Carmen Ferrer Julia Florida International University · elements of design from a shopping mall into the hospital setting. Shortly after, hospital administrators started asking designers

The Effects of Interior Design Elements on Physical Therapy Environments 1

The Effects of Interior Design Elements in Physical Therapy Environments

Carmen Ferrer Julia

Florida International University


Table of Contents

I. INTRODUCTION 3-6 Purpose Statement Significance of Literary Review II. HOSPITAL DESIGN AND HEALTHCARE EVOLUTION 6-8 Influence of Healthcare Hospital Evolution Shopping Mall Concept III. PHYSICAL THERAPY PROFESSION 9-10

IV. PHYSICAL THERAPY PATIENTS 10-13 Psychological Needs Physical Needs V. INFLUENCE OF THE ENVIRONMENT 13-15 Impacts of Natural Environment's Element

VI. INTERIOR DESIGN EFFECTS IN HEALTHCARE SETTINGS 15-22 Influence of Interior Design Elements on the Users Space Planning and Architectural Layouts Impacts Innovative Designs for Healthcare Settings VII. BUILDING CODES 22-24 ADA Fire and Life Safety Codes VIII. CONCLUSIONS 25-26 References 27-28


I. INTRODUCTION

Throughout history, hospitals were considered charitable institutions, but in the early

1900's they seem to have evolved into scientific research centers, where patient comfort has

become of little interest. (Sloane, 1994). At the time the best solution was to incorporate the

elements of design from a shopping mall into the hospital setting. Shortly after, hospital

administrators started asking designers for help on resolving the issue and making the designs

more accessible and welcoming (Sloane, 1994). This design includes the use of hotel-style

lobby, commercial spaces, and even retail and restaurant elements (Sloane, 1994). After applying

this concept to hospital designs it was noticeable that the hospital was able to "[deliver] a more

humane, communal, attractive, and relaxing space in which people can feel comfortable"

(Sloane, 1994, p.90). Architectural critic Mitchell Green agrees with the design concept and

believes that "[d]esigners are emphasizing customer comfort in high-style surroundings,

changing designs to encourage family participation, and creating images which evoke an inviting

combination of social life and community education" (Sloane, 1994, p.90)."

Healthcare is one of the most demanding settings to design, as it affects human lives with

regards to their psychological, physiological, and spiritual well-being, as well as their safety,

hopes and future. Physical Therapy is an important medical branch where patients, through

physical healing, are able to regain faith in themselves; they rejuvenate their bodies in ways that

they never had before, gain strength and look at life in a positive way. According to Arriaga

(1992), the American Physical Therapy Association did an assessment to foresee what the future

held for this segment of medicine and found[:]

The ability to change and evolve successfully is dependent on an understanding


of the environment in which we exist; the factors that will affect change in this

environment; and the opportunities, challenges, and threats presented by these factors.

Thus, the concept of an environmental assessment has become an integral part of the

strategic planning of many organizations and groups. (p.378)

Following this assessment, the organization narrowed their research of the future of

physical therapy within the healthcare system into the six main areas that would affect Physical

Therapy: the economics of healthcare, the demographics of the American population, human

resources in physical therapy, the physical therapy profession in the healthcare sector, the

shaping of public policy, and the role of the association itself (Arriaga, 1992). It would be

appropriate to assume that interior design would affect some of these areas as well because

designers address demographics, employee needs, and even design needs during the schematic

planning phase in order to provide a successful design.

The body of knowledge of Interior Design is constantly growing. This is how designers

learn of the impacts that interior spaces and their designs have on people. A negative or positive

reaction from the users always depends on how the design is executed. Designing for healthcare

takes knowledge, effort, and much attention because the space is being dedicated to people in a

vulnerable state of body and mind. Providing the patients of physical therapy with a setting that

motivates them is important, it can accelerate their recuperation process, and as for the staff it

can result in a space that inspires them to work every day, a space where they go to comfort

themselves while trying to help others, as for designers, it is a goal to reach for and to feel proud

of once it has been met.


PURPOSE STATEMENT

The purpose of this review is to analyze and interpret the existing literature regarding

physical therapy settings in relationship to healthcare, and understand the effects of interior

design on the recuperation process of physical therapy patients and the environmental factors

that promote the healing and rehabilitative process. It is important to study the healthcare

environment because research continues to develop and grow, offering new ideas and standards

for healthcare professionals and patients alike. This research will uncover the optimum

conditions, to encourage a speedy recovery.

SIGNIFICANCE OF LITERATURE REVIEW

Based on the findings obtained, this review proposes implications and suggestions related

to Physical Therapy settings and the optimum conditions for the patients' recovery. American

society is constantly changing due to a number of different factors such as human needs, the

economy, and technology (Arriaga, 1992). Healthcare facilities can offer those that recovering

from traumatic experiences the opportunity of learning and accepting new realities about

themselves, and opportunities to reunite families and a means to look at life from a different

perspective. To progress in life it is necessary to learn and to apply this new knowledge. Arriaga

(1992) believes that healthcare is moving in the right direction[:]

Research in the basic and clinical sciences has led to great strides in understanding the

machinery of the body and the origins of disease and in developing more effective

prevention and treatment methods. Work in the social sciences has improved

understanding of the clinician/patient interaction and has led to more effective methods

for public, patient, and professional education. Studies in the area of health services


research have provided insights into the complex interaction of components of health care

delivery. (p.389)

It is just as important to understand and improve the patient to client relationship, as it is to

research and to further investigate the spatial conditions in which this interaction occurs, and to

prove if in fact the surroundings do have an effect on the physical therapy process and if it they

affect the outcome of the patient.

II. HOSPITAL DESIGN AND HEALTHCARE EVOLUTION

In the early stages of healthcare and hospital care history there was no place for those who

needed treatment; the rich would be treated in the comfort of their home and the poor would

have nowhere to attend. Facilities and hospitals were opened in the 1800s so the poor could

assist and receive proper care. Even if the chances of survival from diseases and wounds were

minimal, these places were indented to serve as charity. The hospitals had poor sanitary

conditions, lack of staff, and minimal humane treatment quality, but it was the only place to

attend hoping that there was a cure for those that couldn't afford a private physician. W. Gill

Wyllie believed that hospitals were a necessity for the homeless and he came to the conclusion

that "the majority of our hospitals... are liable to do more harm than good" (Sloane, 1994, p.84).

Influence of Healthcare

As healthcare evolved, so did hospitals. With the arrival of new technology (X-ray

examination), the wealthy wanted to be considered and be provided with private rooms. The idea

was to be able to attend the hospital and receive small surgeries, and for the women to give birth.

This opened the possibility of changing the design and layout of the everyday hospital. "Opened

in 1885, John Hopkins had five large public wards and two private wards for paying patients


separated by gender" (Sloane, 1994, p.84). They were now being built with private rooms fully

furnished for the wealthy, and the typical bed to bed accommodations on the wards for the poor.

The hiring of trained nurses lowered the mortality rate; nurse reformers found a way of

convincing hospital administrators that what people feared the most about hospitals was "the lack

of cleanness, efficiency, and sanitation" (Sloane, 1994, p. 84).

Hospital Evolution

By the 1900s there were noticeable changes made to the hospital design, it transformed

from an establishment of public charity to an establishment of scientific research. The hospital

was a medium for medical students to learn from patients undergoing care. This era marked a

peak in healthcare as the government got involved into providing funds through the Hill-Burton

Act from 1947, and Medicare and Medicaid in the 1960s (Sloane, 1994). Hospital administrators

had made accommodations for as many people as they could fit from every class (wealthy,

medium, and poor). The main concern was the profit gained instead of the well-being of the

patient. To give an overall description of the settings Sloane (1994) quotes on his research:

The (private) rooms are right and tastefully decorated, furnished with a single bed, a

lounge chair, and a reading table; there are outlets for lamps, television and a telephone.

The general impression is one light, airiness and quiet... The semi-private

accommodations have 60 percent more beds in the same floor space... The ward

accommodations are crowed with equipment and people, sick and well. (p.87)

Shopping Mall Concept


Hospitals were looked at as hotels for the sick. The designs of the architecture were

contemporary for the hotels in the West. The critics found the buildings to be impersonal, high

on costs and uncaring (Sloane, 1994). Hospital administrators went to designers asking for help,

that is how the concept of "the shopping mall" came to be. Gillette suggested that the shopping

mall "was to offer, in short, that ideal middle ground between city and country, public and

private life, which was so often promised for the suburbs but so seldom realized" (Sloane, 1994,

p.91). This concept idea placed the “lobby” in the main entrance, it made emphasis on the way

finding, commercial spaces and retail stores, restaurants, and even included amenities

(comfortable furniture, sculptures, fountains, etc.). This design concept has been used not only

for hospitals but also for hotels, offices, and even restaurants. John Billings the designer of the

hospital John Hopkins, in 1874 was able to identify in a piece he wrote about Hospital

Construction that he never saw a review written from a patients point of view (Billings, 1874).

Past research on the past on physical environments in hospitals has been focused mostly on staff

satisfaction and this one was linked to the service delivery in a specific context (Moushard,

Zhao, 2012). As a result this makes the hospitals administrators aware of the importance that the

opinion of the main users of the space has on building a hospital. Architects are now asked to

design while having the consumer's needs in mind.

As human needs evolve so do all the things around them, in this case, the healthcare and

hospital design has to fit consumers needs. The shopping mall concept became a strong tool for

designing hospitals. The shopping mall elements used incorporated isolated patients with the

healthy, giving them the opportunity to perform normal activities that made them feel like a part

of society again (Sloane, 1994).


III. PHYSICAL THERAPY PROFESSION

"Physical therapy is the core therapy in rehabilitation practice" (Djong et al., 2011). An

assessment was done in the 1990s for the American Physical Therapy Association, the purpose

was to predict the future holding for this profession. Arriaga found six major areas that would

affect the profession: economics, demographics, human resources, the profession within the

healthcare sector, public policy and the role of association (Arriaga, 1994). The significance of

this analyses was to learn what aspects would affect the profession and in which ways.

It was noted that the demographics of the American population would suffer a dramatic

change in the upcoming years (mid 90s and beginning of the millennium), caused by the growing

number of people migrating, the aging of the population, growing poverty, and cultural diversity.

This would result in complex health problems (Arriaga, 1994). "Culture has a powerful influence

on health and illness" (Deutsch, Anderson, 2008, p.31). Decisions about illness seem to be

influenced by personal experiences, values, and customs on which people base their foundations

(Deutsch, Anderson, 2008). Regarding the health care sector Arriaga identified that "[t]he

evolution of health care will create change within all facets of the profession, including practice,

research, and education" (Arriaga, 1994, p. 380). Creating new knowledge is fundamental in

every profession and the opportunities in the physical therapy profession to expand in research

related to outcome/effectiveness studies were predicted to be successful. Public policy would

change and be shaped as groups, individuals and the government would demand. The profession

would definitely find challenges in the upcoming years but it would grow, creating job

opportunities and recognition in the health care sector (Arriaga, 1994).

Physical Therapy has evolved since the 1990s. The body of knowledge keeps growing, the

profession is expanding and implementing new kinds of therapies, psychologically and


physiologically. The implementation of new therapies benefit the patients (Deutsch, Anderson,

2008). Research in the social sciences has proved to be useful to the understanding of the

patient/clinician relationship, this interaction has improved the education of the patient, and the

professional (Arriaga, 1994).

IV. PHYSICAL THERAPY PATIENTS

Human beings are connected in body and mind, one cannot function without the other. "[M]ental processes and the state of the mind can affect the biochemical, immunological, and

physical status of the body" (Deutsch, Anderson, 2008, p.84). Many studies in the medical field

have proved that a good correlation between the physical and the psychological state can provide

great benefits to the well-being of a person.

It has been recognized that stress, depression and anxiety have an important role in causing

illness, intensifying symptoms, and interrupting the recovery of the patients (Deutsch, Anderson,

2008).

Psychological Needs

Davis (2011) did research on the benefits of rooftop gardens in the physical therapy

setting. He used post occupancy evaluation (POE) methods to gather the perspectives and

opinions of all the possible users of the spaces, as well as the designers of the space. All the

patients that participated agreed on the garden being valuable to their recuperation. They seemed

not to care where the therapy was done but they appreciated spending time outside, where they

were able to find themselves after losing their own identities through the recuperation process.

One of the patients said "[w]hen you feel better mentally, emotionally, and spiritually, you do

physically" (Davis, 2011, p.30). It is clear that the connection between mind and body is strong,


furthermore it is essential that designers can create a space where this connection can become

stronger.

There has always been the myth that being exposed to nature or the environment has the

ability to heal. Modern research has shown that in fact being exposed to the natural environment

can benefit in the healing and recovery of a person (Kaplan, 2001). It is this state of mind that

helps the process of recovery to advance and have positive results. Patients undergoing physical

therapy, are in a vulnerable state of mind; they are psychologically wounded, it is necessary for

them to find a place that gives them comfort and the chance to meditate and accept their new

conditions. Sloane (1994) proposes that reducing the seriousness and anxiety of hospital settings

helps in reducing the stress on patients, visitors and the staff. This is to be considered when

designing spaces for the healthcare sector.

Patients have discovered that having a piece of mind can help in their recuperation :

"spiritual well-being helps emotional problems, which in turn have an effect on physical well-

being" (Davis, 2011, p.30). There is a psychological bond to the natural environment that makes

a person feel good and rejuvenated. The colors of nature, the wind, the natural sunlight, these are

elements that people appreciate and have stated to have made a difference when being in a

hospital (Davis, 2011). Studies have also proved that distracting the mind with natural views and

sounds when performing painful tests or exercises to a patient can result in the reduction of pain

and anxiety (Diette et al., 2003). Kaplan (2001) noted in her research of the impact of natural

surroundings that there is an improvement on health if the windows at home face natural

surroundings, with this he proposes to provide window views, gardens and green areas around

the building in order to increase human activity in relation with nature.


Psychologically, physical therapy patients need to be at peace with their new reality in

order to feel spiritually motivated to advance in their recovery. Natural environments seem to be

the catalyst in finding emotional acceptance. Landscape designers and architects have the

opportunity to create spaces for these individuals; spaces that could help them be in constant

contact with nature and with themselves.

Physical Needs

In the past three decades scientists have taken on the task of studying and further exploring

the deep connections between mind and body. "Much evidence exists for the powerful impact

that the mind has on our physical health and the influence of the body’s condition upon our

mental state" (Deutsch, 2008, p.86). It would be appropriate to assume that the rehabilitation

depends on both, but mainly the physical recuperation on the positive state of mind.

In physical therapy it is crucial to move the patient as much as possible regardless of the

kind of impairment that he/she suffers. Movement is essential to avoid muscle atrophy. Every

treatment goes according to the necessity of the patient (Djong et al., 2011). Some of the

activities performed in physical therapy are after the formal assessment of the patient: exercising,

transfers, gait, community mobility, stretching, bed-chair transfers, walking on uneven surfaces,

and the use of orthotic devices (Djong et al., 2011). Studies have also proposed to use new

technologies for rehabilitative exercises, for example the game Wii (Shih, CH. Chen, Shih, CT.,

2012). The use of "assistive technology devices, which are designed to assist people with deficits

in physical, mental, or emotional functioning, are alternative ways of performing actions, task,

and activities" (Shih, CH. Chen, Shih, CT., 2012, p.43). These are only some examples that leave

the designer and architect with an idea of how the setting for physical therapy should be, it gives

a window to the imagination to create spaces for specific activities and interactions. It should be

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taken into consideration that due to the impairments of these patients, the spaces should be ADA

compliant.

It is recognized that physical therapy has a vast amount of patients all suffering from

different or similar impairments (Djong et al., 2011). When creating a space for this sector of

healthcare, many things have to be considered: the users of the space (patients, staff, visitors),

what codes should be follow (ADA), is the location appropriate for its use, how is it going to be

managed, among other things that all together make the design work. Providing the patients a

space that can meet all their needs is the priority. In this case it is used to help in the canalization

of the recovery process.

V. INFLUENCE OF THE ENVIRONMENT

"Within a therapeutic recreation context, recollections of past recreation experiences may

be used to create different levels of physiological arousal and affective conditioning for people

with mental and/or physical disabilities."(Tarrant, Manfredo, Driver, 1994).

"Research suggests a strong association between health outcomes and the physical

environment in which a person lives or receives treatment" (Mourshed, Zhao, 2012, p.362). The

environment on which people interact can have an influence on their health, in their moods and

emotions. "Many psychiatric healthcare organizations understand how built environments can

impact patients[...]" (Doherty, Sell, 2011, p.30). According to many studies, families and patients

seek for environments that do not look institutionalized. Most hospitals usually do not offer the

physical and psychological comfort of being home (Doherty, Sell, 2011). People tend to look for

familiar spaces in order to feel comfort and safeness. It is important to provide the people with

personal space because it improves the restorative qualities of an environment, and a place that is


compatible and coherent. Favorite place experiences are characterized by the feeling of being

away, coherence, fascination and compatibility with the place, which provide a restorative

experience to the person (Korpela, Harting, 1996).

In the research conducted by Davis (2011), patients seemed to prefer spending more time

outside. They wouldn't mind where the therapy would take place, either outside on the rooftop

garden or inside, but they liked the idea of having an outdoor place to retreat. The use of the

rooftop was considered valuable according to the staff members from the physical therapy

department at the hospital. They considered the garden to be a good alternative to working with

the patients, but also to be "capable of improving their emotional or spiritual outlook" (Davis,

2011, p.26). In another research Engelke and Frank (2001) identified that there should be

planning and designing of public features that encourage to walk and bike which would improve

public health.

It is important to look at every perspective of the users of the space, making sure that it

makes a positive impact at least to the majority. In other studies it has been identified that the

good design execution of a hospital environment can increase the effectiveness and satisfaction

of the staff. This leads to a reduction in medical errors and infections that can be acquired in the

hospital. Furthermore, it can decrease staff injuries and stress (Mourshed, Zhao, 2012).

Impacts of Natural Environment's Elements

Previous studies based in the context of hospitals and other settings have demonstrated the

importance of the role of “the view”. Elements such as windows result in faster recovery or in

the reduction of need for health care services (Kaplan, 2001). It is not the window but what

people see out of the window that makes a difference in their health. There is also evidence from

other studies that prove that the use of natural elements can enhance the feeling of well-being, so


it is essential to maximize the use of windows, skylights and glazing. The sunlight has a positive

effect on the well-being of a person (Korpela, Harting, 1996).

Nanda, Eisen and Baladandayuthapani (2008) uses the first landmarks found on the

impacts of nature views on patients' recovery from a hospital in Pennsylvania between 1972 and

1981 in his research about the healing effect of visual art on patients[:]

Findings showed that surgical patients assigned to rooms with windows and looking out

on a natural scene had shorter postoperative hospital stays, received fewer negative

evaluative comments in nurses' notes, and took fewer potent analgesics than matched

patients in similar rooms with windows facing a brick building wall. (p.271)

Patients, when answering questionnaires regarding the benefits of having a garden in the

hospital as a physical therapy center responded that: fresh air, seeing changes while being there,

and getting away from the hospital smells to see green were some of the benefits of having this

natural setting within the hospital (Davis, 2011).

There is an apparent improvement on people's health when exposed in some way to natural

elements' views and physical settings. It would not only be beneficial to the patients, but also to

their doctors. It is reasonable that this should be used as an advantage for designing healthcare

settings.

VI. INTERIOR DESIGN EFFECTS IN HEALTHCARE SETTINGS

Empirical research has proved that elements of interior design have influenced the users of

a space. This research covers the field of healthcare and the main users of the space. Slime says

that "[t]he idea of 'place making' or the provision of an optimum psychological fit between


people and their physical surroundings has received renewed interests among the design

community" (Mourshed, Zhao, 2012, p.362).

Influence of Interior Design Elements on Users

According to Miwa and Hanyu (2006) little research has examined the healing potential

related to design. It is said by Blichik that "[g]ood design on its own cannot heal but, it can make

science work better" (Frost, 2004, p.S-88). Frost (2004) says in his research that "[l]ighting,

offices, public, and private spaces, finishes, wall coverings, acoustics, outdoor seating areas

along the meditation path, and water artwork have all been designed to impact positively as

people try to change their lifestyle" (p.S-88). With this information it seems that in fact, elements

of design do have an effect on people, and if a design is well executed usually the effects are

positive and result in the healing process of a person.

Studies have proved that light can impact the health and performance of humans by

"enabling performance of visual tasks, controlling the body’s circadian system, affecting mood

and perception, and by enabling critical chemical reactions in the body" (Joseph, 2006, p.1).

Joseph’s (2006) findings also include that higher levels of lighting are linked with better

performance when doing visual tasks and as age increases so does the light requirements. Light

can also impact the outcomes in healthcare settings, by controlling the body’s circadian system,

it then can reduce depression, decrease the length of stay in hospitals, and improves the sleeping

and circadian rhythm. It is said to also decrease agitation among dementia patients, ease pain in

patients, and improve staff adjustment to night-shift work. There are also findings indicating that

the presence of windows in the workplace and access to daylight result in an increase of

satisfaction in the work environment. It has been known for years that the exposure to light is


essential for vitamin D in the human metabolism of the body, and exposure to light is also used

as a treatment for neonatal hyperbilirubinaemia (Joseph, 2006). Also in the subject of lighting

Alexander, Ashton-Miller, Giordani, Guire and Schultz, found evidence in their study that as

people age their need for better illumination to perform tasks increases:

Because fall risk is increased by the presence of an environmental hazard [as in an

uneven walking path, (9)],vision becomes more critical in avoiding a fall when the environment

places more demand on vision. Demand is increased in a darkened area, or where there are

hazards to be traversed and stepping accuracy becomes critical. (p.1558)

In healthcare settings it is also important to know which kind of art and objects to use, the

opinion of the users should be considered when selecting the decorations of the space. Nanda,

Eisen and Baladandayuthapani (2008) conducted research of the perceptions between healthcare

patients and students on art for healthcare settings. Patients mainly had a preference for art pieces

that contained natural content, while students preferred abstract art (Nanda, Eisen,

Baladandayuthapani 2008). The spaces should be designed according to the preferences of the

future users of the buildings, leaving aside the preference of the designers.

Mourshed and Zhao (2012) performed a study on the perceptions' of healthcare providers

physical environment design factors in hospitals. Their research had significant findings

regarding design elements and the impact these have on the personnel of the hospital. The

elements they investigated: illumination, air quality, architectural design, daylight, cleanliness

and maintenance, exterior views, furniture layout, plants and landscaping, location and

orientation, acoustics, color scheme, cohesiveness of objects, adjacency, spaciousness, thermal

comfort. In their literary review it was found that elements of design do have an effect on staff

and patient:


• Illumination: According to Shikder and Mourshed (2010), adequate illumination

(artificial and natural lighting) is required to perform visual tasks; and Buchanan, Barker,

Gibson, Jiang, & Pearson (1991) ay that it reduces the chance of errors on medicine-

dispensing (Mourshed, Zhao, 2012).

• Air Quality and Freshness: Air quality and freshness reduce the presence of unpleasant

smells Insufficient ventilation was found to decrease work efficiency and productivity

according to the findings of Seppänen et al (2006). In 2002 there was found a link

between poor air quality and the risk of the increase of nosocomial infection (Mourshed,

Zhao, 2012).

• Daylight: In a research in 2008 consucted by Ulrich, it was found that daylight has an

impact on the performance of visual tasks and the psychological state of a person. It

impacts the patient outcome and provides medical and office workers with restorative

benefits (Mourshed, Zhao, 2012).

• Furniture: Vischer (2007) said that the ergonomics of furniture can cause long-term

muscular or nerve injuries; Tzeng and Yin (2009) found that the majority of patients' falls

were linked to furniture layout (Mourshed, Zhao, 2012).

• Acoustics: Dubbs (2004) directly linked to the outcomes of patients to the noise levels of

the space; he also said that staff effectiveness increased in quiet settings. Loud

environments result stressful and sufficiently high in interfering with their work

according to the findings of Bayo, Garcia & Carcia (1995) (Mourshed, Zhao, 2012).

• Color Schemes: Dalke (2006) said that along with lighting, color schemes have an impact

in people's responses to the environment and affect staff morale and quality of healthcare.


• Cohesiveness of Objects: The use of art has been found by Stucky and Nobel (2010) to be

effective in reducing adverse psychological and physiological outcomes (Mourshed,

Zhao, 2012).

• Thermal Comfort: Fischer (2006) found that thermal discomfort is related to inadequate

nurses' work ability and Witterseh, Wyon, & Clausen (2004) linked it to the reduction of

their productivity (Mourshed, Zhao, 2012).

There is an evident effect on the users from interior design elements on healthcare settings.

It is necessary to have these findings from previous research so they can be used on future

designs to prevail in the good, safe, and innovative design of healthcare environments.

Space Planning and Architectural Layout

In the history of hospitals, the location and orientation of the architecture was thought to be

of importance in order for the building to receive the most from the natural surroundings and

environment. "John S. Billings's pavilion design for Johns Hopkins surrounded the buildings

with light, air, and sun while separating the patients by illness" (Sloane, 1994, p.85). At the time

it was believed that the design had to follow the two main theoretical concepts that guided health

care: 1. Natural elements eliminated pollutants in the air, preventing diseases and infections from

spreading; and 2. Isolating patients would show that physicians were unable to spread disease

within the hospital (Sloane, 1994).

In the research done by Mourshed and Zhao, they found elements rewarding the

architecture and landscape that can also affect the users:

• Architectural Design of the Space: Guenter & Vittori believe that the architectural design

goes beyond that of a geometric organization for the space, that it influences the sensory


perceptions of the users. They also believe that the spatial designs affect staff retention,

and efficiency and productivity (Mourshed, 2012) Exterior Views: It has been found that

views can have a positive effect on the recovery of the patient, even more the views that

have natural content. Ulrich (1984) found that "[v]iews to the outside are manifested as

positive emotional and physiological changes leading to stress reduction or restorative

benefits" (Mourshed, Zhao, 2012, p.364).

• Landscaping and Indoor Plants: Plants and landscaping were recognized as contributors

of a positive distraction and providers of a pleasant working environment. Ulrich (1999)

says that views of natural settings have an influence on the recovery of patients

(Mourshed, Zhao, 2012).

• Location and Orientation: According to Zimring (1990) the location and orientation of

the space is linked to a series of functions within the space: visual, auditory, thermal, and

olfactory environments. The use of a poor location and orientation may lead to a poor

way finding system, it may also contribute to staff stress and waste of time (Mourshed,

Zhao, 2012).

• Adjacency: Long distances between nurse stations and wards has a negative impact on the

performance of the nurses and the quality of care to the patients (Mourshed, Zhao, 2012).

• Spaciousness: The lack of space has been linked to a stressful environment; O'Neil

(1994) believes that it also has an effect on patient satisfaction and staff performance

(Mourshed, Zhao, 2012).

Architecture, Interior Design, and Landscape Architecture are professions that are able to

make a difference in civilization. The structure and the environments that these three professions

are able to build have been recognized through research and investigations to make an impact on


people's lives. In the case of healthcare it has been found that a good design can indeed

accelerate the recovery process of patients, and can reduce stress among staff.

Innovative Designs for Healthcare Settings

America is constantly changing because of the population, new technologies, and

government policies (Arriaga, 1992). It is a world that never stops revolving and evolving. As

humans change so do their needs, and everything around them has to be adapted in order to meet

these needs.

Architects, designers and landscape architects are always on the move to make successful

projects. It is necessary to have a good design team in order to have a successful design.

Innovation is not something that comes easy, there is always the hunt for new ideas that will

bring the wow factor to a space, either by the architecture, the interior design, or the mix of both.

When designing for healthcare, there are numerous things that have to be considered;

safety codes, ethical codes, sustainability, technology, logistics, etc. There are other factors that

have to be considered; the kind of patients that the space is being designed for, the successful

designs of the past that can be used as examples to follow, and the not successful designs that

have to be used as examples to avoid making the same mistakes. An advantage of using the

results of research is that these can be later applied in the decision-making process of an

evidence-based design (Mourshed, Zhao, 2012).

Hamilton says that "[e]vidence-based design is the conscientious, explicit, and judicious

use of current best evidence from research and practice in making critical decisions, together

with an informed client, about the design of each individual and unique project" (Davis,

2011,p.16).


Frost (2004) has proposed that "[h]ealth care organizations integrating spa services into its

offerings hold greater potential for success than health services in a spa setting" (Frost, 2004,

p.S-91). This shows some innovative ideas that could be used when designing for health care

institutions. There are also findings about how the use of green design can improve the profits of

a hospital, but also the satisfaction of the users (Robeznieks, 2010). On an interview that

Robeznieks (2010) did with Allan Bell, the designer of the Dell Children's Hospital he says[:]

We don't have a whole lot of science behind it," Bell says. "Is it the building? Who

knows? But, at the old building, you'd look out the window and see the underside of a

highway. Now you see a healing garden. It's helped us with recruiting doctors and

specialists who we could never get before. This is where everyone wants to take their

kids now. (p. 28).

In the research conducted by Davis (2011) on the rooftop garden as a setting for physical

therapy, he finds the elements of design that were successful and the ones that were not. Therapy

walks for physical therapy, gazebos for groups, ball courts, and outdoor spaces to escape and see

the green were some of the things that he found to be successful. On the other hand he found that

there was limted access to visibility to the garden, no signage for wayfinding, lack of

horticultural therapy, several key plant failures, too many elements in one garden, lack of private

and comfortable seating, and a lack of attention to the views off site to be unsuccessful.

There is evidence that shows that the use of new design concepts, and new ideas, help in

the growth of the profession, and in the inspiration of students who are the future of the world. In

an interview with Bells, he says how the "students from the University of Texas schools of

architecture, engineering and interior design regularly tour the hospital, as do groups from Texas

A&M and Texas Tech"(Robeznieks, 2010, p.29)


VII. BUILDING CODES

When designing for the healthcare sector, there are codes that need to be followed.

Healthcare settings are places that people link to be a center where miracles can occur, it is

where people go to be cured and is a place where they feel safe. It is the responsibility of the

architects and the interior designers to make the space safe for its users. The possibility of

facilities not being allowed to open if they don't follow the correct codes exists. The

administrators of the buildings could be sued for not following the appropriate codes (Patterson,

1997). In previous studies it has been found that priority has been given to fire safety rather than

accessibility (Walbe Osteirn et al., 2007). Keyes (2012), after some observations, believes that

architects are not properly trained for the Life Safety Code, what they have learned has been

through seminars and self-education. Bickenbach, Gray, and Gould (2003) on the other hand

think that design practitioners, landscape architects, city transportation planners, developers and

contractors among others have to be recognized when creating built environments that diminish

disabilities. Nevertheless, all the codes should be met in an equal manner for the users to have a

safe environment and feel free from inequalities.

ADA

The American with Disabilities Act, better known as ADA, was passed as law in the

1990's. Its objective is to provide people with disabilities with equal opportunities. The

perceptions of access among disabled people are really important to be able to evaluate the

effects of ADA, and even more when one out of five Americans has a disability (Menzel Baker,

Kaufman-Scarborough, 2005). The Access Board, a federal agency, writes the American with


Disability Act Accessibility Guidelines (ADAAG) that became enforced when the Department of

Justice and the Department of Transportation adopted them (Patterson, 1997).

The Architectural Barriers Act of 1968, makes it mandatory for buildings that had been

funded by the government to make the building barriers free. Federal buildings and facilities

might not have to follow the ADA but must comply with the Uniform Federal Accessibility

Standards (UFAS) which are the minimum guidelines dictated by the Architectural Barriers Act

(Patterson, 1997).

Healthcares facilities must comply with ADA since they are open to a wide range of

people, among them disabled people. Since physical therapy patients are impaired in some way,

it is mandatory to follow at least the minimal accessible guidelines, in order to provide a safe

and universal environment.

Fire and Life Safety Codes

Fire safety codes are covered by the federal government, state government, and local

authorities. The National Fire Protection Association (NFPA) is in charge of producing codes

and standards in this area. One of the many is the NFPA 101, which dictates that: "locks and

hardware on doors shall be install to permit free escape"; "exits must be marked by a readily

visible sign; and any door in a means of egress must be able to swing from any direction to the

full use of opening", and "[d]oors must swing in the direction of egress when serving a room or

area with 50 or more occupants" (Patterson, 1997. p.71). All healthcare facilities that receive

Medicare and Medicaid funding have to comply with it.

For a project, interior product specification is more than just deciding on colors. It includes

choosing products that match the correct codes for the correct applications, says Patterson


(1997). It is of great importance for the professionals to always thoroughly investigate the

appropriate codes before specifying any material, this is how they will know what complies in

one place or what might not comply in another (Patterson, 1997). It is imperative to follow all

codes when building healthcare facilities. The safety of its users should be the main concern of

the administrators, architects, and designers. There have been cases where the architects do

follow the LSC but after the inspection there are codes that have not been met; it is not the fault

of the architects but is simply that they do not interpret the LSC as the authorities that inspect the

facilities do (Healthcare Life Safety Compliance, 2012).

VIII. CONCLUSIONS

Humans have a tendency of being influenced by their surroundings. After analyzing the

existing literature on how interior design elements can affect the recovery process of admitted

patients in hospitals and other kind of healthcare settings, the findings are that a good design

could make for a quicker recovery. Identified by Sloane (1994), Davis (2011), Mourshed and

Zhao (2012), and other authors of research used for this literature review, natural elements have

a positive effect on the users of hospital settings.

The intent of this literature review is to find as much evidence as possible on how to

properly use the elements of design for a healthcare setting, specifically on the physical therapy

setting. Not much research has been done on the subject of how interior design can influence and

affect the recovery process of physical therapy patients. However, evidence exists about other

healthcare settings (mainly hospitals) which could be applied for the one being investigated.

Davis’s (2011) research helps in identifying that gardens are of great use for physical therapy,

not only for the physical environment that they provide to the patients, but also for the

psychological aspect which results in a spiritual escape.


Since the subject is on temporarily or long-term impaired individuals, it is essential to also

investigate the codes that a physical therapy setting should comply with. Also limited by the

existing literature, the only evidence found were the codes that are to be followed for healthcare

settings, such as ADA and Fire Safety Codes according to Patterson (1997).

The Physical Therapy within healthcare is a division that is still in development (Arriaga,

1992). As the world changes and discovers new technologies, so does every aspect of life.

Humans, find in nature, a restorative quality that cannot be find anywhere else (Kaplan, 2001). It

is the job of designers to be innovative and create environments that can mix the use of

technology with nature, which could result in the optimal conditions for physical therapy patients

to recover in a faster and positive way.


References

Alexander, N. B. Ashton-Miller, J. A. Giordani, B. Guire, K. Schultz, K. A. ( 2005). Age Differences in timed accurate stepping with increasing cognitive and visual demand: a walking trail making test. Journal of Gerontology, 60A(12), 1558-1562. Arriaga, R. (1992). American physical therapy association environmental statement. Physical Therapy Journal, 72(5), 378-397. Billings, J.S. (1874). Notes on hospital construction, public health reports and papers of the american public health association meeting. New York: Hurd and Houghton. Davis, B. (2011). Rooftop hospital garden for physical therapy: a post occupancy evaluation. Health Environments Research and Design Journal, 4(3), 14-43. Deutsch, J. E. Anderson, E. Z. (2008). Complementary therapies for physical therapy: a clinical decision-making approach. St. Louis, Missouri. Sauders Elsevier Inc. Diette, G. Lechtzin, N. Haponik, E. Devrotes, A. Rubin, H. R. (2003). Distraction therapy with nature sights and sounds reduces pain during flexible bronchoscopy. The Cardiopulmonary and Critical Care Journal, 123(3), 941-948. Djong, G. Hsieh, CH. Putman, K. Smout, R. J. Horn, S. D. Tian, W. (2011). Physical therapy activities in stroke, knee anthroplasty, and traumatic brain injury rehabilitation: their variation, similarities, and association with functional outcomes. American Physical Therapy Association, 91(12), 1826-1837. Doherty, J. Sell, J.E.(2011). Deinstitutionalizing design: strategies to design a more residential environment for psychiatric patients. Behavioral Healthcare, 31(1), 30-33. Engelke, P. O. Frank, L.D. (2001). The built environment and human activity patterns: exploring the impacts of urban from on public health. Journal of Planning Literature, 16(2), 202-216. Frost, G. (2004) The spa as a model of an optimal healing environment. The Journal of Alternative and Complementary Medicine, 10(1), S85-92. Gray, D. Gould, M. Bickenbach, J. (2003). Environmental barriers and disability. Journal of Architectural and Planning Research, 20(1), 29-37. Healthcare Life Safety Compliance (2012). Healthcare design and construction challenges. Healthcare Life Safety Compliance, 14(8), 4-5. Joseph, A. (2006). The impact of light on outcomes in healthcare settings. The Center for Health Design, Issue 2, 1-12.


Kaplan, R. (2001). The nature of the view from home: psychological benefits. Environment and Behavior, 33(4), 507-542. Kaufman-Scarborough, C. Menzel Baker, S. (2005). Do people with disabilities believe that the ADA has served their consumer interests? The Journal of Consumer Affairs, 39(1), 1-26. Keyes, B. (2012). Fire barrier management, ICC building codes, and more. Healthcare Life Safety Compliance, 14(4), 9. Korpela, K. Hartig, T. (1996). Restorative qualities of favorite places. Journal of Environmental Psychology, 16(3), 221-233. Miwa, Y. Hanyu, K. (2006). The effects of interior design on communication and impressions of a counselor in a counseling room. Environment and Behavior, 38(4), 484-502. Mourshed, M. Zhao, Y. (2012). Healthcare providers' perception of design factors related to physical environments in hospitals. Journal of Environmental Psychology 32(4), 362-370. Nanda, U. Eisen, S. Baladandayuthapani, V. (2008). Undertaking an art survey to compare patient versus student art preferences. Environment and Behavior, 40(2), 269-301. Sloane, D. C. (1994). Scientific paragon to hospital mall: the evolving design of the hospital. Journal of Architectural Education, 48(2), 82-98. Patterson, M. (1997). Know the codes. Buildings, 91(5), 68. Rashid, M. Zimring, C. (2008). A review of the empirical literature on the relationships between indoor environment and stress in health care and office settings. Environment and Behavior, 40(2), 151-190. Robeznieks, A. (2010). Taking the LEED; hospitals and health systems continue to make strides toward "greener" facility design and construction featuring reduced energy consumption. Modern Healthcare, 40(42), 28. Shih, CH. Chen, LC. Shih, CT. (2011) Assisting people with disabilities to actively improve their collaborative physical activities with Nintendo Wii Balance Boards by controlling environmental stimulation. Research in Developmental Disabilities, 33(1), 39-44. Tarrant, M. A. Manfredo, M. J. Driver, B. L. (1994). Recollections of outdoor recreation experiences: a psychophysiological perspective. Journal of Leisure Research, 26(4), 357. Walbe Ornstein, S. Ono, R. Lopes, M. E. Monteiro, R. Z. (2007). Health care architecture in são paulo, brazil: evaluating accessibility and fire safety in large hospitals. International Journal of Architectural Research, 1(1), 13-25.

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ANNOTATED BIBLIOGRAPHY

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Initial Thesis Project Questions and Purpose Purpose Statement The purpose of this literature review is to understand the effects of interior design can on the recuperation process of physical therapy patients and the environmental factors that promote the healing and rehabilitative process. It is important to study the healthcare environment because research continues to develop, offering new ideas and standards for healthcare professionals and patients alike. This research will uncover the optimum conditions, to encourage a speedy recovery. Reading List 1. How can interior elements positively and negatively influence the patients? Nanda, U. Eisen, S. Baladandayuthapani, V. (2008). Undertaking an art survey to compare patient versus student art preferences. Environment and Behavior, 40(2), 269-301. This article was written by Upali Nanda from the American Art Resources, Sarajane L. Eisen from the Auburn University, and Veerabhadran Baladandayuthapani from the University of Texas. It was published in the year 2008 in the Environment and Behavior Journal by Sage publications.

The purpose of this article is to address the issue of patients’ stated art preferences, and how these compare with the art preferences of those with an art or design background and describes the findings of an art survey containing both best-selling art images and images considered appropriate for health care. There were found significant differences across the three different population's art preferences.

Findings:

• Hospitalized patients preferred images with realistic art like nature views and landscapes than stylized or abstract art. (295)

• Nature images offering a sensory component, familiarity, and foliage were rated higher than other nature images. Figurative art in a nature setting was also rated highly in patients. Flowers in a nature setting was also rated high, but with a limitation of gender bias. (295)

• Best selling art and abstract art generated lots of comments from the patients but rated low. Art that generates comments and discussions is not preferred. (295-296)

• Interior design students preferred abstract art with representative and non representative forms. (296)

31

Quotations: "The patient preference for nature and realistic content over abstract or stylized content, even when the latter is high quality (classics) or popular (best selling), supports the previous research on appropriateness of nature content in hospital settings." (298) "The stated preferences for positive and negative images in health care art can now be validated via clinical-outcome-based studies that test whether artwork with “preferred” image content is more therapeutic." (298) Diette, G. Lechtzin, N. Haponik, E. Devrotes, A. Rubin, H. R. (2003). Distraction therapy with nature sights and sounds reduces pain during flexible bronchoscopy. The Cardiopulmonary and Critical Care Journal, 123(3), 941-948. The authors of this study are Gregory B. Diette with accreditations of MD and MHS; Noah Lechtzin accredited with a MD and MHS; Edward Haponik with MD, FCCP, Pulmonary and Critical Care Medicine; Aline Devrotes who is a RN; and Haya R. Rubin who has a MD and a Ph.D., all belonged to the General Internal Medicine at the Johns Hopkins University School of Medicine. The study took place in the year 2003 was published in the Cardiopulmonary and Critical and Care Journal by the American College of Chest Physicians. The goal of this study is to investigate the impact of using distraction therapy with nature sights and sounds on reducing pain and anxiety and to increase the patient's satisfaction during a bronchoscopy. The authors’ theoretical stance (philosophical worldview) is positivist. The authors already knew from previous research that nature sights and sounds would have this effect on the patients, but after conducting their own research they validated this theory. Findings:

• There is an improvement in pain control with nature sights and sounds. (948) • Patients undergoing a FB are proved to be in a state of anxiety. (948) • The study demonstrates that pain experienced by patients can be reduced by a pleasant

environment but on the other hand anxiety cannot be reduced. (947) • The state of anxiety it is induced perhaps by the fear and not by the procedure itself.

(947) Quotations: "Despite these limitations, this investigation extends the medical application of distraction therapy and identifies an important low-cost opportunity to enhance bronchoscopy practice." (947) "The current investigation lends further support to the importance of addressing pain control and anxiety as distinct considerations during bronchoscopy." (947) Kaplan, R. (2001). The nature of the view from home: psychological benefits. Environment and Behavior, 33(4), 507-542.

32

Rachel Kaplan, the author of this article, was the Samuel T. Dana Professor of Environment and Behavior in the School of Natural Resources and Environment at the University of Michigan at the time when the article was written. It was published in 2001 by Sage Publications in Environment and Behavior. Funded and sponsored by the USDA Forest Service, North Central Experiment Station and the Urban Forestry Unit. This study was based on questions and photographs that were completed at apartment buildings in Ann Arbor, Michigan which served to assess how window views were affecting the well-being and the residential satisfaction. Studies have not been done before to analyze the restorative experiences that window viewing could provide to residents; window views and the penetration of sunlight have been related in the increase of satisfaction and well-being. Findings:

• Windows views are important in the improvement of health and well-being. (534) • There is a greater improvement on health if the windows face natural surroundings. (540) • Windows views, gardens and green areas should be provided around the building to

increase human activity in relation with nature. (535) Quotations: "Nature content contributed substantially and differentially to residents’ satisfaction with nature and with their neighborhood; the availability of gardens and well-landscaped areas was particularly salient to these satisfactions. (539) "There is ample anecdotal support and a growing empirical literature substantiating that windows are favored in diverse settings, including the workplace, schools, hospitals, prisons, and residential contexts" (509). "A series of studies carried out in the context of hospitals and prisons has demonstrated the role of view content in the effectiveness of windows in speeding recovery or reducing the needs for health care services (Moore, 1981; Ulrich, 1984; Verderber, 1986;West, 1986)" (509). Mourshed, M. Zhao, Y. (2012). Healthcare providers' perception of design factors related to physical environments in hospitals. Journal of Environmental Psychology 32(4), 362-370.

The authors for this article were Monjur Mourshed and Yisong Zhao from the Building Energy Research Group, and the School of Civil and Building Engineering at the Loughborough University, in United Kingdom. Published by the Journal of environmental Psychology in the year of 2012. The research was funded by the UK Engineering and Physical Sciences Research Council via the Health and Care Infrastructure Research and Innovation Centre.

The purpose of this article was to further investigate on filling the gap between what are the perceptions of the users and which are the perceptions of the healthcare providers by exploring healthcare providers’ perception of physical environment design factors in hospitals. Research has suggested a strong association between the physical environment in which a person lives or receives treatment and the health outcomes. Findings:



33

• Aspects related to the design for maintenance were perceived to be more important by healthcare

providers than those related to spatial design. (366) • Environmental design aspects related to sensory perceptions were also ranked as very

important. (365-366) • Working patterns had significant associations with the perception of maintenance and

environmental design aspects. (366) • Significant differences among males and females in the perception of the body-contact

and sensory. (368)

Quotations: "Research indicates that staff wellbeing, productivity and satisfaction are linked with a hospital’s physical environment, in particular the aspects that are determined during early design stages of a building’s lifecycle." (362) "There is also a growing body of evidence on the impact of the working environment on healthcare providers’ efficiency, productivity and satisfaction that contribute to patient outcomes." (362)

2. Do patient recuperation outcomes depend on the type of setting in which they are treated? Diette, G. Lechtzin, N. Haponik, E. Devrotes, A. Rubin, H. R. (2003). Distraction therapy with nature sights and sounds reduces pain during flexible bronchoscopy. The Cardiopulmonary and Critical Care Journal, 123(3), 941-948. The authors of this study are Gregory B. Diette with accreditations of MD and MHS; Noah Lechtzin accredited with a MD and MHS; Edward Haponik with MD, FCCP, Pulmonary and Critical Care Medicine; Aline Devrotes who is a RN; and Haya R. Rubin who has a MD and a Ph.D., all belonged to the General Internal Medicine at the Johns Hopkins University School of Medicine. The study took place in the year 2003 was published in the Cardiopulmonary and Critical and Care Journal by the American College of Chest Physicians. The goal of this study is to investigate the impact of using distraction therapy with nature sights and sounds on reducing pain and anxiety and to increase the patient's satisfaction during a bronchoscopy. The authors’ theoretical stance (philosophical worldview) is positivist. The authors already knew from previous research that nature sights and sounds would have this effect on the patients, but after conducting their own research they validated this theory. Findings:

• There is an improvement in pain control with nature sights and sounds. (948) • Patients undergoing a FB are proved to be in a state of anxiety. (948) • The study demonstrates that pain experienced by patients can be reduced by a pleasant

environment but on the other hand anxiety cannot be reduced. (947) • The state of anxiety it is induced perhaps by the fear and not by the procedure itself.

(947)

34

Quotations: "Despite these limitations, this investigation extends the medical application of distraction therapy and identifies an important low-cost opportunity to enhance bronchoscopy practice." (947) "The current investigation lends further support to the importance of addressing pain control and anxiety as distinct considerations during bronchoscopy." (947) Doherty, J. Sell, J.E.(2011). Deinstitutionalizing design: strategies to design a more residential environment for psychiatric patients. Behavioral Healthcare, 31(1), 30-33. This article was written by Joseph Doherty certified LEED AP and A.I.A, the Principal and Core Group Leader of Array Healthcare Facilities Solutions, and also by Jon E. Sell who was the principal and project designer as Array Healthcare Facilities Solutions. It was written in 2011 and published by Behavioral Healthcare. The objective of this study was to further investigate how the strategies of deinstitutionalization of healthcare facilities meet the needs of distinct patient populations. There is a movement of turning hospital facilities into a more residential environment, making these spaces innovative, where the planning, architectural and interior design strategies come together in order to make it happen. Findings:

• A universal room design has become desirable because it can accommodate distinct patient populations and can be adapted in the future for new demographics. (31)

• Main street circulation have replaced the double loaded corridor designs because it separates patients, visitors and staff. (31)

• A three corridor space design has become famous because is a non-institutional design solution, where: visitors arrive to their destinations without passing through the "patient zone", staff can circulate safely and actively between the patient zone and support spaces, and last but not least the staff can easily access the "off stage" areas. (32)

Quotations: "Effective universal pod design combines openness with good sight lines from staff areas. Circulation corridors must be carefully studied and designed to achieve optimal width-to- length ratios while positioning patient activity spaces such that they can easily be supervised by staff. " (32) "Deinstitutionalizing design-identifying and applying strategies and best practices that create and non-institutional or residential feel to the treatment environment- is an important step toward supporting a progressive model of behavioral healthcare." (33) Korpela, K. Hartig, T. (1996). Restorative qualities of favorite places. Journal of Environmental Psychology, 16(3), 221-233. Kalevi Korpela a member Department of Psychology at the University of Tampere in Finland and Terry Hartig a member of the School of Public Health at University of California in Berkeley, California, were the authors of this article. It was published in the Journal of

35

Environmental and Psychology in 1996 by the Academic Press. The authors were received grants; the first author received a grant from the Academy of Finland and the Scientific Foundation of the City of Tampere, and the second author received the grant T32 HL07365-14 from the U.S. National Heart, Lung, and Blood Institute. The study was conducted with the objective of looking at the restorative factors of seven places in order to determine if there is a relationship between the place and the restorative environments. Findings:

• The use of natural elements to enhance the feeling of well-being, maximize the use of windows, skylights and glazing since the sunlight affects in a positive way the well-being of a person. (223)

• Provide the people with personal space because it improves the restorative qualities of an environment, and a place that is compatible and coherent. (231)

• Favorite place experiences are characterized by the feeling of being away, coherence, fascination and compatibility with the place, which provide a restorative experience to the person. (230)

Quotations:

"Ideas about emotion- and self-regulation provide usually experienced when there are elevations in self-esteem and when previously unassimilable means to join the place identity concept with restorative environments theory (Korpela, 1989, 1992, material is assimilated into a person’s self-experience. Displeasure is experienced when self-esteem 1995). Emotion-regulation is not only an inner homeostatic process, but one that also involves is diminished or when there is a failure in assimilation (Epstein, 1990). The four principles are all of interaction with the environment (Vuorinen, 1990; Dodge & Garber, 1991; Fuhreret al., 1993; Kaiser, basic importance, and behavior is viewed as a compromise among them (Epstein, 1985). For 1993)". (222)

Rashid, M. Zimring, C. (2008). A review of the empirical literature on the relationships between indoor environment and stress in health care and office settings. Environment and Behavior, 40(2), 151-190. The authors of this article are Mahbub Rashid an associate professor of design at the University of Kansas; and Craig Zimring an environmental psychologist, also professor of architecture at the Georgia Institute of Technology. The article was published in 2008 in Environment and Behavior by Sage Publications. This article was based on existent literature which helped to analyze the findings of previous studies related to the relationship between indoor environment quality factors and people or workplace needs in a healthcare and office settings.

Findings:

• Lighting, air, noise and temperature affect the psychological stress in both settings: healthcare and office.

36

• Natural lighting has a positive effect on the occupants of the space. • Artificial lighting might have a negative effect on the occupants' health in both healthcare

and office settings.

Robeznieks, A. (2010). Taking the LEED; hospitals and health systems continue to make strides toward "greener" facility design and construction featuring reduced energy consumption. Modern Healthcare, 40(42), 28. The author of this article is Andis Robeznieks. It was written in 2010 and published in Modern Healthcare by Crain Communications, Inc.

The purpose was to have a record of some of the LEED certifies hospitals of the country among them the Dell Children's Medical Center of Central Texas, that was the first hospital to be certified platinum LEED in the whole world. Taking notes of the water and the energy that the facility can save, the technology, and the benefits that this LEED building has brought to the staff, the patients, and the owners.

Findings:

• The new hospital uses 30-40% less of water than four of Central Texas hospital of the same size. (2)

• "The onsite 4.5 megawatt natural gas-fired turbine providing all of the hospital's electricity is 75% more energy efficient than a coal-fired power plant." (2)

• The hospital passed its $75 million donation by other $12 after being certified platinum LEED. (2)

• Students of Architecture, Engineering, and Interior Design go on tours that benefits them in their education.

• Parents are more likely to take their children to the Dell Children's Medical Central than to any other hospital.

Quotations: "We don't have a whole lot of science behind it," Bell says. "Is it the building? Who knows? But, at the old building, you'd look out the window and see the underside of a highway. Now you see a healing garden. It's helped us with recruiting doctors and specialists who we could never get before. This is where everyone wants to take their kids now." (1) Sloane, D. C. (1994). Scientific Paragon to Hospital Mall: The Evolving Design of the Hospital. Journal of Architectural Education, 48(2), 82-98. David Charles Sloane has a PhD and worked at the University of Southern California. The article was written in 1994 and published by Wiley on behalf of the Association of the Collegiate School of Architecture, Inc. The research was partly funded by a grant from the Lusk Center for Real Estate Development at USC.

37

The purpose of this research was to recount the history of the evolution of hospitals. Analyzing the phases that it has gone through and the approaches that have been used for this institution's design. Findings:

• The evolution of health care has affected the architectural and design concept of hospitals. (82-86)

• The Shopping Mall approach has changed the design approach, now hospitals are design to encourage family participation and promote social life. (90-91)

• Creating spatial designs that make the wayfinding easier and do not give the impression of seriousness reduces the stress on the users of the space. (93)

• The exposure of the architecture to the natural elements, like fresh air and daylight, resulted in the lessening of the spread of diseases. (85-86)

Quotations:

"Designers are emphasizing customer comfort in high-style surroundings, changing designs to encourage family participation, and creating images which evoke an inviting combination of social life and community education." (90) "John S. Billings's pavilion design for Johns Hopkins surrounded the buildings with light, air, and sun while separating the patients by illness." (85)

3. What does contemporary research recommend regarding standards within a physical therapy setting? Alexander, N. B. Ashton-Miller, J. A. Giordani, B. Guire, K. Schultz, K. A. ( 2005). Age Differences in timed accurate stepping with increasing cognitive and visual demand: a walking trail making test. Journal of Gerontology, 60A(12), 1558-1562. The authors of this study were Neil B. Alexander, James A. Ashton-Miller, Bruno Giordani, Ken Guire and last but not least Albert B. Schultz. Alexdander belonged to the Division of Geriatric Medicine in the Department of Internal Medicine and Institute of Gerontology at the University of Michigan, he also has credentials from Ann Arbor and Veteran Affairs Ann Arbor Healthcare System Geriatric Research Education and Clinical Center in Michigan; Ashton-Miller belonged to the Department of Mechanical Engineering and Applied Mechanics and Institute of Gerontology; Giordani worked at the Department of Psychiatry and Psychology; Guire was a member of the Department of Biostatistics; and Schultz was a member of the Department of Mechanical Engineering and Applied Mechanics and Institute of Gerontology at the University of Michigan as well. The article was published in the Journal of Gerontology in 2005 by the Gerontological Society of America. The idea the authors had with this study was to investigate the lighting effects and the mental distractions, of young and old individuals, on the stepping performance and the speed. Quantitative methods were used and some of the purposes of the study were to find the effects of aging and dark areas in the stepping accuracy, and to also calculate the accuracy on stepping into irregular shaped objects. Findings:

38

• The results were that indeed the performance time increased with age and also did the cognitive demand. (1558)

• "The time to perform a stepping accuracy task, such as may be required to avoid environmental hazards, increases under reduced lighting and with increased cognitive demand, the latter disproportionately so in older adults" (1558).

• "No other age group interaction effects related to light condition were found, and no gender effects were found". (1560)

Quotations: " Because fall risk is increased by the presence of an environmental hazard [as in an uneven walking path, (9)],vision becomes more critical in avoiding a fall when the environment places more demand on vision. Demand is increased in a darkened area, or where there are hazards to be traversed and stepping accuracy becomes critical." (1558) Arriaga, R. (1992). American physical therapy association environmental statement. Physical Therapy Journal, 72(5), 378-397. The author of this study was Rita Arriaga, a clinical instructor of the Graduate Program in Physical Therapy at the University of California in San Francisco. The author had the assistance of thirteen other staff in order to cover every aspect of the research. The article was published in 1992 by the Physical Therapy Journal. The purpose of this study was to analyze the factors that would make the field of Physical Therapy change in the decade of the 90s. Since it would be a decade of constant evolution there would be challenges all along the period, for this reason the analyses was made to study the changes stimulated by economic factors, technological advances and the needs of the people. Findings:

• There are six major areas that affect the evolution of this field: The Economics of Health Care, The Demographics of the American Population, Human Resources in Physical Therapy, The Physical Therapy Profession in the Health Care Sector, The Shaping of Public Policy, and The Role of the Association. (54/378)

• Physical therapy will continue to gain public recognition. Enhancing the image and perception of the profession, however, first will require that the profession develop a strong self-image and a commitment to becoming a leader in health care delivery. (56/380)

• The profession of Physical Therapy will go under changes that will bring opportunities but it needs to re-define itself in order to be accepted and better understood by the public. (57-58/381-382)

• The Demographics of the population have a great influence on the subject. During the decade of the 90s there was a growing number of immigrants from different countries, with different cultures and costumes, among other factors that challenged the health care system. (60-61/384-385)

Quotations: "The ability to change and evolve successfully is dependent on an understanding of the environment in which we exist; the factors that will affect change in this environment; and the opportunities, challenges, and threats presented by these factors." (54/378)

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Davis, B. (2011). Rooftop hospital garden for physical therapy: a post occupancy evaluation. Health Environments Research and Design Journal, 4(3), 14-43. The author of this study is B. Davis at the time an assistant professor of the College of Environment and Design at the University of Georgia in Athens. The article was written in the year 2011 and published in the Health Environments Research and Design Journal by the Vendome Group. The goal of this study is to examine the impact of hospital rooftop gardens on physical therapy patients and staff, to then improve the conditions of these in the future for this specific population. The authors’ theoretical stance is emancipatory, he used a mixed method for this research, where he did observations and mappings collecting scientific data and where he gave out questionnaires to the participants as well. Findings:

• Patients treated seemed to like the garden setting to perform the therapies and spend time. (41)

• It is sure that the success of these gardens is due to the continuous involvement of the designer and preservation of a garden’s design integrity and that they might provide the greatest healing benefits to patients as well as a great work environment for hospital employees. (41)

• There should be a design of different spaces within the garden so it can meet the needs of specific patients. (42)

• The use of these rooftop garden resulted in a reduction of stress for the staff.(42) Quotations:

"Increasing the visibility of and physical access to the garden is of great importance. Multiple garden viewing rooms could be created in adjacent buildings. These could be used as atria or conservatory-like waiting rooms or break areas to serve distinct areas of the hospital. In addition, other visible rooftops could be made green, even if only as intensive green roofs for viewing from the garden, observation deck, and hospital windows." (39) "The power of garden elements such as a bench for sitting, a path for walking, and access to elements of earth and sky were reported as having physical, emotional, spiritual, and social benefits." (37)

Djong, G. Hsieh, CH. Putman, K. Smout, R. J. Horn, S. D. Tian, W. (2011). Physical therapy activities in stroke, knee anthroplasty, and traumatic brain injury rehabilitation: their variation, similarities, and association with functional outcomes. American Physical Therapy Association, 91(12), 1826-1837. The authors of this study are Gerome Djong who has a PhD, worked at the Center for Post acute Innovation & Research, and at the National Rehabilitation Hospital; C-H Hsieh who has a Phd, and was working in the Center for Post-acute Innovation & Research, and at the National Rehabilitation Hospital; K Putman a physical therapist, with a Phd, and had worked at the Interuniversity Center for Health Economics Research, at the Faculty of Medicine and Pharmacy,

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and at the Vrije Univertsity Brussel in Belgium; R.J. Smout with a MS and MT, worked at the Institute for Clinical Outcomes Research in Utah; SD Horn has a PhD and worked at the Institute for Clinical Outcomes Research; and W Tian wih a MD and a PhD, worked at the Center for Post-acute Innovation & Research and at the National Rehabilitation Hospital. The study was published by the Amercian Physical Therapy Association in the year 2011. The purpose of this study was to find the similarities and differences between the therapies of the different treated groups, who presented three different types of injuries, and to examine if the activities performed during the therapy could be associated with the improvement of the impaired patients. Findings:

• All groups had similar body motor performance. • The patients with knee arthroplasty received the most physical therapy, and the patients

with traumatic brain injury received the least physical therapy. (1832) • Two of the activities performed were positively linked to the performance of body motor

response, and three activities were negatively associated with the motor outcome. (1831-1834)

Quotations:

"In the course of their careers, many physical therapists and physical therapy researchers tend to specialize and focus on specific impairment groups such as patients with stroke. This specialization advances knowledge in a particular field (eg, stroke rehabilitation), which is beneficial for patients and the profession." (1833) " Despite the study's limitations, activity-level data, although less granular than desired, provide insight on how time is spent in physical therapy activities are associated with outcome." (1836)

Engelke, P. O. Frank, L.D. (2001). The built environment and human activity patterns: exploring the impacts of urban from on public health. Journal of Planning Literature, 16(2), 202-216. The authors of this article are Lawrence D. Frank and Peter O. Engelke. Frank has Ph.D. and was assistant professor at the time at the Georgia Institute of Technology, and Engelke was a research associate at the City and Regional Planning Program at the Georgia Institute of Technology. The article was published in 2001 by the Journal of Planning Literature. This article addressed the influence of the design of urban environments and the effect that causes on public health through the walking and biking of the residents. Previously quality of life and the link to the built environment have not been the focus of a study, but the planning of automobile traveling, disregarding the importance of human exercising activity. The findings of this research were based on previous studies, and the methodology used was the review of land use, planning and transportation and the investigation of the ties between non-motorized travel and design features and how they affect public health. Findings:

• The authors identified that there should be planning and designing of public features that encourage to walk and bike which would improve public health. (202)

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Shih, CH. Chen, LC. Shih, CT. (2011). Assisting people with disabilities to actively improve their collaborative physical activities with Nintendo Wii Balance Boards by controlling environmental stimulation. Research in Developmental Disabilities, 33(1), 39-44. Ching-Hsiang Shih, Ling-Che Chen, and Ching-Tien Shih were the authors of this study and article; Ching-Hsiang Shih and Chen belonged to Department of Special Education at the National Dong Hwa University in Taiwan, and Ching-Tien Shih was from the Department of Electronics Engineering and Computer Science at the Tung Fang Design University also in Taiwan. The article was published in the year 2012 in Research in Developmental Disabilities Journal. The purpose of this study was to extend previous research done on Wii Balance Boards application, which was conducted on four people (who were obese) with developmental disabilities. The study adopted the latest software technology with three Wii Balance Boards to detect the participants’ collaborative physical activities in order to assess whether they would be able to actively increase their these activities efficiency. Findings:

• The use of "assistive technology devices, which are designed to assist people with deficits in physical, mental, or emotional functioning, are alternative ways of performing actions, task, and activities." (43)

• With the help of assistive technologies, people with disabilities, can gain additional accessibility, and use their abilities more effectively to participate more in their societies, also to achieve optimal functional ability and independence and improve their quality of life. (43)

• Many commercial products like mousses and Wii remote controls can be turned into assistive devices with an improvement in the design and technology that can be suitable for persons with disabilities. (43)

Quotations: "All participants had poor walking ability, moved very slowly, were obese and were lacking in the desire to exercise. With the guidance of the research assistant, they learned to follow simple orders and carry out specific physical activities (i.e., walking to the specific location and standing there, according to the instructions) in order to obtain their preferred environmental stimulations (e.g., playing their favorite videos). Their parents had given formal consent for their involvementin this experiment." (40) "Assistive technology devices, which are designed to assist people with deficits in physical, mental, or emotional functioning, are alternative ways of performing actions, task, and activities." (43) "Further studies are necessary to extend this study’s application to more application fields concerning people with disabilities, such as obtaining the desired environmental stimulation by following more complex instructions and performing more complex physical activities and exercises, and so on." (43) 4. What type of materials, colors, lighting, and organization promote and stimulate the recuperation process?


http://www.ncbi.nlm.nih.gov/pubmed?term=Chen%20LC%5BAuthor%5D&cauthor=true&cauthor_uid=22093646�


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Frost, G. (2004) The spa as a model of an optimal healing environment. The Journal of Alternative and Complementary Medicine, 10(1), S85-92. An article written by G. Frost who has a Ph.D. and was one of the main personnel of the Canyon Ranch Health Resorts. It was published in the year 2004 in the Journal of Alternative and Complementary Medicine by Mary Ann Liebert, Inc. publisher. The goal of this study is to discuss the factors that contributed to healing environments at spas. Preventive therapies and wellness have been linked before to reduce sickness, decrease the use of prescribed drugs, and the improvement of physical, mental and spiritual health. Findings:

• Incorporating spa services and facilities into healthcare settings can promote healing on the patients. (S-89)

• To create an optimal healing environment is a spa it is necessary to: have a dedicated caring staff at all levels, have a mission driven organization that will not compromise, and have a sound business model and leadership that will ensure permanency. (S-85)

Quotations: "The combination of specific educational programs, medical, behavioral, nutritional and exercise consultations, spa treatments, and first-hand practice with healthy behaviors leads to an increased feeling of individual empowerment and well-being, and improved emotional and physical well-being." (S-91) “Good design on its own cannot heal, but it can make science work better.” Lighting, offices, public and private spaces, finishes, wall coverings, acoustics, outdoor seating areas along the meditation path, and water artwork have all been designed to impact positively as people try to change their lifestyles." (S-88) “A difficult but important challenge for designers is to be sensitive to such group differences in orientations, and try to assess the gains or losses for one group vis-à-vis the other in attempting to achieve the goal of psychologically supportive design.” (S-88)

Miwa, Y. Hanyu, K. (2006). The effects of interior design on communication and impressions of a counselor in a counseling room. Environment and Behavior, 38(4), 484-502. Yoshiko Miwa a member of Nagoya University at Chikusa-ku in Japan, also a counselor in Mie; and Kazunori Hanyu who has a Ph.D and was a associate professor at the College of Humanities and Sciences in the Nihon University in Tokyo, were the authors of this article. The article was published in the year 2006 in Environment and Behavior by Sage Publications. The purpose of this study was to investigate the effects of lighting and interior design on a patient's communication, feelings, and impressions of the counselor. It is possible that the interior design of a space has an influence on the treatment of a patient. Previously research has been done on the evaluation on the pleasant aspect of multiple interior design elements but not on individual design elements. Findings:

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• The authors discovered that dimmed lighting made the patients feel secure and relaxed, giving opportunity to develop positive feelings towards the counselor. (484)

• They also found to be important the education of the professionals about how the interior design environment can influence the psychology and therapy. (484)

Quotations: "The effects by aesthetic interior design may be likely to become more significant through the interaction of visual quality with interpersonal factors and longer-term exposure"(486). Joseph, A. (2006). The impact of light on outcomes in healthcare settings. The Center for Health Design, Issue 2, 1-12. The author of this study is Anjali Joseph, with a Ph.D., and the Director of Research at the Center for Health Design. The paper was published in the year 2006 by the Center for Health Design and it was funded by a grant from the Robert Wood Johnson Foundation. The objective of this study was to identify the mechanisms by which light impacts human health and performance and also to review the literature linking both kinds of light, daylight and artificial light, with health outcomes in healthcare settings. The study was based in journals articles from other fields like architecture, psychology, ergonomics, medicine, etc. Findings:

• Light can impact human health and performance in different ways: by enabling performance of visual tasks, controlling the body’s circadian system, affecting mood and perception, and by enabling critical chemical reactions in the body. (1)

• Light can help to reduce depression among patients, decrease the length of stay in hospitals, improve sleep and circadian rhythm, lessen the agitation among dementia patients, ease pain, and improve adjustment to night-shift work among staff. (1)

• The use of windows for daylight has proven to increase satisfaction in the work environment. (1)

Quotations:

"Light is critical to human functioning in that it allows us to see things and perform activities. But it is also important because it affects human beings psychologically and physiologically." (2) "There is strong evidence that light is critical to human functioning and can be extremely beneficial to patients as well as staff in healthcare settings. Adequate lighting conditions are essential for performance of visual tasks by staff in hospitals, and poor lighting conditions can result in errors." (9) "Clearly, an important goal for facility designers should be to fulfill human needs for light and provide a high-quality lighted environment." (10)

Sloane, D. C. (1994). Scientific Paragon to Hospital Mall: The Evolving Design of the Hospital. Journal of Architectural Education, 48(2), 82-98.

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David Charles Sloane has a PhD and worked at the University of Southern California. The article was written in 1994 and published by Wiley on behalf of the Association of the Collegiate School of Architecture, Inc. The research was partly funded by a grant from the Lusk Center for Real Estate Development at USC. The purpose of this research was to recount the history of the evolution of hospitals. Analyzing the phases that it has gone through and the approaches that have been used for this institution's design. Findings:

• The evolution of health care has affected the architectural and design concept of hospitals. (82-86)

• The Shopping Mall approach has changed the design approach, now hospitals are design to encourage family participation and promote social life. (90-91)

• Creating spatial designs that make the wayfinding easier and do not give the impression of seriousness reduces the stress on the users of the space. (93)

• The exposure of the architecture to the natural elements, like fresh air and daylight, resulted in the lessening of the spread of diseases. (85-86)

Quotations:

"Designers are emphasizing customer comfort in high-style surroundings, changing designs to encourage family participation, and creating images which evoke an inviting combination of social life and community education." (90) "John S. Billings's pavilion design for Johns Hopkins surrounded the buildings with light, air, and sun while separating the patients by illness." (85)

Tarrant, M. A. Manfredo, M. J. Driver, B. L. (1994). Recollections of outdoor recreation experiences: a psychophysiological perspective. Journal of Leisure Research, 26(4), 357. The purpose of this study was to compare the recollections of subject-selected preferred active and passive outdoor recreation experiences with the recollections of a distressful exam condition using psychophysiological measures. Psychophysiology is an exploration of the relationship between verbal reports and behavioral responses. Findings:

• The results of the experiment are consistent with both Lacey's "rejection-intake" hypothesis of arousal and Selye's theory of stress. (7)

• In this study the recollections of the active recreation experience produced moderate elevations in heart rate which contribute to improve cardiovascular functioning (Froelicher &Froelicher, 1991) and increased positive mood which is linked to improved self-esteem, lowered depression, enhanced immune responsiveness and reduced suicide rates. (7)

• "Within a therapeutic recreation context, recollections of past recreation experiences may be used to create different levels of physiological arousal and affective conditioning for people with mental and/or physical disabilities." (7)

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Quotations: "Benefits, defined as improvements in condition (Driver, Brown &Peterson, 1991), include outcomes such as enhanced mental and physical health, increased positive mood, development of self actualization, and reduction of negative stress." (7) 5. What building code requirements must be considered in the healthcare setting? In the Physical therapy setting? Billings, J.S. (1874). Notes on hospital construction, public health reports and papers of the american public health association meeting. New York: Hurd and Houghton. Gray, D. Gould, M. Bickenbach, J. (2003). Environmental barriers and disability. Journal of Architectural and Planning Research, 20(1), 29-37. The authors of this article are David B. Gray, Mary Gould, and Jerome E. Bickenbach. It was published in the year 2003 in the Journal of Architectural and Planning Research. The purpose of this study was to explore the views on the barriers and the facilitators to fill participation in major life activities for those people who have disabilities using focus groups of people with mobility impairments, their significant others, healthcare professionals, and built environment professionals.

Findings:

• Design practitioners, landscape architects, city transportation planners, developers and contractors, among others have to be recognized when creating built environments that mitigate disabilities. (35)

• There is and intermediation between intermediate consumers (builders) and end-user consumer (people with disabilities) before the building process, that makes an integration of knowledge and interest, that result in built environments that meet a wide range of the public and government concerns. (35)

Quotations:

"The concept that environmental factors constitute an essential scientific component of disability has led the World Health Organization (WHO) to include environmental factors as part of its revised classification instrument, the International Classification of Imnpairments, Activities and Participation:A Manual of Dimensions of Disablement and Healtl7 (ICIDH-2 Beta One, WHO, 1997). In this document, the environmental factors are considered as either facilitators or barriers to participation for persons with impairments or activity limitations." (30-31)

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"The Americans with Disabilities Act provides a basis for going beyond simple compliance with minimal building codes in assuring access to buildings by allowing designers to provide for equivalent facilitation of building access. But in order to achieve equivalent facilitation, designers, builders, building owners, and others involved in construction of the built environment have had to learn from the people affected by building design. People with and without disabilities may have differing views of what is needed for access to and use of building spaces." (31)

Keyes, B. (2012). Fire barrier management, ICC building codes, and more. Healthcare Life Safety Compliance, 14(4), 9. Written by Brad Keyes the Senior Editor of the Journal, where he offers every month a small article about his thoughts, comments, and concerns on issues about healthcare life safety. This article was written in the year 2012 and published in Healthcare Life Safety Compliance Journal. The article talks about fire barrier management, modifying the ICC building codes, and fire alarm technicians on staff. Keyes talks about the flukes he has found in these three subjects and to his experience what he thinks it should be done about it. Findings:

• The 2 hours course given by the firestop manufacturer for the maintenance staff in order to receive a certificate that declared them as properly trained to install the products, is not properly working because the staff forgot what they learned within about a week. (9)

• Architects are not properly trained about Life Safety Code, what they have learned has been through seminars and self-education. (9)

• Some of the fire alarm contractors don't know or understand the NFPA 72, it is important that they take courses and seminars in order for them to know this material and avoid problems from surveyors or inspectors about the testing techniques and documentation of the reports they have to do. (9)

Quotations: "When I started my career in facilities management 34 years ago, fire barrier management was not a topic of much concern for us. Primarily, our staff filled whatever holes we found in a rated wall with insulation and covered it with a skim coat of joint compound--not a suitable system by any means." (9) "Architects who design hospitals are trained in the ICC building codes, but not so much on the LSC." (9) Walbe Ornstein, S. Ono, R. Lopes, M. E. Monteiro, R. Z. (2007). Health care architecture in são paulo, brazil: evaluating accessibility and fire safety in large hospitals. International Journal of Architectural Research, 1(1), 13-25. The authors of this study are Sheila Walbe Ornstein, Rosaria Ono, and Maria Elisabete Lopes and are grateful for the valuable cooperation of the management of the Orthopedics and

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Traumatology Institute of the São Paulo General Hospital who provided the research team with this a great opportunity for study, and also for the efforts made by Mr. Tomaz Puga Leivas in putting the research project into practice. The coordinator of this study, Dr. Sheila Walbe Ornstein, also offered her thanks to the National Scientific and Technological Development Board, as a scholarship holder of that institution. This article is a description and discussion of the procedures of scientific and technical interest for applying a Post Occupancy Evaluation, especially questions related to accessibility and fire safety in specialized and complex hospital buildings. The hospital chosen was one of the most important hospital of Latin America, with around one million patients each year, approximately 200 physicians and 890 nurses that worked in the building.

Findings: • The authors saw that in the case of hospital buildings and similar architectural designs,

it is important and effective to apply the POE focused on the topics of accessibility and fire safety, which often overlap in terms of problems and solutions. (24)

• The priority given to fire safety is higher than the priority given to accessibility. (21) • The general areas of circulation, admittance and surgery areas, access doors, as well as

elevators, have proper dimensions that enable persons in wheelchairs to maneuver or be maneuvered. (17)

• "There were problems found with the stairways, with inadequate dimensions, railings and floors, and the absence of visual or tactile signs." (17)

• The building did not have a sprinkling system or fire extinguishers since it had started implementing the codes recently. (18)

Quotations: "Although the POE has been used in academic circles in Brazil since 1984 (Roméro; Ornstein, 2003), only in the 1990s did research in the field of performance evaluation begin, more specifically in relation to POEs focused on hospital buildings. Especially important in this process were studies published by Preiser (1998) on hospital systems in the USA, Europe and Israel. Preiser, an architect (Preiser; Vischer, 2005), and Bechtel (1997), an environmental psychologist, introduced the concept of inter-disciplinarity between architecture and urbanism and other subjects, and the need to include users’ perceptions in research on built environments." (13) Kaufman-Scarborough, C. Menzel Baker, S. (2005). Do people with disabilities believe that the ADA has served their consumer interests? The Journal of Consumer Affairs, 39(1), 1-26. The authors of this article were Carol Kaufman-Scarborough at the time was an associate professor of marketing at Rutgers University School of Business in New Jersey; and Stacey Menzel Baker was also an assistant professor of marketing in the Department of Management & Marketing at the College of Business Administration in the University of Wyoming. It was published on the Journal of Consumer Affairs in 2005 by the American Council of Consumer Affairs. The article was also funded and sponsored by the National Center for Medical Rehabilitation Research, the National Institute of Child Health and Human Development, and Sociometrics Corporation Gran.

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The objective of this study was to determine how disabled people perceive accessibility and the effect of the American with Disabilities Act, better known as ADA. There is the possibility that out of 5 people in this country one has some kind of disability what makes them a big minority. The ADA was passed into law in 1990 and its objective was to provide people with disabilities with equal opportunities as everybody else. The perceptions of access among these individuals are really important to be able to evaluate the effects of ADA. Findings:

• Of the number of the participants in the study only 54% reported knowing about a law that regarding disabilities. (12)

• Only 32% of those who knew about the law felt a difference in their life after the law and other 60% saw no change regarding them. (12)

• Proposition 1: Consumers who are aware of ADA are more likely to perceive positive changes than the ones who are not aware. (12)

• Proposition 2: Consumers aware of the ADA perceive positive changes in: public transportation, public facilities, theaters, and stores, public attitudes toward the disabled, media portrayal, and advertising inclusion than people who are not aware of ADA. (13)

• The implementation of ADA is incomplete and specifically in the education of people with disabilities about their consumer's rights.

Quotations: "As anticipated, respondents indicated feelings of exclusion from various activities due to personal factors in addition to feeling that access has been enhanced through improvements in environmental factors." (14) "The results indicate that consumers with disabilities believe that ADA has served their consumer interests in a variety of ways since its enactment, including increased access to commercial venues, improvements in public transportation, theaters, stores, public attitudes toward the disabled media portrayals, and inclusion of disabled people in advertising. However, the results also demonstrate gaps that need to be addressed if the ADA is to create benefits proponents envision for people with disabilities." (21) Patterson, M. (1997). Know the codes. Buildings, 91(5), 68. The author of this article is Maureen Patterson who at the time of the publication was an associate editor of Building Magazines. The article was published in 1997 by Buildings Journal. The objective of the article was to recognize the importance of following building codes as interior designers, facility manager, etc. Also to mention the most important codes that should be followed in order to have a successful interior project, not only the safety but also the job of the designers might be on jeopardy if the appropriate codes for the type of project are not followed correctly. Findings:

• For a project interior product specification is more than just deciding on colors: It includes choosing products that match the correct codes for the correct applications. (1)

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• The professionals should always thoroughly investigate the appropriate codes before specifying any material, this is how they will know what complies in one place or application might not comply in another. (1)

• It is very important the following of codes and standards because is not only beneficial for good construction but it is a matter of life or death for a building. (1)

• Facilities might not be allowed to open if they don't follow the correct codes, and the owners could be sued for not following these. (1)

Quotations: "It requires that commercial facilities and public accommodations and state and local government facilities be designed, built, and altered to be accessible, to meet guidelines that our agency establishes." (2)

Carmen Ferrer Julia Florida International University · elements of design from a shopping mall into the hospital setting. Shortly after, hospital administrators started asking designers

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