Sustainable Healing and Therapeutic Design Driven Well-Being in Hospital Environment

Abstract

Despite the growing awareness of healing hospitals, they are still far from being globally widespread, and traditional hospital building models are increasingly unable to address the serious resource constraints and environmental stresses that we face today. In addition, sustainable development concepts have become key driving forces in the construction process of healing buildings. Currently, while research on healing hospital design continues to grow, there is relatively little that specifically addresses the integration of sustainable development concepts. Hence, this paper aims to explore the current state of development and knowledge structure of sustainable healing and therapeutic design (HTD) in hospital scenarios using a systematic methodology that integrates macro-quantitative bibliometric analysis and follow-up micro-qualitative content analysis methods based on data from the Web of Science (WOS) database, which investigates eight research objectives, including the background, current state, hotspots, high-frequency words, integration with sustainable development goals (SDGs), particularly SDG3, “Ensure healthy lifestyles and promote well-being of people of all ages”, and the challenges posed by public health emergencies, such as the COVID-19 era, for sustainable HTD in hospitals. This paper identified six main clusters: the environment of a hospital, mental health, quality of life, illness and care, COVID-19, and wound healing. These clusters were taken from keyword network visualization analysis, emphasizing key terms focused on wound healing, mental health, quality of life, nursing, children, and evidence-based design via high-frequency keyword analysis. These have been further grouped into three categories: strategy, approach, and method. Subsequently, this paper further explores how hospital HTD relates to SDG 3 targeted on reducing child mortality (SDG 3.2), promoting mental health and physical health (SDG 3.4), and achieving universal health coverage (SDG 3.8) to explore wound healing, mental health, quality of life, nursing, and children, which are stressed in the results of both macro-quantitative bibliometric and follow-up micro-qualitative content analyses. In addition, it is shown that more changes should be made to sustainable hospital HTD in the context of the pandemic era to cope with unpredictable crises. Finally, the expression HTD is discussed to justify the keywords. The results of this study complement sustainable hospital HTD and provide assistance to future architects, policy makers, and healthcare professionals.

1. Introduction

Hospitals are not only just places for providing medical services but also are complex entities whose operations are deeply rooted in health concepts, welfare, ethical considerations, and environmental protection. They are intricate and complex places, encompassing multiple dimensions and interconnected elements [1]. In this context, medical practice not only aims to cure diseases but also focuses on the overall well-being of patients, adheres to medical ethical norms, and strives to create a sustainable development environment [2]. Therefore, the existence and development of hospitals are multi-dimensional and all-round processes that intend to promote the comprehensive enhancement of human health. In order to provide high-quality healthcare services to citizens, hospital design should take more consideration of health and psychological needs [3]. The concept of healing architecture focuses on using the built environment to promote the physical and mental well-being of patients, which has significantly changed in the field of spiritual health services [4]. However, there is still much to learn about how specific design details affect clinical outcomes and patient recovery. Its importance lies in unveiling the possible links between building design and health results, providing a key entry point for improving medical environments.

Healing and therapeutic design (HTD) for hospitals is a patient-centered design approach that aims to promote the physical and mental health of patients by creating a comfortable and serene environment [5]. This design approach not only focuses on the layout and function of physical spaces but also considers the emotional needs and psychological states of patients and how environmental factors can assist in treatment and accelerate the healing process [4]. For example, the New Herlev Hospital in Denmark is designed based on the healing effects of nature and sunlight [6]. This approach is realized through lush gardens, green roofs, and a large central green area, creating an environment that facilitates rapid patient recovery. Additionally, in the outdoor environment of the Tiantan Hospital of Beijing Medical University in Anhui China, the river design is used as an axis to connect the river walk, roof garden, landscape retreat, resting balcony and central courtyard, creating a five-dimensional green eco-healing space for patients [7]. The above examples demonstrate the focus on the efficient and flexible use of space in hospitals, as well as human-centered space design, to provide a high-quality environment to enhance patient treatment experiences.

Despite the growing awareness of healing hospitals, they are still far from being globally widespread, and traditional hospital building models are increasingly unable to address the serious resource constraints and environmental stresses that we face today [8]. In this context, sustainable development concepts have become key driving forces in the construction of healing buildings. Currently, while research on healing hospital design continues to grow, relatively little specifically addresses the integration of sustainable development concepts. The majority of existing research focuses on the impact of healing hospitals on the quality of life of patients or healthcare workers [9,10], as well as their mental health [11,12] and physical health [13,14]. Extra attention is paid to outdoor landscape design [15,16] and specific areas within hospitals, such as children’s wards [17,18,19], and intensive care units [20,21]. Therefore, the aim of this paper is to explore sustainable HTD in hospitals. Initially, an overview of the existing studies on the utilization of HTD in hospitals is provided. Additionally, future trends and challenges in sustainable HTD in hospitals in response to the sustainable development goals (SDGs), particularly SDG3, “Ensure healthy lifestyles and promote well-being of people of all ages”, are explored.

2. Materials and Methods

This paper explores the current state of development and the knowledge structure of sustainable HTD in hospital scenarios using a systematic methodology based on data from the Web of Science (WOS) database, with the aim of comprehensively and systematically collecting, integrating, and appraising the existing published studies to answer research questions and to explore the current status, trends, and issues [22]. This methodology has a wide range of applications in healthcare, offering a valuable means for assessing the effectiveness and safety of healthcare interventions, as well as the quality and effectiveness of healthcare services [23]. As shown in Figure 1, the research process of this paper consists of six phases: (1) defining the research question, (2) searching databases, (3) defining selection and quality standards, (4) performing macro-quantitative data analysis, (5) conducting micro-qualitative content analysis, and (6) discussing the findings.

2.1. Phase 1: Defining the Research Questions

The purpose of this paper is to explore “sustainable HTD in hospitals”, for which the following eight objectives were addressed:

Q1: What is the research background of hospitals and HTD?

Q2: What is the current state of research on hospitals and HTD?

Q3: What are the hotspots in research on hospitals, sustainability, and HTD?

Q4: What are the high-frequency keywords and classifications in research on hospitals, sustainability, and HTD?

Q5: What are hospital, HTD and SDG 3.2 reducing child mortality?

Q6: What are hospital, HTD and SDG 3.4 promoting physical and mental health?

Q7: What are hospital, HTD and SDG 3.8 achieve universal health coverage?

Q8: What are COVID-19 era warnings for sustainable hospital HTD?

2.2. Phase 2: Searching the Database

In this research, the WOS Core Database (WOSCC), which is known as the most important data source for bibliometric analyses, was used as the data collection source. The keywords “hospital”, “healing and therapeutic design”(HTD), “sustainable”, and “health” were applied.

Table 1. Keyword terms and number of searches for data collection (generated by the authors).

Keywords	Number of Documents Searched
(TOPIC (hospital) AND TOPIC (healing design))	1932
(TOPIC (hospital) AND TOPIC (therapeutic design))	6749
(TOPIC (hospital) AND TOPIC (healing and therapeutic design))	146
(TITLE (hospital) AND TITLE (healing design))	19
(TITLE (hospital) AND TITLE (therapeutic design))	8
(TITLE (hospital) AND TITLE (sustainability))	181
(TOPIC (hospital) AND TOPIC (healing design) AND TOPIC (sustainability))	16
(TOPIC (hospital) AND TOPIC (therapeutic design) AND TOPIC (sustainability))	8
(TOPIC (hospital) AND TOPIC (therapeutic design) AND TOPIC (health))	1671
(TOPIC (hospital) AND TOPIC (healing design) AND TOPIC (health))	447

illustrates the keyword screening phrases that were searched and the number of documents that were subsequently identified. In total, there were 8827 (1932 + 6749 + 146) articles on the topics “hospital” and “HTD”. However, the number of articles retrieved through the “title”-searching process was reduced to 27 (19 + 8). The three keywords “hospital”, “HTD”, and “sustainability” appeared together in 24 (16 + 8) articles. However, when “hospital”, “HTD”, and “health” are considered together, the number of articles rises to 2118 (1671 + 447). Considering the close relationship between health and the concepts of “hospital” and “HTD”, the keyword “health” was shown to be of significant importance. Concurrently, as “sustainability” represents a common objective across numerous industries, and with the current paucity of interdisciplinary research, there is a compelling opportunity to investigate the integration of sustainability with the design of hospitals and healthcare facilities. The aforementioned considerations are based on keyword searching and document counting.

2.3. Phase 3: Defining Selection and Quality Standards

A large number of studies were retrieved in the above phase, and there were duplicates and results of little relevance or irrelevant to the research questions, which needed to be filtered in line with the following criteria:

(1) Filtering duplicate documents;

(2) Excluding publications that are not relevant to the research topic of hospitals;

(3) Excluding research that did not mention design;

(4) Excluding non-English texts;

(5) Adopting articles collected from high-quality databases;

(6) Preference was given to articles that were widely cited in their field;

(7) Adoption of peer-reviewed journal or conference papers;

(8) Preference for articles related to sustainability and HTD.

A total of 2210 texts were retained for macro-quantitative analysis, and the most relevant 100 articles were identified for micro-qualitative analysis.

2.4. Phase 4: Macro-Quantitative Bibliometric Analysis

The main tools used for this phase are the VOSviewer 1.6.15 software and the Citespace 6.3.1 software tools, which were used to analyze the data taken from the WOSCC database. VOSviewer is a tool used to construct and visualize bibliometric networks, with a clustering display that analyses the co-occurring relationships between keywords and indicates the topics represented by clusters [24]. Citespace is citation visualization and analysis software that helps to analyze potential knowledge and illustrate hotspots and trends within related fields [25]. Therefore, this paper employed these two software tools to help understand the current state of research and hotspots in sustainable HTD in hospital scenarios.

This stage is carried out in three steps. Firstly, descriptive statistics on the annual publication volume and journal sources of the research topic were carried out, which can be used to obtain data through the analysis tools provided by WOSCC to obtain the background and research trends in the field; secondly, keyword co-occurrence analysis was carried out using VOSviewer, from which the keywords within the obtained clusters and the relationships between the clusters and inter-clusters were examined to reflect the current status of “hospital”, “HTD”, “sustainability”, and “health”; the third step was to analyze keyword burst detection through VOSviewer high-frequency words and Citespace to confirm research hotspots and trends. The combination of these two tools yields an objective and comprehensive understanding of the current developmental situation as well as the research hotspots and trends encompassed.

2.5. Phase 5: Micro-Qualitative Analysis

Based on the results of the macro-quantitative analysis, the key themes are categorized into three parts: strategy, approach, and method. These themes are centered around “wound healing”, “mental health”, “quality of life”, “nursing”, “children”, and “evidence-based design” to explore the current development of HTD in hospitals in detail.

2.6. Phase 6: Discussion

Based on the macro- and micro-analyses, there are fewer studies that mention “sustainability”. This section explores how SDG 3 can be applied to hospital HTD, as well as warnings about sustainable hospital HTD in the context of public health emergencies, such as the COVID-19 pandemic. The limitations of this paper are discussed, particularly the ways in which the terms “healing design and therapeutic design” are defined and whether the collection of texts may have influenced the results.

3. Results

3.1. Results of Macro-Quantitative Bibliometric Analysis

3.1.1. Descriptive Statistics

• Number of publications

Changes in the annual number of publications and citations can reflect the overall research trends in the research topic, which can be used to find out whether the topic is popular or has recently been receiving more attention. This method is a way of presenting citations and publications together with the literature obtained from all the keyword combinations. However, due to the limitations of the WOS analysis, it is not possible to analyze the search results of multiple combinations; only one keyword combination can be analyzed at a time. Therefore, this paper started with a visual analysis of all the keyword combinations, as shown in Table 1, the results of which suggested that the research intensity of the subject matter is on the rise. The keywords “hospital” and “HTD” were chosen to present the literature published on the topic, as shown in Figure 2. The search includes both the research background “hospital” and “therapeutic design” for treating psychology and disability as well as “healing design” for restoring health and becoming healthy. As shown in Figure 2, relevant published studies have appeared since 1997. Fluctuations have occurred in the number of publications each year, and this persisted until 2016. Beginning in 2017, there has been a continuous increase, maintaining an average of more than 10 publications annually. The citation frequency of this topic also grew from two times in 1998 to more than a hundred times in 2014, reaching 279 citations in 2022. In recent years, the number of publications and citations of the research topic, “hospital”, and “HTD”, has shown an obvious growth trend, becoming a hot topic in recent years and receiving greater recognition and attention.

• Sources of publications

From data of the past 28 years (1997 to 2024) in the WOSCC database, a total of 69 studies have been published related to “hospitals” and “HTD”.

Table 2. Top 10 most productive sources of studies on “hospital” and “HTD” from 1997 to 2024 (generated by the authors).

Ranking	Publication Titles	Record Count	% of 141
Top 1	Surgery	20	14.184
Top 2	Public Environmental Occupational Health	16	11.348
Top 3	Medicine General Internal	15	10.638
Top 4	Dermatology	9	6.383
Top 5	Integrative Complementary Medicine	9	6.383
Top 6	Nursing	9	6.383
Top 7	Orthopedics	8	5.674
Top 8	Architecture	6	4.255
Top 9	Environmental Sciences	6	4.255
Top 10	Medicine Research Experimental	6	4.255

shows the top ten publications in terms of volume and percentage, with their topics mainly being centered on medical-related topics, accounting for 73.759% of all the published studies.

Among them, the top theme “Surgery” was present in most studies (14.184%), followed by “Public Environmental Occupational Health” (11.348%) and “Medicine General Internal” (10.638%), “Dermatology” (6.383%), “Integrative Complementary Medicine” (6.383%), “Nursing” (6.383%), “Orthopedics” (5.674%), “Architecture” (4.255%), “Environmental Sciences” (4.255%), and “Medicine Research Experimental” (4.255%). Thus, the research themes of “hospital” and “HTD” are mainly centered around surgery, public environments, occupational health, medicine, nursing, and architecture.

3.1.2. Network Analysis

• Keyword network visualization

The obtained data were imported into VOSviewer for keyword co-occurrence analysis, with keywords used as the unit for analysis, resulting in 5335 keywords. Since the number of keywords was too large, the minimum number of co-occurrences was set to 5, from which a total of 374 keywords met the requirements after the elimination of 27 meaningless keywords.

Network visualization in the VOSviewer software tool shows the text, circles, connecting lines, and color blocks to present the associated keywords, where larger circles assigned to the text indicate the higher occurrence frequency of the expressed keyword; the thicker the connecting line between two circles, the stronger their direct affinity; the shorter the connecting line (the closer it is), the higher the correlation; and the colors represent different clusters that also reveal relationships within and between clusters. As shown in Figure 3, there are six clusters, i.e., blue, yellow, green, red, purple and orange, on “hospital”, “HTD”, “health” and “sustainability” in the WOSCC database.

Cluster 1 (yellow) centers around terms relating to the environment of a “hospital”, including keywords such as “healthcare”, “healing environment”, “pain”, “patient safety”, “well-being”, “healthcare facilities”, “architecture”, “design”, “hospital design”, “interior design”, “biophilic design”, and “satisfaction”. This indicates that relevant research focuses on discussing the impact of hospital architecture and interior and exterior environments on healthcare. The design of these environments is closely related to patient recovery and medical experience [5]. This is not just relevant for hospitals, therapeutic architecture has now become a discipline within medical building design, highlighting the significant positive interventions that architectural design can have on patient treatment and recovery [26]. In addition, as an evidence-based design approach, “evidence-based design” is widely used to achieve sustainable healthcare services, including the importance of service landscapes in rehabilitation environments [27], post-occupancy evaluations [28], and medical intensive care environments [29]. Evidence-based design helps to better understand patient needs and preferences, allowing for the creation of healthcare products and services that meet patient demands while also improving the effectiveness and safety evaluation of these products and services. Meanwhile, the population of “children” should not be overlooked, especially because “children” frequently appears as a keyword. Relevant HTD research focuses on the design of “healing gardens” in pediatric or children’s hospitals. Garden plants provide a multisensory comfort experience through visual and olfactory stimuli [30], and their medicinal properties also contribute to healing [31]. It is known that the therapeutic effects of nature can alleviate patients’ pain and depression. Therapeutic landscape design has a positive impact on promoting children’s mental health [32], and the introduction of biophilic design patterns plays a practical role in patient recovery [33]. Further, the keyword “sustainability” is very close to “hospital.” Sustainability in this field is reflected in the design of sustainable healthcare buildings using natural elements or sustainable finishing materials [4,34], with attention to improving indoor environmental quality [35], such as air and heating systems [36].

Cluster 2 (green) shows that “mental health” is one of the most important keywords for the research theme, followed by “nurses”, “nursing”, and “depression”. Treatment design interventions are not only about physical health but also about mental health, not only for patients but also visitors and staff. Therapeutic environments play crucial roles in recovery from mental illness, expressed in the form of external landscapes, interior decorations, light, art, and sound [12,37]. In addition, “suicide” and “hypertension” are also described as major research areas where “mobile health” is involved. In order to provide more convenient health services, mobile medical interventions have been developed and promoted in many hospitals to provide psychological counseling and treatment for mental health conditions, which are especially appropriate support for young people facing suicidal crises [38]. This is also relevant for lifestyle-centered text messaging for cardiovascular disease patients in terms of mitigating the impact of risk factors [39]. Further, mobile healthcare allows for the treatment environment to be no longer confined to hospitals but rather enables remote diagnostic monitoring and universal access at home, reducing patient waiting times and improving the quality of services [40].

Cluster 3 (red) focuses on “quality of life”, involving a high proportion of nurses and critically ill patients, as well as in-patients and physicians. There are more references to quality of work life and analyses of how people experience their work, such as nurses and other healthcare professionals [41]. Nursing positions are subject to a high level of turnover [42,43]. In general, the most disabled patients have the poorest quality of life and care in hospitals [44], and subjective quality of life scales should be developed for different condition domains [45]. In addition, keywords such as “rehabilitation”, “anxiety”, “cancer”, “public health”, “palliative care”, and “health services” receive more attention. Apart from hospitals, clinics, community health service centers, schools, and other places are important venues for the provision of public health services, providing disease prevention, especially relating to cancer, health education, and healthcare services to improve public health and reduce disease morbidity and mortality. Further, “older adults” are the main population that appeared in this cluster, and more studies have been dedicated to improving the health and quality of life of older adults via examinations of the organizational factors that affect hospital services [46], assistive devices for older adults [47], and spatial accessibility [48] to improve older people’s hospital and service satisfaction.

The main keywords in Cluster 4 (purple) concern illness and care: “mortality”, “critical care”, “intensive care”, “pediatrics”, “prognosis”, and “critical illness”. Mortality rates are influenced by a variety of factors, including age, gender, race, geographic location, lifestyle, environmental factors, and level of healthcare. In general, mortality rates increase gradually with age. This is due to the gradual decline in physical function and immunity with age, making this population more susceptible to various diseases, such as heart disease, cancer, and diabetes. Mortality in older adults in intensive care units is associated with changes in the characteristics of intensive care unit (ICU) care that can have implications for patient prognostic strategies [49,50]. In reference to critical care, pediatric intensive care is an important part of reducing global mortality, providing a conducive treatment environment, equipment and expertise, and appropriate intensive care services to reduce pediatric morbidity and mortality [51]. Hence, mortality is a key indicator when measuring the effectiveness and social equity of interventions.

Cluster 5 (blue) is related to “COVID-19”, and “healing”, “surgery”, “treatment”, “randomised controlled trial”, “fracture”, and “infection” are associated. COVID-19 is highly contagious and resulted in a pandemic that involved large numbers of infected people who traveled to hospitals or medical isolation sites for treatment. During this period, multiple studies were produced with the aim of improving cure rates. For example, the risk of infection was reduced by designing resilient hospitals, improving the layout of hospital buildings, and altering patient pathways [52,53]. Research also looked into designing outdoor spaces, such as gardens and green spaces, to provide resting places for healthcare workers to alleviate work stress and anxiety [11,54].

Cluster 6 (orange) contains “wound healing” as the core term, with keywords such as “pressure ulcer”, “wound care”, “telemedicine”, “postoperative complications”, and “wound infection”. The presence of the keyword “wound healing” is both unexpected and justified. Wound healing and HTD are interconnected in promoting patient recovery and comfort in healthcare environments. Studies have focused on how to accelerate wound recovery through various therapeutic means and whether the level of wound healing is good at different sites, whether it is delayed or not, and the environment; further, randomized controlled trials have been conducted to determine optimal healing methods [55,56,57].

The above cluster analysis was used to analyze the main keywords in the field, assisting our ability to understand the research hotspots in the field. Concerning the SDGs, the keywords mainly focus on SDG 3. Good health and well-being, as achieved through designs that create a comfortable and peaceful healing environments, promote the physical and mental health of patients and improve the effectiveness of patient treatment and the speed of recovery.

• High-frequency keyword analysis

Table 3. High-frequency keywords from published articles regarding “hospital”, “HTD”, and “sustainable” from 1997 to 2023 created using VOSviewer network visualization (generated by the authors).

Cluster	Keyword	Occurrence	Total Link Strength
1	Hospital	110	212
6	Wound Healing	102	160
3	Quality of Life	78	134
5	COVID-19	71	122
2	Mental Health	49	120
2	Nursing	45	84
1	Healing Environment	44	67
3	Rehabilitation	43	58
1	Children	41	60
1	Sustainability	40	59
2	Qualitative Research	35	67
1	Evidence-based Design	31	62

shows the top 12 keywords from 1997 to 2024, with co-occurrence seen in studies focusing on “hospital”, “HTD”, “sustainability”, and “health”; here, the influence is positively correlated with the intensity and frequency of connections. In addition,

Table 4. Top 24 keywords with the strongest citation bursts on “hospital”, “HTD”, and “sustainable” from 1997 to 2024 created using Citespace (generated by the authors).

Keywords	Year	Strength	Start	End	1997–2024
Quality of life	1997	7.86	1997	2014	▃▃▃▃▃▃▃▃▃▃▃▃▃▃▃▃▃▃▂▂▂▂▂▂▂▂▂▂
Controlled trial	1997	6.7	1997	2014	▃▃▃▃▃▃▃▃▃▃▃▃▃▃▃▃▃▃▂▂▂▂▂▂▂▂▂▂
disease	1997	6.19	1997	2014	▃▃▃▃▃▃▃▃▃▃▃▃▃▃▃▃▃▃▂▂▂▂▂▂▂▂▂▂
Complications	2001	7.58	2001	2014	▂▂▂▂▃▃▃▃▃▃▃▃▃▃▃▃▃▃▂▂▂▂▂▂▂▂▂▂
Children	2004	6.82	2004	2017	▂▂▂▂▂▂▂▃▃▃▃▃▃▃▃▃▃▃▃▃▃▂▂▂▂▂▂▂
Reliability	2006	6.73	2006	2014	▂▂▂▂▂▂▂▂▂▃▃▃▃▃▃▃▃▃▂▂▂▂▂▂▂▂▂▂
Validity	2006	6.73	2006	2014	▂▂▂▂▂▂▂▂▂▃▃▃▃▃▃▃▃▃▂▂▂▂▂▂▂▂▂▂
Evidence-based Design	2008	5.95	2008	2017	▂▂▂▂▂▂▂▂▂▂▂▃▃▃▃▃▃▃▃▃▃▂▂▂▂▂▂▂
Prevalence	2007	7.25	2007	2014	▂▂▂▂▂▂▂▂▂▂▃▃▃▃▃▃▃▃▂▂▂▂▂▂▂▂▂▂
Pain	2008	8.24	2008	2018	▂▂▂▂▂▂▂▂▂▂▂▃▃▃▃▃▃▃▃▃▃▃▂▂▂▂▂▂
Randomized controlled trial	2008	5.51	2008	2013	▂▂▂▂▂▂▂▂▂▂▂▃▃▃▃▃▃▂▂▂▂▂▂▂▂▂▂▂
Injury	2009	5.66	2009	2013	▂▂▂▂▂▂▂▂▂▂▂▂▃▃▃▃▃▂▂▂▂▂▂▂▂▂▂▂
Qualitative research	2017	3.84	2020	2021	▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▃▃▂▂▂
Healing environments	2013	6.17	2013	2014	▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▃▃▂▂▂▂▂▂▂▂▂▂
Mortality	2007	5.51	2013	2016	▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▃▃▃▃▂▂▂▂▂▂▂▂
Services	2017	6.09	2017	2019	▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▃▃▃▂▂▂▂▂
Program	2013	6	2017	2020	▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▃▃▃▃▂▂▂▂
Nurses	2018	4.21	2018	2021	▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▃▃▃▃▂▂▂
Public health	2020	5.94	2020	2024	▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▃▃▃▃▃
Wound healing	2011	7.97	2021	2024	▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▃▃▃▃
Carbon footprint	2022	9.29	2022	2024	▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▃▃▃
Climate change	2022	8.87	2022	2024	▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▃▃▃
Environmental sustainability	2019	7.46	2022	2024	▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▃▃▃
Sustainable development	2022	5.5	2022	2024	▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▂▃▃▃

lists the top 24 most-cited keywords derived when using Citespace on related studies from 1997 to 2024. Further, the main keyword themes presented in Table 3 is supplemented by the high-frequency keyword analysis detailed in Table 4. Citespace burst detection can be used to identify and explore the research frontiers and latest trends in a particular field, which are usually considered to have been the research hotspots in a field during that period of time [58].

The most frequently occurring keyword shown in Table 3 is “wound healing”, and the increasing concentration of this keyword from 2021 onwards can be noted in Table 4. The keyword “healing” is dominant in this setting. Since the concept of HTD is directly related to wound healing in the medical field, “healing” is the relief of mental and physical symptoms, and wound healing is the recovery of physical wounds, which is a kind of “healing”. As such, the “wound healing”-centered Cluster 6 concerns physical healing.

Cluster 2, which focuses on “mental health”, relates to psychological healing. The importance of mental health and psychological healing is further discussed in a later micro-qualitative analysis section in this study. “Quality of life”, as the third most frequent keyword in Table 3 and the keyword with the highest intensity in Table 4, refers to the standard of living and the degree of well-being that a person enjoys over a certain period of time, including their material life, spiritual life, social relationships, health, and environmental quality. Therefore, Cluster 3 is associated with both physical healing and mental healing and emphasizes happiness, social values, and SDG, which will be further investigated as the third element of this research.

The outbreak of COVID-19 defined the broader context of this period, and its spread put enormous pressure on global health systems and social security systems. During the COVID-19 period, most research existed within the context of pandemic research, with relevant research being produced concerning this global crisis. In the future, HTD can be applied as a new way of coping with similar sudden crises by drawing upon past experiences.

Additionally, as presented in Figure 2 and Table 3 and Table 4, the keywords “nursing”, “healing environment”, and “rehabilitation” are related to healing with the intention of providing treatment and cure. Both nursing and rehabilitation are important aspects of healthcare, with nursing emphasizing the care and support provided by healthcare professionals to patients, and rehabilitation focusing on the restoration of physical and cognitive functioning after an illness or injury. Additionally, healing environments are a means of providing HTD that promote the physical and psychological recovery of patients by providing comfortable environments for recovery with safe facilities and supportive healthcare staff. Thus, these keywords will be further explored in the follow-up micro-qualitative analysis section.

Moreover, “children” is the only word in the keywords presented in Table 4 to show consistently strong concentrations since the start of the research period. Children are psychologically immature, more prone to fear, and require a more sensitive healing environment to restore their health. The relevance of children as the main population addressed in studies concerning hospital HTD is also intriguing to explore, and this will be further investigated in the follow-up micro-qualitative analysis section.

Furthermore, “sustainability” is one of the main focuses of this paper, which is presented in Table 4 as “environmental sustainability” and “sustainable development”. A few studies have looked into the integration of “sustainability” and “HTD”, especially in the context of “hospitals”. In contrast, sustainability emphasizes the balanced and coordinated development of economic, social, and environmental aspects. In addition, the concept of sustainable design emphasizes a natural, healthy, and comfortable environment, which is beneficial to the physical and mental health of patients. It not only promotes the physical and mental health of patients, improves the quality of medical services, reduces environmental pollution, and improves resource utilization but also brings economic and social benefits to hospitals. Therefore, sustainability should fill every cluster in order to explore how it is applied and what its role is. Interestingly, the use of research methods such as “qualitative research” and “evidence-based design” is also presented. Most of the studies used qualitative research, the most prominent of which is the evidence-based design methodology, as shown in Table 4, which appeared centrally from 2008 to 2017 and has also been used in recent years. In particular, these methods can be used to help create environments that are conducive to patient recovery, improve healthcare staff productivity, and promote sustainable hospital development.

3.2. Results of the Micro-Qualitative Content Analysis

The results of the network analysis shown in Section 3.1.2 yielded high-frequency, important keywords relating to the field. As shown in Figure 4, in the literature visualization with “hospital”, “HTD”, “sustainable”, and “health” as the initial words, the other keywords that appeared clearly were “wound healing”, “quality of life”, “mental health”, “nursing”, “rehabilitation”, “children”, “COVID-19”, and “evidence-based design”. These are precisely the main keywords that appeared in the high-frequency keyword analysis, leading to the continuation of the following subsection: high-frequency keyword analysis for the micro-qualitative content analysis. These keywords are divided into three parts, strategy, approach, and method, for the follow-up micro-qualitative content analysis.

3.2.1. Strategy

• Wound healing

In healthcare environments, HTD assists patients to recover better. Wound healing is a natural process involving recovery after an injury, which is related to the quality of recovery and quality of life of patients and is an important issue in the field of medicine. In the process of wound healing, HTD is present in a number of aspects, including material selection, technology applications, and treatment strategies. For instance, traditional dressings, particularly gauze, often cause secondary damage to wounds and surrounding tissues, offsetting the healing effects of the dressings when establishing a physical barrier between the wound and the external environment to accelerate healing [13,59]. Modern wound dressings, such as hydrogels, provide a moist environment for the wound, absorbing exudate, forming a physical barrier and accelerating wound healing [60,61]. Thus, personalized treatment strategies are formulated according to the different stages and characteristics of a wound. This has led to the development of heat-sensitive smart hydrogels that respond to minor temperature changes in the environment [61], hydrogels that form in situ for diabetic high-glucose environment wounds [60], bacterial cellulose for infected wounds, acute trauma, burns, and diabetic wounds [62], and bio-inspired hydrogels that mimic wound healing in the oral mucosa [63]. These dressings offer various healing strategies and show potential applications in chronic wound repair, acute repair, cosmetic surgery, and commercial fields [59,62,63].

• Mental health

Hospital HTD is a design concept that focuses on the psychological needs and emotional experiences of patients with the goal of creating a healthcare environment that meets the functional needs of healthcare while providing psychological comfort and well-being. This design concept posits that during treatment, patients need not only physical treatment, such as wound healing but also mental support through emotional communication and social interaction. Hence, mental health is crucial for improving patients’ quality of life and promoting their recovery, relating to the well-being obtained via psychological, emotional, and behavioral aspects that are characterized by stability, adaptability, and positivity.

Hospitals are primary providers of mental health services and are used by patients to cope better with the psychological stress brought about by illness through the creation of a positive therapeutic environment and comfortable rest and social spaces, reducing anxiety and unease and enhancing treatment outcomes and patient satisfaction. Current studies on how HTD in hospitals improves mental health often focus on external environmental design, particularly green interventions provided by nature for psychological healing. In addition, the scientific community has confirmed the importance of nature in relation to human physical and mental health, with short breaks in nature, periods of 20 to 30 min, significantly regulating emotional states, especially in stressful emergency situations [11]. Interestingly, of these nature interventions, healing gardens focusing on outdoor spaces are commonly used; however, these are not yet widely implemented in sustainable hospital HTD.

• Quality of life

Whether it is the birth of a child or the saving of a life, hospitals are important places for people and need to be built to meet the needs and expectations of the public [64]. HTD in hospitals is patient-centered, aiming to create an environment that promotes physical and mental healing. HTD is not only focused on the realization of medical functions but also emphasizes improving patients’ quality of life through environmental design. Research on HTD in hospitals to enhance quality of life mainly highlights the following aspects:

(1) The impact of wound healing on patients’ quality of life

The wound healing process significantly impacts patients’ quality of life. Pain and possible complications during the healing process cause considerable psychological stress, and chronic wounds lead to limited mobility, restrict daily activities, and affect social and work activities. The long-term treatment required for recovery also increases medical expenses and economic burden. For example, patients with secondary surgery for wound healing face restrictions in terms of health-related quality of life [65]. Additionally, chronic pain due to venous ulcers and months-long healing periods require frequent outpatient follow-ups and hospitalizations, significantly affecting psychological health and quality of life [66]. Specifically, elderly patients with pressure ulcers experience prolonged hospital stays, which can severely impact musculoskeletal health, increase mortality, and reduce quality of life [67].

(2) Patients’ perceptions of medical facilities

Medical facilities are sometimes perceived to be cold and highly sterilized, making patients feel helpless and fearful. People tend to imagine hospitals as spaces filled with high-tech equipment, lacking warm decorations [68]. Thus, the design, layout, cleanliness, quietness, and modernity of medical facilities directly impact patients’ medical experiences. To improve patient satisfaction, the development of digital medical facilities, such as self-service kiosks in lobbies, tablets, and smartphones, can simplify the medical process, enhance accessibility to medical services, reduce waiting times, and improve service quality [69]. Some studies even suggest designing hotel-like wards to give patients more control over ward facilities, creating positive interventions that positively impact patients’ physical and mental health. Although these measures incur higher costs, they offer commercial opportunities for the hotel industry to step into hospitals [10].

(3) Patient satisfaction regarding the indoor physical environment of a ward

The cold and sterile atmosphere of hospitals increase patients’ stress, making it essential to create an environment that promotes relaxation and recovery in both indoor and outdoor environments. Indoor design is thought to enhance patients’ subjective well-being, supporting public health through designs that control the environmental features [70]. Features impacting quality of life in the indoor environment include color, light, noise, plants, spatial layout, and the interior materials used.

(4) Quality of care for critical patients

Mortality is listed in Cluster 4 in Section 3.1.2. The mortality rate of critical patients is an important clinical indicator reflecting the risk of death during treatment. Due to the severe conditions of critical patients, high-quality nursing care is crucial for improving survival rates, reducing complications, and improving patient prognosis. This requires a thorough understanding of patients’ pathological information [34], close monitoring of vital signs (temperature, pulse, respiration, and blood pressure), and personalized care plans based on patients’ conditions. In addition, a 15-year review study of the built environment of intensive care units, including the building design, indoor environment, noise, light, and air quality, has been conducted [20]. This study indicated that the built environment of the ICU significantly impacts patient recovery and the efficiency and health of healthcare staff. Therefore, designers and healthcare professionals should collaborate to design more humane, comfortable, and safe ICU environments wherein the quality of care should be indirectly improved through the development of individualized care plans according to a patient’s specific situation, humane healthcare staff, and improved working environments and satisfaction for nurses.

3.2.2. Approach

• Nursing

Nursing is a professional practice focusing on establishing and maintaining a close co-operative relationship between nurses and patients, which typically involves the roles and working methods of nursing staff in medical environments. The core of this relationship lies in nurse–patient interactions, which extend beyond medical services to include educating and guiding patients to promote their health and recovery [71]. The following aspects can be considered relevant:

(1) Healthcare professionals’ views on the nursing environment

The nursing environment requires high standards in terms of professionalism, safety, and hygiene in order to meet patients’ medical needs while ensuring the efficiency and safety of healthcare professionals [72]. This includes healthcare professionals’ assessments of the nursing environment, particularly in-patient settings. New hospitals increasingly offer private rooms, and healthcare professionals have highlighted the advantages of single rooms [73,74]. Additionally, single rooms have a positive impact on improving family and healthcare professional interactions, increasing family members’ satisfaction with staying to care for a patient. The most direct improvements concern protecting patient privacy, enhancing comfort in hotel-style rooms, reducing the possibility of infections, and providing a quiet environment to effectively reduce patients’ stress levels and improve sleep quality. Further, in order to provide adapted therapeutic wards, healthcare professionals also consider adaptive daily rhythm atmosphere (ADRA), artificial skylight (AS), and adaptive stimulus dose (ASD) concepts in a lab environment, anticipating positive impacts on clinical workflow efficiency at almost all stages [75,76].

(2) Improving healthcare professionals’ satisfaction in hospitals

Healthcare professionals face various pressures in hospitals, such as having to make quick decisions in high-pressure environments, long working hours, especially night shifts, interpersonal stress from dealing with different patients and families, and higher health and safety risks from exposure to harmful substances or outbreaks. Therefore, providing a good working environment is key to reducing fatigue, increasing job satisfaction, and improving service quality.

(3) Patient–nurse interactions

Hospitality in the healthcare environment manifests as patients experiencing genuine care, comfort, and healing, surpassing traditional interpersonal interactions and social functions and touching upon the deep essence of human care [77]. Patients who experience hospitality in care establish a profound sense of connection and trust, which is crucial for their recovery. In addition, compassionate care plays a critical role in improving health outcomes and healthcare experiences, for which demonstrating appropriate care and promptly responding to patient needs are key elements of compassion in nursing practice [71]. Therefore, fostering compassion in healthcare professionals and ensuring high-quality medical services are vital to enhancing the overall quality of the healthcare system.

• Children

When exploring HTD in hospitals, children who stay in hospitals for extended periods due to illness are the greatest contributors to the concepts of humane hospital design [78]. Children are more sensitive to their environment, and more factors should be considered in healthcare and environmental design in their context, such as emotions, spatial design, external environment, and social interactions [18]. In studies focused on children healing hospitals, the “Fairy Tale Garden in Northern Thailand”, is a popular case, receiving attention for its beautiful natural scenery and activities, including play, social interaction, and education, which improve children’s acceptance and compliance with treatment and alleviate pain and illness [79,80,81].

3.2.3. Method

• Evidence-based design

As suggested in Section 3.1.2, service landscapes, specifically hospital rehabilitation landscapes, play a crucial role in patient recovery. Evidence-based design is an emerging design theory and method used in medical buildings, using scientific research and rigorous data to confirm the impact of hospital buildings and environments on users [27]. The application of evidence-based design in service landscapes involves multiple aspects, including the principles of humanized design, natural therapy, spatial layout, guidance, and safety [20,27,28]. These principles aim to improve the environment through scientific methods, providing a better recovery environment, meeting patients’ personalized needs, utilizing natural elements to promote psychological and physical recovery, designing reasonable spatial layouts to enhance comfort and recovery, guiding patients in rehabilitation activities, and considering the safety of hospital rehabilitation landscapes to prevent injuries and reduce secondary harm.

4. Discussion

The results presented in Table 1 show that the number of studies integrating “sustainability”, “hospitals”, and “HTD” is limited. In addition, in both macro-quantitative and micro-qualitative analyses, the results are related to hospital HTD, with less emphasis on sustainability, which indicates a lack of research on integrating sustainability into hospital HTD. As such, this section explores the potential of how SDG 3 can be implemented in hospital HTD, along with future trends and challenges, also discussing the challenges related to sustainable hospital HTD in the context of the COVID-19 era, as the results suggest in Section 3.1.2 of the keyword analysis.

4.1. Sustainable Development Goal (SDG) 3 and Healing and Therapeutic Design (HTD) in Hospital Environment

• SDG 3.2 (reduce child mortality)

SDG 3.2 aims to end the preventable deaths of newborns and children under five years of age by 2030. The keyword “children” is highlighted in the results of Section 3.1.2 since children are the future and are vulnerable to global health issues. Their health directly impacts global public health challenges, such as the control of infectious diseases and the prevention of non-communicable diseases. In addition, the results presented in Section 3.2.2 reveal the contributions of “children” to hospitals and the elements of a healing environment that hospitals should provide for children. Since adapting to new environments is a crucial step in children’s recovery, hospital design should consider children’s psychological and physiological characteristics, creating a safe and engaging child-friendly environment. External distractions, such as using bright colors, cartoon patterns, and themes that children love, could positively distract children and reduce their fear of hospitals. In line with SDG 3.2, specific interventions that hospitals could implement include the following:

(1) Multifunctional space design: Hospital interior spaces should be flexible and adaptable to meet the needs of children of different ages. For example, these include interactive spaces such as play areas and parent–child reading areas assist to distract children during medical visits and reduce anxiety [17], and activity zones that support free movement and guidance on wards and associated areas [82].

(2) Family oriented ward design: Ward designs should consider the need for the companionship of family members, providing private and comfortable family style wards where family members can give more care and support to children [83].

(3) Educational and recreational facilities: Hospitals could introduce educational and recreational facilities, such as educational toys and interactive screens to provide learning and entertainment opportunities for children while they receive treatment [79].

(4) Eco-friendly materials: Using eco-friendly materials in hospital construction and renovation reduces the environmental impact and provides a healthy treatment environment for children.

(5) Lighting and ventilation: The positive effects of natural light on health and recovery have been proven, and hospital design should make the full use of natural light and ventilation to create a comfortable indoor environment, which is beneficial to the physical and mental health of children.

(6) Green space design: Outdoor views, especially water features [32] and green plants could alleviate children’s anxiety. Designing these areas with ocean and forest themes encourages children to maintain a positive attitude [19]. Additionally, healing gardens have been proven effective in improving children’s stress levels and well-being [84].

Future trends in HTD for hospitals for children may focus on the following aspects: (1) for personalized and human-centered design, hospital design could focus more on meeting the individual needs of children with different ages and conditions, with an emphasis on child-friendly strategies and the involvement of children as stakeholders in the design process of hospital environments; (2) for interdisciplinary co-operation, where children are involved, hospital design involves specialists from several disciplines, including doctors, nurses, psychologists, and designers, working together to create a comprehensive healing environment; (3) for the integration of modern technologies, such as virtual reality and augmented reality into the treatment of children, as well as entertainment and educational activities, can help them better cope with the stress of the treatment process; and (4) for creating an open environment that allows easier access and support from family and community members might also be feasible.

• SDG 3.4 (promote mental and physical health)

SDG 3.4 aims to reduce premature mortality from non-communicable diseases through prevention, treatment, and the promotion of mental and physical health by 2030, addressing both physical and mental health. The results shown in Section 3.2.1 on wound healing and mental health suggest that wound healing is a significant issue in the medical field, and researching and practicing optimal wound healing methods improve the quality and efficiency of medical services, reduce medical waste, and align with sustainable development principles. For example, using fish skin grafts (FSGs) to treat pediatric patients with different wound etiologies represents an innovative and sustainable wound care solution, showing no signs of itching and shortening both surgery and healing times [85]. Additionally, a 30-day postoperative infection monitoring intervention in a Ghanaian hospital demonstrated that it is a simple, cost-effective, sustainable, and adaptable strategy [86]. Besides using degradable or recyclable materials for wound dressings to reduce environmental pollution, the following technical approaches could promote patients’ physical health through HTD: (1) hospital design should ensure ample natural light and good ventilation to improve patients’ mood, promote wound healing, and reduce infection risk, and (2) designing flexible space layouts that can be adjusted according to different medical needs and patient variations helps to improve the efficiency of hospital operation while providing personalized services for patients. Future wound dressing designs could consider multifunctionality, new materials, and high added value, targeting specific patients with conditions such as diabetes and varicose veins with appropriate dressings. Wound healing research could move toward more diverse and in-depth directions, aiming to enhance the speed and quality of wound healing through the use of new materials, technologies, and methods, thereby alleviating patient suffering and improving their quality of life.

Moreover, the results shown in Section 3.2.1 on mental health indicate that healing gardens are used to promote the restoration of a patient’s physical and mental health through the power of the natural environment; however, they are not yet widely available. From the perspective of hospital HTD, healing gardens are open spaces that are specifically designed to facilitate patient recovery and provide positive emotional effects for healthcare workers, visitors, and other stakeholders. They work alongside traditional therapeutic tools to improve human well-being [11,16,87]. In addition, interaction with nature activates visual, auditory, tactile, olfactory, and kinesthetic senses, which could lead to relaxation through experiencing the scents of trees and flowers, the sight of various colored flowers, and the sound of birdsong [88,89].

(1) Visual: Natural light and open landscapes provide visual comfort [90], helping to alleviate the anxiety and stress associated with confined environments. Using natural materials such as wood and stone to decorate walls and pathways, a calm and warm atmosphere could be created, enhancing overall comfort. Additionally, visually observing plants reduces patient pain, serving as an alternative pain management method [91].

(2) Auditory: natural sounds such as birdsong and flowing water can create a natural concert that is a form of music therapy that is widely used to improve the mood of patients and their sleep quality [92,93].

(3) Tactile: natural elements, i.e., plants and water, offer unique tactile experiences for patients who have an innate affinity for water, stimulating the brain to secrete hormones that have calming and stress-relieving effects when touching plants or water.

(4) Olfactory: the scents of flowers and fresh air in nature trigger positive emotional responses and reduce anxiety when these pleasant odors are detected. Medicinal and aromatic plants are excellent additions to enhance the healing environment of therapeutic gardens [31].

(5) Kinesthetic: walking in gardens increases the physical activity of patients [94], and the emotional value gained from interacting with nature is far greater than that obtained from walking on urban streets.

As the healthcare industry increasingly emphasizes patients’ psychological and physiological health, the concept of hospital therapeutic gardens will become more widely promoted and implemented. Rehabilitation gardens have become an indispensable part of many modern hospitals in Western countries. Although China started later in this regard, it has made significant progress and continues to advance and improve. Therapeutic gardens have become a global future trend.

• SDG 3.8 (achieve universal health coverage)

SDG 3.8 aims to achieve universal health coverage, ensuring that everyone has access to quality essential healthcare services and safe, effective, quality, and affordable essential medicines and vaccines. The results shown in Section 3.2.1 on quality of life and Section 3.2.2 on nursing highlight the importance of providing comprehensive, inclusive, and high-quality healthcare services. This goal emphasizes the importance of health as a fundamental human right and its critical role as the foundation for social and economic development. Hospitals, as primary providers of medical services, play a key role in achieving SDG 3.8. Sustainable HTD can enhance patient satisfaction with the environment and improve quality of life in the following factors:

(1) Color: The use of color in wards is an important design principle that can influence the emotions of patients. For instance, in psychiatric hospitals, the wrong choice of colors can lead to anxiety and self-harming tendencies in patients [95]. Soft light tones, such as light pink, light blue, and beige, generally give patients a relaxed, pleasant, and peaceful sense of their environment.

(2) Light: Light is a crucial element in hospital ward design since it directly affects patients’ sensory experiences and psychological states. Natural lighting is fundamental for creating a comfortable hospital environment, particularly sunlight, which positively impacts patients’ circadian rhythms, helps adjust their sleep cycles, promotes recovery, and contributes to an earlier discharge [96,97]. Additionally, natural lighting makes people feel closer to nature and provides a more comfortable visual experience indoors, satisfying psychological and mental needs. Further, appropriate artificial lighting should be provided for nighttime, emergency, and localized illumination, creating convenient conditions for patients’ nighttime activities [90].

(3) Noise: The noise levels in hospital wards are typically 15 decibels higher than the World Health Organization’s recommended values, negatively impacting patients’ health and comfort [98]. Patients are in a vulnerable state, and their sensitivity to noise is higher than that of healthy people, making them more susceptible to noise disturbances. To improve the acoustic environment in wards, sound-absorbing materials can be used to reduce reflected sound and noise levels. Replacing low-noise equipment and raising awareness among healthcare staff, patients, and their families to maintain low conversation volumes in wards are also recommended.

(4) Plants: Introducing indoor plants in wards affects patients’ subjective well-being, as plants can purify the air, regulate indoor environments, alleviate anxiety, and color the space, providing a comfortable, clean, and positive recovery environment. This indoor intervention can enhance satisfaction and the aesthetic appreciation of a hospital [14].

(5) Space layout: Patients hope for private spaces to maintain privacy and comfort during a hospital stay. Proper partitions to distinguish beds could be used to ensure sufficient personal space. Rooms should be spacious enough to accommodate all necessary functional actions, such as healthcare staff examinations and family accompaniment [99]. The design of wards should consider the need for wheelchair and stretcher access to ensure safety for patients and healthcare workers.

(6) Interior materials: Non-toxic green materials should be used indoors. Floors should be replaced, removing polyvinyl chloride (PVC) and installing non-slip and easy-to-clean materials, such as synthetic rubber [4]. Wall surfaces should be durable and easy to clean. Additionally, antibacterial and deodorizing materials should be chosen to ensure air hygiene and cleanliness, providing patients with a clean and tidy healing environment.

In addition to considering patients’ health and quality of life, hospitals should provide comprehensive services, including prevention, treatment, rehabilitation, and palliative care, ensuring all patients, regardless of socioeconomic background, have equal access to necessary medical services. The results presented in Section 3.2.2 on nursing are associated with ensuring healthcare workers’ health. To improve healthcare workers’ quality of work and life, the following options should be considered:

(1) Comfortable rest areas: Comfortable seating for relaxation, and fitness facilities, such as treadmills and exercise bikes, could be used to relieve work stress during breaks [100]. Studies on eye-tracking and self-recovery in hospital outdoor rest spaces and indoor work environments found that outdoor rest spaces significantly improved healthcare workers’ eye-tracking indicators, such as gaze time, saccades, and blinks, as well as self-recovery evaluations, such as fatigue, psychological state, and work efficiency [101].

(2) Appropriate lighting design: Sufficient brightness and appropriate lighting uniformity ensure that healthcare workers can clearly see patients’ conditions and operate medical equipment, reducing errors and accidents. Using lower color temperatures, such as 3000 K or lower, can reduce healthcare worker eye fatigue and discomfort [102].

(3) Reasonably arranged nurse stations: Nurse stations, the hub of activity in hospitals, where nurses, doctors, patients, families, and visitors interact with each other, need careful consideration in terms of location and spatial layout [103]. Well-organized work areas and corridors assist in reducing interference and conflict among healthcare workers. Since nurses spend much of their work time walking within wards, optimizing the location of nurse stations helps to reduce unnecessary movement, increasing care time and improving work efficiency and collaboration.

(4) Consideration of healthcare workers’ needs and opinions: Allowing healthcare workers to assess the impact of environmental design factors on stress reduction and involving them in the design process can increase their job satisfaction and identification with the medical environment [104].

Achieving universal access to quality essential healthcare services faces challenges such as resource limitations, uneven medical service distribution, high medical costs, and shortages of medical professionals. Addressing these challenges requires efforts in several areas: (1) increasing investment in the healthcare system to improve infrastructure and service quality; (2) reforming health insurance systems to establish fairer and more sustainable systems to reduce patients’ financial burdens; (3) encouraging the development and innovation of medical technology to enhance the efficiency and effectiveness of healthcare services; and (4) promoting international co-operation to share best practices and improve global healthcare levels.

4.2. Public Health Emergencies as a Warning for HTD in Sustainable Hospital Environment

The results shown in Figure 3 and the high-frequency keywords in Section 3.1.2 indicate that public health emergencies, such as the COVID-19 pandemic, have significantly impacted global healthcare systems, exposing the inadequacies of existing medical facilities in responding to large-scale infectious disease outbreaks. Due to the unique nature of the COVID-19 pandemic, the transmission patterns, duration, and response strategies varied across different hospitals and health departments. The virus’s long incubation period and unpredictable course, along with the varied treatment needs of patients, highlighted the weak points in hospital infection control, becoming a major public concern. This complexity made it extremely difficult to accurately predict the number of patients requiring treatment and the consumption of medical resources over time [105]. This situation represents not just a medical crisis but also a resource crisis. Therefore, future hospital designs should incorporate HTD concepts, not only to establish more efficient supply chain management systems to quickly mobilize necessary resources in emergencies but also to strengthen infection control measures. In contrast, HTD should include the addition of negative pressure rooms, improved ventilation systems, and dedicated isolation areas to reduce the risk of cross-infection.

Moreover, healthcare workers frequently face moral dilemmas, such as decisions about end-of-life care, where only one family member may enter the ward. Deciding who can be present when a loved one passes away causes intense emotional turmoil for both medical staff and patients’ families. To avoid such difficult decisions, medical institutions need sufficient resources, including manpower and materials. Considerations should include ethical understanding, critical thinking, emotions, and interpersonal relationships. HTD should ensure a supportive work environment and psychological health for healthcare workers, helping them cope with moral challenges and emotional stress [106].

Furthermore, public health emergencies, like COVID-19, will not be the last pandemic. Hospitals, as one of the most critical assets during an outbreak, need to provide safe and resilient environments. The significance of hospital outdoor spaces in responding to unpredictable crises has increased, with functional requirements becoming more complex for different occupants. For visitors, healing gardens and convenient outdoor areas around outpatient and emergency buildings should be designed as extensions of indoor spaces, providing shelter and amenities to ensure comfort during outdoor activities. Wayfinding systems should be improved for easier navigation. For patients, HTD promotes creating therapeutic and recreational areas conducive to recovery, which should be connected to living and utility areas for easy access. For staff, HTD advocates for the creation of separate staff rest areas to help alleviate stress and fatigue. These areas should be close to work areas and provide views from inside the building to encourage use. Additionally, staff should consider food delivery areas, which should be near workplaces and separate from main entrances [107]. Further, HTD also recognizes the importance of public health awareness and knowledge of epidemic prevention. Future hospital designs should include spaces for public health education and promotion to enhance public health literacy and self-protection capabilities. Technologies such as telemedicine, big data analysis, and artificial intelligence, which demonstrated their importance during the pandemic, should be integrated into future hospital designs to improve the efficiency and quality of medical services and enhance the monitoring and response capabilities for emergencies.

4.3. Limitations

This paper intended to deeply analyze and understand the theory and practice of sustainable HTD in hospitals and how it promotes patient recovery and health under different environments and conditions. It also provides directions and suggestions for future hospital design and construction. As stated in the database search part in Section 2, keywords such as “healing design” and “therapeutic design” were searched. Initially, despite both terms referring to design concepts that create environments beneficial for patient recovery and well-being, there were differences in their focus and application scope. “Healing design” emphasizes creating an environment that promotes physical and mental recovery, typically involving the integration of natural elements and the use of colors and materials that evoke positive emotions in patients. “Therapeutic design” focuses more on the treatment process itself, possibly involving physical spaces and equipment specifically designed for treating certain diseases or symptoms, such as special treatment room layouts, furniture and decor, and high-tech medical equipment aimed at optimizing treatment outcomes, improving efficiency, and reducing patient discomfort. However, there was uncertainty about which keyword to use, but the research results indicated that combining both terms provides a more comprehensive view of hospital HTD, as reflected in the results of both macro-quantitative and micro-qualitative analyses. Therefore, the term “healing and therapeutic design” was chosen in this article.

In addition, the systematic literature review method used in this study involved a large volume of literature. However, when collecting the literature related to hospitals, sustainability, and HTD, it was not possible to obtain enough texts containing all these three keywords in a single search, indicating limited research on the subject. Thus, keywords were combined in pairs to obtain more related literature for visual analysis. However, this method may weaken relevance while increasing the volume of the presented literature due to the exclusion of one keyword. This could lead to instances where large volumes of work, e.g., some sets containing over five thousand documents, including duplicates, were weakly related to the theme. Therefore, in the third phase of the method in Section 2, the literature was restricted to reduce these limitations. Multiple combinations of text sets were tested for keyword network visualization in the early stages to verify whether it affected the final visualization results. The results show that the visualization results did not differ significantly, with key content consistently highlighting wound healing, mental health, quality of life, nursing, children, and evidence-based design.

Further, despite sustainable HTD being a trend for future hospital design, practical implementation is constrained by local economic conditions and technological levels. The diversity and specificity of hospital designs across different cultural and regional backgrounds should not be overlooked. Additionally, patient and healthcare worker opinions and experiences are crucial for evaluating the healing effects of hospital designs. If research does not fully incorporate these perspectives, it may result in a disconnect between design solutions and actual needs.

5. Conclusions

This paper aimed to explore the current state of development and the knowledge structure of sustainable healing and therapeutic design in hospital scenarios using a systematic methodology that integrates macro-quantitative bibliometric analysis and follow-up micro-qualitative content analysis methods based on data from the WOS database, which investigates eight research objectives, including the background, current state, hotspots, high-frequency words, integration with SDGs, particularly SDG, 3 “ensure healthy lifestyles and promote well-being of people of all ages”, and the challenges posed by public health emergencies, such as the COVID-19 pandemic, for sustainable HTD in hospitals. The main contributions are as follows:

In terms of research methods, this paper integrates macro-quantitative bibliometric analysis and follow-up micro-qualitative content analysis methods, forming a systematic methodology to explore research hotspots and trends in the field of sustainable HTD in hospitals.

In terms of research techniques, utilizing VOSviewer and CiteSpace software tools for the network visualization of keyword co-occurrence and keyword burst detection in revealing high-frequency hotspots enhances the data in terms of yielding objective and accurate results.

In terms of the research findings, macro-quantitative bibliometric analysis of keyword network visualization revealed the knowledge structure of the research theme, presenting key directions in six clusters, such as the environment of a hospital, mental health, quality of life, illness and care, COVID-19, and wound healing, emphasizing key terms on wound healing, mental health, quality of life, nursing, children, and evidence-based design via high-frequency keyword analysis. These have been further grouped into three categories, namely strategy, approach, and method. Subsequently, the micro-qualitative content analysis was elaborated according to the above categorization in relation to the specific literature, showing how the keyword is reflected or used in the existing literature in the design of hospital healing. Focusing on hospitals and HTD, this paper further emphasizes how hospital HTD relates to sustainable development goals, i.e., SDG3, which is aimed at reducing child mortality (SDG 3.2), promoting mental health and physical health (SDG 3.4), and achieving universal health coverage (SDG 3.8), to explore how they relate to wound healing, mental health, quality of life, nursing, and children, which are stressed in the results of the both of macro-quantitative bibliometric and micro-qualitative content analysis. In addition, the COVID-19 context is highlighted in the need for hospitals to address both medical and resource crises in future public health emergencies.

Moreover, the elements and factors of sustainable HTD include but are not limited to the following:

Patient engagement and empowerment: enhancing patient involvement in treatment decision making, strengthening self-management capabilities, promoting patient engagement in their health maintenance through education and support.

Spatial layout: a proper spatial layout promotes social interaction, provides privacy and creates a physical environment conducive to rehabilitation.

Environmental design: this includes natural light, color, sound, temperature and air quality, all of which are important environmental factors that affect the emotional and physiological state of an individual.

Psychological and emotional factors: the design should take into account the psychological state and emotional needs of the individual and promote psychological healing by creating a safe, comfortable and stimulating environment.

Technology and innovation: utilize the latest technologies and innovative approaches such as smart materials, bioengineering and digital health tools to enhance the healing effects of the design.

Sustainability: designs should consider environmental sustainability, using eco-friendly materials and energy-efficient technologies to minimize negative impacts on the environment while promoting long-term health.

Furthermore, the results guide designers and decision makers on how to create green healing spaces, such as sky gardens and roof gardens, which not only create nice environments but also provide psychological relief. The results highlight the use of evidence-based design in healthcare buildings, which requires designers and decision makers to optimize designs based on reliable scientific research and statistics to improve building performance and user experience. Through these findings, architects and decision makers can better integrate the concepts of sustainability and healing environments into hospital design to create healthcare spaces that are both energy efficient and promote patient healing.

This paper draws a picture across related fields of a new perspective on the key directions for sustainable HTD in hospitals, along with future trends. Sustainability is a development approach advocated by various industries around the world, and hospital healing design promotes the physical and mental health of patients by creating a comfortable built environment. Sustainable hospital healing design is a desirable trend for the future development of hospitals, not only for the construction of hospital buildings but also for the treatment of patients. As such, in the future, this research can be extended on a larger scale. In addition, the data used in this study were collected solely from the WOS database. Future research could consider incorporating other databases, such as PubMed, Scopus, and the ProQuest Health & Medical Collection, to explore more studies on sustainable HTD in hospitals. Ideally, sustainable HTD could be comprehensively further implemented in the practice of designing a hospital to experiment with the functionality and healing effects.