ARE WE MEASURING WHAT WE OUGHT TO MEASURE

Patient perception of the healthcare physical

environment

Ahmed SADEK

PhD Candidate Faculty of Architecture, Building and Planning

The University of Melbourne | ahmed.sadek@unimelb.edu.au
Research Focus
Research Focus

• Cancer patient experience of the hospital physical

environment
• Patients undergoing intravenous anti-cancer treatment
(e.g. chemotherapy)
• Ambulatory settings

Mixed-methods research design using both

interviews and questionnaires
 Assessing patient perception of the healthcare
physical environment

• Little has been carried out in terms of developing tools to

measure patient perception of the healthcare physical
environment in general and for ambulatory cancer facilities
in particular (Shepley et al., 2012; Timmermann et al., 2013; Ullán et al.,
2012; Wang et al., 2011).
• There is lack of validated instruments to evaluate the
performance of hospital buildings through patients’ eyes
(Mullaney et al., 2016; Richardson et al., 2007).
Assessing patient perception of the healthcare physical environment

The reviewed tools can be generally classified into two

categories:

1. Tools that were purposefully-developed to fit the specific

research purpose
Most of these studies stated that no usable questionnaire was
found to address the range of information desired for their
investigation and therefore attempted to develop their own
questionnaires.
2. Tools developed with standardization intent
Following the principles and techniques of psychometric
evaluation methods.
Assessing patient perception of the healthcare physical environment

Psychometrics
Psychometrics is a field of study that addresses survey
development and refers to the techniques used to establish
the reliability and validity of an instrument (Streiner, Norman, &
Cairney, 2015).
These techniques have been applied to guide the
development of tools within different fields related to
psychology, health sciences, education, and others.
Examples can be found in instruments measuring attributes
such as mental state, attitudes, response to illness, quality of
life and also satisfaction such as patient satisfaction with
nursing care quality (Streiner, Norman, & Cairney, 2015).
Assessing patient perception of the healthcare physical environment

It consists of number of stages and procedures that together

help support the credibility of the developed tool.
• Preparing techniques: aim to establish the content
validity (e.g. reviewing literature; conducting
interviews/focus groups with the targeted population;
consulting with experts, generating items, conducting
usability testing etc.)
• Field testing techniques (through number of statistical
measurements): aim to establish the construct validity
and reliability of the developed tool.

Factor analysis
&
Internal consistency reliability measures
Perceived Quality of Care scale (Rao, Peters, & Bandeen, 2006)

Cancer Fatigue Scale (CFS)

(Okuyama et al., 2000)
 Assessing patient perception of the healthcare physical environment

• A common character of the surveys developed following

these methods is the guidance of a theoretical/conceptual
framework. One of the bespoke steps is to envision the
structure of the tool beforehand (e.g. classifying items into
scales based on the theoretical background and/or
researcher thinking) (Streiner, Norman, & Cairney, 2015). Factor
analysis can then be used to compare the a priori structure
against the pattern of the collected data in order to
investigate the degree to which it fits/corresponds to the
hypothetical framework.
• Such approach implies a strategy of devising items to hold
a unidimensional character, contributing thereby to
constructing scales able to measure one thing or rather
one attribute.
Shortcomings of existing tools
 Shortcomings of existing tools

• Most of the reviewed tools lacked thoughtful

conceptual/theoretical foundation and depended on
statistics to derive the classifications of its constructs.
- Imprecise classification of the questionnaires’ items.
- Insensitive elimination of architectural elements that
are considered of general importance to the healthcare
context.
- Difficulties to reproduce and attain consistent
classification when some tools were reused (difficulty
of reproducing/confirming the initial classification of
the tool’s constructs).
- Possibilities to overlook the inclusion of critical
architecture qualities to the developed tool.
 Shortcomings of existing tools

• PHEQIs_ Perceived Hospital Environment Quality

Indicators (Fornara et al., 2006; Andrade et al., 2012)
The application of confirmatory factor analysis forced the
elimination of items pertaining to cleanliness of the unit,
temperature, and air quality with no other items
compensating for their elimination. Other eliminated
items were related to privacy aspects like
controlling/adjusting people’s own space and finding
places to hold private conversation with staff (36
remaining items out of 72).
• ASPECT_ A staff and patient environment calibration tool
(Phiri, 2014)
• P-HEAT_ Perception of Healing Environment Assessment
Tool (Tak et al., 2015)
 Shortcomings of existing tools

• Healthcare providers’ perception of design factors

(Mourshed & Zhao, 2012)
Maintenance Environmental design Spatial Design
Provision for hand Adequate illumination Indoor plants and interior/exterior
hygiene Availability of daylight Landscaping
Proximity to wards Thermal comfort Furniture layout
Cleanliness and ease of Noise level Exterior view from the space
Maintenance Air quality and freshness Presence of coordinated art objects
Spaciousness Pleasant colour scheme
Architectural design of the space
Location and orientation of the space

The highlighted items appear to (logically) fit into the “spatial design” scale,
while the rest of the “spatial design” items seem to actually tap a different
construct/dimension namely “interior appearance” or “interior aesthetics.”
 Shortcomings of existing tools

• Formulation of the tools items

Most of the tools relied on exploring patient satisfaction with
specific elements of the built environment (e.g. the availability
of sign posts for aiding wayfinding, provision of side tables,
satisfaction with the walls colour, etc.).
- Hindered the ability to attain inclusive list of the buildings’
detailed components (e.g. devoting some questions to the
pleasantness of walls/floors colors covers one aspect of the
environmental aesthetic and omits evaluating many others
like paints, materials, art objects, etc.)
- May have contributed to the inconsistent results of the
generated scales when attempting to reproduce the tools
and confirming the initial classification of their constructs.
 Shortcomings of existing tools
Comparison matrix representing the scope of the
reviewed tools
Key
** The attribute/s is
represented
* Not adequately
represented (did not
comprehensively cover the
aspects of the dimension;
emphasized one aspect
and neglected others;
and/or critical items were
deleted in the
psychometric evaluation)
- Not represented
Moving forward

Moving forward
• Envision the structure of the tool beforehand following the
guidance of a theoretical/conceptual framework.
• Formulation of the questionnaire’s items to hold
unidimensional attribute by capture patient experience of
the overall quality of the physical environment rather than
satisfaction with single elements of the building
components.
Example, the attempt developed by Andrade and Devlin
(2015):
- I can adjust, re-arrange, and re-organize things in my
hospital room as needed.
- In this room there are objects that attract my attention.
- In this hospital room I could enjoy the company of visiting
family and friends.
Why
Why?

Why developing valid and reliable tools?

• This field of research lies under a multidisciplinary domain
where scientifically valid methodologies and mathematical
proofs play a leading role.
• Patient satisfaction is gaining increased attention within
today’s healthcare systems.
• Such tools constitute a critical platform for studies that aim to
empirically investigate/document the impact of the built
environment on patients’ health-related outcomes.
• Not to mention its role in guiding experience-related design
decisions and support negotiating and implementing research
findings in future healthcare projects.
• There are already attempts to develop standardized tools,
however notable limitations exist and need attention if further
level of rigor are to be sought and accomplished for such
tools.
Tools References
1- PHEQIs_ Perceived Hospital Environment Quality Indicators
Fornara, F., Bonaiuto, M., & Bonnes, M. (2006). Perceived hospital environment quality indicators: A
study of orthopaedic units. Journal of Environmental Psychology, 26(4), 321-334.
Andrade, C., Lima, M. L., Fornara, F., & Bonaiuto, M. (2012). Users’ views of hospital environmental
quality: Validation of the Perceived Hospital Environment Quality Indicators (PHEQIs). Environmental
Psychology, 32(2), 97-111.
2- ASPECT_ A staff and patient environment calibration tool
Phiri, M. (2014). Design tools for evidence-based healthcare design. Routledge.
Steinke, C. (2015). Assessing the physical service setting: A look at emergency departments. Health
Environments Research & Design Journal, 8(2), 31-42.
3- P-HEAT_ Perception of Healing Environment Assessment Tool
Tak, Y. R., Woo, H. Y., Kim, J. H., & You, S. Y. (2015). Psychometric Evaluation and Development of the
Perception of Healing Environment Assessment Tool (P-HEAT) for Clinical Nurses. International
Information Institute (Tokyo). Information, 18(6 (B)), 2867.
4- SHEDS_Supportive Hospital Environment Design Scale
Andrade, C. C., & Devlin, A. S. (2015). Stress reduction in the hospital room: Applying Ulrich's theory
of supportive design. Journal of Environmental Psychology, 41, 125-134.
5- Healthcare providers’ perception of design factors
Mourshed, M., & Zhao, Y. (2012). Healthcare providers’ perception of design factors related to
physical environments in hospitals. Journal of Environmental Psychology, 32, 362-370.
6- PedsQL _ Pediatric Quality of Life Inventory: Built Environment Modules for parents and staff
Varni, J. W., Burwinkle, T. M., Dickinson, P., Sherman, S. A., Dixon, P., et al. (2004). Evaluation of the
built environment at a children's convalescent hospital: Development of the pediatric quality of life
inventory(TM) parent and staff satisfaction measures for pediatric health care facilities. Development
and Behavioral Pediatrics, 25(1), 10-20.
7- LpCp_ Listening to people to Cure people tool" tool
Buffoli, M., Bellini, E., Bellagarda, A., Di Noia, M., Nickolova, M., & Capolongo, S. (2014). Listening to
people to cure people: The LpCp–tool, an instrument to evaluate hospital humanization. Ann Ig,
26(5), 447-55.
8- Clinic Design Post-Occupancy Evaluation Toolkit
https://www.healthdesign.org/
Thank you