Rehabilitation environments: Service users’ perspective

Abstract Background Design of rehabilitation environments is usually “expert” driven with little consideration given to the perceptions of service users, especially patients and informal carers. There is a need to engage with consumers of services to gain their insights into what design aspects are required to facilitate optimum physical activity, social interaction and psychological responses when they are attempting to overcome their limitations and regain function. Research design Qualitative exploratory study. Method Interviews were conducted with patients (n = 54) and informal carers (n = 23), and focus groups with rehabilitation staff (n = 90), from the three metropolitan South Australia rehabilitation health services, comprising different building and environmental configurations. Thematic analysis was assisted by the use of NVivo 11 qualitative software, with pooled data from all interviews and focus groups undergoing open, axial and finally selective coding. Results Four major themes were identified as follows: (a) choice can be an Illusion in a rehabilitation ward; (b) access to outside areas is a priority and affects well‐being; (c) socialization can be facilitated by the environment; and (d) ward configuration should align with the model of care. Discussion and Conclusion Participants who encountered the most restrictive environments accepted their situation until probed to consider alternatives; those who enjoyed the most choice and access to facilities showed the greatest enthusiasm for these affordances. Future architectural designers should therefore consider the perceptions of a wide range of consumers with varying experiences to ensure they understand the complex requirements of patients and that the ward design facilitates the optimum rehabilitation model of care.


| BACKG ROU N D
There is a paucity of evidence that addresses the consumer perspective of optimum rehabilitation environments that support models of care known to improve the outcomes of patients who have suffered an illness or injury. Pryor 1 reports that the creation of a rehabilitative milieu for an inpatient setting should consider "external and internal design and location of buildings; adequacy, allocation, usage and availability of space; and location of equipment and facilities". Current design knowledge reflects on "expert-driven and expert determined outcomes" with little input from the end users, patients, staff and visitors. 2 It is important that consumers of facilities are involved in the design to ensure architects and health planners understand the complex requirements at design phase and then in later years to promote consistent and appropriate changes after the design team has completed their task. 2 General rehabilitation is part of all patient care, including acute care, and involves the prevention, assessment, management and supervision of a person with a disability until that person has attained an adequate and appropriate level of performance. 3 Therefore, it seems clear that planning such facilities should take note of affordances, defined as "opportunities to engage and to act in welllearned or instinctive ways" 4 or "what we choose to do, given the opportunity". 5 Although we tend to spend considerable time considering superficial aspects of design like colours and sounds, these "raw sense data" do not provide the more important opportunities that the actual building design can provide: involvement with aspects that are recognizable, and able to be manipulated and used. 6 The commonly used alternative of television watching used frequently in rehabilitation units defines a diminished environment if there are no other activities offered.
As part of a health reform process commenced in public hospitals in South Australia where rehabilitation services were moved and beds redistributed, we commenced an investigation of consumer preferences prior to service reconfigurations. 7 This project was collaboration between consumer investigators from the three metropolitan local health networks of Adelaide, South Australia, and researchers from Flinders University and South Australia Department of Health. This collaborative approach has been promoted as a way of ensuring credibility and relevance of health research. [8][9][10][11] A model of care provides a framework to guide the way in which rehabilitation is delivered and should, where possible, reflect best practice evidence. Recently, in South Australia, a change to the way rehabilitation is delivered was guided by a model of care document which supported re-development of a sustainable service defined by six key objectives. The model of care defined provision of rehabilitation that is person-and family-centred, safe, effective, accessible, efficient and equitable. 12 Investigations have been undertaken that compare the effect on patients of sunlight, sound, odour, windows and spatial layout on variables including fear, arousal, anger/aggression, sadness and attentiveness with currently no conclusive findings to guide architectural practice in a hospital environment. 13 A number of design frameworks have been proposed over the years to help describe and categorize the important aspects of health design. [14][15][16] Roger Ulrich stressed that rehabilitation environments should move beyond functional efficiency and costs and   focus predominately on providing a stress-free environment, and   the way to do this was to design a psychologically supportive environment to help ameliorate the stress of those receiving health care and their significant others. 14 Gesler, a health geographer, subsequently developed the notion of a "therapeutic landscape concept," and he suggested that we could categorize this concept into physical (natural and man-made) environments, social environments and symbolic environments. In addition, Lawton and colleagues (1978Lawton and colleagues ( , 1983Lawton and colleagues ( , 1985 and Lichtenberg and colleagues (2000) introduced and subsequently investigated the Theory of Environmental Press that describes the interaction between an older persons' competencies and the environmental variables (environmental press). 15,[17][18][19] This current study sought clarification from participants to understand how these theories might relate to their experience in rehabilitation facilities in South Australia by developing an interview guide which probed participants to consider these aspects of their environment.

| Research aims
To understand patients' perceptions of how the rehabilitation environment enhanced and/or reduced the quality of their rehabilitation journey.
To understand informal carers' perceptions of the effect of the rehabilitation environment on their family members rehabilitation experience.

| ME THOD
A qualitative investigation using a phenomenological approach was used to explore the perspective of those patients and informal carers who had experienced rehabilitation in the various facilities. Interviews were conducted with patients and past patients (n = 54), informal carers (n = 23) and rehabilitation staff (n = 90) between 7.4.17 and 14.9.17 from all 3 South Australia metropolitan health networks until data saturation had occurred (see Table 1 for participant characteristics). Patient and informal carer interviews (lasting between 20 and 45 minutes) were undertaken with one experienced female researcher (MK, AMc or AW) or one experienced male consumer advocate (DF, AP or PH). Clinical staff from each rehabilitation facility were provided information on the study trial and asked to refer patients, patients who had been admitted within the last 6 months, and informal carers if they agreed to being contacted by research staff on the ward or by phone, if at home, to explain the trial and make a time to meet. Clinical staff and managers were also invited (by email) to contact the researchers if they were interested in participating in staff focus groups. As only those who showed an interest in being interviewed were referred to the researchers, very few people decided not to participate once approached (two patients who felt it would take too much time and 1 informal carer who became disinterested in undertaking an interview).
Each interview was audiotaped and transcribed verbatim. Staff focus groups were undertaken in the three rehabilitation services according to the convenience of participants. An interview guide was followed to ensure questions asked were related to the topic, but the sequence of questions differed for each participant and offered flexibility so that each participant could discuss any issue that were relevant to their situation (see Appendices S1-S3: Interview Guides).
To ensure credibility that a comprehensive report was completed prior to analysis, the researchers continued to seek information until all insights and understandings had been gained from the participants at interview. 20,21 Questions were reframed to gain more information or clarification sought. 21 Dependability and credibility were enhanced by keeping a journal and audit trail during the research.

| Data analysis
Transcriptions were sent to participants for member checking before thematic analysis using NVivo 11 qualitative software. No repeat interviews were required, and participants only made minor changes to the transcripts which were altered before analyses.

| Choice can be an Illusion in a rehabilitation ward
Most people interviewed reported overall satisfaction with their environment initially and were somewhat perplexed when asked probing questions relating to choices and freedom to undertake meaningful activities and enjoy aspects of their environment.
Many patients felt that they were on the ward to undertake their rehabilitation sessions only, and accepted a restrictive environment spending time either in the room where they slept or the therapy room. However, after probing and further questioning, it appeared that many patients, provided the opportunity, would like to make choices about what to do and where to go, in addition to undertaking the tasks or rehabilitation they needed. It was those participants who enjoyed the most choices within their environment already who were the most likely to speak enthusiastically about this issue and to provide even more options that could improve their rehabilitation journey. They wanted to be familiar with the ward environment and be able to utilize areas of the facility that enabled them to carry on with their life to their capacity.
Patients wanted to access facilities inside like the therapy gym and kitchen area either independently when able or with their family, and they were keen to spend time outside with visiting

| Access to outside areas is a priority and affects well-being
This issue was addressed differently depending on the environment the rehabilitation service patients and carers utilized. All patients and carers interviewed at Facility B discussed the issue passionately, as they reflected on the easy access to outside, the variety of beautiful gardens and courtyards, and the option to utilize undercover areas when they wished. All patients and carers valued the ground floor accommodation, which allowed frequent opportunities to go outside, for them to meet in private with family and to spend time with their precious pets. Access was not restricted for patients, with reports of staff helping patients to get outside and sit in nearby courtyards which were visible from the ward or near the ward. The language used by those being interviewed was colourful and rich as they described the environment which they valued.
In contrast, patients and informal carers from Facility A were not as enthusiastic, even though they still voiced a preference for easy access outside and bemoaned their inability to access outside, which was only available to them when family visited. Of the 15 patients interviewed at Facility A, only one patient reported that they had been assisted to get outside by a staff member on one occasion when they had asked for assistance (Facility A, Patient 10

| Ward configuration should align with the model of care
On delving into patients and families experiences, a number of consumers suggested that their rehabilitation environment did not appear to be person-and family-centred, with few design features that suggests that many patients and families will accept this restrictive approach if they are not aware of alternatives.
When designing a rehabilitation building, building codes and standards guide construction in relation to air quality, building materials, water supply and so on. However, there remains a gap in addressing the functional and psychological impact of design aspects on the client in policy making and codes during the planning and development process, which is contradiction to Ulrich's proposal of a stress-free environment. 14,24 Human habitats can provide environments that facilitate both physical and emotional responses in people who come in contact with them, 25 and it seems likely that a human body will react to the environment both consciously and subconsciously continually. 26 This concept has been previously described 16 and is supported by the findings of this current study.
Parallel to research exploring opportunities for increased physical activity within general rehabilitation environments, there is now emerging work investigating methods of affecting psycho-social aspects. 6 The built environment can play a role in psycho-environmental dynamics and reflects on research that has shown the environment to have a significant effect on the psychogenesis of mental illness. 6 As psycho-social aspects of recovery after general rehabilitation are also important, it seems vital to consider these findings in this additional context. Participants in this current study were able to suggest many affordances to improve their feelings of well-being, and most of these suggestions related to issues aside from their formal therapy sessions. Clearly, the quality of time spent outside formal therapy sessions needs to become a higher priority for designers of rehabilitation facilities.
A systematic review of qualitative studies confirmed the importance and relevance to consumers of a number of the findings in this current study including the importance of offering options and choice to patients undertaking rehabilitation. 27 This current study suggested that the rehabilitation environment could influence the level of control assumed by patients undertaking rehabilitation by supporting patients and family members to be oriented to their environment, and allowing easy access to those areas of the environment that were important to them. Independent exercise areas, areas to socialize with family and other patients and easy access to outside were core requirements reported by participants. A number of studies have suggested that "when the environment and person act on each other in a consistent and equivalent way" there is a positive impact on health and well-being. 25,28,29 To achieve this, "empathic design" architects need to understand users' needs and preferences regarding what they want to do and how they wish to engage. 30 It is acknowledged that psychological comfort of patients' undertaking rehabilitation is important for good outcomes. 14,31 Participants Despite an attempt for health services to modernize buildings and engage sophisticated technology, users report that they can find these facilities more confusing than old buildings with poorer facilities. 32 Although it is inevitable that facilities need to be superseded by new, smarter buildings, it will be important to consider the end users' satisfaction in such automated facilities. If buildings do, in fact, influence a patient's physical and psychological resources, it is important to ensure the environment eliminates "noxious" stimuli including loss of identity, loss of loved ones, inability to control their immediate environment, disruption of community life and lack of privacy. 33 Heft 34 points out that the stimuli of "misaffordance" results in psychological discomfort when users of services are unable to easily gauge functional properties of a building or space, and this subsequently affects patients' attitude and behaviour through the processes of sensation, perception and cognition. 35 Patients in other similar studies described feelings of disempowerment and subordination and feeling under "guardianship". 36 This current study suggests that these feelings can be ameliorated when the environment supports people to freely utilize the facilities and offers active involvement in activities that they value. Other studies also support the importance of providing opportunities for independent activities as a way of increasing patient control and promoting feelings of positivity and well-being. 37,38 Similar to this current study, another qualitative systematic review reported carers' distress as they "navigated a foreign culture and environment" and the importance of providing a more inclusive milieu as they prepared to assume a caregiver or supportive role. 39 The importance of access to nature was a repetitive theme amongst interviewed participants who reported the relief of being able to get away from the clinical environment, and the pressures and expectations that could pose. It helps to understand patients' feelings about being outside when we consider the Attention Restoration Theory posed by Rachel and Stephen Kaplan in 1989. 40 They proposed that nature can replenish a person's mental and attentional capacity by helping people recover from directed attention fatigue, which frequently occurs in response to attending rehabilitation sessions. 41 In addition, a number of studies demonstrate that the majority of people prefer natural landscapes to urban views and this is most pronounced when the urban scenes lack vegetation and water features. 31 There was a strong preference in this study that the rehabilita-  43 Clearly, designers of rehabilitation facilities should consider the different mixes of patients and families who are likely to use the facility and reject the "one size fits all" approach.
The current study clearly emphasizes the importance of patients being able to escape the clinical environment and to socialize with other patients and family visitors to prevent loneliness and boredom when formal therapy sessions are not occurring. Patients in another study agreed with these findings and commented on boredom and lack of stimulation which impacted on their morale and impacted on their progress in rehabilitation. 42 In addition, as in our current study, other research has indicated that providing areas where patients can meet together and discuss their various rehabilitation journeys allows a culture of motivational peer support and helps maintain their energy and interest in the rehabilitation process. 44 Other research has shown the many benefits of allowing patients access to their pets while they are in hospital including physical and psychological. 45 This current research also indicates that patients require somewhere suitable to meet with their visiting pets to reduce their anxiety and lift their mood.
This research provides the consumer perspective of the critical requirements to consider when designing an inpatient rehabilitation facility to facilitate an optimum rehabilitation model of care (see Table 2 for summary of recommendations). Patients and informal carers were keen to share their perspectives and did so with a deal of clarity and provided examples to explain their viewpoint. However, there was a sense of acceptance when patients and family were interviewed in those environments, which offered less choice, less access and less opportunity to undertake activities they valued and the interviewer needed to provide sensitive probing to understand their

ACK N OWLED G EM ENTS
The authors acknowledge thanks to Anne Whitehouse, Clinical Practice Consultant, South Adelaide Local Health Network, South Australia Health, who assisted with conducting and managing interviews.