Authors
- Timmermann, Connie RN, MScN
- Uhrenfeldt, Lisbeth RN, MScN, PhD
Abstract
Review question/objective: The objective of this systematic review is to identify, appraise and synthesize the best available evidence regarding patients' experiences of wellbeing in the physical hospital environment.
More specifically, the review question is:
How do hospitalized patients experience and assign meaning to the physical hospital environment in relation to their experience of wellbeing?
Background: The role of the physical hospital environment on patients' health outcomes represents a growing field of research with an underlying rationale pointing at the environment as an important source of recovery, health and wellbeing for the patients.1-4 The majority of research on the hospital environment has tested different environmental variables in relation to patient outcomes; for example the influence of noise on stress and sleep disruptions,5-7 the effect of daylight in the patient rooms on depression8,9 or the significance of nature sights on length of hospital stay,10 pain11 and stress.12 However, this field of research has gradually shifted the perspective from focusing exclusively on the relationship between the physical hospital environment and the patients' health outcomes in relation to, for example length of hospital stay, pain and stress, to including considerations on how the physical hospital environment is able to support the patients' experiences of wellbeing, relief and positive emotions.13-15 Moreover, for several decades, it has been argued, in a nursing context, that the hospital environment plays a significant role in relation to the patients' wellbeing and in caring for the patients.16-20
In this review, wellbeing is to be understood as an experiential phenomenon articulated in a multiplicity of different kinds of wellbeing.21 Galvin and Todres21 describe six different experiential domains within which wellbeing can be emphasized. This means that wellbeing can be experienced spatially, temporally, inter-personally, bodily, in mood, and in terms of the experience of personal identity. Further, these kinds of wellbeing encompass an experience of wellbeing where mobility is emphasized and an experience of wellbeing where dwelling is emphasized as well as a wellbeing possibility where experiences of dwelling and mobility are integrated into an experience of "dwelling-mobility". This experience of "dwelling-mobility" is to be understood as an experience of both "peace" and "movement", an intertwining of an experience of inner peace and dwelling encompassing a path of movement and an energizing potential. Galvin and Todres21 describe this unity of "dwelling-mobility" as the deepest form of wellbeing.
Additionally, Chick and Meleis22 point to environmental factors as imperative for a positive transition process where the patients are able to experience connectedness and stability. A need for hospitalization during illness is described by Schumacher and Meleis23 as including experiences of transitions from one place to another; or from a familiar, predictable and safe environment to an unfamiliar hospital environment. A meta-synthesis informs of how stressful, unpredictable and scary patients experience their hospitalization transitions.24
The findings of existing empirical research on how the environmental factors influence the patients during hospitalization show a tension between clinical and technical sensory impressions, and more aesthetic and homelike ones. Existing empirical research has shown that traditional healthcare environments, where many clinical sensory impressions are dominant, may be experienced by patients as unfamiliar and alienating, fostering feelings of stress, vulnerability and a negative mood.14, 25-27 Contrarily, studies have demonstrated that a hospital environment with a more familiar and home-like physical environment can reduce stress and increase patient satisfaction during hospitalization.28-31 For instance, studies have shown that aesthetic and more homelike sensory impressions in the hospital environment have a significant impact on the patients' general wellbeing as these impressions generate positive thoughts and feelings.13-15,26 The patients found that aesthetic decorations as well as being surrounded by some of their personal items or undertaking familiar tasks created a sense of homeliness that reinforced their positive mood and sense of self.14 A view of nature helped them to forget their negative thoughts for a while and connected them with good memories that enabled them to recall some of their feelings of identity and personal strength.13,15 On the other hand, clinical sensory impressions in the hospital environment such as medical and technical equipment as well as an environment sparsely decorated, randomly furnished or walls painted white with no colors or pictures were generally associated with unfamiliarity and experienced as creating a feeling of insecurity and a negative mood.14 Further, patients have identified personal space, good physical design, access to external areas and provision of facilities for recreation and leisure as necessary for maintaining their wellbeing.32 Equally important, a study has shown how interior design was perceived by the patients as important for their fundamental mood, sense of security, vulnerability and trust as well as their experiences of the room as a life-affirming place.33 In contrast, the findings of Edvardsson and colleagues18 point to the physical hospital environment as being able to express messages of existential matters such as death, danger, shame and stigma; but also messages related to their experiences of being cared for or not. For example a sparsely decorated and run-down environment could convey negative values important for the patients' experience of wellbeing.18
As shown, existing research on the patients' experiences of sensory impressions in the hospital environment, though sparse, points to the importance of expanding our perceptions of wellbeing among patients to include the physical hospital environment. Therefore, to promote wellbeing in hospitalized patients, we are in need of research based knowledge to optimize a healing and caring hospital environment. We need to contribute with the synthesis of knowledge to promote an understanding of the potential impact of the physical environment on patients' experiences of wellbeing.
An initial search of PubMed, CINAHL, The JBI Database of Systematic Reviews and Implementation Reports, Google Scholar and the Trip Database indicated that no systematic review of this topic exists or is currently underway.
Article Content
Inclusion criteria
Types of participants
This review will consider studies that include hospitalized adult patients over 18 years of age with all types of diagnoses and of both genders. Studies focusing on adults admitted with psychiatric or dementia diagnoses will be excluded from the review. Also, studies including children and adolescents will be excluded.
Types of phenomena of interest
This review will consider studies that explore patients' experiences of the physical hospital environment in relation to their wellbeing. For the purpose of this review, wellbeing is described as an experiential phenomenon articulated in a multiplicity of different kinds of wellbeing, for example wellbeing can be experienced spatially, temporally, inter-personally, bodily, in mood, and in terms of the experience of personal identity.21 In relation to this review, experiences are considered to be a person's individual perception of being in the world, for example the individual perceptions of their life world.34
Types of context
This review will consider studies that explore how hospitalized patients in all kinds of wards experience the physical hospital environment. For example the architecture, design features, furnishing and decoration. In summary, for the purpose of this review, the physical hospital environment is defined as architectural features, interior design features and ambient features.
Types of studies
This review will consider qualitative research studies including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research.
Search strategy
The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English, Danish, Norwegian and Swedish will be considered for inclusion in this review. Studies published up until May 2014 will be considered for inclusion in this review.
The databases to be searched include: PubMed/MEDLINE, CINAHL, Embase, Scopus and PsycINFO. The search for unpublished studies will include: MedNar, Google scholar and ProQuest dissertations and Theses. The literature search will be carried out under the guidance of a research librarian.
Initial keywords covering population, phenomena of interest and context (PICO) to be used will be (depending on the different databases):
The search strategy was pilot tested 09.04.2014 within the PubMed database resulting in 658 hits.
((((((patient) OR ("patients"[MeSH Terms] OR "patients"[All Fields]))) AND ((((((((((((("Hospital Design and Construction"[Mesh])) OR "Architecture as Topic"[Mesh]) OR ("Interior Design and Furnishings"[Mesh])) OR "Health Facility Environment"[Mesh]) OR "healing environment") OR "healing environments") OR "architecture") OR "ambient environment") OR "ambient environments") OR "hospital design") OR "interior design") OR "health facility environment")) AND ((((((((("qualitative") OR "qualitative research") OR "Qualitative Research"[Mesh]) OR "Interviews as Topic"[Mesh]) OR "interview") OR "interviews") OR "qualitative studies")) OR ((wellbeing*) OR well being*)))) NOT ((adolescent*) OR child*)
Assessment of methodological quality
Papers selected for retrieval will be assessed by two independent reviewers for methodological validity, prior to inclusion in the review, using standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.
Data collection
Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-QARI (Appendix II). The data extracted will include specific details about the phenomena of interest, populations, study methods and outcomes of significance to the review question and specific objectives.
Data synthesis
Qualitative research findings will, where possible, be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality, and categorizing these findings on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form.
Conflicts of interest
None
Acknowledgements
The reviewers are grateful to Line Jensen (MA) for her work with language revision.
References
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Appendix I: Appraisal instruments
QARI appraisal instrument[Context Link]
Appendix II: Data extraction instruments
QARI data extraction instrument[Context Link]
Keywords: Hospital environment; experience; well-being