The Role of the Spatial Configuration of the System Designed for Intensive Care Units in Creating Healing Environment - Iraqi Hospitals as a Case Study

1.1 Spatial configuration and the healing environment concept

A healing environment is defined as one that reduces stress and encourages the patient's self-healing skills while contributing to the patient's recovery and well-being [1]. The healing environment can so be defined as a place where the body, mind, and soul are healed. It is where illness, healing, death, life, and the healthcare facility that supports these conditions are defined with respect and dignity [2]. The term "healing environment" is used to describe factors that have a psychological and physical impact on the healthcare community. Healing environments should facilitate planning that protects the dignity of patients and enhances their privacy. This can reduce stress, increase comfort, and support recovery and wellness while reaching out to nature can reduce stress and improve outcomes [3].

Healing environments address a wide range of factors surrounding patients and staff in healthcare facilities. It starts with key factors such as air quality, noise control and thermal comfort, and then is optimized to include safety and security privacy. Increase access to nature, access to social support, and reduce environmental stressors [4].

1.2 Literature review

Previous studies that have addressed the role of the physical design of the ICU and the percentage of achieving the healing environment have shown that the most important design feature affects all aspects of ICU services (patient privacy, comfort and safety, staff working conditions, operational efficiency, rotation and movement, logistical support, and family integration) [5]. An ideal ICU should have three areas: patient area, family area, and caregiver area [6].

Studies have focused on the central point in the ICU is the patient's room. The recommend using a single bed instead of multi-bed rooms to enhance patient safety, privacy, and infection prevention. Each room should be equipped to function as an independent area with the necessary space for caregivers and visitors and should provide a therapeutic environment with access to outdoor views [7, 8]. According to the literature, private rooms reduce patient stress and the need to transfer patient's multiple times; given that the mortality rate from infection in the intensive care unit is much higher than in other clinical settings, the use of private rooms is ideal [9].

In ICU patient areas, social support areas are needed to throw families into patient care by providing appropriate space inside or outside the care unit for family members and visitors to provide a therapeutic environment [10].

The nursing station is the main working area of the unit used by nurses or nursing staff supervising health services. Nursing stations include the reception, the registration, and the official registration [11]. The nursing stations are classified into three types (centralized, decentralized, and hybrid nursing stations), each of which has a significant impact on patients and their needs, feeling safe and secure [12].

The approved international standards showed that the number of intensive care unit beds, which determines its ratio to the number of hospital beds, is 13% of the hospital bed capacity, and the minimum number of intensive care unit beds is eight [13, 14]. In addition to thinking about physical design, some standards achieve the healing environment, including security and safety, access to social support, access to nature, and positive distraction. this study showed that the spatial classification of intensive care units plays an essential role in the healing process, directly or indirectly. Thus, providing a healthy and comfortable environment and user satisfaction [10].

The location and spaces size within the ICU through the relationship between them and their functions. Depending on the physical constraints of the space, the designers have implemented different types of layouts and installations that achieve a healing environment such as, Nightingale ward, double corridor, single-corridor, cluster, radial and racetrack are the most common unit layouts in intensive care units [15].

Despite the above studies, a set of specifications of the healing environment in the spatial design of intensive care units were clarified comprehensively and did not clarify the role of the spatial configuration of the design system of the intensive care unit in supporting the healing environment, especially by analyzing the factors (privacy, security, safety and finding way) in particular and their impact on achieving the operational efficiency of the unit and its impact on the behavior of users in particular. In particular, there is a relationship between ICU design patterns and the therapeutic environment for three ICU module types (Nightingale ward, double corridor, and single corridor).

In support of the main research objective, a rigorous evaluation should be carried out using Space Syntax methods to verify the impact of ICU models of selected samples in terms of studying the levels of (privacy, security, safety and finding way) and their impact on the healing environment of the ICU design system in Iraqi hospitals.

1.3 Mixing of the healing environment in the design of intensive care units

The main strategies used in the design of intensive care units were based on patient care and ease of work for medical staff; health care designs were predominantly utilitarian and family visits were limited. This created an inhumane atmosphere for patients. Patients were placed in open wards with common rooms. This design allowed patient care with as few nursing staff as possible. and lack of privacy. With the increase in infection [16], the current trend is toward designing a health system that enjoys the elements of a healing environment, as shown in Figure 1.

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Figure 1. The design elements of the healing environment

The design system supporting the healing environment depends on several elements represented by the following:

A- The human factor: There is a relationship between space and human behavior, many spatial studies indicate the possibility of using the architectural space as a visual guide to determine their direction and the level of visual and auditory vision through:

-   Finding the way: This is defined as the set of visible points from a certain position, in the case of a polygon that is formed by determining the field of view of the observer in a certain position in space, and if we assume that there is an angle of view (360), the higher the value of the viewing polygon, the more appropriate the field of view and observation, therefore, through the signs in each node, which is an intersection point, facilitates observation and independent control through the use of colors and indicative panels for each unit [17]. These guidelines facilitate people's opportunities from loss and anxiety because these reduce operational efficiency and increase dependence on other people to reach the specified place [18].

-   Privacy insurance: It is an innate human feeling that a person needs and is at several levels in the design of the intensive care unit; that may be achieved by providing a single-family system for multiple beds; the open system is an obstacle to the patient's healing environment. The greater the visual vision, the greater the transmittance and the opposite of the privacy factor [19]. Reduce patient staff admissions through the availability of visual follow-up of staff to the patient [8].

B- Spatial factor: The study indicates that the elements of the spatial environment when evaluating intensive care units, represented by color, light, aesthetic elements, and the distribution of furniture in spaces, the use of cold finishing materials tends to create an inharmonious atmosphere, increase stress levels in patients [14], combine natural and artificial elements, and create contemporary, creative and symbolic works of art to help patients to enhance the healing environment, and personalize the architectural space [20].

C- Behavioral factor: There is a reciprocal correlation between human behavior and the general organization of space. Space cannot be designed without understanding and recognizing the nature of the user's behavior and their functional requirements. The mutual support between the family and the patient and providing space for family members in intensive care units and family members must be considered as an important member of the health care team where they can provide patients with the emotional support they need to recover [21]. Emotional and positive support from family and friends influences the recovery of intensive care patients [19].

Intensive Care Units (ICUs) lack aesthetic appearance and have a sterile atmosphere and little visual attention has not been incorporated into their design yet, but with many advances in biomedical equipment and monitoring in intensive care units, integrating modern technology and elements of the healing environment to provide the best design [20].

From the above, the most important features of the healing environment and the impact of integrating them into the design system of intensive care units have been clarified, and some of the types of intensive care unit configurations, in particular the types of selected study samples, have been clarified.

1.4 ICU configuration patterns

Many studies have found that the characteristics of the spaces that make up the unit affect the improvement of patient care and the policy of operation of the unit and these spaces include: Patients and medical staff. Its operational patterns are represented by many types, but the study is concerned with three of the most prevalent models, as follows:

 - Nightingale ward: The unit design consists of large rectangular rooms, with 20–30 beds, one central nursing station, offering large windows and outside views, good monitoring and control, mutual ventilation, natural lighting, low privacy factor, high risk of infection, and long walking distances [21].

 - Double -corridor: The design consists of two corridors and patient rooms on both sides of the corridor, whether single or multiple rooms, and the design contributes to the good possibility of observation and short distances of staff movement, fewer beds (up to 16-20 beds), private and multiple rooms and large windows with natural light, long corridors, and low risk of infection and safety [22].

 - Single-corridor: The design contains a single corridor overlooking all patient rooms and central nursing stations and decentralizes the number of beds from previous studies [12-30] with an increase in the length of the corridor and supply rooms, and because of the long walking distances between nursing stations for patient rooms, it increases the need for decentralized nursing stations to monitor and increase control and control and large windows, natural light [23].

1.5 Research problem

The spatial configuration of intensive care units can play an important role in the healing process, thus creating a healthy, comfortable, and safe environment for patients and medical staff. Based on the results of the data and the study of plans obtained from intensive care units in the region through field research, it was found that the hospital environment was not fully provided in a large group of local hospitals, and research was requested to address this research question and avoid it in future designs. To reach a set of research questions:

-What is the role of the spatial configuration of the ICU design in the realization of the elements of the healing environment?

-What is the design that achieves the healing environment in the intensive care unit system?

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Figure 2. The laborious research methodology of the study

Table 2. The classification and coding of elements

The characteristics of the spaces that make up the unit affect the improvement of patient care and the operational policy of the unit: There are many operational models, but this study will focus specifically on the three most common models: (Nightingale ward, Duplex Corridor, single corridor).

The results showed an analysis of these different models the ability of some spatial configurations of the unit to achieve the healing environment , the sample (c) single-pass pattern achieved the highest results achieved for the healing environment in terms of privacy factor due to the lowest value of the permeability factor, because the privacy factor is inversely proportional to the permeability and pattern of single rooms (C.2.3), and the highest value of the security and safety factor and the system of hybrid nursing stations (C.2.3) leads to increased monitoring and control by the nursing unit on patient rooms and an average value to find the way compared to the rest of the samples with social support through the integration of the family area within the unit (C.3.1) while the samples (A) recorded the average values compared to the models, and the sample (B) achieved the lowest values that achieve the healing environment in terms of privacy, security and safety factor because the spatial organization of the double corridor type with patient rooms of the single and multiple type (C.1.3) and central nursing stations only with a lower field of view, and control and maintenance of security and safety at a lower level than the rest of the samples as shown in Figure 8.

The results showed that the intensive care unit sample (C) with a single corridor had the highest levels of achieving the healing environment due to the small number of patient rooms, which is 8 beds, which leads to a short corridor and increases the factor of finding the way, with a single room style, achieving high rates of privacy and user satisfaction and decentralized nursing stations, which increases monitoring, security, and safety and reduces the number of times to enter patient rooms due to the increase in visual supervision.

While the sample (A) achieved the average values of the level of verification of the healing environment with an open pattern of 12 beds , this is due to the achievement of low privacy rates because it has a multifamily system and is served by a central nursing station in the middle of the unit The control rate is high with an increase in the possibility of infection and the values of finding the road are high because the schemes are highly integrated and easy to access.

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Figure 8. The analysis of healing environment factors based on Space Syntax evaluation

While the sample (B) with a double aisle pattern  achieved the lowest values to achieve the healing environment with an increase in the sample size because the unit has [24] beds, so the design of the unit contributes in terms of a central location for nursing stations to monitor patient rooms well, but remote rooms have weaker monitoring rates with the use of a multi-bed system and fewer rates of visual and auditory privacy and the fact that the plan has depth, which leads to finding the road more difficult

The results were represented by the following paragraphs:

• Preference for single-bed patient rooms based on research evidence, which takes a parallel path to previous literature and studies, which provide special spaces for the patient and medical supplies, which helps the comfort of the patient, facilitates the work of the staff, reduces the number of times entering the patient's rooms and increases the privacy factor.
• The spatial configuration pattern of the Nightingale ward type allows higher visual vision and integration of spaces and central nursing stations the site controls the patient rooms overlooking them with increased supervision and a higher access factor and reduce walking distances for nursing staff and medium ratios of the safety and safety factor as it increases the rates of transmission of infection As for the privacy factor, it achieves the lowest level of selected models because it has a multi-family open system and a high level of permeability and lack of privacy.
• The spatial configuration pattern of the double corridor type helps that the services and nursing stations are medium from the unit, which makes the walking distances medium and the access factor medium access while lower ratios for the level of safety and safety because the unit has turns, intersections and distant points with the increase in the size of the unit in general, and the composition also contributes to monitoring patients close to both sides well, preferably the design of hybrid nursing stations to increase the factor of monitoring, security and safety and achieve medium levels of the privacy factor for a multi-family design.
• The spatial configuration pattern of the single corridor type is suitable for single patient rooms to increase the privacy factor and reduce the levels of space permeability, and is commensurate with the hybrid design of nursing stations because the central nursing station site is ineffective to monitor all patient rooms sufficiently to achieve the factor of security and safety with easy access staff to care for patients effectively and achieve efficiency health care and a supportive environment for healing.

Based on the analysis of the different models of intensive care unit configurations, the results showed some indicators about the elements of the care unit achieved for the healing environment, the study determined the appropriate intensive care unit design for physical interaction between patients and health care staff in terms of the type of single rooms to increase privacy and in terms of the types of hybrid nursing stations for monitoring and controlling patients , and achieve connectivity and integration of spaces and reduce the size of the unit to achieve the access factor. Increase the depth of the unit chart and increase the sample size, thus confirming a direct relationship between the factors of the healing environment with the spatial configuration of units that lead to the comfort of patients and staff alike.

Finally, the results of this study raise a number of questions for future research:

How do spatial configuration patterns in the design of intensive care units affect patient and staff behavior and affect the operational efficiency of the care unit? Is there a relationship between ICU patterns and unit size with increasing the number of beds to achieve ICU that supports the hospitalization environment? How can some of the architectural functional requirements in the ICU design system be linked to the software requirements and modern technology of the building to provide a hospital environment and ensure the well-being of patients and staff?