The Impact of the Physical Environment on Staff in Healthcare Facilities: A Systematic Literature Review

Abstract

This article investigates the staff outcomes that are influenced by physical environment features in a healthcare facility. Over the past few decades, research on the physical environment and its effects on hospital staff has advanced steadily. Focusing on the physical environment has become a research area with great potential because it is crucial to provide a favorable work environment for health professionals, which directly impacts the quality of care. A systematic literature review was conducted to identify research articles from two scientific databases and a healthcare journal. Articles that fulfilled the inclusion and exclusion criteria for relevant articles were included in this review. Relevant data were derived from the final shortlisted articles. The features identified in the articles were divided into three dimensions of the physical environment. The results demonstrate different outcomes for staff. This review shows the need to develop a comprehensive study involving the most important features of the three dimensions of the physical setting and its effects on staff. This study contributes invaluable insights for hospital administrators, architects, and designers by informing them about the critical factors shaping the healthcare workplace environment.

1. Introduction

The healthcare industry has more dynamic and complicated environments than other service industries [1]. It is a complex environment with continually functioning organizational systems, technological infrastructure, and users, including patients, families, and staff [2]. These interactions are dynamic since patient needs, service care, and technology are unpredictable over time and are likely to change, which places a heavy burden on how the built environment is designed. The physical environment is critical for enhancing patient well-being and providing a supportive workplace for healthcare workers [3]. Every aspect of the physical environment influences staff outcomes in a healthcare environment [4]. The physical environment is the physical features of the environment where users carry out tasks [5]. According to [6,7], the physical environment encompasses architectural elements, interior design, and ambient features. Within healthcare settings, staff outcomes are influenced by these physical factors and include a range of indicators, such as well-being, satisfaction, performance, productivity, stress and burnout, commitment, turnover, and other impacts on healthcare professionals in their workplace. The healthcare setting can create a stressful environment, as physical environmental factors act as environmental stressors [8]. In addition to providing treatment, healthcare settings face new challenges, including protecting users from infectious diseases [9]. According to [10], healthcare settings need to be designed to be resilient for continual development by integrating additional information about the influence of various design strategies on the users and other outcomes related to the organizations.

Studies have shown that variables like long work hours, variable schedules, patient distress, high patient volumes, workplace violence, and illness risk can lead to stressful work circumstances [11,12]. According to reports from Mental Health America (2020), 93% of healthcare personnel are stressed, 82% have mental and physical fatigue, 45% of nurses claim that they do not receive appropriate emotional care, and 22% of health professionals experience depression and post-traumatic stress [13]. In addition, 69% of doctors reported depression, 13% had suicidal thoughts, 64% of female doctors reported burnout [14], and frontline staff, nurses, and young staff had major psychological indications other than depression [15].

Many scientific studies [12,16,17,18,19,20,21,22,23,24,25] have gathered evidence demonstrating relationships between the physical healthcare environment and outcomes for patients, families, staff, and organizational outcomes. Consequently, there is an increasing consensus that an effectively designed environment can improve patient outcomes, promote a supportive work environment for users, and meet organizational and business goals. Although research on the effects of the work environment on healthcare workers has significantly increased, with more than 1.1 million hits in Google Scholar and 50,000 articles in the last five years [26], these studies have focused mainly on the task context, social context, organizational culture context, and physical context.

The healthcare environment has immense opportunities to be an effective intervention for reducing and preventing mental exhaustion [27] and can lessen stress and provide restorative conditions [28] for healthcare professionals. Research has also demonstrated the significance of physical environmental design on performance and efficiency among staff in healthcare facilities [5].

The majority of studies have proven that the physical environment in healthcare facilities has an impact on patient and staff outcomes. Healthcare professionals are increasingly conscious of the need for a well-designed physical workplace environment, as this environment is crucial for fostering positive and supportive work environments, and improved designs can make the jobs of staff much easier [12,16,20,26,29]. A great deal of potential exists for healthcare physical environment design to be an efficient approach for minimizing and eliminating negative impacts on staff [27]. Additionally, understanding the complex interplay between the physical environment and staff outcomes is essential for healthcare administrators, architects, designers, and policymakers. A supportive and conducive workplace environment enhances staff well-being and improves patient care quality, safety, and satisfaction.

Although the previously published research provides relevant information, those studies dealt with specific factors, as opposed to a more comprehensive assessment of physical environmental factors. It is vital to understand the extent to which physical environmental factors are studied and their impact on staff in healthcare settings. This article provides a systematic review of peer-reviewed articles to comprehensively understand the physical environmental factors that impact staff in healthcare facilities. This study aimed to address the following questions. Research question (RQ) 1: Which physical environmental factors contribute to staff outcomes in healthcare settings? RQ 2: What staff outcomes concerning the physical environment in healthcare settings have been studied? RQ 3: Which theories pertaining to the physical environment have been discussed in the literature?

2. Review Methods

A systematic review must employ an established method, as outlined by [30] for searching, filtering, reviewing, interpreting, synthesizing, and reporting findings obtained from various publications. We selected relevant studies for review in six steps: (i) identifying the concepts to be included in this study; (ii) selecting relevant databases; (iii) identifying keywords and search strategies; (iv) selecting the inclusion and exclusion criteria; (v) screening the data; and (vi) obtaining the search results.

In step (i), we identified the following concepts of interest: the population, setting(s), and outcome of the study. The population of interest was healthcare staff, the setting(s) of interest was the physical healthcare environment, and the outcome was the staff outcome. In step (ii), we selected two databases: PubMed and Scopus. In addition, manual searching was performed in the Health Environments Research and Design (HERD) Journal. PubMed was chosen because it is a healthcare-based database, and Scopus is one of the largest databases of peer-reviewed literature. The search included articles published between January 2010 and September 2022 to capture a decade of research given the surge in healthcare environment research starting from 2010 onward. In step (iii), we identified keywords and the search strategy. Using Boolean operators, the literature was searched for “physical environment”, “staff outcomes”, and “hospital” and their related terms.

Table 1. Keywords used in the search.

All Words Related to the Hospital	All the Words Related to The Physical Environment	All Words Related to Staff Outcomes
Healthcare Hospital Healthcare building Healthcare facility Healthcare setting Healthcare sector	Physical environment Healthcare design Built environment Building design Hospital environment Hospital design Environmental factors Healthcare environment	Employee outcomes Staff safety Staff stress Staff satisfaction Staff efficiency Staff performance Staff burnout Turnover intent Job satisfaction Workplace satisfaction perception

lists the keywords used. The searches used standard search filters. The titles and abstracts were examined for relevant information. The approach involved search terms related to the hospital, physical environment, and staff outcomes and included several search strings for every database. Repeated searches were carried out using various terms and search string combinations.

In step (iv), the inclusion and exclusion criteria were defined, and the criteria for selecting articles are given in

Table 2. Inclusion and exclusion criteria.

Inclusion Criteria	Rationale
Only peer-reviewed journal publications	Ensuring that articles are peer-reviewed maintains a high standard of research quality and credibility.
Available in electronic databases	Limiting the search to electronic databases ensures the accessibility and verifiability of the sources, facilitating the replication of the review process and ensuring that the articles are easily retrievable.
Limited to the healthcare context only	Focusing on the healthcare context ensures that the findings are directly relevant to healthcare environments, where the impact of design features on staff outcomes is critically important.
All healthcare professionals at any level working in a healthcare facility	Including all healthcare professionals ensures a comprehensive understanding of how design features impact various roles within healthcare settings, providing a holistic view of staff outcomes across different professional levels.
Articles published in the English language only	Limiting the review to English-language publications ensures that the reviewers can accurately interpret and analyze the content, maintaining the integrity of the review process.
Full-text articles	Including only full-text articles ensures that all relevant details of the studies can be thoroughly examined and assessed, allowing for a complete understanding of the research findings and methodologies.
Studies employing robust research methodologies, including quantitative, qualitative, or mixed-method approaches	Including methodologically rigorous studies ensures that the findings are based on sound research practices, enhancing the validity and reliability of the review.
Exclusion Criteria	Rationale
Book chapters, conference proceedings, reports, and review papers	Excluding these articles ensures that the review focuses on original research studies that provide direct evidence of the impact of design features on staff outcomes.
Sectors other than healthcare	Excluding articles from other sectors ensures that the findings are specific to healthcare environments, where the specific challenges and dynamics may differ significantly from other settings.
Articles with only abstracts	Excluding articles that provide only abstracts ensures that the review is based on comprehensive data and detailed methodologies, which are necessary for a thorough analysis and accurate interpretation of the study results.

.

In step (v), data screening, this review was conducted using article titles within the database to screen out irrelevant articles, and duplicates were removed. The abstract of each article was screened for relevance. The full articles were critically reviewed, and all relevant information required for this review was documented.

In step (vi), for the search results, a total of 4869 articles were initially retrieved and subsequently checked. Based on the analysis of the titles and abstracts, 4172 articles (books, conference proceedings, dissertations, editorial commentaries, and review articles) were excluded. By employing the full-text inclusion and exclusion criteria, 439 articles were excluded. Consequently, 258 articles were assessed for eligibility. A total of 191 articles failed quality checks and were removed. Finally, 67 articles were selected for this review. These articles were thoroughly reviewed and verified by the authors. Figure 1 shows the flowchart of the article selection process.

3. Data Extraction and Synthesis

After the quality assessment, 67 articles were selected for this review. These articles were thoroughly reviewed and verified by the two authors. All 67 articles were analyzed and summarized. The first author gathered information from the included studies.

3.1. Analysis of the Included Articles

This section addresses RQ 1 and RQ 2. The information obtained included information such as (i) the articles published per year, (ii) the countries in which the studies were performed, (iii) the research techniques, (iv) the sampling types, (v) the sampling frames, (vi) the study settings, and (vii) the methods of data collection.

3.2. Identification of Variables

This section provides insights into the physical environmental variables considered to study the impacts on various staff outcomes. The physical environment was classified into three dimensions based on the study by [6,7,31]. The three dimensions included architectural design features, which represent relatively permanent aspects; interior design features, which include less-permanent elements of the environment; and ambient features, which encompass environmental conditions and sensory stimuli. Clusters were formed based on these three dimensions of the physical environment. Similarly, the staff outcome measures were also assessed for this study. This was crucial because it mapped the independent and dependent variables.

3.3. Theories Identified

Several theories have been established in the domains of environmental psychology, the environment and behavior, and organizational behavior. These theories provide valuable frameworks for analyzing the interaction between the environment and human behavior in an organizational context. Environmental psychology theories focus on how individuals perceive and interact with their immediate physical surroundings, while environment and behavior theory investigates how environmental factors influence individuals’ behavior. Organizational behavior theory investigates individuals’ behavior in organizations and how it influences organizational success. These theories provide support for the research undertaken to better understand the complex interplay between the environment and its impact on the individual. This understanding can guide the design of more supportive and conducive environments. This section presents the answer to RQ 3 by identifying the theories used in the review articles in the fields of environmental psychology, the environment and behavior, and organizational behavior.

3.4. Keyword Analysis

Figure 2 depicts a weighted cloud theme generated by Jason Davies’s word cloud generator. It is a comprehensible technique for visualizing text data. The commonly used keywords in the articles were design, environment, satisfaction, and nurse. It can be concluded that most articles discussed environmental design and its impact on staff satisfaction.

4. Results and Discussions

4.1. General Characteristics

An analysis of the published articles led us to the conclusion that more articles were published in PubMed than in the Scopus database. Regarding the distribution of articles reported in the systematic review between 2010 and 2022 (Figure 3), there was a peak in the related research area during 2015, with twelve studies, and in 2018, with nine studies.

Relevant research originated from multiple countries, including 30 (n = 30) from the USA; 5 from China; 3 from Australia; 2 each from Canada, the UK, and Iran; and 1 each from Denmark, Jordan, Uganda, Portugal, Brazil, Taiwan, Finland, Hong Kong, the Netherlands, and Japan (Figure 4).

4.2. Research Technique

Of the total articles reported for this review (

Table 3. Research methods reported in this review.

Sl. No.	Research Methods	Number of Articles Reported in this Review (n = 67)
1	Quantitative methods	27 [17,22,23,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54]
2	Qualitative methods	10 [55,56,57,58,59,60,61,62,63]
3	Mixed methods	30 [8,18,19,56,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89]

), 45% used mixed methods, followed by quantitative methods (40%) and qualitative methods (15%). The quantitative methods used questionnaire survey methods for data collection, and the qualitative methods included focus group discussions, structured or semi-structured interviews, and observational studies. Both qualitative and quantitative mixed methods were used.

4.3. Sampling Technique

Nonprobability sampling was adopted by 31 articles; 7 articles used the probability-sampling technique, and the remaining articles did not report the sampling technique adopted. The sampling techniques adopted in this review are reported in

Table 4. Sampling techniques reported in this review.

Sampling Techniques	Types of Sampling Techniques	Number of Articles Reported in this Review (n = 67)
Probability sampling	▪ A random sample (n = 4) [23,71,85] ▪ Cluster random sample (n = 1) [33]	7
Nonprobability sampling	▪ Convenience sample (n = 19) [5,8,34,37,38,40,48,49,51,56,60,64,70,76,77,85,86,87,89] ▪ Volunteer/self-selected sample (n = 5) [59,72,78,83,88] ▪ Purposive sample (n = 3) [57,58,74] ▪ Sequential sample (n = 1) [18] ▪ Convenience and snowball sample (n = 2) [67,81] ▪ Convenience and purposive sample (n = 1) [55] ▪ Non-random sample (n = 1) [45]	31
Not mentioned	▪ [17,19,22,31,32,35,36,39,41,42,43,44,46,47,50,52,53,61,62,65,66,68,69,73,75,79,80,82,90]	29

.

4.4. Sampling Frame

There was a wide variety of participants in the studies. Nurses and doctors were the respondents in most of the studies. The studies on nurses were considered the highest sampling frame. The nurses included registered nurses, senior nurses, charge nurses, associate chief nurses, chief nurses, critical care nurses, circulating nurses, intensive care nurses, and nurse managers. The second most studied healthcare professionals were the care team staff members, comprising physicians, therapists, advanced practice specialists, physician supporters, and nurse practitioners. The clinical and non-clinical staff sample frame was the third most investigated sample frame. A detailed summary of the health professionals (study participants) included in this review is given in

Table 5. Study participants included in this systematic review.

Healthcare Professionals (Study Participants)	Number of Articles Reported in this Review
Nurses	[8,17,19,22,39,40,42,47,55,56,61,64,65,70,75,78,79,82,84,89]
Care team staff members	[23,32,36,51,71]
Clinical and non-clinical Staff	[38,53,57,58,59,77,80]
Staff members	[63,66,67]
Physicians/medical doctors, nurses, and therapists	[5,18,31,33,37,41,44,46,67,71,73,81,86,91]
Nurses and technicians	[41]
Diagnostic, pharmacy, sterilization, rehabilitation, and health science department staff	[43]
Midwives and supporters	[60]
Medical directors	[49]
Nursing, social work, and therapy staff	[54]
Healthcare providers/employees	[50,62,88]
Technicians	[52]

.

4.5. Study Settings

Although the context of the studies varied, most of the studies were performed at general hospitals (n = 15), followed by acute care hospitals (n = 7). The detailed settings of the included studies in this review are provided in

Table 6. Settings of the selected studies.

Study Setting	Selected Studies Carried Out in This Setting
Hospital	15 [34,47,49,50,52,53,58,67,69,72,73,74,76,80,85]
Public nonprofit hospital	2 [64,81]
Somatic hospital	1 [55]
University teaching hospital/academic medical center	6 [17,35,43,51,61,87]
Maternity facility	2 [60,65]
Primary care facility	2 [32,77]
General hospital	2 [46,66]
Ambulatory care	1 [18]
Community hospital	3 [5,44,56]
Acute care hospital	7 [22,31,39,57,77,78,89]
Mental healthcare facility	1 [77]
Tertiary care facility	3 [38,54]
Medical care center	1 [40]
Care and rehabilitation facility	1 [42]
Veterans’ affairs healthcare facility	1 [62,63]
Children’s hospital	1 [90]
No contextual information	18 [8,19,23,33,36,37,41,45,48,59,70,75,79,82,83,84,86,88]

. The designs of the listed studies varied. The sample sizes varied considerably, from as low as 9 to 1561 staff participants.

4.6. Methods of Data Collection

Eleven studies used experimental and quasi-experimental designs [22,42,43,54,65,75,78,81,83,90], thirteen studies used interview methods [55,56,57,64,72,73,83], and six studies used focus group discussions [8,59,61,74,79,86]. One ethnographic study [60] and two thematic content analyses were used [18,59]. The remaining 53 studies [17,19,23,31,32,33,34,35,36,39,40,44,45,46,47,48,49,50,52,53,65,66,67,68,70,71,77,80,82,84,85,87,88,89,92] used survey questionnaire methods along with other methods. Few other studies used methods such as behavior mapping [48], participatory guided tours [62], visual assessment, simulation, and observational studies [41,51].

This review identified a wide range of research methods employed to investigate the impact of the physical environment on staff, which significantly helped us to understand the topic in depth. These studies investigated various aspects of environmental factors while gaining insights from various perspectives by employing a variety of research methods. The quantitative methods employed in the review articles included experimental and quasi-experimental research designs and survey research to acquire quantifiable data on staff outcome measures. The articles that employed experimental research allowed the researchers to manipulate specific environmental variables and observe their impacts on staff. These methods also provided useful information about the prevalence and extent of the impact of the environment on staff. The qualitative research methods, such as observational studies, interviews, and focus group discussions, enabled the researchers to delve deeper into the subjective experiences and perceptions of the physical environment. Furthermore, the mixed-method approach integrates both qualitative and quantitative methods, providing a more comprehensive understanding of complex phenomena. Overall, the diversity of the research methods allowed a more holistic approach to investigating various factors of the relationship between the physical environment and staff outcomes.

4.7. Identification of Physical Environmental Variables and Their Impacts on Staff Outcomes

4.7.1. Architectural Design Features and Their Impacts

Architectural design features were grouped into restorative elements, spatial layout and connections, design characteristics, workspace elements, and room and spatial dimensions.

Table 7. Architectural design features and their impacts on staff outcomes.

Architectural Design Features	Staff Outcomes
	Satisfaction	Performance	Productivity	Burnout	Perception	Behavior	Communication	Experience	Efficiency	Collaborations	Teamwork	Privacy	Stress	Mood	Security/Safety	Work Pattern and Flow Disruption	Wellness	Activity	Well-Being	Attrition	Absenteeism	Medical Errors	Commitment	Comfort	Environmental Demand
Restorative elements	7	2	1	1	3		1		1			1	4	2			1		1	1	1	1
Author/year	[8,23,34,42,43,50,53,56,64,66,78,80,85,93]
Spatial layout and connections	16	5	1	1	10	1	9	2	7	1	1	2	5			1		1	1				1	1	1
Author/year	[17,18,31,32,33,35,36,38,39,41,43,47,48,50,53,54,59,61,67,69,70,71,72,73,74,75,76,78,82,83,84,85,90]
Design characteristics	6	1			8		3	1	10		4	3
Author/year	[5,37,41,57,59,67,69,73,78,82,86]
Workspace elements	4	3			3		1		3			1	1
Author/year	[41,54,57,70,72,82,86,90]
Room and spatial dimensions	4	1			2		1	1	2			1	2		2
Author/year	[43,49,53,57,58,73,74,78,82,89]

shows the staff outcomes for architectural design features studied by various authors, and Figure 5 shows the number of articles on the effects of architectural design features on staff outcomes.

Restorative Elements

Restorative elements in healthcare settings are designed to provide staff with environments that support relaxation, reduce stress, and promote overall well-being. The key restorative elements identified in the literature included break spaces [8,64], windows with views [23,34,42,50,53,80,85], balconies [64], and outdoor spaces [66]. Restorative break spaces are designated areas where staff can relax and recharge, often featuring comfortable seating and calming décor, significantly improving staff satisfaction [8,64], performance [64], and productivity [64] and reducing staff stress [8,64]. Windows that offer views of nature significantly enhance staff satisfaction [50,56,85], performance [22], communication [22], efficiency [56], and mood [5,22] and reduce stress [50,56]. Balconies, as outdoor extensions of interior spaces, provide fresh air, natural light, and views, offering a retreat from the high-pressure working environment. Outdoor spaces, such as gardens, are designed for relaxation and social interaction, allowing staff to connect with nature and take breaks, which are important for maintaining both mental and physical health.

Spatial Layout and Connections

Spatial layout refers to the organization and arrangement of various spaces within a healthcare facility. An effective layout ensures efficient workflows [48], easy access to essential areas, and minimal unnecessary movement, thereby enhancing staff satisfaction [17,18,37,41,43,47,50,54,71,73,75,78,84,85], efficiency [41,67,69,70,73,75,83], performance [36,37,43,70,91], productivity [83], behavior [17], communication [18,32,39,48,69,71,74], experience [71,73], privacy [69,85], collaboration [33], and teamwork [83]; improving perception [33,38,48,50,53,67,69,70,94], staff activity [38], well-being [83], commitment [43], and comfort [47]; and reducing burnout [35] and stress [35,50,61,83]. Visual connection, or the ability of staff to see and visually connect different areas within the facility, supports supervision, enhances communication [32], and improves the sense of safety and community among staff. The effective arrangement of spaces considers the need for privacy, ease of movement, and proximity to related functions, further enhancing workflow and reducing stress.

Design Characteristics

In healthcare settings, the design configuration plays a crucial role in determining how efficiently staff can perform their tasks, access necessary equipment, and interact with patients and coworkers. Flexibility refers to the ability of a space to adapt to different uses and needs over time. Flexible designs in healthcare can accommodate changing medical practices, emergencies, and evolving staff requirements without significant alteration and can help to improve staff perceptions [67,82], efficiency, and teamwork [67]. Accessibility ensures that all areas are easily accessible to staff by incorporating features such as wide doorways, ramps, and clear signage, which facilitate efficient and safe movement throughout the facility. Improving accessibility in healthcare settings enhances staff perceptions [57,67], efficiency [67], and privacy [57]. Good visibility supports patient supervision and enhances staff satisfaction [37,41,73], performance [71], communication [5,69], experience [73], efficiency [41,67,69,73], teamwork [5,67], and privacy [69] and promotes a collaborative environment among staff. Proximity is essential in healthcare settings for maintaining efficient workflows, ensuring quick response times, reducing physical strain on staff, and improving satisfaction [78], perception [67,82], communication [69], efficiency [67,69], teamwork [67], and efficiency.

Workspace Elements

An adequate workspace is essential for staff to perform their duties effectively and comfortably. Well-designed functional spaces promote staff performance [91]. Additionally, effective storage solutions are vital for organizations, reducing clutter, and ensuring that necessary items are easily accessible, all of which enhance staff satisfaction [41,43,54,63,86], performance [43,70,91], and efficiency [41,70].

Room and Spatial Dimensions

An appropriate room size is crucial for accommodating staff activities and equipment, ensuring a comfortable working environment, enhancing staff satisfaction [73,78], efficiency [73], and overall experiences [73], and reducing stress [89] in healthcare settings. Corridors should be wide enough to facilitate the easy movement of staff, patients, and equipment, as well-designed corridors can improve staff communication, privacy, and safety [74]. Personal spaces such as changing rooms and private offices are essential for staff well-being, offering personal comfort, and reducing stress [49]. Additionally, a well-designed layout of entrances, including doors and lobbies, provides easy access, security, and a welcoming atmosphere, benefiting staff by improving satisfaction [78], efficiency, and security [58]. The perception of space within a room or area is influenced by factors such as the ceiling height, lighting, and furniture arrangement. These elements contribute to a sense of spaciousness, enhancing comfort and reducing feelings of overcrowding and stress among staff.

While analyzing the distribution of research articles related to architectural design features, several key findings emerged. Staff satisfaction gained significant attention, with 23% of the research articles focusing on this aspect. Within staff satisfaction, spatial layout emerged as a prominent theme, constituting 43% of the discourse, followed by restorative elements, at 19%. Staff perceptions were researched in 16% of the articles, with a notable emphasis on design characteristics (31%) and spatial layout (38%). Staff efficiency, another vital aspect, was addressed in 14% of the articles, with a predominant focus on design characteristics (43%) and spatial layout (30%). These proportions reflect a nuanced exploration of how architectural design impacts staff, highlighting spatial layout as a common thread across satisfaction, perception, and efficiency considerations while also underscoring the importance of design characteristics in shaping staff efficiency and perceptions.

Considering the overall staff outcomes within architectural design features studies, spatial layout and connections emerged as the most explored aspects, encompassing 67% of the research, followed by design characteristics (36%) and restorative elements (28%). These findings underscore the central role of spatial design considerations in shaping staff outcomes, emphasizing the need for a comprehensive approach that integrates spatial layout, design characteristics, and elements conducive to restoration within built environments.

4.7.2. Interior Design Features and Their Impacts

Interior design features group elements such as natural elements, ergonomics and comfort, aesthetic and visual appeal, and navigation and orientation.

Table 8. Interior design features and their impacts on staff outcomes.

Interior Design Features	Staff Outcomes
	Satisfaction	Performance	Burnout	Perception	Efficiency	Privacy	Stress	Wellness	Activity	Well-Being	Comfort	Environmental Demand
Natural elements	3		2	2			4	3	1
Author/year	[34,40,49,52,53,64,80,81]
Ergonomics and comfort	3	1	1	5	1	1	1
Author/year	[31,34,43,53,70,78,82,84,86,89]
Aesthetic and visual appeal	7	2		4	1		1					1
Author/year	[44,53,54,59,62,70,78,82,84,91]
Navigation and orientation	3	1		1						1	1	1
Author/year	[37,42,47,54,59,82]

summarizes the staff outcomes for interior design features studied by various authors, and Figure 6 shows the number of articles on the effects of interior design features on staff outcomes.

Natural Elements

In the healthcare context, incorporating natural elements such as gardens and landscaping can significantly impact staff well-being by reducing stress and providing a calming environment. Features such as aquariums also contribute to a soothing atmosphere, promoting staff wellness [80] and helping to alleviate anxiety and stress levels among staff [49]. Additionally, integrating artwork into healthcare spaces can boost morale and create a positive and inspiring atmosphere, ultimately reducing stress [49] and burnout [34] and improving satisfaction [64], wellness [80], activity [81], and perception [53] among staff. Furthermore, the projection of nature scenes (animations) on walls and ceilings improves staff satisfaction [52], and the presence of water features reduces stress [49].

Ergonomics and Comfort

In healthcare settings, prioritizing ergonomics and comfort for staff is essential for creating conducive work environments. Designing workspaces with ergonomic principles, such as adjustable desks and chairs, can significantly improve performance, efficiency, and perception [70] and reduce burnout [34] among staff members. Additionally, selecting comfortable and adjustable furniture supports good posture, reduces the risk of physical discomfort or injuries during long shifts, and improves satisfaction [84] and perception [31,53]. The incorporation of soft furnishings such as cushions and curtains further increases comfort levels, creating a warm and inviting atmosphere in staff areas and improving staff satisfaction [86] and perception [31,82].

Aesthetic and Visual Appeal

The aesthetic and visual appeal of healthcare settings are significantly influenced by elements such as flooring, carpeting, color schemes, and overall aesthetics. Comfortable and supportive flooring materials help reduce fatigue and minimize the risk of slips and falls, ensuring a safer environment for staff and improving satisfaction [44,78]. The use of calming colors and appealing design elements creates a welcoming and soothing atmosphere, which can positively impact staff satisfaction [78,84] and perception [53,82]. A visually appealing environment enhances the overall experience, making the workspace more enjoyable and uplifting for healthcare staff by improving satisfaction [54,84], performance [70,91], perception [62,70], and efficiency [70].

Navigation and Orientation

Effective wayfinding and signage are essential for navigation and orientation within healthcare facilities. Clear and strategically placed signs enable staff, patients, and visitors to easily find their way around, reducing confusion and stress. Well-designed wayfinding systems help minimize the time spent searching for specific locations, thereby enhancing satisfaction [37,47,54], performance [37], perception [82], and the overall workflow and safety within the healthcare environment.

While exploring research articles concerning interior design features, significant findings were obtained. Staff satisfaction emerged as a focal point, accounting for 30% of the research discourse. Within this realm, a significant proportion (44%) delved into the aesthetic and visual appeal of interior spaces, underscoring the importance placed on creating visually pleasing environments for staff. Staff perceptions, another critical aspect, were addressed in 23% of the articles, with a notable focus on spatial layout (38%) and design characteristics (31%). The efficiency of staff operations was also a key concern, as reflected in 42% of the articles focusing on ergonomics and comfort, followed closely by 33% on aesthetics and visual appeal. These findings highlight a multifaceted approach to understanding how interior design impacts staff experiences; emphasize the intersections between satisfaction, perceptions, and operational efficiency; and highlight the significance of aesthetics, spatial design, and ergonomic considerations in shaping these experiences within interior environments.

Delving deeper into interior design features studies, 31% of the articles examined aesthetics and visual appeal, indicating a continued interest in creating visually pleasing environments. Natural elements garnered attention in 29% of articles, highlighting the role of nature in enhancing staff experiences, while ergonomics remains significant at 25%, underlining the importance of designing spaces for comfort and well-being. These findings underscore the multifaceted nature of interior design features research, emphasizing the interplay between aesthetics, spatial design, natural elements, and ergonomic considerations in shaping staff satisfaction, perceptions, efficiency, and other outcomes within interior environments.

4.7.3. Ambient Features and Their Impacts

The ambient features were grouped into auditory environment, thermal comfort, lighting, air quality, and ventilation.

Table 9. Ambient design features and their impacts on staff outcomes.

Ambient Features	Staff Outcomes
	Satisfaction	Performance	Burnout	Perception	Communication	Efficiency	Privacy	Stress	Mood	Anxiety	Vigilance and Workplace Alertness	Wellness	Activity	Attrition	Absenteeism	Medical Errors	Comfort	Physiological and Psychological Response
Auditory environment	9	1	2	6	1	1		4		1			1
Author/year	[19,31,34,38,43,47,50,51,53,62,64,70,78,87,90]
Thermal comfort	4	3	1	4		2	1				1						2
Author/year	[17,31,34,43,47,53,59,70,77,84,85]
Lighting	13	6	1	9	2	2	1	4	2		1	1	1	1	1	1	1	1
Author/year	[17,22,23,31,34,38,43,45,47,50,52,53,56,59,65,70,77,79,80,82,84,85,88,90,95]
Air quality and ventilation	3	1		3			1										1
Author/year	[17,31,43,46,47,53,84,85]

shows the staff outcomes for ambient features studied by various authors, and Figure 7 shows the number of articles on the effects of ambient features on staff outcomes.

Auditory Environment

Ambient features are essential for creating a comfortable and efficient work environment. Integrating nature sounds or calming music into the auditory environment can help improve satisfaction [64], reduce stress, and improve focus, creating a more serene atmosphere for staff. Effective acoustic design in the healthcare setting impacts satisfaction [19,47,50,51,78,87,90], performance [70], perception [31,38,53,62,70,90], communication [90], efficiency [70], activity [38], comfort [47], burnout [19,34], stress [50,87,90], and anxiety [19].

Thermal Comfort

Thermal comfort is crucial for maintaining a comfortable work environment. Ensuring an optimal temperature is essential, as it prevents discomfort from excessive heat or cold, thereby enhancing staff satisfaction [47,53,84,85], performance [17,70], perception [31,53,70], efficiency [70], privacy [85], alertness [77], burnout [34], comfort [47], and productivity. Additionally, maintaining proper humidity levels is important for creating a comfortable atmosphere [47,70] as it reduces the risk of respiratory issues, contributes to a pleasant working environment, and improves efficiency and comfort.

Lighting

Lighting plays a pivotal role in creating an effective and pleasant work environment [96]. Access to natural daylight can significantly boost mood, energy levels, and overall well-being, which, in turn, leads to improved staff satisfaction [56,65,85,88], performance [17,22,70,88], communication [22], efficiency [56,70], privacy [85], mood [22,56], alertness [77], wellness [80], and activity [38] and reduced burnout [34], stress [56], attrition [23], absenteeism [23], and medical errors [23]. Additionally, adequate artificial lighting is essential for tasks that require precision, ensuring that staff can work efficiently even in areas with limited natural light, which can have an impact on satisfaction [45,47,50,52,65,68,79,84,90], performance [79,95], stress [50,52,90], and comfort [47]. Together, these lighting elements significantly contribute to making the workplace more satisfying.

Air Quality and Ventilation

In the healthcare context, air quality and ventilation are vital for maintaining a healthy and comfortable work environment. Good ventilation systems ensure a constant supply of fresh air, which reduces the risk of airborne infections and helps maintain the overall health of users. Additionally, maintaining high air quality is essential for creating a pleasant working atmosphere, which significantly contributes to staff satisfaction, performance [43,47,84,85], and comfort [47]. Together, these elements ensure a safe, healthy, and comfortable environment for healthcare staff.

While examining the impacts of ambient features on staff experiences, the research articles revealed a strong focus on various outcomes. Staff satisfaction was a major theme, representing 29% of the research, with a significant emphasis on lighting (45%) and the auditory environment (31%). Staff perceptions were addressed in 22% of the articles, with lighting, again, being a primary focus (41%), followed by the auditory environment (27%). Staff performance, although less extensive, at 11%, highlights the critical role of lighting (55%) and thermal comfort (27%). Overall, the ambient feature studies indicated that lighting was the most frequently explored aspect, accounting for 48% of the research, followed by the auditory environment (26%) and thermal comfort (18%). These findings underscore the paramount importance of lighting in shaping staff satisfaction, perceptions, and performance while also highlighting the significant roles of auditory and thermal environments in creating optimal working conditions.

4.8. Overall Impact of the Physical Environment on Staff Outcomes

The findings of research articles shortlisted for this study highlight the varying emphasis placed on various physical environmental features concerning staff outcomes. Architectural design features received the most attention, with 52% of studies focusing on how these features impact staff experiences and outcomes. Ambient features, accounting for 32% of the research, highlight the importance of elements such as lighting, the auditory environment, and thermal comfort in shaping staff satisfaction, perceptions, and performance. Interior design features were the least studied in this context, comprising 16% of the research, indicating a smaller but still significant interest in aspects such as aesthetics, visual appeal, and ergonomics. These proportions reflect the critical role of spatial and environmental design in influencing staff well-being and efficiency, highlighting areas of greater research concentration and potential gaps for future exploration.

4.9. Theories, Models, and Frameworks

There were a few requirements that needed to be met to qualify the use of relevant theories. Theories used to emphasize the findings of a study have to be supported by appropriate references. Seven existing theories (attention restoration theory, stress reduction theory, space syntax theory, systems theory, person–environment fit theory, emotional congruence theory, and organizational theory), two new theories through inductive analysis (grounded theories), and three conceptual frameworks (organizational ecology, the environmental comfort model, the Donabedian model, the naturalistic model, and the new care model) were relevant and were used in the review articles. Most of the theories used are from the domain of environmental psychology and examine the relationship between humans and their environment. The studies also included multidisciplinary approaches to examine individual behavioral responses as well as motives. Only a few of the review studies focused on developing theoretical propositions by inductive analysis of participant data, as opposed to using pre-existing theoretical frameworks. Using “structure”, “process”, and “outcomes”, the conceptual Donabedian model offered a framework for reviewing health facilities and assessing the quality of healthcare.

Table 10. Theories identified in this review.

Authors	Theory/Model
[64]	Attention restoration theory (ART)
[34]	Attention restoration theory and stress reduction theory
[74]	Becker and Parsons’s (2007) organizational ecology Vischer’s (2007, 2008) environmental comfort model of workspace quality
[39]	Space syntax theory
[75]	Systems theory
[57]	Grounded theory
[59,89]	Person–environment fit theory (Person–environment (P-E) congruence model)
[61,83]	New care model
[81]	Emotional congruence theory
[82]	Organization theory

lists the authors of the review articles and the theories or models they employed for the studies.

5. Study Implications

This article consolidated findings from diverse geographical locations encompassing a wide range of physical environment factors, staff outcomes, theoretical applications, data collection techniques, etc. Although the researchers shared a common goal, i.e., to investigate the impact of physical environmental features on staff, most studies failed to identify the important features and levels at which these features have favorable and unfavorable effects on staff.

The majority of studies focused exclusively on outcomes among nurses (26 studies) in hospitals. The sample sizes ranged from 12 to 1561 staff. Few studies with multisite cross-sectional designs included large sample sizes. However, some studies with good study designs had relatively small sample sizes, limiting their generalizability. Most of the studies adopted non-random sampling (n = 31), while 29 did not report the sampling techniques adopted.

Our study revealed that only a few theories and conceptual frameworks (n = 10) were explicitly used in the review articles. The identified theories were from the field of environmental psychology and organizational behavior. Most of the studies did not mention or use any of the theories. It is crucial to employ theories when formulating research questions because they might affect the environmental characteristics that are analyzed and the connections between these characteristics and behavioral responses that are investigated. Theories are frequently employed to formulate research questions, devise research methodologies, and/or attempt to interpret results.

This review revealed the need to develop a comprehensive study involving the most important features of the three dimensions of the physical setting and to study the effects of these features on staff. The use of theories that explain the relationships between various constructs is of paramount importance in research.

Table 11. Research gaps and directions for future research.

Shortages in Reviewed Articles	Research Gap Characteristics	Future Directions
The studies having a complex relationship between the environment and humans lacked empirical testing. Few studies used a dichotomous scale (yes versus no) while investigating the impacts of physical environmental features.	Evaluation gap	More empirical investigations by combining different techniques are needed. Multidimensional scaling techniques to understand the complex relationship between environmental variables and their impacts must be included in the research.
The studies conducted to date provided no holistic solution for how the healthcare physical environment favorably affects staff. There were fewer studies from developing countries, as the majority of the previous studies were conducted in the United States. Generalizability was lacking. The majority of the studies also lacked how much the physical environmental features affected the various outcomes in healthcare professionals (efficiency, satisfaction, performance, productivity, etc.) The existing studies failed to include social, cultural, and behavioral considerations while studying the impact of the healthcare environment on its employees.	Knowledge void	Rigorous studies need to be conducted to identify the most important environmental features in the healthcare setting that have positive and negative outcomes among staff. This will help to strengthen evaluation methods by developing measurement instruments that describe different features of the physical environment. Social, cultural, and demographic variables should be included while investigating the impact of the environment on staff.
Theoretical application was absent in the majority of the studies. Most of the researchers did not show concern in applying environmental psychology theories, such as social learning theory (which promotes awareness of ingrained society standards); control theory (which discusses behavioral restrictions and how much control a person feels they have over their actions and behaviors); the theory of affordances (which provides an instantly recognizable function of environmental features); the preference model (positing that humans prefer engaging scenes to boring scenes); the pleasure–arousal–dominance hypothesis (positing that these three emotional responses translate into positive feelings); the behavior setting theory (positing that settings evoke particular patterns of behavior); and the biophilia hypothesis (positing that humans prefer being surrounded by nature).	Theoretical application void	The application of theories in studies about the healthcare environment has to be given more attention. It is crucial to use theories when posing research questions because theories can influence which environmental variables are addressed and which relationships between these elements and the behavioral responses of humans are examined. Researchers should describe theoretical constructs or conceptual structures and the relationships between physical environmental features based on these constructs or structures and link them to staff outcomes.
Even though there were a large number of mixed-method studies, the quantitative studies were equally large in number, and there were fewer qualitative studies. This implies that most studies did not consider both qualitative and quantitative methods, as the mixed method is a good approach to fully explore the research question. Most studies utilized only one research technique to study the effects.	Methodological void	Research problems and complicated phenomena can be better understood by combining qualitative and quantitative methodologies than by using just one of them. Future researchers should focus on utilizing both qualitative and quantitative tools.
The majority of earlier studies had study participants as nurses, implying a lack of studies on other healthcare professionals like physicians, technicians, and non-clinical staff.	Population void	A study on all healthcare professionals is required as they are exposed to a similar environment in healthcare settings.

shows the shortages in the reviewed articles and the possible directions for future research.

6. Conclusions

To obtain insights into the impact of the physical environment on staff in healthcare settings, the research questions were defined, gaps were identified in the literature, and systematic directions were provided for prospective researchers. The results also suggest the need to include the social, cultural, and demographic information of staff while examining the impact of the physical setting on staff. The authors believe that this article offers helpful information about the state of the current literature on healthcare staff outcomes, which is critical because healthcare professionals are crucial in the healthcare service industry, as satisfied employees are more loyal to organizations and experience greater patient satisfaction. This review contributes to the literature by identifying the physical environmental variables in a healthcare setting. These variables were categorized based on the three dimensions of the physical environment, i.e., architectural design, interior design, and ambient elements. This study highlights that a comprehensive model needs to be developed to include important physical and environmental features to study their impacts on staff. The study also revealed important outcomes among staff in healthcare settings. These included a wide range of outcomes among staff. Among all the outcomes, staff satisfaction was the most investigated.

Future research should focus on several key areas to gain comprehensive insights into their impacts on staff outcomes. In architectural design, the effects of biophilic elements, flexible spaces, and integrating design characteristics into spatial layouts and connections need further exploration to better understand their impacts on staff and the interactions with patients and coworkers. Longitudinal studies should assess the long-term benefits of natural integration, while simulation models can be used to replicate and analyze real-world systems to understand the behavior and predict outcomes. In interior design, the influence of ergonomic furniture, color schemes, and material choices requires more investigation. Ergonomic assessments using tools like posture analysis and user feedback; experimental designs on color psychology to explore how various color schemes and psychometric testing determine beneficial colors; and comparative studies on materials to guide material selection will provide valuable insights into enhancing the physical environment. Ambient design research should examine the effects of lighting, acoustics, and thermal comfort. Controlled experiments on lighting systems can explore the effects of various lighting conditions, such as natural versus artificial light. Sound mapping, which involves creating acoustic profiles of different environments, should be conducted to help understand the impact of noise levels. Cross-sectional studies in different climatic conditions can provide insights into how temperature, humidity, and airflow affect occupant comfort. By addressing these areas with clear and actionable recommendations, future research can enhance evidence-based design practices and optimize built environments for improved staff outcomes.

The findings presented encourage the development of future investigations that can aid healthcare designers, hospital administrators, and designers in providing better design recommendations for healthcare settings. Furthermore, this study provides insights into the administrative aspects of healthcare facilities, with an emphasis on the well-being of workplace staff. It examined factors influencing satisfaction, productivity, performance, etc., and offers avenues for improvement in healthcare facility administration. The results serve as a basis for establishing policies and procedures to increase stakeholder satisfaction, optimize operational efficiency, and improve overall care.

This study investigated the theoretical implications of the review articles by providing insights into theoretical frameworks that strengthen the understanding of how the physical environment influences staff outcomes. Only a few articles used theories when presenting the rationale for research on the physical environment in healthcare. This review emphasizes that future researchers should explicitly use theories as they can powerfully influence how evidence is collected, analyzed, understood, and used.

This research focused on addressing specific research questions. Despite our best efforts, the sheer volume of articles may have prevented the literature search from capturing all pertinent studies. Nevertheless, this review contributes new insights to the knowledge on healthcare design. The gaps identified in this study will permit future researchers to undertake additional studies and provide design recommendations for staff workplaces in healthcare settings for overall well-being.

A few limitations of this study are that this review did not report contextual factors, such as organizational culture and management practices, which could significantly influence staff outcomes. Another limitation of this study is the lack of quantitative synthesis. While qualitative synthesis provides valuable insights, it does not offer the same level of statistical rigor that a meta-analysis would.