By Terri Zborowsky, R.N., Ph.D., and Mary Jo Kreitzer, Ph.D., R.N.
As evidence about the benefits of healing environments accumulates, health care organizations are starting to incorporate features into hospital design that reduce stress and promote healing. This article discusses some of the research supporting healing design and provides examples of how it is being used in new construction and renovations.
When you think of a healing environment, what comes to mind? A spa? A Japanese garden? Perhaps a corner of your house? Few of us would immediately think of a clinic or hospital. But that view is beginning to change as health care organizations are becoming aware of the growing body of evidence that shows the benefits of a healing environment, and are incorporating ideas generated by such studies into new facilities.
Among other things, they’re taking to heart ideas from environmental psychology, sociology, geography, architecture, landscape architecture, interior design, nursing, medicine, and public health research that demonstrate how specific design changes in health care environments can reduce stress and alleviate the physical outcomes associated with it. These changes also can help prevent medical errors and hospital-acquired infections, while improving staff morale and efficiency.1 As Jain Malkin, a founding member of the Center for Health Design’s board of directors and an authority on healing environments, says, “the environment can influence the healing process.”2
Such insight comes at a time when the U.S. health care system is poised to spend hundreds of billions of dollars building new hospitals, nursing homes, and clinics to replace out-of-date facilities from the 1960s and ’70s and to respond to the demands of aging baby boomers who want cutting-edge care delivered in a comfortable environment.
But what exactly contributes to a healing environment? The answer is complex in part because it can vary based on a person’s culture and preferences.
The Healing Environment
The word “healing” comes from the Anglo-Saxon word haelen, which means to make whole. One way to understand the term is as harmony of mind, body, and spirit.
Healing is not the same as curing, which is about fixing problems, eradicating disease, and decreasing symptoms. People can be healed even if they are not cured. For example, those with a chronic disease can learn to be at peace despite their condition. Conversely, people may be cured but not healed. For example, a woman whose breast cancer had gone into remission could find herself grieving and angry about her losses and unable to function. Thus, healing environments are designed to promote harmony of mind, body, and spirit.
Such environments can reduce stress and anxiety, which positively affects our health in a number of ways. Neuroscience is showing that our brain and nervous, endocrine, and immune systems are constantly interacting. As neuroscientist Candace Pert said, “What you are thinking at any moment is changing your biochemistry.”3
Thus, a noisy, confusing hospital room might leave a patient not only feeling worried, sad, or helpless but also might raise his or her blood pressure and heart rate and increase muscle tension.4 In addition, hormones released in response to stress could suppress the patient’s immune system, causing wounds to heal more slowly.5
Just what contributes to healing is the subject of much research. The Samueli Institute, a nonprofit organization dedicated to research on healing, has developed a model that suggests that healing is the result of intention, personal wholeness, relationships, healthy lifestyle, collaborative medical care, healing organizations, and healing spaces.6 This inclusive view of what is needed for healing is not new. Thousands of years ago, the Greeks designed temples that surrounded patients with nature, music, and art to restore harmony and promote healing. In the 19th century, Florence Nightingale spoke of the importance of natural light, fresh air, and quiet for healing, saying that health care providers should put the patient in the best possible condition so that nature can act and healing occur.
Evidence for Creating a Healing Environment
A number of studies have linked the physical environment of hospitals to health outcomes. According to Ulrich and Zimring, more than 600 articles that illustrate how aspects of health care design can influence patient outcomes have been published.1 Much of this research has shown that the conventional way hospitals have been designed with their bland color schemes, hallways that echo, cramped patient rooms, and loud, overhead paging systems, contributes to stress.
This not only can hinder a patient’s ability to heal but also can affect the productivity of staff. Because of poor design, nurses in most hospitals spend a great deal of time gathering what they need to provide care. One study showed that almost one-third of nurses’ time was spent walking. If facilities were designed more efficiently, nurses could instead spend that time with patients.1
Evidence that good design can have the opposite effect is mounting. Malkin has identified the following ways research is showing how organizations can adapt health care facilities in order to alleviate stress and ultimately improve patient outcomes:7
Increase connection to nature. A number of studies have presented strong evidence that even 3 to 5 minutes of contact with nature can significantly decrease stress, reduce anger and fear, and increase pleasant feelings.8-11 This calming effect can be achieved by providing views to the outside, interior gardens or aquariums, or artwork with a nature theme.
Offer options and choices. Giving patients a sense of control can significantly decrease stress. Hospitals can do this by allowing them to adjust lighting and temperature, choose the music they want to listen to, select where they would like to sit, and control the timing of meals. In addition, better wayfinding (signs and information about where to go) lessens disorientation. Also, a thoughtful layout that makes it easier for frail patients to get around by themselves increases their independence, giving them a greater feeling of control.
Provide positive diversions. A study by Ulrich showed that heart surgery patients in intensive care units who viewed landscape scenes reported less anxiety and stress and needed fewer pain medications than a control group that was not exposed to the pictures.12 Diversions that have a calming effect may include artwork depicting scenes of nature (not abstract art, which has actually proved to have the opposite effect), fireplaces, videos of nature, and aquariums.
Provide access to social support. An extensive amount of research has shown that support from family and close friends can help in healing. For example, Uchino and Garvey found that having social support accelerates recovery in heart patients and improves the emotional well-being and quality of life of late-stage cancer patients.13 Hospitals can promote social support by providing waiting rooms and lounges with comfortable furniture, designing patient rooms that accommodate visitors, and providing amenities that make it easier for family members to stay overnight.
Reduce environmental stressors. Recent studies have shown that excessive noise, glare, and poor air quality can create stress as is evidenced by increased heart rate and blood pressure and reduced oxygen levels in the blood in both adults and babies who are exposed to these environmental concerns.4,14-16 Good design can dampen noise from paging systems, equipment, alarms, roommates, and staff, making hospitalization less stressful and more restful for patients.
Healing and Health Care Design Trends
Most of the hospitals and clinics built in the 20th century were not designed for patients and their loved ones and, thus, were not designed to promote healing. Consider, for example, how the focus of many hospital rooms is on somewhat frightening medical equipment. Hallways are painted practical-but-depressing hospital green, and floors are covered with noisy, but easy-to-clean, linoleum or vinyl.
Some have gone so far as to compare hospitals to prisons: Both institutional environments offer few concessions to aesthetics. In both settings, clothing and personal effects are taken away, and the inmate/patient has few choices about where they can go, what and when they can eat, and how long friends and family members can visit. However, this is beginning to change as health care organizations move toward a more patient-centered and holistic care-delivery model that takes into consideration the needs and preferences of patients, family members, and staff. In order to create environments that work in harmony with this model, organizations are using Malkin’s guidelines to alleviate stress and anxiety among patients. They are also using evidence from the quality-improvement movement to add features that reduce the chance of contracting a hospital-acquired infection, improve workflow patterns and processes, and increase patient safety by reducing falls and medical errors. This emphasis on creating facilities that promote safety and healing are showing up in the following design trends:
Private rooms. Most facilities today are building rooms that accommodate only 1 patient. In fact, the American Institute of Architects’ 2006 edition of its Guidelines for Design and Construction of Health Care Facilities, which is used by the Joint Commission for the Accreditation of Healthcare Organizations and several federal agencies that review designs, construction plans, and completed health care facilities, notes that all new hospital construction will include single-patient rooms.
Private rooms reduce the risk of infection. They are also more efficient, as the area set aside for staff may include a sink for hand washing, storage for supplies, and a computer for charting or retrieving records.
Private rooms are often designed to provide access to the patient’s support network and give patients a greater sense of control. They have amenities for loved ones such as sofas that covert to a bed, separate reading lights, and Internet access. They may also have a small refrigerator to store homemade food, lighting and window blinds that can be controlled from the bed by the patient, and wall-mounted flat-screen televisions.
In addition to having more privacy at a time when they are most vulnerable, patients in private rooms have their sleep interrupted less often and can talk more freely with caregivers when discussing private matters.
Acuity-adaptable rooms. These rooms allow a patient to stay in the same place, rather than be transferred as their need for more or less intense care changes. Designed for a single patient, these rooms have access to medical gases and power sources that can support critical care and portable equipment that can be brought in and out as the patient’s needs change.
Park Nicollet Heart and Vascular Center, St. Louis Park
The patient and waiting areas on Park Nicollet’s Methodist Hospital campus were designed to look out over a wetland, which is part of the Minnehaha Creek Watershed District, and bring in daylight.
Photo by George Heinrich, courtesy of Ellerbe Becket
This type of room may reduce medical errors because care of the patient is not handed off from the staff in one department to staff in another part of the hospital.17 They also cultivate healing relationships because patients may have the same nursing staff during their entire stay. Thus staff, patients, and family members get to know and become comfortable with each other.
Indoor gardens, aquariums, and landscapes to bring nature into the environment. Current design standards encourage the use of large windows in patient areas that allow patients and their visitors to see outside and receive the benefits of natural light (Figure). Patients in rooms that receive more sunlight may be less depressed and have shorter stays. For those reasons, windows are now considered a therapeutic component of patient rooms.
Hospitals are also adding healing or therapeutic gardens. One newly designed facility created an interior healing garden that is accessible from the intensive care unit. The goal was to offer the healing benefits of nature to patients, families, and staff in highly stressful situations.
Less noise. Hospitals are attempting to both reduce the sources of noise (for example, by eliminating overhead paging) and improve soundproofing with sound-absorbing ceilings and carpeting in order to reduce stress. Carpet alone can reduce ambient noise by up to 70%.18 Architects are also attempting to reduce noise when designing a facility’s infrastructure by wrapping ducts, providing higher levels of soundproofing in the walls, and building walls to the deck of the floor above. Designers are also paying attention to the location of pneumatic tube stations and ice makers, both of which can be sources of noise 24 hours a day.
Better wayfinding. Facilities are using color, images, and signage to better orient patients and families and help them find their destination. Designers also recognize the importance of providing windows that look out on exterior landmarks that might help people navigate large, complex facilities.
Lounges and waiting rooms with a purpose. Hospitals need large spaces where patients and families can come together to celebrate or grieve. They also need smaller, quiet places where individuals can go off by themselves to find peace.
Staff also require different spaces to meet their various needs. One facility added a large break room as well as a smaller private room where staff members can make phone calls or grieve the death of a patient.
Can the built environment affect healing? The early Greeks who built healing temples intuitively knew the answer. Today, however, administrators charged with building and renovating health care facilities can rely on research in order to use their limited resources in a way that offers the most benefit to patients, family members, and staff. In order to justify their decisions, they are arming themselves with evidence that shows the beneficial effect of a view of nature on a patient’s stress level or of a private room on infections and medical errors. Continued research demonstrating these and other benefits of facility design on patient well-being will go a long way toward changing the standard in hospital facility design. MM