The hospital designed by hospitalized children and adolescents.

OBJECTIVE
to identify, through the contributions of hospitalized children and adolescents, the characteristics they consider necessary for a hospital that promotes well-being and development.


METHOD
descriptive and exploratory study, with qualitative data analysis, carried out with a total of 30 hospitalized children and adolescents. Data were collected through semi-structured interviews, mediated by drawing, and analyzed by inductive thematic analysis, supported by the theoretical framework of the humanization of health care and the Florence Nightingale's Environmental Theory.


RESULTS
the designed hospital takes up the principles of Florence Nightingale's Environmental Theory, as well as one of the guidelines of the National Humanization Policy, the environment, from two perspectives: elements and material resources from the physical environment; elements of comfort and well-being environment.


FINAL CONSIDERATIONS
hospitals such as the projected institution corroborate what is recommended in public policies, as they qualify health care.

In the 19th century, Florence Nightingale, in her first books, Notes on nursing: what it is and what it is not (5) , Sick nursing and health nursing (6) and Notes on hospitals (7) , already argued that the care environment, the hospital one in this case, could negatively impact the health, emotional and spiritual state of hospitalized people. According to her, some factors could cause discomfort during the hospitalization process: lack of light, hygiene and ventilation; unpleasant odors; beds with sheets wet with sweat or with sheets that had folds causing pressure points on the patients' skin; and environmental noise capable of impairing the hospital patients' need for rest (5) .
Based on these observations, and from a different perspective on the environment, Florence proposed that these institutions be designed to meet the individuals' essential needs, which, according to her, would favor the restoration of their health (5,(8)(9) . This is the context that originated Florence Nightingale's Environmental Theory (9) , which determines changes in European hospital institutions in order to associate nursing care with elements of the physical environment, such as color variations, adequate ventilation, lighting and noise control (5,9) .
Although this theory was presented in the 19th century, its principles remain valid nowadays, as studies have reiterated that the hospital environment can negatively interfere in the hospitalization process, resulting in a potentially traumatic (1)(2)(3)(4)(10)(11) or non-traumatic (1,(12)(13) experience. Thus, when this environment allows the establishment of friendships, it promotes well-being, with specific recreational activities according to the age group, it is characterized as a space for healing and also as an element that favors a less painful experience for the patients (1)(2) .
In favor of a non-traumatic ecology, Nightingale already defended humanized care, based on the adequacy of the space around the individual, seen as someone who has relationships and interactions with the environment (5) and biopsychosocial needs, that need to be met (8) .
Thus, the National Humanization Policy (NHP), promulgated in 2003, reinforced the need to structure the hospital environment in order to contribute to the restoration of the individuals' well-being (14) . A structural element of the NHP is the hospital environment, which is divided into three axes. The first one is comfortability, focused on privacy and individuality in order to promote a comfortable and welcoming environment for users and health professionals, through the combination and balance of colors, sounds, lighting and odors, since these elements can act as modifiers and qualifiers of the space, essential in health production. The second axis, production of subjectivities, allows users, workers and managers to use the hospital space to act and reflect on the work process, producing new knowledge. Finally, the third axis, space, is used as a tool to facilitate the work process and aims at building an environment that transcends architecture, promoting the individuals' well-being and health (15) .
It has already been proven that the incentives received by the children, especially in their first years of life, are fundamental for the maturity of their brain circuit, as they promote emotional and intellectual development (16) . These findings corroborate the Bioecological Theory of Human Development (17) , according to which the environment influences the change of individuals' biopsychological characteristics. Therefore, children and adolescents need to live in environments that contribute to the acquisition of skills essential to the development stages, even during hospitalization processes.
Environments that promote recreational activities are strong allies of motor, emotional, mental and social development, in addition to contributing to a less traumatic hospitalization, as they favor coping with the situation, the (re) significance of pathology and acceptance of treatment (18) . A qualitative approach study with children aged from 7 to 12 years old under outpatient therapeutic follow-up at a pediatric university hospital in Sao Paulo showed that the therapeutic environment, when designed from the perspective of these patients, allows them to know their preferences, as well as their health and disease conditions and treatment, which makes it less traumatic (19) .
Although the construction of hospital environments that promote well-being (14)(15)20) and development is present in health policies, the literature still reports the maintenance of worrying adverse effects of hospitalization (1)(2)(3)(4) . Thus, this study intends to broaden the understanding of this complex and dual phenomenon, that is, the hospital as a place of pain and suffering and, at the same time, a promoter of healing and development, based on the contributions of children and adolescents who experience hospitalization processes and not from the adult-centric perspective, usually analyzed.

OBJECTIVE
To identify, through the contributions of hospitalized children and adolescents, the characteristics they consider necessary for a hospital that promotes well-being and development.

Ethical aspects
The study was approved by the Research Ethics Committee of the Nursing School in Ribeirao Preto at the University of Sao Paulo (EERP-USP), in compliance with the guidelines of Resolution 466/2012 of the National Health Council (21) . The participants were duly informed about the objectives of the study and procedures for data collection and, then, those who agreed to participate signed the Informed Consent Form (guardians) and the assent form (children and adolescents). To ensure anonymity, the interviewees chose their codenames, and in the case of repeated choices, the letters A, B and C were added to differentiate them. The study was developed according to the recommendations for the preparation of qualitative research by COREQ (Consolidated Criteria for Reporting Qualitative Research).

Type of study
This is an exploratory, descriptive study, with qualitative data analysis, having as theoretical framework one of the guidelines of the NHP, the environment and Florence Nightingale's environmental theory.

Study scenario
The study was carried out in the pediatrics unit of a university hospital in the state of Sao Paulo considered a reference for the treatment of chronic diseases.

Participants of the study
A total of 30 children and adolescents hospitalized between March and December 2016, aged between 7 and 17 years old, of both genders and with a hospital stay of five days or more participated in the study. We chose to include participants in this age group because they are in a phase of human development in which they are able to talk about their experiences and needs (1)(2)(3)(4) , contributing to the understanding of the studied phenomenon. Children and adolescents unable to establish communication to answer the interview questions, according to the assessment of the nursing team, were excluded. Two participants refuse to participate, without justifying their decision.

Data collection and organization
For data collection, we chose the semi-structured interview mediated by drawing, which was used to initiate the approach, that is, as a facilitating element. However, it was verified, in the first interviews, that although the drawing favored motivation and initial dialogue of the participants with the main researcher, it was not sufficient for them to answer the questions in a broader way, contributing to the reach of the study objective, since the answers were mostly brief.
For this reason, in the second month of study, precisely in the sixth interview, the main researcher participated in hospital recreation activities, in order to strengthen the bond with the participants. In addition, she made her personal cell phone available for them to choose some drawings they would like to paint, which were printed and distributed by the unit psychology/pedagogy.
It should be noted that the participation of the researcher in the activities was essential, as it favored the construction of bonds and, therefore, the data collection on hospitalization. Sometimes, during the activities, participants spontaneously commented on the hospitalization process and its needs. Another strategy used was to identify topics of interest to the participants in order to gradually introduce the guiding questions. In general, this approach was carried out a few days before the interview.
The interviews lasted approximately 30 minutes and were conducted in a private room, with or without companions, as long as they did not give their opinion during the recordings. At this time, participants were also asked to prepare drawings representing what they would like to have in the hospital, describe what they had drawn and discuss the following guiding question: tell me what you would like to have in the hospital. Those who wanted, 23 in total, also had access to their own interviews, so that they could listen to them.
Data collection ended after a total of 30 interviews, when it was observed that the information already revealed, in quantity and intensity, the multiple dimensions of the studied phenomenon (22) , and when the repetition of findings was identified, indicating the achievement of the proposed objective (23) .
In addition to the interviews, demographic and clinical data were collected from the medical records in order to characterize the study participants.

Data analysis
Data analysis followed the principles of inductive thematic analysis (24) and took place in six stages: familiarization with the data; identification of initial ideas; generation of initial codes; search for themes; themes review; and preparation of a final report with analysis and interpretation of the themes according to the theoretical framework constituted by the environment, one of the guidelines of the NHP, and by the Environmental Theory, considering the context of the participants and the researcher. This process was carried out by four researchers. The first and fourth authors independently identified the themes, and then gathered to review them, analyze the discrepancies and compare the agreements and consensus. After that, they were certified and validated by the second and third authors (senior authors). The final report presents the results in two dimensions: Elements of the physical environment and material resources; and Elements of comfort and well-being environment.

RESULTS
Regarding the characteristics of the 30 participants, 21 were aged between 13 and 16 years old; 17 were girls and all of them attended school: 25 were in elementary school and five in high school. The most frequent diagnoses were Neoplasms (7), Cystic Fibrosis (6) and Type 1 Diabetes Mellitus (5). The average number of hospitalizations was 5.5, with a standard deviation of 4.84. With regard to their cities, 11 were from the same city of the hospital where the data were collected and the others from cities in that region or even from other states. Participants were accompanied by their mothers (25), sisters (2), grandmother (1), grandfather (1) and father (1).
Data analysis revealed two dimensions: Elements of the physical environment and material resources; and Elements of comfort and well-being environment.

Elements of the physical environment and material resources
In the first category, the interviewees revealed how they idealized the design and physical resources of the hospital, describing the wards, recreation space, cafeteria and the type of food provided. According to them, wards should be large and provide closets for personal items: There should also be a bathroom for the companions inside the wards, as this would allow them to always be close to the patients: There should be a bathroom for mothers here. There is a bathroom, but it's far away, I wanted a bathroom in the same room as the patients, so that when I needed my mom, she would be close. (Andressa, 12 years old, I. 22) They also suggested changing the color of health professionals' lab coats: Children and adolescents also suggested changes in the hospital design that favor subjectivity and, therefore, the care process. According to them, the environment should be comfortable and guarantee privacy and autonomy, which highlighted the second category.

Elements of comfort and well-being environment.
To reduce the number of beds, increase the size of the rooms and improve the circulation and interaction of people, a reorganization of the furniture and objects in the wards was suggested: The room is very small, on one side there are three beds, it even has more space than on the other side of the room which has four beds. It would be good to remove a bed, there would be three beds on both sides. (Bruno A., 14  Still thinking about providing more sleeping comfort, they recommended replacing the armchair available to the companions by a comfortable bed, next to them: They also suggested paintings in the wards that represented the children's universe, to make the environment more cheerful: [ According to them, the distance of family and friends could be reduced by using computers that provide Internet access. This would also allow distraction while on treatment and hospitalization: They also said that the communication between nutritionists and users should be more effective, so that they could inform their food preferences and, thus, improve food acceptance: They reported the extreme importance of recreation spaces, as they promote distraction and allow, even for brief moments, that they do not think about hospitalization: We get distracted with recreation, we paint, cut, do a new activity every day. (Sofia B., 11 years old, I. 16) The school is very nice [...], because they're trying to make us feel not as we were at a hospital, but at home, trying to make we get our routines back, this is really cool. (Helena, 16 years old, I. 29) Another recommendation was the creation of a music room, aiming to distract and alleviate the adverse effects of hospitalization:

DISCUSSION
At the moment we gave voice to the study participants to express themselves about what they considered important in the hospital environment, making it more welcoming, we faced a challenge to perform data collection. We tried many approaches to conduct the interviews until we find one that made the communication and interaction between the interviewees and the interviewer easier. Thus, we built a rich empirical material, corroborating the argument of some authors (1,3,8,10,12) about the fact that children and adolescents are able to express their experience in the hospital with a wealth of information, through verbal or non-verbal communication. They are also able to express their points of view through questionnaires, interviews, storytelling, drawing or playing. In the case of this study, they provided us with important information for the improvement of health services, contributing to care qualification.
With regard to the hospital environment in the care of children and adolescents, it must provide conditions to meet their biological and emotional needs, so that they can recognize aspects of their daily lives and some of their references in this place.
So, the first reflections on the environment as an element related to health conditions are made by Florence Nightingale. For her, clean air, light, heat, pure water, cleanliness, adequate food and a peaceful environment would not only favor the recovery of sick people, but were essential for people not to get sick (5) .
As seen in the reports, the interviewees wished for an environment of comfort, privacy and value for subjectivity, individuality and uniqueness, in addition to providing well-being, according to the Environmental Theory (9) , as well as the principles of humanization in health (14) and the hospital environment (15) .
Regarding comfortability principles, the idealized hospital would provide it not only for children and adolescents, but for everyone: companion, family, friends and health team. Therefore, wards should provide enough closets to store personal belongings, as well as water dispensers, comfortable beds and mattresses for a peaceful sleep, which is essential to restore physical exhaustion resulting from the hospitalization process, which is an essential need, especially for these people that needs to recover their health (25) . There would also be fans and air conditioning, to keep the environment cool and ventilated; the cleanliness would be rigorous and the environment colorful, translated into a welcoming environment.
A study (26) carried out with a total of 55 children attended at three children's hospitals in Ireland revealed a preference for colorful furniture and themes that represented the children's universe, fauna and flora, with geometric shapes windows and furniture. These studies, as identified in this research, concluded that hospital environments needed to be built not only to be appropriate for children, but also respecting their rights to dignity, privacy and family support.
Considering the comfortability principles for companions, the projected wards are in line with the Resolution of the Collegiate Board 50 (RCB 50) (27) and NHP (14) , for guaranteeing the right to the presence of a companion (20) and design a cozy and comfortable space for them to rest beside the bed of the children or adolescents. In addition, the wards would have their own bathrooms for the companions, in order to keep them close to their loved ones, since they are a source of emotional support (1,28) , in addition to promoting well-being (10) . Moreover, participants expressed the wish that other family members and friends could be present during hospitalization and, thus, suggested open visits, as recommended by the NHP (14) .
Communication with distant friends and family and also with the outside world could be encouraged if the projected institution provided computers and internet access, so that they could talk with friends and rescue, even partially, their routines. This would also allow, in addition to support and distraction, a disconnection from this disease and care environment (12) .
The right to privacy of hospitalized children and adolescents is proposed by the Statute of the Child and Adolescent (20) and was also valued in this study, as some participants suggested accommodation in individual suites, with private bathrooms, that could be locked. A research (4) carried out with a total of 130 children in a hospital in Turkey also showed the desire for greater privacy in the hospital environment, since 19.2% of participants reported a preference for single rooms and 15.4% for rooms with private bathrooms.
The absence of privacy can cause adverse effects throughout the hospitalization process, for example, depersonalization (11) , which implies the incorporation of hospital rules and norms to the detriment of considering particularities and singularities (29) . For this reason, health professionals are asked to provide care without violating the privacy of children and adolescents, in order to avoid adverse effects during hospitalization. However, the installation of keys in hospital rooms and bathrooms is controversial, as the Patient Safety Primer prohibits this action, as it understands that it does not offer safety. The document also warns of some unpredictable situations during the care process, such as falls (30) , which can aggravate the patients' health status, especially if they are in a locked place, which makes it difficult to provide care. Thus, health professionals should reflect on the subjectivities of each patient and the best way to provide privacy in the hospital environment.
Study participants emphasized the need to establish effective communication with the health team, which is a strong therapeutic tool, capable of helping to cope with stressors from hospitalization (31) . Also as a way of stimulating communication, the cafeteria would be bigger, accommodating all children and adolescents and serving a dual purpose: to be a space for meals and for meetings and conversations.
Still according to the reports, food preferences should be considered and meals offered in colorful trays, aiming at favoring the acceptance of diets. These findings are in line with the results of a prospective observational study conducted with a total of 58 children and adolescents between 1 and 16 years old hospitalized in a hospital in Canada. For the interviewees, the preparation of any hospital diet should respect and consider the individualities of each patient and, as far as possible, include foods of their preference, since the disease process can often cause a lack of appetite. The study also showed that the aesthetics of the dish is essential for food acceptance (32) .
As noted in the reports, the recreation space would be designed so that everyone could attend and participate in recreational activities, which are essential for hospitalized children and adolescents, as they are tools of great potential to minimize the suffering and trauma resulting from the situation experienced, in addition to essential for the motor, emotional, mental and social development of any child (33) . Political guidelines (15) recommend that a hospital has adequate space for recreation and leisure activities in pediatric units. Other health-promoting environments were also included in the projected hospital, such as the music room and outdoor space (solarium). Some studies have shown that music can contribute to a less traumatic hospitalization process for children and adolescents (34) , alleviating anxiety (34)(35) , anguish and fears, while providing beneficial effects of relaxation and tranquility that favor healthy and adaptive coping (33) .
Outdoor spaces, with different types of vegetation and leisure area, can promote well-being (15,33) , as they favor new friendships, socialization and subjectivity between hospitalized people and the health team. Thus, these spaces can mitigate the adverse effects of hospitalization (36) .
Corroborating the results of this study, Researches conducted in hospitals in the United States of America (37) and the Netherlands (10) showed that children and adolescents seek for hospitals that value comfortability, privacy, particularities and subjectivities, attributes similar to those mentioned by the participants of this study. Therefore, cancer treatment centers named Aquario Carioca were built in Rio de Janeiro-RJ, alluding to furniture and equipment with shapes and colors that resemble the seabed, as well as illustrations of reefs, fish, submarines and typical vegetation that make this space attractive, fun and cheerful. This environment, similar to the projected hospital, also advocates privacy, comfortability and the production of subjectivities. A study pointed out that the Aquario Carioca environment can directly interfere in the health/disease process, favoring the restoration of health (13) .
Therefore, it is noted that the results of this study help to understand the hospital environment and its implications for the well-being of hospitalized children and adolescents, as they reveal the perspective of those involved. Likewise, they may enhance interventions for the creation of therapeutic environments that promote development, capable of minimizing the adverse effects of hospitalization.

Limitations of the study
As a limitation of the study, it should be noted that interviews were conducted only with children older than 7 years old, which makes it impossible to have a deeper understanding of the phenomenon studied.

Contributions to the area of nursing, health or public policy
The reflections about the hospital environment, based on the contributions of children and adolescents, can subsidize public policies aiming to alleviating the trauma eventually caused by hospitalization. Likewise, they can also qualify health care, particularly nursing care, meeting the real needs of hospitalized children and adolescents and their families.

FINAL CONSIDERATIONS
From the results, we observed that the participants, when designing their own hospitals, advocated a model of care centered on the needs of hospitalized children and adolescents. The suggested changes contemplated not only architectural and material requirements but also modified the hospital environment, so that it valued the care process, subjectivity, privacy, individuality, and autonomy. In summary, the participants designed a space of dual function: place of healing and interactions.
These are important results, which can motivate reflections about care centered on the principles of humanization of health services and, therefore, contribute to the qualification of care, favoring a less traumatic hospitalization process.