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Health Implications of Indoor Plants: Oxygen Consumption, Moisture, Mold, and Respiratory Risk in Home and Office Environments
- Aug 8
- 20 min read
Author: Fatima Al Mansouri
Affiliation: Swiss International University (SIU)
ORCID ID: 0009-0003-3004-395X
Submitted 10 April 2026; Revised 05 June 2026; Accepted 20 July 2026; Available online 08 August 2026; Version of Record 08 August 2026.
Doi: https://doi.org/10.65326/u7y10028
Volume 3, December 2026, (10028)
Abstract
Indoor plants are widely seen as harmless additions to homes, offices and schools, valued for oxygen, air purification and comfort. This article argues that the health question is more complex. In ordinary rooms, oxygen depletion by potted plants is unlikely to be a meaningful risk, because plant respiration is small relative to room air volume and human respiration. More relevant risks arise from conditions plants can create or intensify: wet soil, poor drainage, damp surfaces, microbial growth, dust and allergens. Combining a literature review with an 18-month comparison of ten educational institutions (five with indoor plants, five with greenery outdoors only), the study examined breathing comfort, moisture, maintenance and absence. The findings do not support a causal claim that plants alone determine health or performance, but plant-free indoor spaces were easier to clean and keep dry, and more consistently linked to comfortable breathing. The article shifts attention from the oxygen myth to the practical governance of moisture, ventilation and maintenance, drawing on symbolic capital and institutional isomorphism to explain why schools adopt indoor planting despite uncertain health value. It concludes that schools should prioritize ventilation, dry surfaces, humidity control and outdoor greenery over permanent indoor planting.
Keywords: Indoor plants; Indoor air quality; School health; Respiratory risk; Dampness and mold; Ventilation
1. Introduction
Indoor plants occupy a familiar place in homes, offices, schools, clinics, hotels and public institutions. They are visually associated with freshness, care, environmental awareness and comfort. In schools, plants may also have educational value, because they can support lessons about growth, ecology and responsibility. These design and pedagogical functions are legitimate, but they do not settle the environmental-health question. A classroom is not only a decorated room; it is a shared breathing environment used for long periods by children, teachers and staff, including people with asthma, rhinitis, allergies or other respiratory sensitivities.
The most common justification for indoor plants is that they add oxygen and purify indoor air. This argument is built on a biological truth: in sufficient light, plants photosynthesize and release oxygen. The argument becomes weaker when it is transferred to ordinary rooms, where light may be poor, ventilation may be variable and plants also respire. Respiration occurs continuously, including at night and in low-light conditions. The amount of oxygen consumed by typical potted plants is nonetheless very small in relation to the oxygen available in a normal room. A health argument focused mainly on oxygen depletion therefore risks overstating a minor mechanism while ignoring more plausible risks.
The more important concern is the microenvironment around the plant. Potted plants usually require soil, watering and organic matter. When soil remains wet, pots drain poorly, dead leaves accumulate or plants are placed on porous surfaces, they may contribute to dampness, microbial activity, dust and odors. These factors are particularly relevant in schools, where rooms may be crowded, cleaning routines may be stretched, windows may remain closed for climate or pollution reasons, and children may touch soil or leaves. Indoor environmental quality in schools has been linked to health symptoms, absence and learning conditions in a substantial body of research (Daisey et al., 2003; Sadrizadeh et al., 2022; Wargocki et al., 2020; Wargocki and Wyon, 2017). Dampness and mold exposure have also been repeatedly associated with respiratory and allergic outcomes (Caillaud et al., 2018; Fisk et al., 2007; Fisk et al., 2019; Jaakkola et al., 2013; Mendell et al., 2011; Mudarri and Fisk, 2007; Quansah et al., 2012).
The research gap addressed here is not whether plants can look pleasant or whether vegetation has value. The gap is narrower and more practical. The literature often treats plant benefits, dampness risks, ventilation research and institutional symbolism separately, but it rarely asks whether permanent decorative planting inside educational buildings is a prudent indoor-air practice once maintenance capacity, respiratory sensitivity and shared occupancy are taken seriously. Existing plant-air-quality studies also caution that chamber findings cannot be generalized directly to real buildings (Cummings and Waring, 2020). This article therefore examines indoor plants as part of a wider institutional and environmental system rather than as isolated decorative objects.
The article has three aims. First, it distinguishes the oxygen myth from more credible moisture and respiratory risks. Second, it reports an 18-month observational comparison of educational institutions with and without permanent indoor plants. Third, it develops a theoretical explanation for why schools may adopt indoor plants as a symbol of care and sustainability even when the health case is uncertain.
2. Background and Theoretical Framework
2.1 Plants and oxygen balance
Plant physiology matters, but it should be interpreted proportionately. Photosynthesis depends on adequate light, while respiration occurs continuously. A medium-sized room may contain thousands of liters of oxygen; the amount used by one or several potted plants overnight is small compared with this volume and much smaller than the oxygen demand of the human occupants. This does not mean that plants function as meaningful oxygen-management systems. It means that both popular claims should be treated carefully: ordinary indoor plants are unlikely to create direct oxygen deficiency, but they also should not be presented as substitutes for ventilation.
Indoor air quality is governed mainly by source control, ventilation, filtration, humidity control and maintenance. Research on schools shows that classroom ventilation is frequently inadequate and that better ventilation is associated with reduced illness absence and stronger learning conditions (Bako-Biro et al., 2012; Fisk, 2017; Haverinen-Shaughnessy et al., 2011; Haverinen-Shaughnessy and Shaughnessy, 2015; Mendell et al., 2013). Studies of office environments also show that ventilation, carbon dioxide and volatile organic compounds can affect cognitive performance and perceived indoor quality (Allen et al., 2016; Satish et al., 2012). Against this evidence, decorative plants should be understood as a minor and highly context-dependent element, not as a primary air-quality intervention.
2.2 Moisture, mold and bioaerosols
The strongest health concern is not oxygen but damp organic material. Indoor dampness and mold are consistently associated with respiratory and allergic symptoms across multiple reviews and meta-analyses (Caillaud et al., 2018; Fisk et al., 2007; Fisk et al., 2019; Jaakkola et al., 2013; Kanchongkittiphon et al., 2015; Mendell et al., 2011; Mudarri and Fisk, 2007; Quansah et al., 2012). Schools and day-care settings are especially important, because children and staff spend long hours in shared rooms and because maintenance problems can persist unnoticed. Bioaerosols are dynamic: biological particles can be emitted, resuspended, deposited and removed through ventilation, cleaning and filtration (Cox et al., 2020; Nazaroff, 2016). Wet soil, decaying leaves and dusty surfaces may not automatically create harmful exposure, but they add unnecessary complexity to environments that should be easy to clean and keep dry.
2.3 Indoor plants and air-cleaning claims
The idea that indoor plants purify air became prominent partly because sealed-chamber studies showed that plants, or plant-associated microorganisms, could remove selected volatile organic compounds. Real buildings are different. Doors open, people move, ventilation dilutes pollutants, cleaning products emit chemicals and pollutant sources vary over time. Reviews have therefore questioned whether potted plants can meaningfully improve indoor air quality under ordinary building conditions (Cummings and Waring, 2020; Han and Ruan, 2020; Ravindra et al., 2022). Recent evidence suggests that plants may influence relative humidity more than carbon dioxide or temperature in some office settings (Jiang et al., 2024). In a dry climate this may sometimes be perceived as comfortable, but in poorly ventilated or moisture-sensitive rooms, added humidity can be undesirable.
2.4 Symbolic capital
Bourdieu’s concept of symbolic power helps explain why indoor plants retain institutional appeal (Bourdieu, 1989). A green reception area or a plant-filled classroom can signal care, modernity, environmental awareness and taste. These symbolic meanings are socially powerful, because visitors, parents and staff may interpret greenery as evidence of wellbeing. The problem is not the symbolism itself; it arises when symbolic health is mistaken for measured or well-managed health.
2.5 Institutional isomorphism
DiMaggio and Powell’s theory of institutional isomorphism explains why practices spread even when their technical value is uncertain (DiMaggio and Powell, 1983). Schools may copy the green corners, biophilic design language or reception-area plants used by other institutions. Over time, a decorative practice can become normalized, and its maintenance burden may be overlooked. This article therefore treats indoor planting as both an environmental object and an institutional practice.
2.6 Equity and context
Indoor plant risk is not uniform. A bright, spacious, well-ventilated building with trained facility staff is different from a crowded, humid, under-maintained one. Hot climates may keep windows closed because of air conditioning; cold climates may keep them closed for heat retention; polluted urban environments may keep them closed to avoid outdoor pollutants. In each case, the same potted plant may carry different implications for moisture, cleaning and user comfort. A precautionary school policy should therefore consider local climate, ventilation, occupant vulnerability and maintenance capacity.
3. Methodology
3.1 Research design
The study used a qualitative comparative case-study design, supported by an observational component and a focused review of the environmental-health literature. The design was appropriate because the research question concerns institutional practice, maintenance conditions and perceived indoor comfort rather than clinical diagnosis. The study did not seek to isolate a single biological cause; it examined whether permanent indoor plants formed part of a broader pattern of indoor environmental risk in educational settings.
3.2 Case selection
Ten schools or educational institutes were observed over 18 months. The cases were selected to create a practical contrast between two institutional approaches. Group A included five institutions that kept potted plants inside classrooms, corridors, reception areas, staff rooms or shared learning spaces. Group B included five institutions that maintained plants outside only, such as in gardens, entrance landscaping, courtyards or exterior planters, without permanent soil-based plants in indoor learning spaces. The comparison was designed to preserve the original observational logic while improving analytical clarity: the unit of analysis was the institution as an indoor environmental system, not the individual plant. Table 1 summarizes the characteristics of the two groups.
Table 1. Characteristics of the two institutional groups.
Feature | Group A – Indoor-plant institutions | Group B – Plant-free indoor institutions |
Number of institutions | 5 | 5 |
Plant location | Inside classrooms, corridors, reception areas, staff rooms and shared learning spaces | Outdoors only: gardens, entrance landscaping, courtyards and exterior planters |
Permanent indoor soil-based plants | Present | Absent |
Observation period | 18 months | 18 months |
Unit of analysis | Institution as an indoor environmental system | Institution as an indoor environmental system |
3.3 Scope and data sources
Data consisted of repeated site observations, field notes on visible moisture and maintenance conditions, informal non-identifiable feedback from staff where available, and institutional-level attendance and learning-stability impressions where institutions could share such information in general terms. No medical examinations, lung-function tests, personal health records or laboratory air samples were collected. The analysis therefore does not make clinical claims. It reports institutional patterns and interprets them in light of established evidence on dampness, mold, ventilation and classroom air quality.
3.4 Observation focus
The observations focused on six domains, set out in Table 2: the location and density of indoor plants; watering and drainage conditions; visible signs of dampness, staining, dead leaves, odor, insects or dust; the cleanability of surfaces around pots; perceived breathing comfort in classrooms and corridors; and general patterns of absence or learning continuity, as described or observed at the institutional level. Attention was also given to plausible confounders, including building age, crowding, ventilation habits, cleaning routines, climate conditions, management discipline and room use. Teacher-reported building-related symptoms and child respiratory symptoms in moisture-damaged schools provide relevant support for including these domains in school observations (Casas et al., 2017; Kielb et al., 2015).
Table 2. Observation domains and the indicators recorded for each domain.
Observation domain | Indicators recorded |
1. Location and density of indoor plants | Placement (classrooms, corridors, reception, staff rooms); number and concentration of pots per space |
2. Watering and drainage | Watering regularity; standing water; drainage adequacy; presence of an assigned caretaker |
3. Visible dampness and contamination | Damp soil, water marks, staining, dead leaves, musty odor, insects, dust accumulation |
4. Cleanability of surfaces | Porous vs. non-porous surfaces around pots; clutter; ease of inspection and cleaning |
5. Perceived breathing comfort | Staff and student descriptions of air as clear, dry, heavy or musty near plant locations |
6. Absence and learning continuity | Institution-level patterns of attendance and learning stability described or observed over time |
Confounders considered | Building age, crowding, ventilation habits, cleaning routines, climate, management discipline, room use |
3.5 Analytical procedure
The analysis used cross-case pattern matching. First, the field notes from the indoor-plant group were compared with those from the plant-free indoor group. Second, repeated observations over the 18-month period were distinguished from one-time events. Third, the emerging patterns were interpreted conservatively against the literature. A pattern was treated as meaningful only when it appeared repeatedly or coherently across cases; it was not treated as proof of causation. This conservative approach is important because absence and academic performance are shaped by many factors beyond the indoor environment.
3.6 Ethical scope
The study relied on non-identifiable institutional observations and did not collect personal medical data, individual student records or identifiable participant responses. It should therefore be read as an environmental and organizational case comparison rather than as human-subject clinical research.
4. Analysis and Findings
This section reports the cross-case patterns observed over the 18-month period. Table 3 summarizes the comparative observations across the six domains for the two groups, and Figure 1 presents these patterns as a graphical summary. The detailed findings and their associated propositions follow, and are consolidated in Table 4.
Table 3. Comparative summary of observations across the two groups over the 18-month period.
Observation domain | Group A – Indoor-plant institutions | Group B – Plant-free indoor institutions |
Oxygen-related risk | No indication of measurable oxygen depletion; oxygen claims sometimes used to justify planting | No indication of measurable oxygen depletion; ventilation framed as the main air concern |
Moisture and maintenance | Recurrent damp soil, inconsistent watering, water marks, dead leaves and occasional musty odors | Fewer soil-based and water-retaining objects; simpler moisture control |
Cleanability of spaces | More cluttered corners, organic residues and objects requiring specialized maintenance | Fewer cluttered corners and organic residues; easier inspection and cleaning |
Perceived breathing comfort | Occasional reports of heaviness, musty smell or discomfort near plant locations | Rooms more often described as clear, dry and easier to breathe in when ventilated |
Absence and learning continuity | No causal pattern identified; influenced by many external factors | Cautiously more stable attendance and learning routines during parts of the period |
Symbolic value | Plants prominent in visible spaces, signaling care; able to mask maintenance problems | Care signaled through outdoor greenery and tidy, dry indoor spaces |
Figure 1. Graphical summary of the comparison between indoor-plant and plant-free indoor learning spaces, highlighting the shift in emphasis from the oxygen myth toward moisture, maintenance and respiratory comfort.
4.1 Oxygen was not the main risk
The first finding is that the oxygen argument is often misunderstood. Plants do respire and therefore use oxygen, particularly when photosynthesis is limited. In normal indoor settings, however, oxygen use by ordinary potted plants is too small to explain meaningful oxygen deficiency. The more important implication is educational and managerial: the belief that plants oxygenate rooms can create false confidence and distract schools from ventilation, source control and moisture management (Cummings and Waring, 2020; Fisk, 2017).
Proposition 1. In ordinary educational rooms, indoor plants are unlikely to create direct oxygen depletion, but oxygen-related claims can mislead institutions when they are used to justify permanent planting without adequate ventilation and maintenance.
4.2 Moisture and maintenance were the strongest practical concerns
The indoor-plant institutions showed more visible plant-related maintenance issues. These included damp soil, inconsistent watering, water marks near pots, dead leaves left in containers, plants placed near porous materials and occasional musty odors. These observations do not prove harmful exposure, but they are consistent with the literature identifying dampness and mold as preventable respiratory risk factors (Caillaud et al., 2018; Fisk et al., 2007; Fisk et al., 2019; Jaakkola et al., 2013; Kanchongkittiphon et al., 2015; Mendell et al., 2011). The plant-free indoor institutions had fewer soil-based and water-retaining objects in learning areas, which made cleaning and moisture control simpler.
Proposition 2. Where maintenance is inconsistent, permanent indoor plants can become avoidable moisture-management liabilities in schools, especially when soil, pots and surrounding surfaces remain damp.
4.3 Plant-free indoor spaces were easier to keep clean and dry
The comparison suggested that classrooms and corridors without potted plants had fewer cluttered corners, fewer organic residues and fewer objects requiring specialized maintenance. Cleanability is a practical indoor-health variable. It is not only a matter of visual tidiness; it affects dust accumulation, inspection routines and the ability to identify dampness quickly. This finding aligns with the broader principle that source control and maintenance are central to indoor environmental quality (Cox et al., 2020; Daisey et al., 2003; Nazaroff, 2016; Sadrizadeh et al., 2022).
Proposition 3. Plant-free indoor learning spaces may support better environmental control because they reduce unnecessary damp organic material and simplify cleaning, inspection and maintenance routines.
4.4 Perceived breathing comfort favored the plant-free indoor group
Across the observation period, staff and students in plant-free indoor settings more often described rooms as clear, dry or easier to breathe in, particularly when the rooms were ventilated and uncluttered. In the indoor-plant group, feedback occasionally mentioned heaviness, a musty smell or discomfort near plant locations. These reports are subjective and cannot be treated as clinical outcomes. They are nevertheless relevant, because perceived air quality influences comfort and may shape attention, fatigue and satisfaction in educational settings (Allen et al., 2016; Satish et al., 2012; Wargocki et al., 2020; Wargocki and Wyon, 2017).
Proposition 4. Plant-free indoor policies may improve perceived breathing comfort when combined with ventilation, dry surfaces and disciplined cleaning routines.
4.5 Absence and learning stability showed a cautious favorable pattern
The plant-free indoor institutions appeared to show more stable attendance and learning routines during parts of the observation period. This finding must be stated carefully. Absence is affected by infections, family decisions, transport, seasonality, school policy, socioeconomic background and many other variables. Academic performance is affected by teaching, curriculum, leadership and student background. The study therefore does not claim that removing plants directly reduces absence or raises grades. The more defensible interpretation is that simpler, cleaner and drier indoor environments may support attendance and learning conditions indirectly, which is consistent with research linking classroom ventilation and air quality with absence and performance (Bako-Biro et al., 2012; Haverinen-Shaughnessy et al., 2011; Haverinen-Shaughnessy and Shaughnessy, 2015; Mendell et al., 2013; Wargocki et al., 2020).
Proposition 5. Plant-free indoor environments should be understood as one component of a broader preventive strategy that may support attendance and learning continuity, rather than as an independent determinant of academic outcomes.
4.6 Indoor plants carried symbolic value
The indoor-plant institutions often used plants in visible spaces such as entrances, corridors and shared rooms. In these settings, plants communicated care, naturalness and institutional warmth. This symbolic value is understandable and may improve first impressions. However, it can also obscure maintenance risk. A plant can look healthy while its soil is damp, its leaves are dusty or its pot is leaking. The symbolic analysis matters because many school decisions are not purely technical; they are shaped by what appears modern, caring and legitimate (Bourdieu, 1989; Bringslimark et al., 2009; DiMaggio and Powell, 1983).
Proposition 6. Indoor plants can function as symbolic capital in educational institutions, but symbolic indicators of care should not be allowed to replace evidence-based indoor environmental management.
Table 4. Summary of the main findings and their associated analytical propositions.
Finding | Key observation | Proposition |
4.1 Oxygen | No measurable oxygen depletion; oxygen claims can create false confidence | P1: Oxygen claims can mislead when used to justify planting without ventilation |
4.2 Moisture | Recurrent damp soil, water marks, dead leaves and musty odors in the plant group | P2: Indoor plants can become avoidable moisture liabilities where maintenance is weak |
4.3 Cleanability | Plant-free spaces had fewer residues and were easier to inspect and clean | P3: Plant-free spaces simplify cleaning, inspection and moisture control |
4.4 Comfort | Plant-free rooms more often described as clear and easier to breathe in | P4: Plant-free policies may improve perceived comfort alongside ventilation |
4.5 Absence/learning | Cautiously more stable attendance in plant-free settings | P5: Plant-free spaces are one component of a broader preventive strategy |
4.6 Symbolism | Plants signaled care but could mask maintenance problems | P6: Symbolic care should not replace evidence-based management |
5. Discussion
The findings support a cautious and proportionate position. Indoor plants should not be described as inherently dangerous. A small, well-maintained plant in a bright, ventilated, non-crowded area may create little risk. The stronger argument is not prohibition in every possible setting but prevention in high-occupancy learning spaces, where children or sensitive users share air for long periods. In such spaces, avoidable sources of damp soil, dust and microbial growth should be minimized unless there is a clear educational purpose and a clear maintenance protocol.
The article contributes to indoor environmental quality research by reframing the indoor-plant debate. Much public discussion treats plants either as oxygen producers or as natural air purifiers. This framing is too narrow. The more useful framework is environmental governance: who waters the plant, how drainage is managed, whether surfaces can be cleaned, whether soil remains wet, whether leaves collect dust, whether humidity is monitored, and whether the room has adequate air exchange. This shift moves the debate from plant symbolism to facility-management responsibility.
The article also contributes to school-health debates by connecting respiratory risk with everyday design practices. Research on ventilation, dampness and classroom air quality already shows that learning environments are health environments (Daisey et al., 2003; Fisk, 2017; Sadrizadeh et al., 2022; Wargocki et al., 2020). The present study adds a practical micro-level issue: decorative soil-based objects can become part of the indoor environmental burden when they are unmanaged. This contribution is modest but important, because many school risks are not dramatic hazards; they are small, repeated, preventable conditions that accumulate through routine neglect.
The theoretical contribution is to show how symbolic capital and institutional isomorphism help explain why potentially weak practices persist. Plants may be adopted because they make schools look caring, ecological and modern. Once adopted by many institutions, the practice becomes normal and may escape scrutiny. This does not mean that all symbolic practices are harmful. It means that institutional symbols should be tested against health, maintenance and equity criteria. A healthy school is not defined by how green it looks indoors, but by whether its indoor spaces are dry, clean, ventilated and safe for vulnerable users.
The findings also refine debates on biophilic design. Exposure to nature and greenery can support wellbeing, and the psychological literature recognizes potential benefits of indoor plants in some contexts (Bringslimark et al., 2009). The present argument does not reject greenery; it relocates greenery. Outdoor gardens, courtyards, balcony planting, supervised short-term classroom experiments and exterior landscaping can support ecological education while reducing permanent indoor moisture sources. This distinction matters, because it allows schools to preserve environmental learning without treating permanent indoor planting as a health intervention.
6. Practical Implications
• Schools and institutes should avoid using indoor plants as an air-cleaning or oxygen-management strategy. Ventilation, filtration, humidity control, low-emission materials and systematic cleaning are more reliable measures.
• Permanent indoor plants should be avoided in classrooms, nurseries, sleeping rooms, libraries with poor ventilation, crowded corridors, carpeted areas and rooms used by children with known respiratory sensitivity.
• Where plants are kept indoors for limited decorative purposes, they should be few in number, placed on non-porous cleanable surfaces, kept away from carpets and books, watered only under assigned responsibility and removed immediately if there is mold, odor, insects, water leakage or decaying material.
• Environmental education should prioritize outdoor gardens, exterior planting, supervised laboratory activities and temporary experiments with clear cleanup procedures.
• Schools should treat humidity, dampness and ventilation as routine governance issues, not as problems to be addressed only after visible mold or complaints appear.
7. Limitations and Future Research
This study has limitations. It was observational and qualitative, not randomized or clinical. The number of institutions was small, and the cases were not statistically representative. The study did not include air sampling, microbial identification, lung-function testing, medical records or standardized psychometric measures of perceived air quality. Absence and academic performance were interpreted cautiously, because they are influenced by many institutional, social and seasonal factors. The findings should therefore be understood as analytical and preventive propositions rather than as causal estimates.
Future research should test these propositions with larger mixed-method designs. Useful studies would combine standardized building inspections, humidity monitoring, ventilation-rate measurement, microbial sampling, occupant symptom surveys and anonymized attendance data. Experimental or quasi-experimental studies could examine schools before and after removing permanent indoor plants while controlling for cleaning, ventilation and season. Further research should also distinguish between climates, building types, plant species, soil media, watering protocols and room uses. Such work would help move the debate from general claims about plants to evidence-based guidance for specific educational environments.
8. Conclusions
Indoor plants are not a major direct oxygen-depletion risk in ordinary rooms, but the oxygen debate is the wrong center of attention. In schools and other shared learning spaces, the more credible concern is moisture, mold, microbial activity, dust, allergens and uneven maintenance. The 18-month comparison reported here suggests that plant-free indoor learning spaces can be easier to keep clean, dry and comfortable, while outdoor greenery can still support environmental learning.
The contribution of this article is both practical and theoretical. Practically, it recommends a precautionary shift from decorative indoor planting toward ventilation, humidity control, dry surfaces and outdoor greenery. Theoretically, it shows how indoor plants can operate as symbols of care and modernity even when their health value is uncertain. For educational institutions, the safest message is simple: greenery is valuable, but shared indoor air should be governed by evidence, maintenance capacity and respiratory protection rather than by appearance alone.
Funding
No specific funding was received for this research from public, commercial or non-profit organizations.
Data Availability Statement
The study is based on non-identifiable institutional observations and literature analysis. No personal medical data or identifiable participant data were collected. Additional raw field notes are not publicly shared, because they could indirectly identify the institutions.
Ethics Statement
The study used non-identifiable institutional observations and did not involve clinical testing, intervention, personal health records or identifiable human-subject data. Formal ethics approval was therefore not required under the scope of this environmental and organizational case analysis.
Declaration of Competing Interest
The author declare no conflict of interest.
Declaration on the Use of Artificial Intelligence
Artificial intelligence tools were used only to improve the language, style and editing of the manuscript. The ideas, theory, analysis, interpretation and final decisions were made by the author. The author take full responsibility for the content and integrity of the manuscript.
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