“Although the premise that physical environment affects well-being reflects common sense, evidence-based design is poised to emulate evidence-based medicine as a central tenet for healthcare in the 21st century.”

—Colin Martin

This quote from The Lancet, a wellknown medical journal published in the United Kingdom, is evidence of how far the field of evidence-based design has come.

But what is evidence-based design?

Like evidence-based medicine, it is research-informed, and its results affect not only patients' medical outcomes, but also staff satisfaction and facility operations. It looks at building design as involving not only physical space, but also the total sensory environment of sight, sound, touch and smell. Evidence-based design research is divided into five areas:


1. Access to nature. Access-to-nature research focuses on human response to exposure to indoor plants and gardens, outdoor gardens, views of nature (both artificial and real) and natural light. One study, for instance, looked at psychiatric patients' length of stay in sunny versus non-sunny rooms; patients in sunny rooms stayed an average of 16.9 days, while patients in non-sunny rooms stayed 19.5.

2. Control. This research area focuses on patient options and choice, access to privacy and wayfinding. Research on hospitalized patients, as well as hospital employees and workplaces, has demonstrated that a sense of control is important to people's feelings of self-esteem and security. Lack of control can lead to results such as depression, passivity, elevated blood pressure and reduced immune function. The more a person has a sense of control over his or her environment, the more he or she might be able to manage the negative effects of a source of stress.

3. Positive distractions. Distractions such as nature, water, play areas, art, music, etc.—i.e., positive distractions, in that they provide a moderate level of positive stimulation—can foster a sense of engagement and well-being. Evidence shows that a lack of positive stimulation can be numbing and depressing for patients. Research in environmental psychology finds several specific sources of positive distraction, such as (1) happy, laughing faces, (2) presence of pets or unthreatening animals and (3) nature elements, such as trees, plants and views of natural landscapes. In one study, researchers compared the pain levels of patients undergoing laceration repair surgery with or without headset music. Patients with headset music perceived noticeably less pain.

4. Social support. This includes provision of support for family members and display of cultural sensitivity. Also, healing environments provide space and structure for social interaction. Environmental psychologists researching healthcare and workplace situations have found that individuals with a high level of social support experience less stress and greater wellness. People with lower levels of social support experience both higher rates of illness and less favorable recovery indicators. For example, cardiac patients with a higher level of social support recover more quickly from heart attacks and have more favorable long-term survival rates.

Social interaction in healthcare facilities can be influenced by furniture placement and floor/room layouts. Heavy or unmovable furniture inhibits social interaction, while comfortable, movable furniture that can be arranged in small, flexible groups can facilitate it. Although more research is needed, healthcare designers and space planners are initiating layouts that increase social support, including multiple-family waiting areas, and locating these areas closer to patient rooms.

5. Environmental stressors. This area encompasses research on noise, glare/light levels and indoor air quality.

Environmental elements can increase stress if their disturbing presence is difficult to minimize. A patient who is awakened by the hospital paging system, or has his/her sleep disturbed by employees talking in the hallway, is likely to experience the negative effects of stress.

Patients and visitors must often cope with sources of negative distractions. Waiting in a crowded lobby or sitting in stiff, unmovable chairs while a television blares, without control over programming or sound levels, certainly requires dealing with a stressful environment. Designers are introducing layouts, furnishings and processes that reduce such negative distractions and, ideally, replace them with positive distractions.

In looking at the social and economic factors that are influencing today's healthcare industry, we see that evidence-based design will continue to play an increasingly significant role in the design of healthcare facilities. The business case for doing so already exists—consider, for example:

  • the graying of America—perhaps the most important trend of the 21st century—causing an influx of demand on facilities.

  • baby boomers' dominating the econo-my, stock market, politics and health-care, demanding more and expressing higher expectations than any generation preceding them.

  • the cracking of the genetic code, which has opened the floodgates for new pharmaceuticals, gene-based diagnostic tests and customized gene therapies, promising to create a plethora of new facility needs and demands for increased design flexibility.

  • America's 281 million consumers' gaining access to health services at an increasingly rapid pace, with providers catering to them and pushing up the use of hospitals, surgery and pharmaceuticals. The declining power of managed care to “steer” patients also means that consumers will have more choice in selecting a healthcare facility.

  • hospitals' continuing to look for more ways to cut costs and finding solutions by managing clinical care more efficiently. On the flip side of this, however, the nursing shortage is no longer looming in the distance; it's here and now, and making itself felt every day.

While paging through this issue of HealthCare DESIGN, look at the projects through the eyes of evidence-based design. See not only the aesthetic success of the project, but the excellent examples addressing the five areas just discussed. See where the use of nature has helped to create a space where harried staff can get some relief from daily stress, and frightened and overwhelmed patients and families can have a respite from the high-tech side of healthcare. See the use of innovative artwork, the use of windows in areas often relegated to dark interior spaces. See new models indicating where the healthcare industry is headed. See how these proven design features—proven, that is, in the projects here before you—might work their way into the facilities that you are designing, building and renovating for 21st-century healthcare. HD

The Center for Health Design is located in San Francisco, California