How does the built environment support inpatient neurorehabilitation? A situated analysis

Accumulating research evidence recognises the interaction between people and place, and demonstrates the potential for the built environment to provide a supportive influence on a person’s health status and recovery journey following illness or injury. However, the nature of the supportive influence of the healthcare built environment is not well understood, particularly within inpatient neurorehabilitation settings, where people experience prolonged admissions and due to the functional, cognitive and social challenges often resulting from serious injury, may be particularly dependent on the environment to support rehabilitation and recovery. Despite the relevance of the built environment during this critical stage in the rehabilitation process, there are no clear guidelines for the design of supportive neurorehabilitation settings. Design of these settings has often focused on functional and safety requirements as dictated by building codes and industry standards. This is not commensurate with the current healthcare focus on patient-centred approaches to practice, which has broadened the focus from safety, clinical efficiencies and cost-effectiveness, toward supporting user activity and experiences of care (Bate & Robert, 2007a; Gesler, Bell, Curtis, Hubbard & Francis, 2004). Further, the lack of research specific to neurorehabilitation populations and in-depth examination of user experiences limits the development of supportive settings that contribute positively to recovery and rehabilitation experiences following serious spinal cord and brain injury. The current study employed a multi-method, multiple-case study approach to explore how patients and staff interact with and experience the neurorehabilitation built environment at two sites, a spinal injury unit (SIU) and a brain injury unit (BIU). It aimed to address the central research question, how does the built environment support the inpatient neurorehabilitation experience? Each case (neurorehabilitation unit) included four embedded units of analysis to explore the potential supportive function of the built environment. This included 1) analysis of available archival data on the original building purpose and design, 2) independent surveys of physical features of the setting and the likely experiences they afford, 3) observations of user activity and 4) interviews and focus groups with patients and staff to understand user experiences. In accordance with the multiple-case study approach outlined by Yin (2009), results for each of the four types of data collected were first analysed independently for the SIU and BIU (within-case analyses). A cross-case thematic analysis of user experiences was then conducted to provide deeper insight into patterns and underlying themes in user experiences and further investigate similarities and differences across the two sites. Results from the within-case analyses identified a built environment focus on safety and processes, with limited inclusion of features to support positive user experiences. This environmental focus was in contrast with current patient-centred approaches to rehabilitation and was detrimental to positive user experiences of the setting. Patients and staff at both units described the settings as no longer supportive of current rehabilitation practice, describing a number of key challenges impacting activity and experiences within the current settings including a lack of space, issues with accessibility and functionality, a lack of privacy, poor aesthetics and sensory environment, and outdated buildings. In the absence of built environment support for day-to-day activities, users were able to adapt to operate within the limitations of the current settings. However, this adaptation was limited in scope and was often experienced as stressful and as placing unnecessary pressure on users, who suggested that a more supportive setting would be required for improved rehabilitation practice and experiences. The potential for more supportive, adaptive rehabilitation environments was identified in the cross-case thematic analysis of user experiences, which identified a number of important environmental considerations for neurorehabilitation settings. An adaptive environment was one that could better support rehabilitation by facilitating a balance between change and certainty. The process of change described the dynamic nature of rehabilitation and the need for a built environment to facilitate this development at two levels, namely, changes to rehabilitation practice and changes at an individual level. The process of certainty described the need for a predictable, reliable environment, which would allow users to understand the environment, facilitate users to retain control over the immediate environment, and support patients to regain or maintain their sense of self. The current study extends the current evidence-based design literature, highlighting the importance of environmental support that extends beyond safety and functionality and providing a model for holistic, patient-centred design of more supportive neurorehabilitation environments. Although the buildings for the sites studied were designed and constructed over 30 years ago, they were representative of buildings of this age designed for people with complex conditions. Findings can inform the development of future neurorehabilitation settings that actively contribute to rehabilitation, recovery and wellbeing following life-changing spinal cord or brain injury.