An appraisal of the appropriateness of physical environment in organized inpatient stroke care units in southern Sri Lanka.

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Pathirana V.D, Wijesundara J, Pathirana K.D, De Zoysa W, Vidanagamage A This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8806898/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The impact of hospital building design on the health and well-being of individuals, especially in the context of stroke care in Sri Lanka, remains an underexplored area, despite the high prevalence of stroke in the country. It is identified that the absence of appropriately designed stroke units is contributing to a delay in the recovery of stroke. The study seeks to evaluate the existing stroke care units in the Southern Province of the island, highlighting its high population and limited specialized stroke care facilities. This study assesses whether these units adhere to specific design guidelines. Methods The research involves a descriptive cross-sectional study, semi-structured interviews, and an open-ended questionnaire to assess seven design elements from existing literature. Medical officers, consultants, physiotherapists, occupational therapists, and speech therapists who possessed experience and expertise in the rehabilitation field within the hospital were interviewed. Seven individuals were interviewed from each unit at a minimum. Staff feedback was also obtained through an open-ended questionnaire distributed to 20 individuals from each unit including nurses and other supportive staff. Results Existing healthcare units exhibit strengths like co-located staff spaces and weaknesses with inadequate outdoor access, bed spacing, distance of therapy spaces, and disabled access. However, the main problem observed is the need for more planning for these units, as many are repurposed from existing hospital areas without being specialized for stroke care. The staff provided feedback on each case, with extensive expertise in stroke care. Conclusion This study offers insights to architects to develop building guidelines for stroke care in state hospitals, given their widespread utilization, especially by individuals relying on economically viable healthcare services. Architecture, Design and Planning Neurology stroke units stroke prevalence healthcare design guidelines stroke care environments Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Healthcare settings are crucial in fostering sustainable communities [ 1 ]. It is also found that emphasizing the profound impact of healthcare facility design on patient and staff behaviour influences health, well-being, clinical efficiency, and health-related outcomes. Realizing this interaction underscores the importance of carefully planning healthcare environments, promoting long-term benefits for patients and healthcare professionals, and supporting community sustainability. Recent studies on stroke treatment emphasize that hospital design plays a crucial role in influencing essential aspects of patient care. Defined by the World Health Organization [ 2 ] as a brain attack, stroke stands out as a leading global cause of disability and the second leading cause of death. Notably, data from 2022 reveals a concerning 50% increase in the lifetime risk of experiencing a stroke over the last 17 years, estimating that one in four individuals may undergo a stroke in their lifetime [ 2 ]. This escalating risk is particularly pronounced in the Southeast Asia Region (SEAR), which bears nearly half of the developing world's burden of stroke cases [ 3 ]. Sri Lanka, a population of over 22 million faces a high crude stroke prevalence of 10.4 per 1000 individuals, resulting in 200,000 stroke patients [ 4 ]. Annually, over 60,000 stroke patients are admitted to state sector hospitals, with around 4,000 in-hospital deaths [ 5 ]. Additionally, the study has noted that strokes account for 10% of hospital fatalities in Sri Lanka, positioning the country among those with the highest occurrences of strokes. Consequently, the focus on stroke prevention is gaining prominence in the country [ 6 ]. Building design guidelines and clinical practice guidelines are identified as crucial factors in stroke prevention [ 7 , 8 ]. Despite the increasing focus on stroke prevention in Sri Lanka, stroke care faces challenges, including a slow pace and insufficient organized stroke care facilities [ 9 ]. The study has shown that even at hospitals with stroke units, the majority of stroke patients are admitted to general medical wards due to a lack of stroke beds. Many of these patients may be prematurely sent to their homes and may turn to complementary or alternative medicine [ 10 ]. The lack of proper treatment at home, as required, results in a worsening of disabilities for stroke patients. Moreover, stroke is the leading cause of home death in Sri Lanka [ 11 ]. Even though the number of stroke units in the region has increased, units equipped to provide acute care remain limited, with fewer than 100 available stroke beds nationwide [ 3 ]. It is identified that the current absence of organized stroke care facilities in most hospitals poses a significant challenge in Sri Lanka. Even though the healthcare sector is growing, stroke has a limited environmental evidence base. The studies rarely address specifically built environments. The clinical guidelines for stroke care currently lack specific references to the built environment and fail to provide recommendations on how the physical surroundings can optimally facilitate patient care [ 12 ]. Currently, there is a lack of comprehensive review of the physical environment of stroke units, particularly in Sri Lanka [ 5 ]. Therefore, more research needs to be done on the essentials necessary in the physical environment of stroke unit designs. Research Questions Has the design of the stroke units been designed to facilitate efficient staff assistance while allowing patients to independently engage in daily activities and adapt to their new life after a stroke? Are the current stroke units designed according to the special design requirement, and to what extent is each design element in each case used? What insights are gained regarding the strengths and weaknesses of design principles in stroke care facilities? How satisfied will the staff be, on behalf of stroke patients, with the design and current facilities provided in their stroke unit? Research Objectives The main objective is to identify the special design requirements specific to the stroke care environment and to assess the physical surroundings of stroke units. Hospitals in the Southern province of Sri Lanka are considered as samples. To achieve the above main objective, the following Specific Objectives are suggested. To compare the extent to which the stroke units have responded to the special design requirements. To investigate whether the stroke units have been designed to address the convenience of patients as well as the staff. In this study, only the design-related factors of functioning stroke units in Southern Province will be observed. Only healthcare workers within the stroke unit are included in this study, while other staff members within the stroke unit will be excluded. Materials and Methods The selection of suitable sampling methods is essential for accurately representing the research problem, a principle that forms the core of the research design in this study [ 13 , 14 ]. The focus is on three case studies within the southern province, one of the top three most populous provinces that lacks a specialized stroke unit will be observed in this study [ 15 ]. An in-depth examination of the physical environments within stroke care settings will be carried out in this study to identify necessary areas for improvement. The selected hospitals include Teaching Hospital Karapitiya, District General Hospital Matara, and General Hospital Hambantota. The primary focus will be on investigating and utilizing factors based on seven design elements identified in the literature. Collecting information from stroke units involves considering various parameters, including their location and type, which may focus on acute care, rehabilitation, or a combination of stroke and internal medicine. Further observations encompass aspects such as bed allocation, room layout, and rehabilitation space availability. Evaluation of ward layout involves analyzing floor plans, circulation spaces, staff-patient proximity, and amenities placement while also assessing environmental factors like light, noise, and ventilation. The presence of communal spaces and access to natural elements, recreational activities, and enrichment features are also examined to gauge overall environmental quality. Observing patients' behaviour closely within the ward without disrupting their treatments constitutes data collection. The methodology utilized in this study involved employing a semi-structured interview and an open-ended questionnaire (the questionnaire is available in ‘Supplementary Material S1’) based on seven design elements identified in the literature. Feedback regarding the current unit was obtained from staff members, as they possess extensive knowledge about the services that truly need enhancement in the stroke units. Seven individuals were interviewed from each unit at a minimum. Staff feedback was also obtained through an open-ended questionnaire distributed to 20 individuals from each unit, including nurses and other supportive staff. These interviews and questionnaires were focused on evaluating the existing facilities of stroke care environments, identifying the strengths and weaknesses of each unit, and exploring potential enhancements in designing stroke units from admission to the discharge process. The interview guides were developed based on a thorough literature review and in collaboration with the clinical staff currently working on each case study. Additionally, interviews were conducted regarding inpatient stroke patients, stroke survivors, and carers. This methodological approach aimed to encompass the perspective of the physical environment throughout the rehabilitation process from various viewpoints. Descriptive statistics, including frequency and percentages, were employed to analyze the gathered data. Respondents were allowed to offer in-depth descriptions, which were utilized to clarify the quantitative results that ultimately led to the formulation of conclusions. The seven key design elements emphasized in the evidence regarding stroke care environments are from the published research articles sourced from systematic literature reviews and the Centre for Healthcare Design research repository [ 12 ]. Table 1 categorizes the seven design elements based on their practicality within the Sri Lankan context. These elements serve as a comprehensive framework for assessing and enhancing the overall design of stroke care facilities. Table 1 Seven design elements specific to stroke care environments [ 12 ]. Seven Design Elements Description Co-location of staff spaces Proximity to patient areas, visibility, and supervision. Outdoor spaces Accessibility to outdoor spaces, presence of plants, scenic views, and paintings with natural motifs in the stroke unit. Number of beds in the patient room The number of beds dedicated to stroke patients, the distance between beds, space efficiency (check whether the bed does not obstruct movement and access to other essential areas), and patient privacy. Adjacency and suitable therapy spaces Whether there is space for rehabilitation in or in direct relation to the unit. Adequate light & ventilation, therapeutic ambiance (wall colour, etc.), accessibility, functional layout, furniture, and equipment arrangement. Versatility of spaces in multipurpose circulation spaces (corridors) Accessibility and clear pathways, lighting, and safety features like handrails, etc. Communal spaces for patients/ visitors (indoor) Availability of indoor and outdoor communal areas to patients. Shared staff spaces are crucial for effective communication and teamwork among diverse health professionals [ 16 , 17 ]. They argue that separating clinical and therapy spaces can increase staff travel time and impact clinical decision-making, unlike therapy spaces which lack holistic environments. Healthcare workers frequently use corridors for informal encounters, essential for exchanging information and socializing [ 18 ]. Exposure to outdoor environments is linked to stress reduction and improved well-being [ 12 ]. It is proven that hospital gardens, often overlooked by patients and visitors, provide exercise, exploration, and socialization opportunities. Outdoor spaces also serve as restorative environments for healthcare staff, reducing stress and enhancing attention. Evaluating the ratio of single rooms to multiple-bed rooms is critical in ward design. While single rooms offer advantages in infection control, the impact on falls and social connections should be considered, balancing privacy and accessibility [ 19 ]. Designing therapy spaces for stroke patients is crucial, as is optimizing rehabilitation through adequate space, specialized equipment, a holistic approach, and elements like natural light [ 12 , 20 ]. A welcoming ambiance contributes to the overall well-being of stroke patients, fostering a conducive environment for their rehabilitation and recovery. The proximity of therapy spaces and wards is critical for efficient stroke care, minimizing patient travel and optimizing time for therapeutic activities [ 21 ]. This study also reveals that placing therapy spaces adjacent to the ward fosters a collaborative environment, enhancing communication and coordination of care. Multipurpose circulation areas, like corridors, should prioritize accessibility and safety for stroke patients. Incorporating seating areas, therapeutic elements, and flexible layouts contributes to a patient-centered environment, promoting functionality and a positive atmosphere [ 22 ]. Indoor communal spaces for stroke patients should be thoughtfully designed, prioritizing accessibility and inclusivity [ 23 ]. Comfortable seating arrangements, diverse amenities, and designated meeting places encourage socialization and emotional support among stroke patients and visitors. Results The study has chosen three hospitals within the Southern Province that offer treatments for stroke patients as follows. National Hospital Karapitiya, District General Hospital Matara and District General Hospital Hambantota. (To maintain privacy, the names of the hospitals will not be disclosed in each study and will instead be described as separate case studies, as outlined below.) Case Study 1: The proposal aimed to create a national stroke unit in Mulleriyawa alongside nine provincial stroke units throughout Sri Lanka, with case study 1 being among them. The unit includes areas for staff, therapy, clinics, the High Dependency Unit (HDU), discussion, and dining, in addition to the ward. The proposed staff comprises 21 nurses with three doctors, three consultants, six junior health staff members, one speech therapist, two physiotherapists, and one occupational therapist. Case Study 2: The stroke unit was initially established following the introduction of thrombolytic therapy, prompting the need for a dedicated stroke unit with comprehensive therapy services. This unit, equipped with either three or occasionally two beds, was primarily designated for stroke patients but also accommodated other neurology patients when stroke cases were lacking. It's worth noting that this unit is not fully independent and is managed by the same staff, underscoring the need for more specialized stroke care infrastructure. The unit features areas for staff, therapy, and the ward. The staff includes ten nurses, six doctors, one consultant, seven junior health staff members, one speech therapist, one occupational therapist, and one physiotherapist. Case study 3 - Due to the absence of allocated spaces the neurology unit was shared with the dermatology unit. Specifically, three beds were allocated for the neurology unit in both the male and female wards. The unit includes spaces for staff, dining, changing, therapy, isolation and storage in addition to the ward. The staff comprises eight nurses, three doctors, one consultant, five supporting health staff members, three speech therapists, four occupational therapists, and three physiotherapists. Case Study 1 The design of key spaces within the layout was structured around various functional areas, including therapy units, discussion areas, wards, toilets, clinic rooms, staff areas, and an HDU. (Fig. 1 ) The stroke unit has specialized areas for HDU and separate sections for male and female stroke patients. A notable feature of this layout is the positioning of the nurse station directly facing the HDU, necessitating close attention and direct supervision by healthcare staff. Additionally, the design includes a dedicated room for staff discussions and decision-making on patient care, distinguishing it from other stroke unit designs. Insufficient bed spacing and beds positioned facing a half-partition wall restrict certain patients from fully enjoying the outdoor views. One notable drawback of the stroke unit design is the absence of separate visitor areas. The arrangement of beds lacks proper access from either side, affecting the ease of patient care. Patients are categorized based on their condition, a beneficial organizational strategy. Toilets are conveniently attached to the unit, with disabled access and ample natural light and ventilation, contributing to patient comfort and convenience. On a positive note, the unit includes separate clinic rooms, enhancing privacy and specialized care delivery. The physiotherapy unit in the stroke facility features a notably spacious layout, yet it is divided into separate rooms for staff and patient use. A positive aspect highlighted is the provision of distinct rooms for speech therapy to conduct one-to-one sessions without disturbing others. There's a suggestion to relocate the clinic rooms closer to the floor entrance, where the speech therapy units are currently located. Notably, the plan does not allocate space for an occupational therapy area; however, it's mentioned that this will be accommodated once the unit is open to the public, indicating a flexible approach to space allocation. Additionally, the therapy spaces are designed with disabled access, ensuring inclusivity and ease of use for all patients. The placement of the lift in the corner of the floor presents a challenge when maneuvering wheelchairs or stretchers. However, the corridor width is adequate, providing enough space for movement. Despite this, there is a lack of grab bars along the corridor, which would greatly assist disabled individuals in navigating the space more easily. A significant advantage of the design is that all units, including therapy spaces, are situated on the same floor. Having all essential units nearby enhances efficiency and convenience for both patients and staff, promoting better coordination of services. A communal area for stroke patients to socialize has not been included in the design. However, there is a dedicated dining area for patients even though it is not spacious. This design for the stroke unit incorporates nearly all essential spaces required for patient care, with notable exceptions being a communal space, an occupational therapy room, and designated outdoor areas. Case Study 2 Significant areas within the unit include the ward, stroke unit, staff rooms, toilets, and therapy spaces. (Fig. 2 ) The stroke unit was repurposed in a free room without being designed specifically for stroke care as a result, all male and female patients share a confined three-bedroom space. The nurse station is notably distant from the stroke unit but closer to the general medical ward, leading to emergency treatment patients being admitted there. Long-term rehabilitation patients, on the other hand, are admitted to the stroke unit. There is a lack of distinct staff discussion areas unlike in the previous case study. The stroke unit has an insufficient number of beds with proper bed spacing. This is reflected in the admission of stroke patients to general medical wards under staff observation due to insufficient beds in the specific unit. The beds are placed in proximity to the wall, limiting staff observation of the affected side of patients and potentially slowing down recovery. Windows of smaller heights are present but face corridors without providing outdoor views. However, natural plants and fish tanks are placed in corridor-free spaces. Despite these elements, the ward's congestion may hinder its calming effects on patients. Calm music is played to aid in relaxation. This unit lacks a designated visitor area. Toilets are attached to the stroke unit but not tailored to accommodate disabled individuals, featuring entryways with steps in certain instances. There is a lack of a distinct clinic space set aside for stroke patients unlike in case study 1. The therapy spaces are well-equipped to accommodate essential therapy sessions. However, the lack of disabled access restricts bedbound patients from accessing crucial physiotherapy sessions within the therapy unit. Hence, some therapy sessions are being conducted in the corridor. The occupational therapy unit is located near the stroke unit, while the physiotherapy unit is positioned at a considerable distance. The speech therapy unit is located one floor below the stroke unit, making access to speech therapy sessions challenging. The corridor width is adequate but often blocked by unnecessary furniture, hindering circulation. Stretcher and wheelchair placements further impede circulation, along with garbage bins that may raise hygiene concerns. Crash bars are missing in corridors, and lift malfunctions occasionally, necessitating patient transport through staircases, which are also insufficiently wide. No communal space was designed specifically for stroke patients. Patients are forced to have meals and wash their hands in corridor sinks due to space constraints within the ward. Although tables are available for dining, they are also positioned within the congested corridor. Since every design element in this case study was improperly considered in developing these components are essential for renovating or designing a new stroke unit. Case Study 3 The unit includes wards, staff areas, an isolation room, a dining area, toilets, and a storeroom, as depicted in the plan below. (Fig. 3 ) Patient wards are divided into male and female sections as in case study 1. Nurse stations, along with other staff areas, are strategically positioned directly in front of the ward, enabling convenient observation. However, there is a lack of discussion areas for staff to make crucial decisions on patients. The bed arrangement poses a risk of spreading infections between different patient groups. Each ward bed is spaced approximately 450 mm apart, insufficient for conducting therapy sessions or accommodating bystanders between beds. The bedside table further obstructs these gaps, hindering mobility and access to therapy sessions. Patients lying in beds face difficulties in seeing outdoor views due to the height of the bed. However, when patients are seated, they can access outdoor views. Natural plants are not incorporated into the design, further limiting connections with outdoor environments. There is no designated visitor area, and seating has been arranged by utilizing space from the corridor. Single-accessible bathrooms and separate changing rooms are provided for patients to practice daily activities independently, such as buttoning up a shirt with the affected side. This setup offers privacy, allowing patients to learn without feeling embarrassed in front of others. However, the shared washroom with other patients lacks infection control measures, posing further risks. This unit lacks dedicated clinic rooms specifically designed for stroke patients. The therapy space, located eight floors below the ward, presents challenges in moving patients to the therapy unit, especially considering the limited size of the lift. Additionally, the basement-level therapy space lacks proper light, ventilation, and mobilization space. The therapy units are not adjacent to the ward, complicating patient transfers and coordination between units. Corridor widths are less than 5 ft and often blocked by visitor chairs, obstructing the movement of wheelchairs and stretchers. The circulation space is insufficient, affecting overall accessibility within the ward and therapy areas. The ward includes a separate dining area for socialization, but due to infection concerns, stroke patients avoid using it and opt to have meals in bed. However, there is no additional communal space available for patients to socialize. Discussion The majority of the staff members are pleased with the therapy spaces provided, as evidenced by the high satisfaction rate. In contrast to the first case study which lacks an occupational therapy unit, the other case studies generally have well-equipped therapy spaces, although they lack disabled access. Similarly, staff satisfaction is high regarding the co-location of staff spaces and the number of beds in patient rooms, with most cases adequately addressing these aspects. However, staff satisfaction is lower concerning circulation spaces and the adjacency of therapy spaces in the ward, which are often not well-designed. Notably, communal spaces and outdoor areas are the least satisfactory design elements according to the study, with most staff members expressing dissatisfaction in these areas. The relationship between activities and locations has been identified and mapped for a typical stroke unit in Australia [ 24 ]. Accordingly, the care process map in the southern province of Sri Lanka exhibits some differences, from a well-designed stroke unit which often lacks lounge and outdoor areas. (Fig. 4 ) Apart from the seven design elements outlined in the study, additional factors were discovered to influence the stroke care environment. These supplementary design elements like wayfinding elements [ 25 ] and sanitary facilities play a crucial role in enhancing the overall quality of care. Recommendation This study is crucial as Sri Lanka currently lacks centralized monitoring or standardization for stroke unit design. The findings of the study revealed significant disparities and variations in the design and layout of stroke units across different healthcare facilities in Sri Lanka. It was surprising to note instances where stroke units were combined with other units, such as dermatology, potentially compromising the specialized care required for stroke patients. This amalgamation, possibly due to resource constraints, indicates a broader issue within the healthcare system. Additionally, the research emphasized the vital role of accessibility, infection control measures, outdoor accessibility and communal areas in promoting social interactions and aiding recovery post-stroke. In many cases well-equipped therapy spaces are provided. Similarly, the co-location of staff spaces and the number of beds in patient rooms are also adequately addressed in most cases. However, in many cases, the design of therapy units and other essential spaces like circulation spaces and sanitary facilities did not consider the needs of disabled individuals. Furthermore, the arrangement of furniture frequently obstructed pathways, creating difficulties with accessibility. Prioritizing such patients' care is essential to make sure staff areas are situated close to the unit for convenient patient observation. Similarly, therapy units should also be placed close by as well since most of them are located on various floors making it challenging for both staff and patients. In order to improve patient outcomes and healthcare quality in Sri Lanka, comprehensive national standards covering every aspect of stroke unit design must be developed going ahead. These standards would enable medical practitioners to make informed decisions. Conclusion The construction of healthcare facilities poses considerable challenges due to their complexity and high costs. Designing hospitals that meet user needs, enhance patient experiences, and consider economic factors is crucial. In Sri Lanka, these challenges are compounded by significant deficiencies in stroke care infrastructure, as recent studies have shown. Establishing dedicated stroke units within state hospitals, particularly in underserved regions like the Southern Province, is urgently needed to improve outcomes and relieve strain on general medical wards. Many existing healthcare units have certain strengths and weaknesses. While co-located staff spaces facilitate regular observation, outdoor spaces are often underutilized due to limited direct access. The adequacy of beds is generally met, but spacing between beds is often insufficient. Additionally, the proximity of therapy spaces to each other is not always considered, impacting operational efficiency. Despite these challenges, most units boast well-equipped therapy facilities, although disabled access remains a concern. Communal spaces, when well-designed, enhance social interaction among patients and staff, but this aspect is lacking in some units. The prevalent issue noted is the lack of prior planning for these units, with many being repurposed from existing hospital spaces. This can significantly impact patient recovery outcomes. In addressing these challenges, it's essential to plan and design healthcare facilities more effectively. Despite economic challenges, creating new stroke units is a significant hurdle, particularly in a developing country like Sri Lanka. However, this research offers strategies to improve stroke care environments without building new units. Enhancing stroke care in government hospitals, especially those providing free healthcare, is crucial for public health. Architects have a social responsibility to design stroke units based on specialized guidelines to positively impact patient recovery. Collaborating with staff before designing the unit proves more effective than making post-construction changes based on their advice. Addressing infrastructure deficiencies and optimizing resources within existing hospital spaces are crucial steps toward better patient outcomes and healthcare quality in Sri Lanka. This effort not only enhances patient care but also fulfills a social responsibility for societal well-being. Scope and Limitations Only the design-related factors of functioning stroke units in Southern Province, one of the top three most populous provinces that lacks a specialized stroke unit, will be observed in this study. Moreover, only healthcare workers in the stroke unit are included in this study, while other staff members within the stroke unit will be excluded. Author Contribution statement (CRediT) Viduni Dedduwa Pathirana data collection, wrote the original draft, performed the data analysis, and drafted the initial manuscript. Jeeva Wijesundara made the format of the analysis and methodology and supervised the overall research while editing and reviewing the manuscript. Kithsiri Dedduwa Pathirana provided subject-matter expertise and conceptualized and designed the study. He has also provided overall supervision and critically reviewed and edited the initial manuscript. Warsha De Zoysa the supervisor to get ethical clearance. She has also reviewed and edited the manuscript. Anomali Vidanagamage provided subject-matter expertise and reviewed the manuscript. All authors reviewed and approved the final version of this manuscript and accept responsibility for its content. Declarations Author Contribution statement (CRediT) Viduni Dedduwa Pathirana: data collection, wrote the original draft, performed the data analysis, and drafted the initial manuscript. Jeeva Wijesundara: made the format of the analysis and methodology and supervised the overall research while editing and reviewing the manuscript. Kithsiri Dedduwa Pathirana: provided subject-matter expertise and conceptualized and designed the study. He has also provided overall supervision and critically reviewed and edited the initial manuscript. Warsha De Zoysa: the supervisor to get ethical clearance. She has also reviewed and edited the manuscript. Anomali Vidanagamage: provided subject-matter expertise and reviewed the manuscript. All authors reviewed and approved the final version of this manuscript and accept responsibility for its content. Funding This research was carried out without external funding. Institutional Review Board Statement: Ethical approval was granted by the ethics review committee, Teaching Hospital Karapitiya, Galle, Sri Lanka. (Ref No: THK / ERC/24/06, approval date 04.04.2024) All procedures adhered to the ethical standards of the institutional research committee and the principles outlined in the Declaration of Helsinki (revised 2013). Informed Consent Statement Written informed consent was obtained from every participant prior to participation in this study. Data Availability Statement Data available upon reasonable request due to privacy and ethical restrictions. Acknowledgement The authors would like to thank all participants and the relevant approving authorities for their time and effort in conducting this study. Conflict of Interest The authors declare no conflict of interest. References Reiling J, Hughes R, Murphy M The Impact of Facility Design on Patient Safety. [online].2008. https://www.ncbi.nlm.nih.gov/books/NBK2633/ (accessed 4 April 2024). World Health Organisation. 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Scand J Caring Sci. https://DOI:org/10.1111/scs.13112 Juan S, Lipson R, White M et al Stroke Inpatient Rehabilitation Environments; Aligning Building Construction and Clinical Practice Guidelines Through Care Process Mapping. 10.1161/strokeaha.123.044216 Kevdzija M Everything looks the same, wayfinding behaviour and experiences of stroke inpatients in rehabilitation clinics. 10.1080/17482631.2022.2087273 Additional Declarations The authors declare no competing interests. Supplementary Files SupplementaryMaterialS1.pdf Questionnaire Administered to the Study Participants Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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V.D","email":"data:image/png;base64,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","orcid":"https://orcid.org/0009-0008-4273-4447","institution":"Liverpool School of Art and Creative Industries, Liverpool John Moores University, Liverpool, United Kingdom","correspondingAuthor":true,"prefix":"","firstName":"Pathirana","middleName":"","lastName":"V.D","suffix":""},{"id":586973622,"identity":"2182049a-5fd5-42b5-92e9-b09e5ab3584e","order_by":1,"name":"Wijesundara J","email":"","orcid":"https://orcid.org/0009-0000-4082-9516","institution":"School of Architecture, Sri Lanka Institute of Information Technology, Colombo, Sri Lanka","correspondingAuthor":false,"prefix":"","firstName":"Wijesundara","middleName":"","lastName":"J","suffix":""},{"id":586973623,"identity":"d1493f2e-75b7-40f0-b0ed-cac596606e57","order_by":2,"name":"Pathirana K.D","email":"","orcid":"https://orcid.org/0000-0002-2298-2266","institution":"Department of Medicine, University of Ruhuna, Galle, Sri Lanka","correspondingAuthor":false,"prefix":"","firstName":"Pathirana","middleName":"","lastName":"K.D","suffix":""},{"id":586973624,"identity":"4b0a14e0-c917-4d64-8c88-9791d43ad924","order_by":3,"name":"De Zoysa W","email":"","orcid":"https://orcid.org/0000-0002-6209-9806","institution":"Department of Medicine, University of Ruhuna, Galle, Sri Lanka","correspondingAuthor":false,"prefix":"","firstName":"De","middleName":"Zoysa","lastName":"W","suffix":""},{"id":586973625,"identity":"2d4aca96-b961-4e0d-9a02-b66edb735313","order_by":4,"name":"Vidanagamage A","email":"","orcid":"https://orcid.org/0000-0002-3898-8419","institution":"Department of Neurology, District General Hospital Hambantota, Hambantota, Sri Lanka","correspondingAuthor":false,"prefix":"","firstName":"Vidanagamage","middleName":"","lastName":"A","suffix":""}],"badges":[],"createdAt":"2026-02-06 12:10:56","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-8806898/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8806898/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102297626,"identity":"e911834c-c96c-411d-8376-c941308aa7c5","added_by":"auto","created_at":"2026-02-10 10:28:33","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":655199,"visible":true,"origin":"","legend":"\u003cp\u003eFloor plan of case study 1.\u003c/p\u003e","description":"","filename":"figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8806898/v1/473227efc7980a3857a4afcc.jpg"},{"id":102261591,"identity":"5d22bee5-25de-4da5-9687-fec431260032","added_by":"auto","created_at":"2026-02-10 00:41:28","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":604250,"visible":true,"origin":"","legend":"\u003cp\u003eFloor plan of case study 2.\u003c/p\u003e","description":"","filename":"figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8806898/v1/fa6ab9994bf10468352bf4d6.jpg"},{"id":102261593,"identity":"e79e39d7-209a-45fa-9e88-6c274442d85f","added_by":"auto","created_at":"2026-02-10 00:41:28","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":693002,"visible":true,"origin":"","legend":"\u003cp\u003eFloor plan of case study 3.\u003c/p\u003e","description":"","filename":"figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8806898/v1/57dc00f98e4be6efb03798a2.jpg"},{"id":102297745,"identity":"e434006e-a09d-44c0-8537-462978bde029","added_by":"auto","created_at":"2026-02-10 10:29:01","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":18071,"visible":true,"origin":"","legend":"\u003cp\u003eCare process map of a typical stroke unit in the Southern Province.\u003c/p\u003e","description":"","filename":"figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-8806898/v1/0192d3d1376c7d036b37efbf.png"},{"id":102962151,"identity":"e9212c0d-e4a7-4d16-9fbd-a11f74b44fa2","added_by":"auto","created_at":"2026-02-19 04:04:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2586184,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8806898/v1/7e9dca9c-7c55-420b-a4f0-4c9058154b57.pdf"},{"id":102297770,"identity":"d126ceb8-941d-4b69-9315-49c55bf1f5d9","added_by":"auto","created_at":"2026-02-10 10:29:06","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":193975,"visible":true,"origin":"","legend":"\u003cp\u003eQuestionnaire Administered to the Study Participants\u003c/p\u003e","description":"","filename":"SupplementaryMaterialS1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8806898/v1/96c41623c4639625b68ef3f6.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eAn appraisal of the appropriateness of physical environment in organized inpatient stroke care units in southern Sri Lanka.\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHealthcare settings are crucial in fostering sustainable communities [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It is also found that emphasizing the profound impact of healthcare facility design on patient and staff behaviour influences health, well-being, clinical efficiency, and health-related outcomes. Realizing this interaction underscores the importance of carefully planning healthcare environments, promoting long-term benefits for patients and healthcare professionals, and supporting community sustainability.\u003c/p\u003e \u003cp\u003eRecent studies on stroke treatment emphasize that hospital design plays a crucial role in influencing essential aspects of patient care. Defined by the World Health Organization [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] as a brain attack, stroke stands out as a leading global cause of disability and the second leading cause of death. Notably, data from 2022 reveals a concerning 50% increase in the lifetime risk of experiencing a stroke over the last 17 years, estimating that one in four individuals may undergo a stroke in their lifetime [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This escalating risk is particularly pronounced in the Southeast Asia Region (SEAR), which bears nearly half of the developing world's burden of stroke cases [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Sri Lanka, a population of over 22\u0026nbsp;million faces a high crude stroke prevalence of 10.4 per 1000 individuals, resulting in 200,000 stroke patients [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Annually, over 60,000 stroke patients are admitted to state sector hospitals, with around 4,000 in-hospital deaths [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Additionally, the study has noted that strokes account for 10% of hospital fatalities in Sri Lanka, positioning the country among those with the highest occurrences of strokes. Consequently, the focus on stroke prevention is gaining prominence in the country [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Building design guidelines and clinical practice guidelines are identified as crucial factors in stroke prevention [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the increasing focus on stroke prevention in Sri Lanka, stroke care faces challenges, including a slow pace and insufficient organized stroke care facilities [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The study has shown that even at hospitals with stroke units, the majority of stroke patients are admitted to general medical wards due to a lack of stroke beds. Many of these patients may be prematurely sent to their homes and may turn to complementary or alternative medicine [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The lack of proper treatment at home, as required, results in a worsening of disabilities for stroke patients. Moreover, stroke is the leading cause of home death in Sri Lanka [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Even though the number of stroke units in the region has increased, units equipped to provide acute care remain limited, with fewer than 100 available stroke beds nationwide [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. It is identified that the current absence of organized stroke care facilities in most hospitals poses a significant challenge in Sri Lanka.\u003c/p\u003e \u003cp\u003eEven though the healthcare sector is growing, stroke has a limited environmental evidence base. The studies rarely address specifically built environments. The clinical guidelines for stroke care currently lack specific references to the built environment and fail to provide recommendations on how the physical surroundings can optimally facilitate patient care [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Currently, there is a lack of comprehensive review of the physical environment of stroke units, particularly in Sri Lanka [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Therefore, more research needs to be done on the essentials necessary in the physical environment of stroke unit designs.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eResearch Questions\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eHas the design of the stroke units been designed to facilitate efficient staff assistance while allowing patients to independently engage in daily activities and adapt to their new life after a stroke?\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAre the current stroke units designed according to the special design requirement, and to what extent is each design element in each case used?\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWhat insights are gained regarding the strengths and weaknesses of design principles in stroke care facilities?\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHow satisfied will the staff be, on behalf of stroke patients, with the design and current facilities provided in their stroke unit?\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eResearch Objectives\u003c/p\u003e \u003cp\u003eThe main objective is to identify the special design requirements specific to the stroke care environment and to assess the physical surroundings of stroke units. Hospitals in the Southern province of Sri Lanka are considered as samples. To achieve the above main objective, the following Specific Objectives are suggested.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eTo compare the extent to which the stroke units have responded to the special design requirements.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTo investigate whether the stroke units have been designed to address the convenience of patients as well as the staff.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eIn this study, only the design-related factors of functioning stroke units in Southern Province will be observed. Only healthcare workers within the stroke unit are included in this study, while other staff members within the stroke unit will be excluded.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe selection of suitable sampling methods is essential for accurately representing the research problem, a principle that forms the core of the research design in this study [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The focus is on three case studies within the southern province, one of the top three most populous provinces that lacks a specialized stroke unit will be observed in this study [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. An in-depth examination of the physical environments within stroke care settings will be carried out in this study to identify necessary areas for improvement. The selected hospitals include Teaching Hospital Karapitiya, District General Hospital Matara, and General Hospital Hambantota. The primary focus will be on investigating and utilizing factors based on seven design elements identified in the literature.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eCollecting information from stroke units involves considering various parameters, including their location and type, which may focus on acute care, rehabilitation, or a combination of stroke and internal medicine. Further observations encompass aspects such as bed allocation, room layout, and rehabilitation space availability. Evaluation of ward layout involves analyzing floor plans, circulation spaces, staff-patient proximity, and amenities placement while also assessing environmental factors like light, noise, and ventilation. The presence of communal spaces and access to natural elements, recreational activities, and enrichment features are also examined to gauge overall environmental quality. Observing patients' behaviour closely within the ward without disrupting their treatments constitutes data collection.\u003c/p\u003e \u003cp\u003eThe methodology utilized in this study involved employing a semi-structured interview and an open-ended questionnaire (the questionnaire is available in \u0026lsquo;Supplementary Material S1\u0026rsquo;) based on seven design elements identified in the literature. Feedback regarding the current unit was obtained from staff members, as they possess extensive knowledge about the services that truly need enhancement in the stroke units. Seven individuals were interviewed from each unit at a minimum. Staff feedback was also obtained through an open-ended questionnaire distributed to 20 individuals from each unit, including nurses and other supportive staff. These interviews and questionnaires were focused on evaluating the existing facilities of stroke care environments, identifying the strengths and weaknesses of each unit, and exploring potential enhancements in designing stroke units from admission to the discharge process. The interview guides were developed based on a thorough literature review and in collaboration with the clinical staff currently working on each case study. Additionally, interviews were conducted regarding inpatient stroke patients, stroke survivors, and carers. This methodological approach aimed to encompass the perspective of the physical environment throughout the rehabilitation process from various viewpoints.\u003c/p\u003e \u003cp\u003eDescriptive statistics, including frequency and percentages, were employed to analyze the gathered data. Respondents were allowed to offer in-depth descriptions, which were utilized to clarify the quantitative results that ultimately led to the formulation of conclusions.\u003c/p\u003e \u003cp\u003eThe seven key design elements emphasized in the evidence regarding stroke care environments are from the published research articles sourced from systematic literature reviews and the Centre for Healthcare Design research repository [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e categorizes the seven design elements based on their practicality within the Sri Lankan context.\u003c/p\u003e \u003cp\u003eThese elements serve as a comprehensive framework for assessing and enhancing the overall design of stroke care facilities.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSeven design elements specific to stroke care environments [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeven Design Elements\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCo-location of staff spaces\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProximity to patient areas, visibility, and supervision.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutdoor spaces\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAccessibility to outdoor spaces, presence of plants, scenic views, and paintings with natural motifs in the stroke unit.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of beds in the patient room\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe number of beds dedicated to stroke patients, the distance between beds, space efficiency (check whether the bed does not obstruct movement and access to other essential areas), and patient privacy.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjacency and suitable therapy spaces\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhether there is space for rehabilitation in or in direct relation to the unit.\u003c/p\u003e \u003cp\u003eAdequate light \u0026amp; ventilation, therapeutic ambiance (wall colour, etc.), accessibility, functional layout, furniture, and equipment arrangement.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVersatility of spaces in multipurpose circulation spaces (corridors)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAccessibility and clear pathways, lighting, and safety features like handrails, etc.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunal spaces for patients/ visitors (indoor)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAvailability of indoor and outdoor communal areas to patients.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eShared staff spaces are crucial for effective communication and teamwork among diverse health professionals [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. They argue that separating clinical and therapy spaces can increase staff travel time and impact clinical decision-making, unlike therapy spaces which lack holistic environments. Healthcare workers frequently use corridors for informal encounters, essential for exchanging information and socializing [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eExposure to outdoor environments is linked to stress reduction and improved well-being [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. It is proven that hospital gardens, often overlooked by patients and visitors, provide exercise, exploration, and socialization opportunities. Outdoor spaces also serve as restorative environments for healthcare staff, reducing stress and enhancing attention.\u003c/p\u003e \u003cp\u003eEvaluating the ratio of single rooms to multiple-bed rooms is critical in ward design. While single rooms offer advantages in infection control, the impact on falls and social connections should be considered, balancing privacy and accessibility [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDesigning therapy spaces for stroke patients is crucial, as is optimizing rehabilitation through adequate space, specialized equipment, a holistic approach, and elements like natural light [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. A welcoming ambiance contributes to the overall well-being of stroke patients, fostering a conducive environment for their rehabilitation and recovery. The proximity of therapy spaces and wards is critical for efficient stroke care, minimizing patient travel and optimizing time for therapeutic activities [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This study also reveals that placing therapy spaces adjacent to the ward fosters a collaborative environment, enhancing communication and coordination of care.\u003c/p\u003e \u003cp\u003eMultipurpose circulation areas, like corridors, should prioritize accessibility and safety for stroke patients. Incorporating seating areas, therapeutic elements, and flexible layouts contributes to a patient-centered environment, promoting functionality and a positive atmosphere [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIndoor communal spaces for stroke patients should be thoughtfully designed, prioritizing accessibility and inclusivity [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Comfortable seating arrangements, diverse amenities, and designated meeting places encourage socialization and emotional support among stroke patients and visitors.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe study has chosen three hospitals within the Southern Province that offer treatments for stroke patients as follows. National Hospital Karapitiya, District General Hospital Matara and District General Hospital Hambantota. (To maintain privacy, the names of the hospitals will not be disclosed in each study and will instead be described as separate case studies, as outlined below.)\u003c/p\u003e \u003cp\u003eCase Study 1: The proposal aimed to create a national stroke unit in Mulleriyawa alongside nine provincial stroke units throughout Sri Lanka, with case study 1 being among them. The unit includes areas for staff, therapy, clinics, the High Dependency Unit (HDU), discussion, and dining, in addition to the ward. The proposed staff comprises 21 nurses with three doctors, three consultants, six junior health staff members, one speech therapist, two physiotherapists, and one occupational therapist.\u003c/p\u003e \u003cp\u003eCase Study 2: The stroke unit was initially established following the introduction of thrombolytic therapy, prompting the need for a dedicated stroke unit with comprehensive therapy services. This unit, equipped with either three or occasionally two beds, was primarily designated for stroke patients but also accommodated other neurology patients when stroke cases were lacking. It's worth noting that this unit is not fully independent and is managed by the same staff, underscoring the need for more specialized stroke care infrastructure. The unit features areas for staff, therapy, and the ward. The staff includes ten nurses, six doctors, one consultant, seven junior health staff members, one speech therapist, one occupational therapist, and one physiotherapist.\u003c/p\u003e \u003cp\u003eCase study 3 - Due to the absence of allocated spaces the neurology unit was shared with the dermatology unit. Specifically, three beds were allocated for the neurology unit in both the male and female wards. The unit includes spaces for staff, dining, changing, therapy, isolation and storage in addition to the ward. The staff comprises eight nurses, three doctors, one consultant, five supporting health staff members, three speech therapists, four occupational therapists, and three physiotherapists.\u003c/p\u003e \u003cp\u003eCase Study 1\u003c/p\u003e \u003cp\u003eThe design of key spaces within the layout was structured around various functional areas, including therapy units, discussion areas, wards, toilets, clinic rooms, staff areas, and an HDU. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe stroke unit has specialized areas for HDU and separate sections for male and female stroke patients. A notable feature of this layout is the positioning of the nurse station directly facing the HDU, necessitating close attention and direct supervision by healthcare staff. Additionally, the design includes a dedicated room for staff discussions and decision-making on patient care, distinguishing it from other stroke unit designs.\u003c/p\u003e \u003cp\u003eInsufficient bed spacing and beds positioned facing a half-partition wall restrict certain patients from fully enjoying the outdoor views. One notable drawback of the stroke unit design is the absence of separate visitor areas. The arrangement of beds lacks proper access from either side, affecting the ease of patient care. Patients are categorized based on their condition, a beneficial organizational strategy. Toilets are conveniently attached to the unit, with disabled access and ample natural light and ventilation, contributing to patient comfort and convenience.\u003c/p\u003e \u003cp\u003eOn a positive note, the unit includes separate clinic rooms, enhancing privacy and specialized care delivery. The physiotherapy unit in the stroke facility features a notably spacious layout, yet it is divided into separate rooms for staff and patient use. A positive aspect highlighted is the provision of distinct rooms for speech therapy to conduct one-to-one sessions without disturbing others. There's a suggestion to relocate the clinic rooms closer to the floor entrance, where the speech therapy units are currently located. Notably, the plan does not allocate space for an occupational therapy area; however, it's mentioned that this will be accommodated once the unit is open to the public, indicating a flexible approach to space allocation. Additionally, the therapy spaces are designed with disabled access, ensuring inclusivity and ease of use for all patients.\u003c/p\u003e \u003cp\u003eThe placement of the lift in the corner of the floor presents a challenge when maneuvering wheelchairs or stretchers. However, the corridor width is adequate, providing enough space for movement. Despite this, there is a lack of grab bars along the corridor, which would greatly assist disabled individuals in navigating the space more easily.\u003c/p\u003e \u003cp\u003eA significant advantage of the design is that all units, including therapy spaces, are situated on the same floor. Having all essential units nearby enhances efficiency and convenience for both patients and staff, promoting better coordination of services.\u003c/p\u003e \u003cp\u003eA communal area for stroke patients to socialize has not been included in the design. However, there is a dedicated dining area for patients even though it is not spacious.\u003c/p\u003e \u003cp\u003eThis design for the stroke unit incorporates nearly all essential spaces required for patient care, with notable exceptions being a communal space, an occupational therapy room, and designated outdoor areas.\u003c/p\u003e \u003cp\u003eCase Study 2\u003c/p\u003e \u003cp\u003eSignificant areas within the unit include the ward, stroke unit, staff rooms, toilets, and therapy spaces. (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe stroke unit was repurposed in a free room without being designed specifically for stroke care as a result, all male and female patients share a confined three-bedroom space. The nurse station is notably distant from the stroke unit but closer to the general medical ward, leading to emergency treatment patients being admitted there. Long-term rehabilitation patients, on the other hand, are admitted to the stroke unit. There is a lack of distinct staff discussion areas unlike in the previous case study. The stroke unit has an insufficient number of beds with proper bed spacing. This is reflected in the admission of stroke patients to general medical wards under staff observation due to insufficient beds in the specific unit. The beds are placed in proximity to the wall, limiting staff observation of the affected side of patients and potentially slowing down recovery. Windows of smaller heights are present but face corridors without providing outdoor views. However, natural plants and fish tanks are placed in corridor-free spaces. Despite these elements, the ward's congestion may hinder its calming effects on patients. Calm music is played to aid in relaxation. This unit lacks a designated visitor area. Toilets are attached to the stroke unit but not tailored to accommodate disabled individuals, featuring entryways with steps in certain instances.\u003c/p\u003e \u003cp\u003eThere is a lack of a distinct clinic space set aside for stroke patients unlike in case study 1. The therapy spaces are well-equipped to accommodate essential therapy sessions. However, the lack of disabled access restricts bedbound patients from accessing crucial physiotherapy sessions within the therapy unit. Hence, some therapy sessions are being conducted in the corridor. The occupational therapy unit is located near the stroke unit, while the physiotherapy unit is positioned at a considerable distance. The speech therapy unit is located one floor below the stroke unit, making access to speech therapy sessions challenging.\u003c/p\u003e \u003cp\u003eThe corridor width is adequate but often blocked by unnecessary furniture, hindering circulation. Stretcher and wheelchair placements further impede circulation, along with garbage bins that may raise hygiene concerns. Crash bars are missing in corridors, and lift malfunctions occasionally, necessitating patient transport through staircases, which are also insufficiently wide. No communal space was designed specifically for stroke patients. Patients are forced to have meals and wash their hands in corridor sinks due to space constraints within the ward. Although tables are available for dining, they are also positioned within the congested corridor.\u003c/p\u003e \u003cp\u003eSince every design element in this case study was improperly considered in developing these components are essential for renovating or designing a new stroke unit.\u003c/p\u003e \u003cp\u003eCase Study 3\u003c/p\u003e \u003cp\u003eThe unit includes wards, staff areas, an isolation room, a dining area, toilets, and a storeroom, as depicted in the plan below. (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePatient wards are divided into male and female sections as in case study 1. Nurse stations, along with other staff areas, are strategically positioned directly in front of the ward, enabling convenient observation. However, there is a lack of discussion areas for staff to make crucial decisions on patients. The bed arrangement poses a risk of spreading infections between different patient groups. Each ward bed is spaced approximately 450 mm apart, insufficient for conducting therapy sessions or accommodating bystanders between beds. The bedside table further obstructs these gaps, hindering mobility and access to therapy sessions. Patients lying in beds face difficulties in seeing outdoor views due to the height of the bed. However, when patients are seated, they can access outdoor views. Natural plants are not incorporated into the design, further limiting connections with outdoor environments. There is no designated visitor area, and seating has been arranged by utilizing space from the corridor. Single-accessible bathrooms and separate changing rooms are provided for patients to practice daily activities independently, such as buttoning up a shirt with the affected side. This setup offers privacy, allowing patients to learn without feeling embarrassed in front of others. However, the shared washroom with other patients lacks infection control measures, posing further risks.\u003c/p\u003e \u003cp\u003eThis unit lacks dedicated clinic rooms specifically designed for stroke patients. The therapy space, located eight floors below the ward, presents challenges in moving patients to the therapy unit, especially considering the limited size of the lift. Additionally, the basement-level therapy space lacks proper light, ventilation, and mobilization space. The therapy units are not adjacent to the ward, complicating patient transfers and coordination between units. Corridor widths are less than 5 ft and often blocked by visitor chairs, obstructing the movement of wheelchairs and stretchers. The circulation space is insufficient, affecting overall accessibility within the ward and therapy areas. The ward includes a separate dining area for socialization, but due to infection concerns, stroke patients avoid using it and opt to have meals in bed. However, there is no additional communal space available for patients to socialize.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe majority of the staff members are pleased with the therapy spaces provided, as evidenced by the high satisfaction rate. In contrast to the first case study which lacks an occupational therapy unit, the other case studies generally have well-equipped therapy spaces, although they lack disabled access. Similarly, staff satisfaction is high regarding the co-location of staff spaces and the number of beds in patient rooms, with most cases adequately addressing these aspects. However, staff satisfaction is lower concerning circulation spaces and the adjacency of therapy spaces in the ward, which are often not well-designed. Notably, communal spaces and outdoor areas are the least satisfactory design elements according to the study, with most staff members expressing dissatisfaction in these areas.\u003c/p\u003e \u003cp\u003eThe relationship between activities and locations has been identified and mapped for a typical stroke unit in Australia [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Accordingly, the care process map in the southern province of Sri Lanka exhibits some differences, from a well-designed stroke unit which often lacks lounge and outdoor areas. (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eApart from the seven design elements outlined in the study, additional factors were discovered to influence the stroke care environment. These supplementary design elements like wayfinding elements [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and sanitary facilities play a crucial role in enhancing the overall quality of care.\u003c/p\u003e \u003cp\u003eRecommendation\u003c/p\u003e \u003cp\u003eThis study is crucial as Sri Lanka currently lacks centralized monitoring or standardization for stroke unit design. The findings of the study revealed significant disparities and variations in the design and layout of stroke units across different healthcare facilities in Sri Lanka. It was surprising to note instances where stroke units were combined with other units, such as dermatology, potentially compromising the specialized care required for stroke patients. This amalgamation, possibly due to resource constraints, indicates a broader issue within the healthcare system. Additionally, the research emphasized the vital role of accessibility, infection control measures, outdoor accessibility and communal areas in promoting social interactions and aiding recovery post-stroke.\u003c/p\u003e \u003cp\u003eIn many cases well-equipped therapy spaces are provided. Similarly, the co-location of staff spaces and the number of beds in patient rooms are also adequately addressed in most cases. However, in many cases, the design of therapy units and other essential spaces like circulation spaces and sanitary facilities did not consider the needs of disabled individuals. Furthermore, the arrangement of furniture frequently obstructed pathways, creating difficulties with accessibility. Prioritizing such patients' care is essential to make sure staff areas are situated close to the unit for convenient patient observation. Similarly, therapy units should also be placed close by as well since most of them are located on various floors making it challenging for both staff and patients.\u003c/p\u003e \u003cp\u003eIn order to improve patient outcomes and healthcare quality in Sri Lanka, comprehensive national standards covering every aspect of stroke unit design must be developed going ahead. These standards would enable medical practitioners to make informed decisions.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe construction of healthcare facilities poses considerable challenges due to their complexity and high costs. Designing hospitals that meet user needs, enhance patient experiences, and consider economic factors is crucial. In Sri Lanka, these challenges are compounded by significant deficiencies in stroke care infrastructure, as recent studies have shown. Establishing dedicated stroke units within state hospitals, particularly in underserved regions like the Southern Province, is urgently needed to improve outcomes and relieve strain on general medical wards.\u003c/p\u003e \u003cp\u003eMany existing healthcare units have certain strengths and weaknesses. While co-located staff spaces facilitate regular observation, outdoor spaces are often underutilized due to limited direct access. The adequacy of beds is generally met, but spacing between beds is often insufficient. Additionally, the proximity of therapy spaces to each other is not always considered, impacting operational efficiency. Despite these challenges, most units boast well-equipped therapy facilities, although disabled access remains a concern. Communal spaces, when well-designed, enhance social interaction among patients and staff, but this aspect is lacking in some units. The prevalent issue noted is the lack of prior planning for these units, with many being repurposed from existing hospital spaces. This can significantly impact patient recovery outcomes. In addressing these challenges, it's essential to plan and design healthcare facilities more effectively.\u003c/p\u003e \u003cp\u003eDespite economic challenges, creating new stroke units is a significant hurdle, particularly in a developing country like Sri Lanka. However, this research offers strategies to improve stroke care environments without building new units. Enhancing stroke care in government hospitals, especially those providing free healthcare, is crucial for public health. Architects have a social responsibility to design stroke units based on specialized guidelines to positively impact patient recovery. Collaborating with staff before designing the unit proves more effective than making post-construction changes based on their advice. Addressing infrastructure deficiencies and optimizing resources within existing hospital spaces are crucial steps toward better patient outcomes and healthcare quality in Sri Lanka. This effort not only enhances patient care but also fulfills a social responsibility for societal well-being.\u003c/p\u003e\n\u003ch3\u003eScope and Limitations\u003c/h3\u003e\n\u003cp\u003eOnly the design-related factors of functioning stroke units in Southern Province, one of the top three most populous provinces that lacks a specialized stroke unit, will be observed in this study. Moreover, only healthcare workers in the stroke unit are included in this study, while other staff members within the stroke unit will be excluded.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAuthor Contribution statement (CRediT)\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eViduni Dedduwa Pathirana\u003c/strong\u003e \u003cp\u003edata collection, wrote the original draft, performed the data analysis, and drafted the initial manuscript.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eJeeva Wijesundara\u003c/strong\u003e \u003cp\u003emade the format of the analysis and methodology and supervised the overall research while editing and reviewing the manuscript.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eKithsiri Dedduwa Pathirana\u003c/strong\u003e \u003cp\u003eprovided subject-matter expertise and conceptualized and designed the study. He has also provided overall supervision and critically reviewed and edited the initial manuscript.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eWarsha De Zoysa\u003c/strong\u003e \u003cp\u003ethe supervisor to get ethical clearance. She has also reviewed and edited the manuscript.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAnomali Vidanagamage\u003c/strong\u003e \u003cp\u003e provided subject-matter expertise and reviewed the manuscript.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eAll authors reviewed and approved the final version of this manuscript and accept responsibility for its content.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contribution statement (CRediT)\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eViduni Dedduwa Pathirana:\u003c/strong\u003e data collection, wrote the original draft, performed the data analysis, and drafted the initial manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJeeva Wijesundara:\u003c/strong\u003e made the format of the analysis and methodology and supervised the overall research while editing and reviewing the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKithsiri Dedduwa Pathirana:\u003c/strong\u003e provided subject-matter expertise and conceptualized and designed the study. He has also provided overall supervision and critically reviewed and edited the initial manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWarsha De Zoysa:\u003c/strong\u003e the supervisor to get ethical clearance. She has also reviewed and edited the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnomali Vidanagamage:\u003c/strong\u003e provided subject-matter expertise and reviewed the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors reviewed and approved the final version of this manuscript and accept responsibility for its content. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was carried out without external funding.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional Review Board Statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was granted by the ethics review committee, Teaching Hospital Karapitiya, Galle, Sri Lanka. (Ref No: THK / ERC/24/06, approval date 04.04.2024) All procedures adhered to the ethical standards of the institutional research committee and the principles outlined in the Declaration of Helsinki (revised 2013).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent Statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from every participant prior to participation in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData available upon reasonable request due to privacy and ethical restrictions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all participants and the relevant approving authorities for their time and effort in conducting this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eReiling J, Hughes R, Murphy M The Impact of Facility Design on Patient Safety. 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[online].2021. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://brainybirdz.net/2021/02/02/the-influence-of-ward-layout-on-everyday-communications-between-healthcare-workers-an-evidence-based-study\u003c/span\u003e\u003cspan address=\"https://brainybirdz.net/2021/02/02/the-influence-of-ward-layout-on-everyday-communications-between-healthcare-workers-an-evidence-based-study\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (accessed 11 July\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnaker A, Vonkoch L, Eriksson G et al The physical environment and multi-professional teamwork in three newly built stroke units. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/09638288.2020.1793008\u003c/span\u003e\u003cspan address=\"10.1080/09638288.2020.1793008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLipson R, Pflaumer L, Elf M et al Built environments for inpatient stroke rehabilitation services and care; a systematic literature review. BMJ open 2021;p.e050247. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjopen-2021- 050247\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2021- 050247\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJanssen H, Ada L, Bernhardt J et al Physical, cognitive and social activity levels of stroke patients undergoing rehabilitation within a mixed rehabilitation unit. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0269215512466252\u003c/span\u003e\u003cspan address=\"10.1177/0269215512466252\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHadi K, Zimring C Design to Improve Visibility. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1937586715621643\u003c/span\u003e\u003cspan address=\"10.1177/1937586715621643\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnaker A, Morichetto H, Elf M The physical environment is essential, but what do the design and structure of stroke units look like? A descriptive survey of inpatient stroke units in Sweden. Scand J Caring Sci. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://DOI:org/10.1111/scs.13112\u003c/span\u003e\u003cspan address=\"https://DOI:10.1111/scs.13112\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJuan S, Lipson R, White M et al Stroke Inpatient Rehabilitation Environments; Aligning Building Construction and Clinical Practice Guidelines Through Care Process Mapping. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1161/strokeaha.123.044216\u003c/span\u003e\u003cspan address=\"10.1161/strokeaha.123.044216\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKevdzija M Everything looks the same, wayfinding behaviour and experiences of stroke inpatients in rehabilitation clinics. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/17482631.2022.2087273\u003c/span\u003e\u003cspan address=\"10.1080/17482631.2022.2087273\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Liverpool John Moores University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"stroke units, stroke prevalence, healthcare design guidelines, stroke care environments","lastPublishedDoi":"10.21203/rs.3.rs-8806898/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8806898/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe impact of hospital building design on the health and well-being of individuals, especially in the context of stroke care in Sri Lanka, remains an underexplored area, despite the high prevalence of stroke in the country. It is identified that the absence of appropriately designed stroke units is contributing to a delay in the recovery of stroke. The study seeks to evaluate the existing stroke care units in the Southern Province of the island, highlighting its high population and limited specialized stroke care facilities. This study assesses whether these units adhere to specific design guidelines.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe research involves a descriptive cross-sectional study, semi-structured interviews, and an open-ended questionnaire to assess seven design elements from existing literature. Medical officers, consultants, physiotherapists, occupational therapists, and speech therapists who possessed experience and expertise in the rehabilitation field within the hospital were interviewed. Seven individuals were interviewed from each unit at a minimum. Staff feedback was also obtained through an open-ended questionnaire distributed to 20 individuals from each unit including nurses and other supportive staff.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eExisting healthcare units exhibit strengths like co-located staff spaces and weaknesses with inadequate outdoor access, bed spacing, distance of therapy spaces, and disabled access. However, the main problem observed is the need for more planning for these units, as many are repurposed from existing hospital areas without being specialized for stroke care. The staff provided feedback on each case, with extensive expertise in stroke care.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003e This study offers insights to architects to develop building guidelines for stroke care in state hospitals, given their widespread utilization, especially by individuals relying on economically viable healthcare services.\u003c/p\u003e","manuscriptTitle":"An appraisal of the appropriateness of physical environment in organized inpatient stroke care units in southern Sri Lanka.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-10 00:41:23","doi":"10.21203/rs.3.rs-8806898/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e3a4e0b3-9b6b-4f11-aee0-d9bb5c42b262","owner":[],"postedDate":"February 10th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":62453440,"name":"Architecture, Design and Planning"},{"id":62453441,"name":"Neurology"}],"tags":[],"updatedAt":"2026-02-10T00:41:23+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-10 00:41:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8806898","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8806898","identity":"rs-8806898","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}