the scientific community has confirmed the importance of nature in relation to human
physical and mental health, with short breaks in nature, periods of 20 to 30 min, significantly
regulating emotional states, especially in stressful emergency situations [
11
]. Interestingly,
of these nature interventions, healing gardens focusing on outdoor spaces are commonly
used; however, these are not yet widely implemented in sustainable hospital HTD.
•Quality of life
Whether it is the birth of a child or the saving of a life, hospitals are important places
for people and need to be built to meet the needs and expectations of the public [
64
]. HTD
Buildings 2024,14, 2731 13 of 26
in hospitals is patient-centered, aiming to create an environment that promotes physical
and mental healing. HTD is not only focused on the realization of medical functions but
also emphasizes improving patients’ quality of life through environmental design. Research
on HTD in hospitals to enhance quality of life mainly highlights the following aspects:
(1) The impact of wound healing on patients’ quality of life
The wound healing process significantly impacts patients’ quality of life. Pain and
possible complications during the healing process cause considerable psychological stress,
and chronic wounds lead to limited mobility, restrict daily activities, and affect social and
work activities. The long-term treatment required for recovery also increases medical
expenses and economic burden. For example, patients with secondary surgery for wound
healing face restrictions in terms of health-related quality of life [
65
]. Additionally, chronic
pain due to venous ulcers and months-long healing periods require frequent outpatient
follow-ups and hospitalizations, significantly affecting psychological health and quality of
life [
66
]. Specifically, elderly patients with pressure ulcers experience prolonged hospital
stays, which can severely impact musculoskeletal health, increase mortality, and reduce
quality of life [67].
(2) Patients’ perceptions of medical facilities
Medical facilities are sometimes perceived to be cold and highly sterilized, making
patients feel helpless and fearful. People tend to imagine hospitals as spaces filled with
high-tech equipment, lacking warm decorations [
68
]. Thus, the design, layout, cleanliness,
quietness, and modernity of medical facilities directly impact patients’ medical experi-
ences. To improve patient satisfaction, the development of digital medical facilities, such as
self-service kiosks in lobbies, tablets, and smartphones, can simplify the medical process,
enhance accessibility to medical services, reduce waiting times, and improve service qual-
ity [
69
]. Some studies even suggest designing hotel-like wards to give patients more control
over ward facilities, creating positive interventions that positively impact patients’ physical
and mental health. Although these measures incur higher costs, they offer commercial
opportunities for the hotel industry to step into hospitals [10].
(3) Patient satisfaction regarding the indoor physical environment of a ward
The cold and sterile atmosphere of hospitals increase patients’ stress, making it essen-
tial to create an environment that promotes relaxation and recovery in both indoor and
outdoor environments. Indoor design is thought to enhance patients’ subjective well-being,
supporting public health through designs that control the environmental features [
70
].
Features impacting quality of life in the indoor environment include color, light, noise,
plants, spatial layout, and the interior materials used.
(4) Quality of care for critical patients
Mortality is listed in Cluster 4 in Section 3.1.2. The mortality rate of critical patients
is an important clinical indicator reflecting the risk of death during treatment. Due to the
severe conditions of critical patients, high-quality nursing care is crucial for improving
survival rates, reducing complications, and improving patient prognosis. This requires a
thorough understanding of patients’ pathological information [
34
], close monitoring of vital
signs (temperature, pulse, respiration, and blood pressure), and personalized care plans
based on patients’ conditions. In addition, a 15-year review study of the built environment
of intensive care units, including the building design, indoor environment, noise, light, and
air quality, has been conducted [
20
]. This study indicated that the built environment of
the ICU significantly impacts patient recovery and the efficiency and health of healthcare
staff. Therefore, designers and healthcare professionals should collaborate to design more
humane, comfortable, and safe ICU environments wherein the quality of care should be
indirectly improved through the development of individualized care plans according to a
patient’s specific situation, humane healthcare staff, and improved working environments
and satisfaction for nurses.
Buildings 2024,14, 2731 14 of 26
3.2.2. Approach
•Nursing
Nursing is a professional practice focusing on establishing and maintaining a close co-
operative relationship between nurses and patients, which typically involves the roles and
working methods of nursing staff in medical environments. The core of this relationship lies
in nurse–patient interactions, which extend beyond medical services to include educating
and guiding patients to promote their health and recovery [
71
]. The following aspects can
be considered relevant:
(1) Healthcare professionals’ views on the nursing environment
The nursing environment requires high standards in terms of professionalism, safety,
and hygiene in order to meet patients’ medical needs while ensuring the efficiency and
safety of healthcare professionals [
72
]. This includes healthcare professionals’ assessments
of the nursing environment, particularly in-patient settings. New hospitals increasingly
offer private rooms, and healthcare professionals have highlighted the advantages of single
rooms [
73
,
74
]. Additionally, single rooms have a positive impact on improving family
and healthcare professional interactions, increasing family members’ satisfaction with
staying to care for a patient. The most direct improvements concern protecting patient
privacy, enhancing comfort in hotel-style rooms, reducing the possibility of infections, and
providing a quiet environment to effectively reduce patients’ stress levels and improve sleep
quality. Further, in order to provide adapted therapeutic wards, healthcare professionals
also consider adaptive daily rhythm atmosphere (ADRA), artificial skylight (AS), and
adaptive stimulus dose (ASD) concepts in a lab environment, anticipating positive impacts
on clinical workflow efficiency at almost all stages [75,76].
(2) Improving healthcare professionals’ satisfaction in hospitals
Healthcare professionals face various pressures in hospitals, such as having to make
quick decisions in high-pressure environments, long working hours, especially night shifts,
interpersonal stress from dealing with different patients and families, and higher health
and safety risks from exposure to harmful substances or outbreaks. Therefore, providing
a good working environment is key to reducing fatigue, increasing job satisfaction, and
improving service quality.
(3) Patient–nurse interactions
Hospitality in the healthcare environment manifests as patients experiencing genuine
care, comfort, and healing, surpassing traditional interpersonal interactions and social
functions and touching upon the deep essence of human care [
77
]. Patients who experience
hospitality in care establish a profound sense of connection and trust, which is crucial
for their recovery. In addition, compassionate care plays a critical role in improving
health outcomes and healthcare experiences, for which demonstrating appropriate care
and promptly responding to patient needs are key elements of compassion in nursing
practice [
71
]. Therefore, fostering compassion in healthcare professionals and ensuring high-
quality medical services are vital to enhancing the overall quality of the
healthcare system.
•Children
When exploring HTD in hospitals, children who stay in hospitals for extended periods
due to illness are the greatest contributors to the concepts of humane hospital design [
78
].
Children are more sensitive to their environment, and more factors should be considered
in healthcare and environmental design in their context, such as emotions, spatial design,
external environment, and social interactions [
18
]. In studies focused on children healing
hospitals, the “Fairy Tale Garden in Northern Thailand”, is a popular case, receiving
attention for its beautiful natural scenery and activities, including play, social interaction,
and education, which improve children’s acceptance and compliance with treatment and
alleviate pain and illness [79–81].
Buildings 2024,14, 2731 15 of 26
3.2.3. Method
•Evidence-based design
As suggested in Section 3.1.2, service landscapes, specifically hospital rehabilitation
landscapes, play a crucial role in patient recovery. Evidence-based design is an emerging
design theory and method used in medical buildings, using scientific research and rig-
orous data to confirm the impact of hospital buildings and environments on users [
27
].
The application of evidence-based design in service landscapes involves multiple aspects,
including the principles of humanized design, natural therapy, spatial layout, guidance,
and safety [
20
,
27
,
28
]. These principles aim to improve the environment through scientific
methods, providing a better recovery environment, meeting patients’ personalized needs,
utilizing natural elements to promote psychological and physical recovery, designing rea-
sonable spatial layouts to enhance comfort and recovery, guiding patients in rehabilitation
activities, and considering the safety of hospital rehabilitation landscapes to prevent injuries
and reduce secondary harm.
4. Discussion
The results presented in Table 1show that the number of studies integrating “sustain-
ability”, “hospitals”, and “HTD” is limited. In addition, in both macro-quantitative and
micro-qualitative analyses, the results are related to hospital HTD, with less emphasis on
sustainability, which indicates a lack of research on integrating sustainability into hospital
HTD. As such, this section explores the potential of how SDG 3 can be implemented in
hospital HTD, along with future trends and challenges, also discussing the challenges
related to sustainable hospital HTD in the context of the COVID-19 era, as the results
suggest in Section 3.1.2 of the keyword analysis.
4.1. Sustainable Development Goal (SDG) 3 and Healing and Therapeutic Design (HTD) in
Hospital Environment
•SDG 3.2 (reduce child mortality)
SDG 3.2 aims to end the preventable deaths of newborns and children under five
years of age by 2030. The keyword “children” is highlighted in the results of Section 3.1.2
since children are the future and are vulnerable to global health issues. Their health
directly impacts global public health challenges, such as the control of infectious diseases
and the prevention of non-communicable diseases. In addition, the results presented
in Section 3.2.2 reveal the contributions of “children” to hospitals and the elements of a
healing environment that hospitals should provide for children. Since adapting to new
environments is a crucial step in children’s recovery, hospital design should consider
children’s psychological and physiological characteristics, creating a safe and engaging
child-friendly environment. External distractions, such as using bright colors, cartoon
patterns, and themes that children love, could positively distract children and reduce their
fear of hospitals. In line with SDG 3.2, specific interventions that hospitals could implement
include the following:
(1) Multifunctional space design: Hospital interior spaces should be flexible and
adaptable to meet the needs of children of different ages. For example, these include
interactive spaces such as play areas and parent–child reading areas assist to distract
children during medical visits and reduce anxiety [
17
], and activity zones that support free
movement and guidance on wards and associated areas [82].
(2) Family oriented ward design: Ward designs should consider the need for the
companionship of family members, providing private and comfortable family style wards
where family members can give more care and support to children [83].
(3) Educational and recreational facilities: Hospitals could introduce educational and
recreational facilities, such as educational toys and interactive screens to provide learning
and entertainment opportunities for children while they receive treatment [79].
Buildings 2024,14, 2731 16 of 26
(4) Eco-friendly materials: Using eco-friendly materials in hospital construction and
renovation reduces the environmental impact and provides a healthy treatment environ-
ment for children.
(5) Lighting and ventilation: The positive effects of natural light on health and recovery
have been proven, and hospital design should make the full use of natural light and
ventilation to create a comfortable indoor environment, which is beneficial to the physical
and mental health of children.
(6) Green space design: Outdoor views, especially water features [
32
] and green plants
could alleviate children’s anxiety. Designing these areas with ocean and forest themes
encourages children to maintain a positive attitude [
19
]. Additionally, healing gardens
have been proven effective in improving children’s stress levels and well-being [84].
Future trends in HTD for hospitals for children may focus on the following aspects:
(1) for personalized and human-centered design, hospital design could focus more on
meeting the individual needs of children with different ages and conditions, with an
emphasis on child-friendly strategies and the involvement of children as stakeholders
in the design process of hospital environments; (2) for interdisciplinary co-operation,
where children are involved, hospital design involves specialists from several disciplines,
including doctors, nurses, psychologists, and designers, working together to create a
comprehensive healing environment; (3) for the integration of modern technologies, such as
virtual reality and augmented reality into the treatment of children, as well as entertainment
and educational activities, can help them better cope with the stress of the treatment process;
and (4) for creating an open environment that allows easier access and support from family
and community members might also be feasible.
•SDG 3.4 (promote mental and physical health)
SDG 3.4 aims to reduce premature mortality from non-communicable diseases through
prevention, treatment, and the promotion of mental and physical health by 2030, addressing
both physical and mental health. The results shown in Section 3.2.1 on wound healing
and mental health suggest that wound healing is a significant issue in the medical field,
and researching and practicing optimal wound healing methods improve the quality and
efficiency of medical services, reduce medical waste, and align with sustainable develop-
ment principles. For example, using fish skin grafts (FSGs) to treat pediatric patients with
different wound etiologies represents an innovative and sustainable wound care solution,
showing no signs of itching and shortening both surgery and healing times [
85
]. Addi-
tionally, a 30-day postoperative infection monitoring intervention in a Ghanaian hospital
demonstrated that it is a simple, cost-effective, sustainable, and adaptable strategy [
86
].
Besides using degradable or recyclable materials for wound dressings to reduce environ-
mental pollution, the following technical approaches could promote patients’ physical
health through HTD: (1) hospital design should ensure ample natural light and good
ventilation to improve patients’ mood, promote wound healing, and reduce infection risk,
and (2) designing flexible space layouts that can be adjusted according to different medical
needs and patient variations helps to improve the efficiency of hospital operation while pro-
viding personalized services for patients. Future wound dressing designs could consider
multifunctionality, new materials, and high added value, targeting specific patients with
conditions such as diabetes and varicose veins with appropriate dressings. Wound healing
research could move toward more diverse and in-depth directions, aiming to enhance the
speed and quality of wound healing through the use of new materials, technologies, and
methods, thereby alleviating patient suffering and improving their quality of life.
Moreover, the results shown in Section 3.2.1 on mental health indicate that healing
gardens are used to promote the restoration of a patient’s physical and mental health
through the power of the natural environment; however, they are not yet widely available.
From the perspective of hospital HTD, healing gardens are open spaces that are specifically
designed to facilitate patient recovery and provide positive emotional effects for healthcare
workers, visitors, and other stakeholders. They work alongside traditional therapeutic
tools to improve human well-being [
11
,
16
,
87
]. In addition, interaction with nature activates
Buildings 2024,14, 2731 17 of 26
visual, auditory, tactile, olfactory, and kinesthetic senses, which could lead to relaxation
through experiencing the scents of trees and flowers, the sight of various colored flowers,
and the sound of birdsong [88,89].
(1) Visual: Natural light and open landscapes provide visual comfort [
90
], helping
to alleviate the anxiety and stress associated with confined environments. Using natural
materials such as wood and stone to decorate walls and pathways, a calm and warm
atmosphere could be created, enhancing overall comfort. Additionally, visually observing
plants reduces patient pain, serving as an alternative pain management method [91].
(2) Auditory: natural sounds such as birdsong and flowing water can create a natural
concert that is a form of music therapy that is widely used to improve the mood of patients
and their sleep quality [92,93].
(3) Tactile: natural elements, i.e., plants and water, offer unique tactile experiences for
patients who have an innate affinity for water, stimulating the brain to secrete hormones
that have calming and stress-relieving effects when touching plants or water.
(4) Olfactory: the scents of flowers and fresh air in nature trigger positive emotional
responses and reduce anxiety when these pleasant odors are detected. Medicinal and
aromatic plants are excellent additions to enhance the healing environment of therapeutic
gardens [31].
(5) Kinesthetic: walking in gardens increases the physical activity of patients [
94
], and
the emotional value gained from interacting with nature is far greater than that obtained
from walking on urban streets.
As the healthcare industry increasingly emphasizes patients’ psychological and phys-
iological health, the concept of hospital therapeutic gardens will become more widely
promoted and implemented. Rehabilitation gardens have become an indispensable part of
many modern hospitals in Western countries. Although China started later in this regard, it
has made significant progress and continues to advance and improve. Therapeutic gardens
have become a global future trend.
•SDG 3.8 (achieve universal health coverage)
SDG 3.8 aims to achieve universal health coverage, ensuring that everyone has access
to quality essential healthcare services and safe, effective, quality, and affordable essential
medicines and vaccines. The results shown in Section 3.2.1 on quality of life and Section 3.2.2
on nursing highlight the importance of providing comprehensive, inclusive, and high-
quality healthcare services. This goal emphasizes the importance of health as a fundamental
human right and its critical role as the foundation for social and economic development.
Hospitals, as primary providers of medical services, play a key role in achieving SDG
3.8. Sustainable HTD can enhance patient satisfaction with the environment and improve
quality of life in the following factors:
(1) Color: The use of color in wards is an important design principle that can influence
the emotions of patients. For instance, in psychiatric hospitals, the wrong choice of colors
can lead to anxiety and self-harming tendencies in patients [
95
]. Soft light tones, such as
light pink, light blue, and beige, generally give patients a relaxed, pleasant, and peaceful
sense of their environment.
(2) Light: Light is a crucial element in hospital ward design since it directly affects
patients’ sensory experiences and psychological states. Natural lighting is fundamental
for creating a comfortable hospital environment, particularly sunlight, which positively
impacts patients’ circadian rhythms, helps adjust their sleep cycles, promotes recovery, and
contributes to an earlier discharge [
96
,
97
]. Additionally, natural lighting makes people
feel closer to nature and provides a more comfortable visual experience indoors, satisfying
psychological and mental needs. Further, appropriate artificial lighting should be provided
for nighttime, emergency, and localized illumination, creating convenient conditions for
patients’ nighttime activities [90].
(3) Noise: The noise levels in hospital wards are typically 15 decibels higher than
the World Health Organization’s recommended values, negatively impacting patients’
health and comfort [
98
]. Patients are in a vulnerable state, and their sensitivity to noise is
Buildings 2024,14, 2731 18 of 26
higher than that of healthy people, making them more susceptible to noise disturbances.
To improve the acoustic environment in wards, sound-absorbing materials can be used
to reduce reflected sound and noise levels. Replacing low-noise equipment and raising
awareness among healthcare staff, patients, and their families to maintain low conversation
volumes in wards are also recommended.
(4) Plants: Introducing indoor plants in wards affects patients’ subjective well-being,
as plants can purify the air, regulate indoor environments, alleviate anxiety, and color the
space, providing a comfortable, clean, and positive recovery environment. This indoor
intervention can enhance satisfaction and the aesthetic appreciation of a hospital [14].
(5) Space layout: Patients hope for private spaces to maintain privacy and comfort
during a hospital stay. Proper partitions to distinguish beds could be used to ensure
sufficient personal space. Rooms should be spacious enough to accommodate all necessary
functional actions, such as healthcare staff examinations and family accompaniment [
99
].
The design of wards should consider the need for wheelchair and stretcher access to ensure
safety for patients and healthcare workers.
(6) Interior materials: Non-toxic green materials should be used indoors. Floors
should be replaced, removing polyvinyl chloride (PVC) and installing non-slip and easy-to-
clean materials, such as synthetic rubber [
4
]. Wall surfaces should be durable and easy to
clean. Additionally, antibacterial and deodorizing materials should be chosen to ensure air
hygiene and cleanliness, providing patients with a clean and tidy healing environment.
In addition to considering patients’ health and quality of life, hospitals should provide
comprehensive services, including prevention, treatment, rehabilitation, and palliative
care, ensuring all patients, regardless of socioeconomic background, have equal access to
necessary medical services. The results presented in Section 3.2.2 on nursing are associated
with ensuring healthcare workers’ health. To improve healthcare workers’ quality of work
and life, the following options should be considered:
(1) Comfortable rest areas: Comfortable seating for relaxation, and fitness facili-
ties, such as treadmills and exercise bikes, could be used to relieve work stress during
breaks [
100
]. Studies on eye-tracking and self-recovery in hospital outdoor rest spaces
and indoor work environments found that outdoor rest spaces significantly improved
healthcare workers’ eye-tracking indicators, such as gaze time, saccades, and blinks, as well
as self-recovery evaluations, such as fatigue, psychological state, and work efficiency [
101
].
(2) Appropriate lighting design: Sufficient brightness and appropriate lighting uni-
formity ensure that healthcare workers can clearly see patients’ conditions and operate
medical equipment, reducing errors and accidents. Using lower color temperatures, such
as 3000 K or lower, can reduce healthcare worker eye fatigue and discomfort [102].
(3) Reasonably arranged nurse stations: Nurse stations, the hub of activity in hospitals,
where nurses, doctors, patients, families, and visitors interact with each other, need careful
consideration in terms of location and spatial layout [
103
]. Well-organized work areas
and corridors assist in reducing interference and conflict among healthcare workers. Since
nurses spend much of their work time walking within wards, optimizing the location of
nurse stations helps to reduce unnecessary movement, increasing care time and improving
work efficiency and collaboration.
(4) Consideration of healthcare workers’ needs and opinions: Allowing healthcare
workers to assess the impact of environmental design factors on stress reduction and
involving them in the design process can increase their job satisfaction and identification
with the medical environment [104].
Achieving universal access to quality essential healthcare services faces challenges
such as resource limitations, uneven medical service distribution, high medical costs, and
shortages of medical professionals. Addressing these challenges requires efforts in several
areas: (1) increasing investment in the healthcare system to improve infrastructure and
service quality; (2) reforming health insurance systems to establish fairer and more sustain-
able systems to reduce patients’ financial burdens; (3) encouraging the development and
innovation of medical technology to enhance the efficiency and effectiveness of healthcare
Buildings 2024,14, 2731 19 of 26
services; and (4) promoting international co-operation to share best practices and improve
global healthcare levels.
4.2. Public Health Emergencies as a Warning for HTD in Sustainable Hospital Environment
The results shown in Figure 3and the high-frequency keywords in Section 3.1.2
indicate that public health emergencies, such as the COVID-19 pandemic, have significantly
impacted global healthcare systems, exposing the inadequacies of existing medical facilities
in responding to large-scale infectious disease outbreaks. Due to the unique nature of the
COVID-19 pandemic, the transmission patterns, duration, and response strategies varied
across different hospitals and health departments. The virus’s long incubation period and
unpredictable course, along with the varied treatment needs of patients, highlighted the
weak points in hospital infection control, becoming a major public concern. This complexity
made it extremely difficult to accurately predict the number of patients requiring treatment
and the consumption of medical resources over time [
105
]. This situation represents not
just a medical crisis but also a resource crisis. Therefore, future hospital designs should
incorporate HTD concepts, not only to establish more efficient supply chain management
systems to quickly mobilize necessary resources in emergencies but also to strengthen
infection control measures. In contrast, HTD should include the addition of negative
pressure rooms, improved ventilation systems, and dedicated isolation areas to reduce the
risk of cross-infection.
Moreover, healthcare workers frequently face moral dilemmas, such as decisions about
end-of-life care, where only one family member may enter the ward. Deciding who can be
present when a loved one passes away causes intense emotional turmoil for both medical
staff and patients’ families. To avoid such difficult decisions, medical institutions need
sufficient resources, including manpower and materials. Considerations should include
ethical understanding, critical thinking, emotions, and interpersonal relationships. HTD
should ensure a supportive work environment and psychological health for healthcare
workers, helping them cope with moral challenges and emotional stress [106].
Furthermore, public health emergencies, like COVID-19, will not be the last pandemic.
Hospitals, as one of the most critical assets during an outbreak, need to provide safe
and resilient environments. The significance of hospital outdoor spaces in responding to
unpredictable crises has increased, with functional requirements becoming more complex
for different occupants. For visitors, healing gardens and convenient outdoor areas around
outpatient and emergency buildings should be designed as extensions of indoor spaces,
providing shelter and amenities to ensure comfort during outdoor activities. Wayfinding
systems should be improved for easier navigation. For patients, HTD promotes creating
therapeutic and recreational areas conducive to recovery, which should be connected to
living and utility areas for easy access. For staff, HTD advocates for the creation of separate
staff rest areas to help alleviate stress and fatigue. These areas should be close to work areas
and provide views from inside the building to encourage use. Additionally, staff should
consider food delivery areas, which should be near workplaces and separate from main
entrances [
107
]. Further, HTD also recognizes the importance of public health awareness
and knowledge of epidemic prevention. Future hospital designs should include spaces for
public health education and promotion to enhance public health literacy and self-protection
capabilities. Technologies such as telemedicine, big data analysis, and artificial intelligence,
which demonstrated their importance during the pandemic, should be integrated into
future hospital designs to improve the efficiency and quality of medical services and
enhance the monitoring and response capabilities for emergencies.
4.3. Limitations
This paper intended to deeply analyze and understand the theory and practice of
sustainable HTD in hospitals and how it promotes patient recovery and health under
different environments and conditions. It also provides directions and suggestions for
future hospital design and construction. As stated in the database search part in Section 2,
Buildings 2024,14, 2731 20 of 26
keywords such as “healing design” and “therapeutic design” were searched. Initially,
despite both terms referring to design concepts that create environments beneficial for
patient recovery and well-being, there were differences in their focus and application scope.
“Healing design” emphasizes creating an environment that promotes physical and mental
recovery, typically involving the integration of natural elements and the use of colors and
materials that evoke positive emotions in patients. “Therapeutic design” focuses more on
the treatment process itself, possibly involving physical spaces and equipment specifically
designed for treating certain diseases or symptoms, such as special treatment room layouts,
furniture and decor, and high-tech medical equipment aimed at optimizing treatment
outcomes, improving efficiency, and reducing patient discomfort. However, there was
uncertainty about which keyword to use, but the research results indicated that combining
both terms provides a more comprehensive view of hospital HTD, as reflected in the results
of both macro-quantitative and micro-qualitative analyses. Therefore, the term “healing
and therapeutic design” was chosen in this article.
In addition, the systematic literature review method used in this study involved a
large volume of literature. However, when collecting the literature related to hospitals,
sustainability, and HTD, it was not possible to obtain enough texts containing all these three
keywords in a single search, indicating limited research on the subject. Thus, keywords
were combined in pairs to obtain more related literature for visual analysis. However, this
method may weaken relevance while increasing the volume of the presented literature
due to the exclusion of one keyword. This could lead to instances where large volumes of
work, e.g., some sets containing over five thousand documents, including duplicates, were
weakly related to the theme. Therefore, in the third phase of the method in Section 2, the
literature was restricted to reduce these limitations. Multiple combinations of text sets were
tested for keyword network visualization in the early stages to verify whether it affected
the final visualization results. The results show that the visualization results did not differ
significantly, with key content consistently highlighting wound healing, mental health,
quality of life, nursing, children, and evidence-based design.
Further, despite sustainable HTD being a trend for future hospital design, practical
implementation is constrained by local economic conditions and technological levels.
The diversity and specificity of hospital designs across different cultural and regional
backgrounds should not be overlooked. Additionally, patient and healthcare worker
opinions and experiences are crucial for evaluating the healing effects of hospital designs. If
research does not fully incorporate these perspectives, it may result in a disconnect between
design solutions and actual needs.
5. Conclusions
This paper aimed to explore the current state of development and the knowledge
structure of sustainable healing and therapeutic design in hospital scenarios using a system-
atic methodology that integrates macro-quantitative bibliometric analysis and follow-up
micro-qualitative content analysis methods based on data from the WOS database, which
investigates eight research objectives, including the background, current state, hotspots,
high-frequency words, integration with SDGs, particularly SDG, 3 “ensure healthy lifestyles
and promote well-being of people of all ages”, and the challenges posed by public health
emergencies, such as the COVID-19 pandemic, for sustainable HTD in hospitals. The main
contributions are as follows:
In terms of research methods, this paper integrates macro-quantitative bibliometric
analysis and follow-up micro-qualitative content analysis methods, forming a systematic
methodology to explore research hotspots and trends in the field of sustainable HTD
in hospitals.
In terms of research techniques, utilizing VOSviewer and CiteSpace software tools
for the network visualization of keyword co-occurrence and keyword burst detection in
revealing high-frequency hotspots enhances the data in terms of yielding objective and
accurate results.
Buildings 2024,14, 2731 21 of 26
In terms of the research findings, macro-quantitative bibliometric analysis of keyword
network visualization revealed the knowledge structure of the research theme, presenting
key directions in six clusters, such as the environment of a hospital, mental health, quality
of life, illness and care, COVID-19, and wound healing, emphasizing key terms on wound
healing, mental health, quality of life, nursing, children, and evidence-based design via
high-frequency keyword analysis. These have been further grouped into three categories,
namely strategy, approach, and method. Subsequently, the micro-qualitative content
analysis was elaborated according to the above categorization in relation to the specific
literature, showing how the keyword is reflected or used in the existing literature in the
design of hospital healing. Focusing on hospitals and HTD, this paper further emphasizes
how hospital HTD relates to sustainable development goals, i.e., SDG3, which is aimed
at reducing child mortality (SDG 3.2), promoting mental health and physical health (SDG
3.4), and achieving universal health coverage (SDG 3.8), to explore how they relate to
wound healing, mental health, quality of life, nursing, and children, which are stressed
in the results of the both of macro-quantitative bibliometric and micro-qualitative content
analysis. In addition, the COVID-19 context is highlighted in the need for hospitals to
address both medical and resource crises in future public health emergencies.
Moreover, the elements and factors of sustainable HTD include but are not limited to
the following:
Patient engagement and empowerment: enhancing patient involvement in treatment
decision making, strengthening self-management capabilities, promoting patient engage-
ment in their health maintenance through education and support.
Spatial layout: a proper spatial layout promotes social interaction, provides privacy
and creates a physical environment conducive to rehabilitation.
Environmental design: this includes natural light, color, sound, temperature and air
quality, all of which are important environmental factors that affect the emotional and
physiological state of an individual.
Psychological and emotional factors: the design should take into account the psycho-
logical state and emotional needs of the individual and promote psychological healing by
creating a safe, comfortable and stimulating environment.
Technology and innovation: utilize the latest technologies and innovative approaches
such as smart materials, bioengineering and digital health tools to enhance the healing
effects of the design.
Sustainability: designs should consider environmental sustainability, using eco-friendly
materials and energy-efficient technologies to minimize negative impacts on the environ-
ment while promoting long-term health.
Furthermore, the results guide designers and decision makers on how to create green
healing spaces, such as sky gardens and roof gardens, which not only create nice environ-
ments but also provide psychological relief. The results highlight the use of evidence-based
design in healthcare buildings, which requires designers and decision makers to optimize
designs based on reliable scientific research and statistics to improve building performance
and user experience. Through these findings, architects and decision makers can better
integrate the concepts of sustainability and healing environments into hospital design to
create healthcare spaces that are both energy efficient and promote patient healing.
This paper draws a picture across related fields of a new perspective on the key di-
rections for sustainable HTD in hospitals, along with future trends. Sustainability is a
development approach advocated by various industries around the world, and hospital
healing design promotes the physical and mental health of patients by creating a comfort-
able built environment. Sustainable hospital healing design is a desirable trend for the
future development of hospitals, not only for the construction of hospital buildings but also
for the treatment of patients. As such, in the future, this research can be extended on a larger
scale. In addition, the data used in this study were collected solely from the WOS database.
Future research could consider incorporating other databases, such as PubMed, Scopus,
and the ProQuest Health & Medical Collection, to explore more studies on sustainable HTD
Buildings 2024,14, 2731 22 of 26
in hospitals. Ideally, sustainable HTD could be comprehensively further implemented in
the practice of designing a hospital to experiment with the functionality and healing effects.
Author Contributions: Conceptualization, H.F., Y.L., Z.L., Z.C. and M.O.; methodology, H.F., Y.L.,
Z.L., Z.C. and M.O.; software, H.F., Y.L., Z.L. and Z.C.; validation, H.F., Y.L., Z.L., Z.C. and M.O.;
formal analysis, H.F., Y.L., Z.L. and Z.C.; investigation, H.F., Y.L., Z.L. and Z.C.; resources, H.F., Y.L.
and Z.L.; data curation, H.F., Y.L., Z.L. and Z.C.; writing—original draft preparation, H.F., Y.L., Z.L..
and Z.C.; writing—review and editing, H.F., Y.L., Z.L., Z.C. and M.O.; visualization, H.F., Y.L., Z.L.
and Z.C.; supervision, Y.L.; project administration, Y.L.; funding acquisition, Y.L. All authors have
read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Data Availability Statement: Publicly available datasets were analyzed in this study. These data can
be found here: https://access.clarivate.com/login?app=wos&alternative=true&shibShireURL=https:
//www.webofknowledge.com/?auth=Shibboleth&shibReturnURL=https://www.webofknowledge.
com/?DestApp=UA&action=transfer&mode=Nextgen&path=%252Fwos&referrer=mode=Nextgen&
path=%252Fwos&DestApp=UA&action=transfer&roaming=true (accessed on 1 May 2024).
Acknowledgments: The authors would like to thank all the people who support this research.
Conflicts of Interest: The authors declare no conflicts of interest.
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