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The Role of Patients’ Psychological Comfort in Optimizing Indoor

Healing Environments: A Case Study of the Indoor Environments
of Recently Built Hospitals in Sulaimani City, Kurdis...

Article in HERD Health Environments Research & Design Journal · December 2019
DOI: 10.1177/1937586719894549

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Evaluation
Health Environments Research
& Design Journal
1-15
The Role of Patients’ ª The Author(s) 2019
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DOI: 10.1177/1937586719894549

Optimizing Indoor Healing journals.sagepub.com/home/her

Environments: A Case Study

of the Indoor Environments
of Recently Built Hospitals
in Sulaimani City, Kurdistan, Iraq

Fouad Jalal Mahmood, MSc1,2 , and Abdullah Yusif Tayib, PhD1

Abstract
Objective: This study investigates how patients and medical staff assess the physical environments
of two recently built hospitals in Sulaimani City to understand the extent to which indoor environ-
mental factors influence the creation of an optimal healing environment. Background: A contem-
porary healing environment may be recognized by the quality of an indoor environment in positively
influencing patients’ psychological comfort and supporting their recovery. Method: Post-occupancy
evaluations were conducted in Shar General Hospital and Faruk Medical City wards. A 43-item
questionnaire was distributed to 312 patients, doctors, and nurses to gather their perspectives. In
total, 175 valid questionnaires were retrieved. Results: The results show that the quality of the
indoor environments met patients’ psychological needs and expectations, and as a result, they were
generally satisfied with the indoor healing environments. The findings from the patient and medical
staff surveys suggest three essential factors in creating a healing environment, which are (1) Interior
appearance, (2) Privacy, and (3) Comfort and control. Significant negative correlations of some
demographic characteristics, such as educational attainment and age, with patient satisfaction were
observed. Conclusions: This study shows that exploring patients’ and medical staff’s experiences can
reveal factors that positively influence patients’ satisfaction levels, which may vary depending on their
sociocultural perspectives and personal characteristics. Additionally, the findings emphasize the role of
the tested factors in increasing patients’ satisfaction levels, optimizing healing environments, and
informing design decisions.

1
Department of Architecture Engineering, College of Engineering, University of Sulaimani, Kurdistan, Iraq
2
Department of Architecture Engineering, Cihan University–Sulaimani, Kurdistan, Iraq

Corresponding Author:
Fouad Jalal Mahmood, MSc, Department of Architecture Engineering, College of Engineering, University of Sulaimani, Sulaimani
46011, Kurdistan, Iraq.
Email: fouad.mahmood@univsul.edu.iq
2 Health Environments Research & Design Journal XX(X)
Keywords
evidence-based design, healing environment, psychological comfort, interior design, healthcare
facilities, POE, wards, correlation
In the past few decades, the hospital’s indoor
environment has considered the needs of the med-
ical staff, technological health requirements, and
new movements in medical care to provide
patients with the best possible healthcare; how-
ever, it failed to consider the patient a human
being with psychological needs (safety, love and
belonging, and esteem) other than treatment
(Ghazali & Abbas, 2017; McLaughlan, 2018;
Mourshed & Zhao, 2012; Ulrich, 1984). The
indoor physical environment influences the
health of patients through direct unmediated phy-
siological effects (heart rate, respiration, and
adrenaline secretion) and indirect effects, in
which the physical environment influences occu-
pants through psychological processes as a con-
sequence of sensory perceptions. Using these
physical elements in the indoor environment
design can have a positive effect on the patients’
satisfaction level and the healing environment as
a result (Huisman, Morales, van Hoof, & Kort,
2012; Monti et al., 2012).
In the late 19th century, Florence Nightingale
discussed the effects of the built environment on
users’ health and the relationship of these effects
on the quality of hospital treatment as a general
framework for nursing environment theory (Dev-
lin, Andrade, & Carvalho, 2016; Nightingale,
1893; Ulrich, 1991). The theory contributes to
wide-ranging principles used to create an ideal
environment for optimal healing. According to
Nightingale (1893), these principles include
ventilation, heat, lighting, noise, diversity, social
support, diet, and cleanliness. Based on Nightin-
gale’s principles, the theory of supportive design
emerged and was developed by Ulrich (1991)
who emphasized the importance of creating
spaces that encourage healing by reducing the
stress associated with disease. This strategy can
be achieved by providing patients with a sense of
control, social support, and positive distraction
through the incorporation of works of art and
natural elements. This development led to the
emergence of a new field of design known as
evidence-based design (EBD), which is a practi-
cal application of research. The field of EBD
aimed to establish design decisions that contrib-
ute to creating healing environments to support
the physical and psychological recovery of
patients. Hospital wards are no longer places for
treating patients’ illnesses; now, they also are
intended to promote healing by addressing the
senses and alleviating pain and stress. Unlike cur-
ing, healing relates to aspects of health that are
psychological and spiritual. This approach has
become the theoretical basis underpinning the
concept of healing environments (Ghazali &
Abbas, 2017; Mourshed & Zhao, 2012; Ulrich
et al., 2008; Ulrich, Berry, Quan, & Parish,
2010). There has been a shift in the medical com-
munity away from a narrow pathogenic concep-
tion of disease and health toward an expanded
perspective that includes an emphasis on health
promoting experiences and processes (Zhao &
Mourshed, 2017).
There has been a shift in the medical
community away from a narrow
pathogenic conception of disease and
health toward an expanded perspective
that includes an emphasis on health
promoting experiences and processes.
A number of factors have been found to affect
the quality of the healing environment of a hos-
pital building. These factors can significantly
contribute to patients’ satisfaction levels and the
performance of the indoor healing environment
(Dellinger, 2010; Dilani, 2009; Huisman et al.,
2012; Mourshed & Zhao, 2012; Zhao, 2012;
Figure 1). Interior design aspects, such as the use
of a variety of colors, suitable materials, adequate
and pleasant furniture, comfortable seating, and a
view of hospitals as homelike, have an impact on
patients’ responses to the indoor environment and
affect the quality of the healing environment,
 INTERIOR APPEARANCE: 1, 6, 7
- Indoor spaces feel safe and secure 3, 2, 6
- Indoor spaces prevent patient falls 2, 3
- Patients’ spaces feel homely 6, 7
- The interior feels light and airy 7
- Variety of colors, textures and views 4, 7
- Pleasant color scheme 6, 7
- Spaces are clean, tidy and cared for 3, 4, 7
- Provision for art, plants and flowers 3, 5, 6, 7
- Interesting Ceilings design and look7
- Availability of display personal items 7
- Flooring with suitable material 5, 7
- Pleasant furniture layout 5
- Adequate number of seats 4
- Comfort Seating 4, 5
FACILITIES: 6, 7
- Easy chairs, tables and desks6, 7
- Facilities to make drinks7
- Space for religious observances 7
- Spaces for entertainment facilities 6, 7
- Facilities for patients’ relatives or
friends to stay overnight 7
Figure 1. Factors associated with an optimal healing environment. Source: Authors. Adapted from 1Escobar (2014), 2Zhao (2012),
3
Huisman et al. (2012), 4Mourshed and Zhao (2012), 5Locklear (2012), 6Dellinger (2010), and 7DH Estates and Facilities (2008).
3
PRIVACY: 1, 2, 3, 6, 7
- Single-bed accommodation 1, 2, 3, 6
- Visual privacy 1, 3, 7
- Private conversation 6, 7
- Isolation from other patients
and staff 6, 7
- Gathering places for patients1, 7
Optimal
Healing
Environment
FAMILY SUPPORT: 2, 3, 6
- Easy access to patients’ room 3
- Adequate space for accommodation
with patients 1, 2, 3, 6
- Adequate sitting area for
visitors 3, 6
COMFORT & CONTROL: 3, 6 ,7
- Easy observation or Proximity to
nursing staff 4
- Spaces were cleaned inadequate ways3
- Easily excluding sun light and
day light 3, 4, 7
- Easily control the artificial lighting 1, 3, 6, 7
- Variety of artificial lighting
patterns 1, 3, 4, 6, 7
- Easily control the temperature 1, 3, 4, 6, 7
- Easily open windows / doors 7
- Minimize noise and vibration 1, 3, 6, 7
- Easily control the positive ambient
sounds 3, 7
- Absence of Unpleasant smell (odor) 3, 7
VIEWS: 3, 5, 6, 7
- Spaces have windows 1, 3, 4, 5, 6 ,7
- Easily seeing the sky 7
- Easily seeing the ground 7
- The view outside is calming 6, 7
- The view outside is interesting 6, 7
- Easily seeing plants, vegetation and
nature 4, 5, 7
4 Health Environments Research & Design Journal XX(X)
enhancing patient recovery, and increasing
patients’ satisfaction levels (Dellinger, 2010;
Escobar, 2014). Additionally, providing patient
rooms with views to the outside, enabling patients
to see the sky, and that feature plants and natural
elements have been found to reduce stress and
influence patients’ satisfaction by distracting
them from their pain and leading to an improved
healing environment (Huisman et al., 2012;
Locklear, 2012). Other studies have shown that
both comfortable conditions and the ability to
control levels of comfort, such as proximity to
the nursing station, the ability to block out sun-
light, to control the lighting and temperature, pos-
itive sounds, and a lack of odors, could be very
important in reducing stress. Thus, allowing
patients to control their environment is important
and can support the healing environment (Dellin-
ger, 2010; DH Estates & Facilities, 2008; Huis-
man et al., 2012).
Previous studies have linked patient satisfac-
tion levels and the quality of the healing environ-
ment to privacy factors. Patients’ ability to
control their privacy and their interactions with
others can be achieved through the provision of
single-occupancy rooms, privacy curtains, acous-
tically absorbent building materials, and isolation
from others (Dellinger, 2010; McLaughlan, 2018;
Zhao, 2012). Beyond hospital visitation policies,
family support is a key factor in relieving anxiety,
fear, and stress. Family support can be facilitated
by strengthening the concept of the home envi-
ronment through providing easy access to
patients for their families, adequate accommoda-
tions, and seating areas for visitors who play an
important role in patients’ psychological comfort
(Escobar, 2014; Huisman et al., 2012). Another
factor affecting the quality of the healing envi-
ronment is the provision of amenities to make the
family more comfortable. Providing space for
relatives to stay, for religious practice, and for
entertainment may be important for creating a
healing environment (Dellinger, 2010; DH
Estates & Facilities, 2008). The design of an
indoor environment plays an important role in
creating an optimal healing environment (OHE);
an OHE not only provides medical care to
patients but also addresses aspects related to the
fulfillment of patients’ physical, psychological,
spiritual, and social needs (Jonas & Chez, 2004).
The design of an indoor environment plays
an important role in creating an optimal
healing environment (OHE); an OHE not
only provides medical care to patients but
also addresses aspects related to the
fulfillment of patients’ physical,
psychological, spiritual, and social needs.
Users’ psychological comfort or satisfaction
may be defined differently according to the sci-
entific context of the research. Some definitions
may refer to the relationship between a user’s
satisfaction and the indoor environment quality
(thermal, visual, acoustic, and air quality), in
addition to the place of work and the characteris-
tics of interior spaces (such as size, aesthetic
appearance, furniture, and cleanliness). Patient
satisfaction is frequently described as patients’
subjective experiences within the healthcare
environment. Patient satisfaction reflects their
opinions and whether their expectations of pro-
vided service have been met with the standard
facilities (MacAllister, Zimring, & Ryherd,
2018; Zhao & Mourshed, 2017). Demographic
factors such as gender, age, and educational
attainment also affect patients’ satisfaction and
psychological well-being in relation to the indoor
environment in hospital wards (Dellinger, 2010).
Studies have shown differences in the extent to
which these factors affect the psychological com-
fort of patients, regardless of social and cultural
differences (Devlin et al., 2016; Ghazali &
Abbas, 2017). In Kurdish culture, privacy is
important, especially for women, who have a
higher expectation for privacy than men, such
as in religious societies. Moreover, Kurdish soci-
ety is strengthened by the ethic of healing one
another, strong family relations and a solid
familial fabric, social interaction, and more col-
lectivist than individualist values. The beauty of
Kurdish designs is enriched by the use of differ-
ent colors, such as blue, green, and red; terra-
cotta, natural textures, and local materials
(wood, brick, and stone); artwork and antiques;
positive references to the light and sun; and
Mahmood and Tayib
connections to nature. Consequently, Kurdish
indoor designs are warm and welcoming (Abdul-
lah, 2010; Aloomary, 2008).
Few studies have explored the range and order
of factors that patients consider to be the most
important to their psychological comfort (Zhao
& Mourshed, 2017). This study aims to bridge
this research gap through two objectives: to
investigate the factors that increase patients’ psy-
chological comfort to provide evidence about
how patients experience the physical environ-
ments of hospital wards and to investigate
patients’ and medical staff’s opinions on the
degree of importance and effectiveness of these
factors in creating an optimal indoor healing
environment in regard to patients’ psychological
comfort. The importance of this research lies in
determining the most important factors to pro-
mote optimal healing and support the design of
an environment that can offer better psychologi-
cal support to patients in hospital wards.
Method
In this study, indoor physical environments were
assessed using the following methods: question-
naire surveys, in-person site visits, ward observa-
tions, and evaluations. Institutional review board
approval was not required. Permission was
granted before visiting the hospital building, and
consent was given by the hospital director, recog-
nized through a formal application. After the pri-
mary briefings about the hospitals’ arrangements,
representatives from the hospital accompanied
the research on the building visits and offered
answers to spontaneous general questions about
the wards’ indoor environments.
Questionnaire Survey
For this study, patient psychological comfort was
measured by designing a questionnaire to exam-
ine the relationships between indoor environment
quality in the wards and the patient satisfaction
experience. As a result, two questionnaires were
developed specifically for this research. They
comprise a set of questions adopted from the
results of studies performed in the same field
(Dellinger, 2010; Escobar, 2014; Huisman et al.,
5
2012; Locklear, 2012; Mourshed & Zhao, 2012;
Zhao, 2012) and from A Staff and Patient Envi-
ronment Calibration Toolkit. This was designed
by the British Healthcare Design Centre based on
a database with data from over 600 studies that
has been used by the UK’s The National Health
Service (NHS) since 2008 to assess the influence
of healthcare indoor physical environment on
staff and patient satisfaction levels and on
patients’ recovery (The Department of Health
[DH] Estates & Facilities, 2008).
Questionnaire A targeted patients in hospital
wards and was completed by the patients them-
selves. The goal was to determine patients’ level
of agreement with items related to the following
subjects: Privacy, Views, Comfort and control,
Interior appearance, Family support, and Facil-
ities. The questionnaire is divided into three
main sections. The first section addresses demo-
graphic information such as patients’ age and
gender. In the second section, which is the main
part of the questionnaire, patients are asked to
rate their satisfaction levels with the ward’s
indoor environment on a 5-point Likert-type
scale, ranging from very dissatisfied to very sat-
isfied. This section of the survey includes 43
questions regarding the hospital ward which
focuses on patients’ privacy, views, patients’
comfort and control, interior design elements
of the ward, family support, and ward facilities.
The third section of the questionnaire investi-
gates the degree of importance of the main fac-
tors, namely, Privacy, Views, Comfort and
control, Interior appearance, Family support,
and Facilities, in promoting patients’ psychologi-
cal comfort from patients’ points of view. The
respondents were asked to give their opinions
by rating these items on a Likert-type scale of the
degree of importance.
Questionnaire B, targeting the medical staff
(doctors and nurses) at hospital wards, is divided
into two main sections; the goal of this question-
naire is to determine staff members’ perspectives
and experiences of the degree of effectiveness of
the factors of Privacy, Views, Comfort and con-
trol, Interior appearance, Family support, and
Facilities in promoting patients’ psychological
comfort. The first section of this questionnaire
consists of questions about demographic
6 Health Environments Research & Design Journal XX(X)
Table 1. Information About the Selected Hospitals.
Building
Area Number
Hospital Type in ft2 of Floors
Shar General Hospital General 543,653 6 63
Faruk Medical City General 473,612 8 124
information. The second section includes 43
questions regarding the hospital ward. The
respondents are asked to rate their perceptions
about an item on a 5-item Likert-type response
scale with the following options: not effective (1),
slightly effective (2), neutral (3), effective (4), and
very effective (5). A higher score for a factor indi-
cates a higher level of effectiveness. Conse-
quently, factors with higher effectiveness
ratings have higher degrees of importance in pro-
moting patients’ psychological comfort. The
combination of the results of this staff question-
naire with the results from the third section of the
patient questionnaire led to a more comprehen-
sive evaluation of the degree of importance of the
factors influencing patients’ satisfaction.
The study was conducted among occupants,
including patients, doctors, and nurses, of the
wards at two general hospitals in Sulaimani City,
namely, Shar General Hospital (Sgh) and Faruk
Medical City (Fmc). These two hospitals were
chosen because of their sizes, large numbers of
staff and patients, reputations, recent construction
(after 2013) with more than 100 beds, and differ-
ences in room types (only single-bed rooms vs.
multiple- and single-bed rooms). The first hospi-
tal, Sgh was built in 2013, is located in Kurdsat
District on the Malik Mahmood Circular Street of
Sulaimani City. Sgh is a general hospital that
provides healthcare for all specialties; it has 400
beds, 12 intensive care units, and 23 operating
suites. The hospital policy is to provide the best
possible care for patients and their families;
accordingly, great attention is paid to every detail
of not only the medical treatment but also the
patient’s psychological health. The second hospi-
tal, Fmc, lies in Qirga District on the Malik Mah-
mood Circular Street of Sulaimani City; it was
Single-Bed
Rooms Multibed Rooms
Number of Number of Number Number
One Bed Two Beds of Four of Six
Rooms Room Beds Room Beds Room
43 6 25
— — —
built in 2014 on 753,473 ft2 and accommodates
210 beds, including 11 advanced operating
rooms, 21 modern suites outfitted with world-
class medical equipment, 3 presidential suites
equipped with devices for disabled patients, and
6 open-heart intensive care beds. The interior of
the building was designed to enable all patients
and their relatives to easily have access to the
various areas of the hospital (Table 1).
In this study, the population size (N) of hos-
pital users (patients and medical staff) was 610
total between the two hospitals. Based on a 90%
level of confidence that the sample size accu-
rately represents the population, the sampling
error was (e ¼ 0.1). Sloven’s formula was used
to calculate the representative sample of respon-
dents (n) necessary to consider the study statis-
tically valid (Kanire, 2013). The calculation
resulted in a sample size of (n ¼ 86).
N
n¼ : ð1Þ
1 þ Ne2
Respondents were randomly selected to com-
plete the questionnaire; they were contacted in
writing and told that participation in the question-
naire was voluntary and that confidentiality of the
data would be maintained. A total of 312 ques-
tionnaires were distributed, 187 to patients and
125 to medical staff; 175 valid questionnaires
(contained the required information and has been
filled correctly), approximately 56% of the dis-
tributed questionnaires, were retrieved, 113 from
patients (Sgh ¼ 65, Fmc ¼ 48) and 62 from the
medical staff (Sgh ¼ 34, Fmc ¼ 28). Thus, the
results of this study were based on the valid ques-
tionnaires returned by 175 occupants (medical
staff and patients) of the wards of the two
hospitals.
Mahmood and Tayib 7

Table 2. Demographic Information of Patient through the primary school level, 19% were well
Respondents. educated and had completed education through
Total
the bachelor’s level, and 5% had completed edu-
Number of cation through the postgraduate level. Regarding
Respondents the duration of stay, the results indicate that most
(n ¼ 113) of the patients (54%) stayed in the wards 3 days
or less, 34% stayed between 4 and 7 days, and
Item Classification Frequency %
12% stayed for more than 8 days.
Gender Male 63 56 The results for the medical staff show that
Female 50 44 the majority were nurses 68%, while 32% were
Age (years) 18–30 61 54 doctors. Regarding their practical experience in
31–45 40 35 hospital wards, 32% of the staff respondents had
46–59 10 9 6–10 years of practical experience, 26% had 5
>60 2 2
Educational Less than primary 37 33
years or less of practical experience, and 27% had
attainment Secondary 49 43 more than 10 years of practical experience.
BSc 21 19
MSc and above 6 5
Duration of stay 3 Days or fewer 61 54 Satisfaction Levels of the Respondents
4–7 Days 38 34
8 Days or more 14 12 The patient assessment included six sections, and
their satisfaction levels are discussed as follows
Source: Fieldwork (2018).
(Table 3 and Figure 2).

Privacy. This factor is associated with single-bed

Statistical Analysis
A descriptive analysis was conducted on the
data from the questionnaires distributed to
patients and medical staff of the selected gen-
eral hospitals in Sulaimani City. t Tests were
used to compare the data from the two hospitals
to assure that the findings were not obtained by
chance, and the statistical significance was
assessed by using p < .05. The analysis was
conducted with the statistical software program
IBM Statistical Packages for Social Sciences
(Version 22) to scrutinize the questionnaire data
and to determine the percentages, mean satis-
faction scores, and the correlations between
some variables.
Results
The descriptive analysis of the patients’ personal
characteristics is shown in Table 2. The results
show that the majority were male 56%, while
44% were female, 54% were between 18 and 30
years, 35% were between 31 and 45 years old,
and 2% were above 60 years. The results reveal
that 43% of the patients had education through
the secondary school level, 33% had education
accommodation, visual privacy, private conver-
sation, isolation from others, and the ability for
close relations to gather. Among the subfactors,
“single-bed accommodation” was rated higher
(92.5%) at Fmc than at Sgh (81.5%) by the
respondents. The results regarding this factor
show a significant difference in the mean score,
which was neutral (2.9) at Sgh and very satisfied
(4.31) at Fmc. This result indicates that the
patients’ satisfaction with privacy was higher at
Fmc, which has more single-bed rooms than Sgh.
Views. This factor refers to having windows, being
able to see the sky and the ground, seeing calming
and interesting outside views, and being exposed
to plants and natural elements. The subfactor
“having windows” at Sgh and “being able to see
the sky and the ground” at Fmc were highly rated
by the respondents 63.1% and 62.5%, respec-
tively. There was a substantial difference in the
recorded mean scores, with a neutral score (3.27)
at Sgh and a satisfied score (4.11) at Fmc. The
results reveal that the patients at Fmc had higher
levels of satisfaction; the designers were aware of
importance of these two factors, as they provided
large windows with a view either of nature (a
8 Health Environments Research & Design Journal XX(X)

Table 3. Results of Highly Rated of Patients’ Satisfaction Level Percentage for Shar General Hospital and Faruk
Medical City.

Response (%)

1 2 3 4 5
Hospitals Factors Questionnaire Item (Indoor Attributes) VD D N S VS Mean

Shar General Privacy Patients can have a single-bed 9.2 9.2 0 0 81.5 4.35
Hospital accommodation.
Views Spaces where patients spend time to have 9.2 0 0 27.7 63.1 4.35
windows.
Comfort and Spaces were cleaned in adequate ways. 0 0 9.2 9.2 81.5 4.72
control Patients can easily control the artificial 0 9.2 9.2 9.2 72.3 4.45
lighting.
There is not any unpleasant smell (odor). 0 9.2 9.2 9.2 72.3 4.45
Interior Interior spaces feel safe and secure. 0 0 0 18.5 81.5 4.82
appearance Interior spaces prevent patient falls. 0 0 9.2 9.2 81.5 4.72
The interior looks clean, tidy, and 0 0 0 36.9 63.1 4.63
cared for.
Floors are covered with suitable material. 0 0 0 9.2 90.8 4.91
Faruk Medical Privacy Patients can have a single-bed 0 0 0 7.5 92.5 4.93
City accommodation.
Views Patients can easily see the sky. 0 0 0 37.5 62.5 4.63
Comfort and Spaces were cleaned in adequate ways. 0 0 0 37.5 62.5 4.67
control Patients can easily control the artificial 0 9.2 9.2 9.2 72.3 4.45
lighting.
Interior Patients’ spaces feel homely. 0 0 0 33.3 66.7 4.67
appearance The interior feels light and airy. 0 0 8.3 16.7 75.0 4.63
The interior has a variety of colors, 0 0 4.2 29.2 66.7 4.67
textures, and views.
The interior looks clean, tidy, and 0 0 0 33.3 66.7 4.71
cared for.
The interior has provision for art, plants, 0 0 8.3 12.5 79.2 4.63
and flowers.
Ceilings are designed to look interesting. 0 0 8.3 20.8 70.8 4.67

PRIVACY 4.31
2.9
VIEWS 4.11
3.27
COMFORT & CONTROL 4.36
4.02 Fmc
Factor

INTERIOR APPEARANCE 4.55

4.17 Sgh
FAMILY SUPPORT 4.26
2.85
FACILITIES 3.96
1.8

0 1 2 3 4 5

Mean

Figure 2. Patients’ satisfaction means of the factors for the two hospitals.
Mahmood and Tayib
streetscape with trees) or buildings and nature
(the other view).
Comfort and control. This factor includes proximity
to the nursing station, cleanliness, the ability to
block out sunlight, the ability to control and vary
lighting and temperature, minimal noise, positive
sounds, and a lack of odors. “Cleanliness” was
rated higher (81.5%) at Fmc, while “ability to con-
trol and vary lighting” was rated higher (72.3%) at
Sgh by the respondents. The results regarding this
factor show slightly higher satisfaction at Fmc,
with mean scores of 4.02 at Sgh and 4.11 at Fmc.
This difference reflects the effect of providing
individual lights, electric beds that are adjustable
with a remote, the ability to control lighting and
temperature, and positive sounds for patients at
newer hospitals.
Interior appearance. The factor is characterized by
feelings of safety and security, a homey feeling, a
variety of colors, suitable materials, adequate and
pleasant furniture, and comfortable seating.
Among the interior appearance subfactors,
“suitable materials” (90.8%) and “feeling safe
and secure” (81.5%) were rated highly by the
respondents from Sgh, while “provision of art”
was highly rated (79.2%) by the respondents from
Fmc. Patients’ satisfaction with this aspect was
lower at Sgh, with a mean score of 4.17, than at
Fmc, with a very satisfied mean score of 4.55.
This result indicates the effect of using more than
two colors, natural materials (wood), appropriate
and comfortable seating, artwork on the walls,
and TVs with remotes on patients’ satisfaction
at Fmc.
Family support. This factor is associated with easy
access to patients by their families and adequate
accommodation and seating areas for visitors.
This aspect differed between the two hospitals
similarly to the privacy aspect, with a neutral
mean score of 2.85 at Sgh and a very satisfied
mean score of 4.26 at Fmc. Because of the visita-
tion policies at Sgh, patients receive few visits
and have fewer opportunities for engagement
than at Fmc. Additionally, Fmc provides many
comfortable areas for visitors and window seats
9
that provide additional seating for family mem-
bers and visitors.
Facilities. This factor describes the presence of an
easily accessible table, spaces for religious prac-
tice and entertainment, and facilities for relatives
to stay. This factor was remarkably different
between the two facilities, with a dissatisfied
mean score of 1.8 at Sgh and a satisfied mean
score of 3.96 at Fmc. Fmc provides adjustable
tables that allow the use of a personal computer
and appropriate furniture for relatives’ accommo-
dation, reflecting the importance of facilities in
the new trend in hospital design to achieve
patients’ satisfaction.
The findings also reveal that male patients
were more satisfied than female patients in gen-
eral. Males had the following mean scores: Pri-
vacy (3.78), Views (3.94), Comfort and control
(4.39), Interior appearance (4.54), Family sup-
port (3.63), and Facilities (2.77). Meanwhile, the
mean scores for females were as follows: Privacy
(3.15), Views (3.23), Comfort and control (3.89),
Interior appearance (4.07), Family support
(3.23), and Facilities (2.66).
Degree of Importance of the Factors
The results of the patients’ rankings of the six
factors in terms of their perceived importance in
promoting patients’ psychological comfort at
hospital wards are shown in Figure 3. Privacy and
Family support were rated as the most important
factors for patients’ psychological comfort, with
mean scores of 4.68 and 4.66, respectively. Then
Interior appearance and Comfort and control with
mean scores of 4.29 and 4.14, respectively. Facil-
ities and Views were the least important factors,
with mean scores of 3.48 and 3.54, respectively.
Figure 4 shows the medical staff ratings of the
six factors in terms of their effectiveness in pro-
moting patients’ psychological comfort at hospi-
tal wards, based on the practical experience of the
staff. Views was rated the least effective factor,
with a mean score of 3.43, followed by Family
support and Facilities, with mean scores of 3.52
and 3.64, respectively. Interior appearance was
rated the most effective factor for patients’ psy-
chological comfort, with a mean score of 4.53,
10 Health Environments Research & Design Journal XX(X)

4.68 PRIVACY
4.66 FAMILY SUPPORT
Factor

4.29 INTERIOR APPEARANCE

4.14 COMFORT & CONTROL

3.54 VIEWS

3.48 FACILITIES

2.5 3 3.5 4 4.5 5

Mean

Figure 3. Patients’ ranking of the importance of factors.

4.53 INTERIOR APPEARANCE

4.08 COMFORT & CONTROL
Factor

3.98 PRIVACY
3.64 FACILITIES

3.52 FAMILY SUPPORT

3.43 VIEWS

2.5 3 3.5 4 4.5 5

Mean

Figure 4. Medical staff ranking for importance factors.

followed by Comfort and control, with a mean
score of 4.08, and Privacy, with a mean score
of 3.98. When the results of the patients and the
medical staff are compared, Interior appearance,
Privacy, and Comfort and control are ranked as
the top three factors by both patients and medical
staff. This finding suggests that three factors of
the four ranked can substantially promote
patients’ psychological comfort and optimize the
healing environment.
Correlations Between the Factors and Patient
Satisfaction
The fourth analytical section demonstrates the
results of the correlations between the factors and
patients’ satisfaction levels. Regarding the
correlation between patients’ satisfaction and the
three most substantial factors Privacy, Interior
appearance, and Comfort and control, as shown
in Table 4, there was a significant positive corre-
lation of Privacy (r ¼ .737, p ¼ .01) and Interior
appearance (r ¼ .658, p ¼ .01) with patients’
satisfaction levels. The correlation for the Com-
fort and control factor demonstrated a positive
moderate correlation (r ¼ .474, p ¼ .01) in hos-
pital wards. Consequently, the study results
reveal that the patients’ psychological comfort
increases when they are strongly satisfied with
Privacy, Interior appearance, and Comfort and
control, and thus, the healing environment can
be optimized in the hospital ward.
The correlations between the demographic
information and patients’ satisfaction scores are
Mahmood and Tayib
Table 4. Correlation Between the Factors and Patients’ Satisfaction for the Two Hospitals.
Correlation Matrix Overall Satisfaction
Overall satisfaction 1 .737a
Interior appearance .737a
Privacy .658a
Comfort and control .474a
a
Correlation is significant at the .01 level (two-tailed).
Table 5. Correlation Between Demographic Characteristics and Patients’ Satisfaction for the Two Hospitals.
Correlation Matrix Overall Satisfaction
Overall satisfaction 1 .026a
Duration of stay .026a
Patient age .118a
Educational attainment .679a
a
Correlation is significant at the .01 level (two-tailed).
shown in Table 5. The results reveal a significant
negative relationship (high correlation; r ¼ .679,
p ¼ .01) of patients’ educational attainment,
a weak negative (r ¼ 0.118, p ¼ .01) relation-
ship of patients’ age and a weak negative
(r ¼ .26, p ¼ .01) relationship of the duration
of patients’ stays in the hospital with their over-
all satisfaction levels. The overall correlation
reveals a more negative trend. In other words,
patients’ satisfaction levels decrease when the
duration of stay is longer, educational attain-
ment is higher, and the patient is older.
Discussion
This study shows that patients’ psychological
comfort levels are strongly linked to the quality
of the indoor healing environment in healthcare
buildings. These results are in accordance with
those of previous studies (Escobar, 2014; Ghazali
& Abbas, 2017), which have found that patients’
satisfaction levels are significantly related to the
quality of the indoor environment of the health-
care setting. The findings indicate that the respon-
dents were generally satisfied with the indoor
healing environment of Sgh and Fmc, suggesting
that the indoor environment of the hospital wards
generally provided them with psychological com-
fort and met their expectations. This finding
11
Interior Appearance Privacy Comfort and Control
.658a .474a
1 .556a .550a
.556a 1 .366a
.550a .366a 1
Duration of Stay Age Educational Attainment
.118a .679a
1 .300a .140
.300a 1 .228
.140 .228 1
seems to support those of another study
(Mourshed & Zhao, 2012), which found that the
occupants of recently constructed healthcare
buildings were more satisfied with the indoor
environment of the facilities.
The study reveals that the majority of the
respondents gave high ratings to physical aspects
such as artificial lighting, the variety of colors
and views, the provision of art and plants, the
use of suitable materials, and interesting ceiling
designs (Table 3). A possible explanation for
this result is that the sociocultural background
of the patients is characterized by particular
senses of beauty (use of different colors, art-
work, positive references to daylight and the
sun, and a strong relationship to nature). This
finding is similar to previous studies (Devlin
et al., 2016; Huisman et al., 2012) which
reported that the sociocultural perspectives may
differentially affect how people experience and
react to indoor environmental elements.
When comparing the patients’ satisfactory lev-
els in the two hospitals, patients at Fmc seemed to
be more satisfied than those at Sgh, given that
Fmc has more single-bed accommodations than
Sgh, which provides privacy and individual facil-
ities like those that patients usually have at home.
This finding supports previous studies (Devlin
et al., 2016; Escobar, 2014), indicating that the
12
provision of single rooms ensures adequate facil-
ities, isolation from other patients, and reduction
in ambient noise levels, thus increasing patients’
satisfaction level. Also, the results reported that
when comparing the patient and medical staff
ratings for the six factors, Privacy was rated the
most effective factor for patients’ psychological
comfort with a mean score of 4.68 by the patients.
However, the medical staff rated Privacy as a
third effective factor with a mean score of 3.98
after Interior appearance and Comfort and con-
trol. This may be due to the medical staff’s prac-
tical experience and their perceiving of the degree
of effectiveness of the factors that influence the
patient’s psychological comfort.
The findings reveal that Interior appearance,
Privacy, and Comfort and control were ranked as
the top three factors by both patients and medical
staff in terms of their degree of importance and
effectiveness in promoting patients’ psychologi-
cal comfort. This may be due to Kurdish patients’
sociocultural nature, which is characterized by
precise senses of beauty (a strong relationship
to nature, artwork, and use of different colors).
In other words, the interior designers were aware
of the findings of the previous studies and the new
trends in healthcare interior designs and used
updated theories and new finishing materials to
enhance the quality of the indoor healing envi-
ronment, as shown in Table 3.
This finding suggests that the three factors can
substantially promote patients’ psychological
comfort and optimize a healing environment. It
is also evident that among these important fac-
tors, Interior appearance, with the highest mean
score of 4.41, was considered to be the most
important factor and had a significant positive
correlation (r ¼ .737) with patients’ overall satis-
faction. The role of interior design in supporting
patients’ satisfaction has been indicated in many
studies (Huisman et al., 2012; Ulrich, 1984;
Ulrich et al., 2008). Privacy was the second most
important factor, with a mean score of 4.33 and a
significant positive correlation (r ¼ .658) with
patients’ overall satisfaction. This result was in
part expected, as previous studies (Escobar, 2014;
Huisman et al., 2012) have suggested a generally
positive effect of privacy in increasing the satis-
faction level of patients. Comfort and control was
Health Environments Research & Design Journal XX(X)
the third most important factor, with a mean
score of 4.11 and a moderate positive correlation
(r ¼ .474) with patients’ overall satisfaction. The
effect of this factor on patients has been investi-
gated in a number of previous studies (Huisman
et al., 2012; Zhao, 2012).
This study found no significant differences
between male and female patients’ satisfaction.
In general, male patients were more satisfied than
female counterparts regarding the most important
factor, Privacy (with mean scores of 3.78 vs.
3.15). This difference in satisfaction may be due
to the cultural preferences of Kurdish women, as
females have higher expectations of privacy than
males. In other words, females expect more iso-
lation from strangers in a healing environment. In
addition, for Interior appearance (with mean
scores of 4.54 vs. 4.07) and Comfort and control
(4.39 vs. 3.89), the findings are in line with those
of previous studies indicating that females show
greater sensitivity and perceptions of sensations
and have more difficulty being satisfied (Dellin-
ger, 2010; Zhao & Mourshed, 2017). Further
studies will be needed to validate these findings.
Furthermore, the results show that demo-
graphic characteristics such as age, educational
attainment, and duration of stay had significant
negative relationships with patients’ overall satis-
faction, as shown in Table 5. The lowest negative
relationship was observed between the stay dura-
tion and satisfaction level. This relationship
might be caused by the fact that in Kurdish cul-
ture, collectivist values are more prevalent than
individualistic values. Beyond hospital visitation
policies, patients receive few visits and have few
opportunities for engagement. Thus, the sense of
loneliness and isolation that the patients experi-
ence as a result of hospitalization increases with
the duration of the stay. This finding appears to be
in line with the results of other studies (Dellinger,
2010; Devlin et al., 2016), which indicate that a
patient’s satisfaction level could be impacted by
the duration of the stay in a facility. In addition,
according to the conducted study, the patient
level of satisfaction decreases slightly as age
increases. This finding appears to be in support
of those of previous studies (Abinama & Jafari,
2015; Farmahini Farahani, Shamsikhani, &
Sajadi Hezaveh, 2014), in which patients’
Mahmood and Tayib
satisfaction levels have been observed to decrease
slightly as their age increases. This effect may be
caused by increasing feelings of anxiety, fear, and
stress as patients become older and may feel
lonely in the community.
Additionally, a significant negative correlation
was found between overall satisfaction and edu-
cational attainment. It is possible that well-
educated patients are more aware of their rights
and expect the interior design to be warm and
welcoming. This result is in line with those of
previous studies showing that patients with
higher education have lower levels of satisfaction
with healthcare services and vice versa (Al-
Doghaither, 2004; Mawajdeh, Daabseh, Nasir,
& Al-Qutob, 2001). Farmahini Farahani, Shamsi-
khani, and Sajadi Hezaveh (2014) noted that the
range of impacts of these characteristics is not
equal in all countries. In other words, some demo-
graphic characteristics could strongly affect the
psychological comfort of patients in terms of the
indoor healing environment and the performance
of the hospital building.
In other words, some demographic
characteristics could strongly affect the
psychological comfort of patients in terms
of the indoor healing environment and the
performance of the hospital building.
Clearly, the findings of this research are lim-
ited by the questionnaire survey approach that
was implemented in two hospitals constructed
after 2013 in Sulaimani City, with a focus on the
indoor healing environments of the hospital
wards only. In addition, the findings emphasize
the necessity for further research to be conducted
on the details of the indicators and considerations
included in the questionnaires to confirm their
consistency with all healthcare users’ satisfaction
levels. Finally, it seems that post-occupancy
evaluation (POE) studies had never been con-
ducted in current hospital wards in Sulaimani
City; the term “evidence-based design” is still
new in the Kurdistan Region of Iraq, and many
building practitioners are still unfamiliar with the
approach of the practical application of study
findings as a basis for new designs of healthcare
facilities.
13
Conclusion
The research has evaluated the association
between indoor environment qualities and
patients’ psychological comfort in hospital
wards. The main concepts and theories have
evolved in recent decades to emphasize the cre-
ation of healing environments that not only help
patients receive medical services but also create
a friendly environment free of anxiety, fear, and
stress. This evaluation is a pioneering study in
assessing problems of indoor healing environ-
ments based on patient perspectives and medical
staff’s practical experience. The outcomes of the
questionnaire survey show that inpatients and
medical staff recognized the importance of the
indoor physical environment for patients’ satis-
faction levels.
This study suggests six main factors (Privacy,
Views, Comfort and control, Interior appearance,
Family support, and Facilities) that play a signif-
icant role in creating an OHE. Based on the
patients’ perspectives and medical staff’s practi-
cal experiences, three factors, that is, Interior
appearance (artificial lighting, a variety of col-
ors, the provision of art and plants, and interesting
ceiling designs), Privacy (more single-bed
accommodation which provided Comfort and
control like home), and Comfort and control
(cleanliness, control of lighting and temperature,
and positive sounds), had the greatest impacts in
promoting patients’ satisfaction levels and meet-
ing their psychological needs and expectations in
the indoor healing environments. The study
reveals that patients’ psychological comfort
depends on their satisfaction with indoor environ-
mental factors, but that levels of satisfaction can
vary depending on personal characteristics such
as gender, age, educational attainment, and dura-
tion of stay.
Additionally, the findings of the present study
reveal that sociocultural perspectives have a
direct effect on patients’ perspectives regarding
the degree of importance of the factors in opti-
mizing healing environments. For example, Pri-
vacy was ranked as very important by the
patients, followed by Family support and Interior
appearance. In the culture of the study region,
privacy is very important in daily life, and society
14
is strengthened by a solid familial fabric with a
strong sense of beauty.
This study results can familiarize designers
with POEs of indoor environments from patients’
perspectives and medical staff’s practical experi-
ence, which, when combined, lead to more reli-
able assessments of the role of inpatients’
psychological comfort in the indoor healing envi-
ronment. Thus, EBD should incorporate the fac-
tors that have been tested in this study to enhance
patient satisfaction levels and ward performance
and lead to a better quality of healing and opti-
mization of the healing environment.
Implications for Practice
 Architects, engineers, designers, developers,
and healthcare facility managers who are
directly involved in designing an optimal heal-
ing environment need to be aware of the main
factors identified in the study. In particular, the
interior appearance, privacy, and comfort and
control are considered to be the most important
factors.
 When designing new indoor physical environ-
ments to achieve quality of care in hospital
wards, patients’ experiences of the physical
environment can become central and could be
valuable in the design process. Thus, interior
design elements that both allow patients to
view the outside world and include natural ele-
ments in the physical environment should be
considered.
 The study reinforces the roles of single-bed
rooms that provide privacy, family support,
and individual facilities such as those that
patients usually have at home. Moreover, to
decrease isolation, single-bed rooms should
be designed to allow patients to visit communal
areas where they have access to a stimulating
environment that includes entertainment and
social interaction.
 More attention should be paid to psychological
comfort factors to contribute to future interior
design solutions. It is thus important for
designers, engineers, and building owners to
consider the integration of patients’ medical,
physical, and psychological needs and employ
EBD for future healthcare facilities.
Health Environments Research & Design Journal XX(X)
Declaration of Conflicting Interests
The authors declared no potential conflicts of
interest with respect to the research, authorship,
and/or publication of this article.
Funding
The authors received no financial support for the
research, authorship, and/or publication of this
article.
ORCID iD
Fouad Jalal Mahmood https://orcid.org/0000-
0002-2766-9666
Supplemental Material
Supplemental material for this article is available
online.
References
Abdullah, T. (2010). The effect of artistics taste on the
modern interior element change: Case study of
living spaces in Sulaimani modern houses (MSc
thesis). University of Sulaimani, Iraq.
Abinama, A., & Jafari, M. (2015). The impact of the
design of hospitals on hospital hoteling: Healing
process and medical tourism. Modern Applied Sci-
ence, 9(12), 43–51.
Al-Doghaither, A. (2004). Inpatient satisfaction with
physician services at king Khalid university hospi-
tal, Riyadh, Saudi Arabia. Eastern Mediterranean
Health Journal, 10(3), 358–364.
Aloomary, R. (2008). The influencing factors on the
architectural form: An analytical study of the archi-
tecture of the Kurdistan region of Iraq (MSc thesis).
University of Sulaimani, Iraq.
Dellinger, B. (2010). Healing environments. In C. S.
McCullough (Ed.), Evidence-based design for
healthcare facilities (pp. 45–80). Edwards Brothers.
Devlin, A., Andrade, C., & Carvalho, D. (2016). Qualities
of inpatient hospital rooms: Patients’ perspectives.
Health Environments Research & Design Journal,
9(3), 1–22. doi:10.1177/1937586715607052
DH Estates & Facilities. (2008, January 15). A staff
and patient environment calibration toolkit
(ASPECT): Summary, NHS, UK. Retrieved from
http://www.dh.gov.uk/en/Publicationsandstatistics/
Publications/PublicationsPolicyAndGuidance/DH_
082087
Mahmood and Tayib
Dilani, A. (2009). Psychosocially supportive design: A
salutogenic approach to the design of the physical
environment. In Proceedings of the First Interna-
tional Conference on Sustainable Healthy Build-
ings, Seoul, Korea, 6 February 2009, pp. 55–65.
Escobar, C. (2014). Evidence-based healthcare design:
A theoretical approach to a Substance abuse treat-
ment facility interior design (MSc thesis). Michigan
State University.
Farmahini Farahani, M., Shamsikhani, S., & Sajadi
Hezaveh, M. (2014). Patient satisfaction with nur-
sing and medical care in hospitals affiliated to
Arak University of medical sciences in 2009.
Retrieved March 2015, from https://www.ncbi.
nlm.nih.gov/pmc/articles/PMC4332990/pdf/nms-
03-14022.pdf
Ghazali, R., & Abbas, M. (2017). Pediatric wards:
Healing environment assessment. Asian Journal of
Environment–Behaviour Studies, 2(3), 77–87.
Huisman, E. R., Morales, E., van Hoof, J., & Kort, H.
S. (2012). Healing environment: A review of the
impact of physical environmental factors on users.
Building and Environment, 58, 70–80.
Jonas, B. W., & Chez, R. A. (2004). Toward optimal
healing environments in health care. The Journal of
Alternative and Complementary Medicine, 10(1),
S1–S6.
Kanire, G. (2013). Social science research methodol-
ogy: Concepts, methods and computer applications.
GRIN Verlag.
Locklear, K. (2012). Guidelines and considerations for
biophilic interior design in healthcare environments
(MSc thesis). University of Texas at Austin.
MacAllister, L., Zimring, C., & Ryherd, E. (2018).
Exploring the relationships between patient room
layout and patient satisfaction. Health Environments
Research and Design Journal. Advance online pub-
lication. doi:10.1177/1937586718782163
Mawajdeh, S., Daabseh, K., Nasir, M., & Al-Qutob, R.
(2001). Patients’ expectations and satisfaction in
View publication stats
15
different hospitals in Irbid, Jordan. Saudi Medical
Journal, 22(7), 625–629.
McLaughlan, R. (2018). Psychosocially supportive
design: The case for greater attention to social
space within the pediatric hospital. Health Envir-
onments Research & Design Journal, 11(2),
151–1625.
Monti, F., Agostini, F., Dellabartola, S., Neri, E., Bozi-
cevic, L., & Pocecco, M. (2012). Pictorial interven-
tion in a pediatric hospital environment: Effects on
parental affective perception of the unit. Journal of
Environmental Psychology, 32(3), 216–224.
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.
Nightingale, F. (1893). Sick nursing and health
nursing. The International Congress of Charities,
Correction and Philanthropy.
Ulrich, R. S. (1984).View through a window may influ-
ence recovery. Science, 224(4647), 224–225.
Ulrich, R. S. (1991). Effects of interior design on well-
ness: Theory and recent scientific research. Journal
of Health Care Interior Design, 3, 97–109.
Ulrich, R. S., Berry, L. L., Quan, X., & Parish, J. T.
(2010). A conceptual framework for the domain of
evidence-based design. Health Environments
Research & Design Journal, 4(1), 95–114.
Ulrich, R. S., Zimring, C., Zhu, X., DuBose, J., Seo,
H. B., Choi, Y. S., & Joseph, A. (2008). A review of
the research literature on evidence-based healthcare
design. Health Environments Research & Design
Journal, 1(3), 61–125.
Zhao, Y. (2012). Evidence based design in healthcare:
Integrating user perception in automated space lay-
out (PhD thesis). University of Loughborough,
England.
Zhao, Y., & Mourshed, M. (2017). Patients’ perspec-
tives on the design of hospital Outpatient areas.
Building, 7(4), 2–13.