Roger Ulrich, PhD, is perhaps the most cited and influential evidence-based healthcare design researcher in the world. His studies have been lauded for their scientific rigor, and his findings continue to be readily implemented by healthcare managers, clinicians, design practitioners, and policy makers in the United States and abroad. Without question, Ulrich's work has directly impacted the design of many billions of dollars of hospital construction, and improved the safety and health outcomes of patients across the globe.
A Beale Endowed Professor of Health Facilities Design at Texas A&M University (TAMU), Ulrich is a professor of architecture and landscape architecture, and a faculty fellow of the Center for Health Systems and Design, an interdisciplinary center housed jointly in the colleges of architecture and medicine at TAMU.
He is a sought-after speaker and consultant, having worked extensively in Scandinavia, the United Kingdom, Canada, Australia, and the United States. In Sweden, Ulrich carried out research at the Karolinska Institute of Medicine in Stockholm, Uppsala University, and Lund Institute of Technology. He has also served as visiting research professor in healthcare architecture at the University of Florence, Italy; visiting professor at The Bartlett School of Architecture, University College London; and as invitation research fellow at the Japan Society for the Promotion of Science.
In 2005, Ulrich was invited by Britain's National Health Service to serve as senior advisor for its program to create scores of new hospitals-a true reflection of his knowledge and leadership in the evidence-based design (EBD) field. In addition, he was a member of The Joint Commission's task force on the hospital of the future, is an adjunct scientist with the Ontario Agency for Health Protection and Promotion, and serves on the Board of Directors of The Center for Health Design (CHD) as well as the Editorial Advisory Board of HEALTHCARE DESIGN.
I interviewed Ulrich on a rainy day in Chicago at the Hyatt Rosemont after a CHD board meeting. We first met each other in 1990 when he spoke at the Symposium on Healthcare Design, San Francisco. Shortly thereafter, he joined the Symposium's advisory board and in 1993 became one of the founding board members of CHD. We sat down in a meeting room after everyone else had left and spoke for two hours.
Sara O. Marberry: When did you first become interested in healthcare design research?
Roger Ulrich, PhD: About 30 years ago. I had started as an assistant professor doing research on environmental aesthetics, whether beauty mattered in terms of affecting emotional well-being and physiological stress. My interest in research was from a basic science perspective with no practical applications in mind. When I learned that most nature scenes produced positive emotional states and helped to calm stress, it fit with other work my colleagues and I were doing that showed reduced blood pressure and other physiological indicators of stress reduction.
In the early 1980s, I began to wonder about practical applications and asked myself, “Which groups of people experience a lot of emotional duress and might benefit from a view of nature?” The answer was hospital patients and prisoners.
But there was something else in my background that was playing an increasingly powerful role in my interest in healthcare. As a teenager, I had serious bouts of nephritis, or kidney disease. Fortunately, I came out of it just fine, but there were long periods spent at home in bed feeling quite bad, looking out the window at a big pine tree. I think seeing that tree helped my emotional state. Like other kidney patients then and now, there were unpleasant experiences in gloomy, sometimes brutal, healthcare buildings.
Marberry: And how old were you when this happened?
Ulrich: The first time I was 10 or 11 and the second time-the worst, was at age 16. My own experiences with clinics and procedures and seeing other patients in duress motivated me to try to do something to improve the environments where patients were treated.
Marberry: Your landmark study, “View through a Window May Influence Recovery from Surgery,” that was published in the journal Science in 1984 is still referenced today by many in the industry. What was the impact of that study on your career?
Ulrich: Over time, it has been considerable. The Science article got a great deal of media coverage-it was covered worldwide and in all major wire services, and was the medical news of the week.
One of the gratifying things about the study is that in recent years, several medical researchers working independently have reproduced the main results. In other words, the findings hold up when tested by others. There is quite an active area of medical research today that uses nature distraction to reduce pain. Most of these studies are rigorous; virtually all have reported significant pain-reduction effects; and all cite the window view study as a starting point. But the study could not exactly be duplicated today because the same type of patient-gall bladder surgery patients who spent seven days in the hospital-doesn't exist anymore because the procedure has become less invasive and stays are much shorter.
Marberry: So that study has had not only an impact on you and your career, but also on the healthcare and design industry as a whole?
Ulrich: There were early adopters, such as Derek Parker at Anshen+Allen, who implemented design ideas around nature in the Lucile Packard Children's Hospital at Stanford. By the late 1980s and early 1990s, other architects had begun to implement the research, but it was still more the exception than the rule.
Beginning about 1990, The Center for Health Design's activities encouraged adoption of ideas in the study, as did growth of the healing environments movement, which evolved later into the evidence-based design movement. The research gained more momentum from the fact that mind-body medical science was developing rapidly and confirming that patient stress and emotional states affect clinical outcomes.
Initially, medical audiences I spoke to in the 1980s listened politely, though probably some were dubious and did not really accept the findings. But today, after so much progress in mind-body medical research, few would seriously question the notion that if an environmental design intervention is shown to reduce patient stress, then it could also foster better clinical outcomes. The idea that stress-reducing interventions improve clinical outcomes has become mainstream knowledge that medical students learn.
Marberry: Let's talk about the term “evidence-based design.” I've always believed that the first time it was ever in print was when Colin Martin, a reporter at The Lancet, interviewed you in 2000. So, did you coin the term?
Ulrich: I did mention it during the interview, but don't believe that sole credit should go to me for its origin. Some of my colleagues on the board at The Center for Health Design at the time deserve part of the credit. I do recall thinking during the interview, though, that “evidence-based design” might resonate more with that reporter and the audience of a world-class medical journal than a more subjective-sounding term, such as “healing environments.”
Marberry: In the 1990s, you were talking and writing a lot about supportive design or psychologically supportive design. That's the same thing as evidence-based design, isn't it?
Ulrich: Yes, it was an early attempt to define this concept. At that time, there was very little rigorous published science, so I wrote a paper in 1991 called “A Theory of Supportive Design.” It began with the premise that it would be desirable to have evidence-informed design guidelines flexible enough to be adapted to the specifics of individual design projects. Because there was an absence of directly relevant research at that time to underpin such guidelines, I searched through research literature in health-related fields-such as health psychology, environmental psychology, and so on-and from this, identified three broad principles that were supported by a large body of scientific knowledge.
A major influence in my work at the time was the fact that I had moved to College Station, Texas, in the fall of 1988 to become an architecture professor at Texas A&M. My background and training were not in architecture, but rather the social sciences, something like environmental psychology. Arriving at Texas A&M, I was surrounded by designers and jointly taught studio with Mardelle Shepley, a real honest-to-goodness architect. Teaching studio taught me a lot about how designers think, and this helped me to understand the mindset of the design audiences I was addressing in my writing and speaking.
“IF ONE INSISTS ON RANDOMIZED CLINICAL TRIALS FOR ALL HEALTHCARE DESIGN OR MEDICAL RESEARCH, THEN ONE QUICKLY ENCOUNTERS MAJOR ETHICAL OBJECTIONS.”
-Roger Ulrich, Phd
Marberry: One of The Center for Health Design board members called you the “father of evidence-based design.” Do you consider yourself the father of evidence-based design?
Ulrich: That would be overstating it. But to the extent that my “View Through a Window” study has been cited by so many people as marking the beginning of the attempt to generate serious science, then maybe I'm one of the founders of the field.
At the time, it was obvious that the lack of credible design research that could be presented to decision-makers was a serious problem contributing to poorly designed healthcare buildings. Certainly there was scientific research in this field before my 1984 study-the British Nuffield Trust studies, in fact, produced good empirical research in the 1970s.
What was new and different about my work was that it was among the first to measure the importance of the built environment in terms of its impact on health outcomes-how long the patient stayed in the hospital, how many pain drug doses they needed, and so on. I believed that the field had to go in that direction for it to have influence in the medical community. I had seen many new hospitals in the 1970s and 1980s that were functionally efficient but designed in ways that seemed oblivious to the emotional needs of patients. Many others felt that way as well, and that was why The Center for Health Design's founders started a conference and began looking at ways to advance the field.
Marberry: What did you think when you spoke at the Symposium on Healthcare Design for the first time in 1990?
Ulrich: I was struck by the passion and shared sense that this was a noble cause-the belief that hospitals ought to be much better and could be much better. Although the belief seemed plausible to me, it was evident at the Symposium that there was little substantive research to point the way to design approaches that would be consistently successful in creating healing environments.
There was an eccentric, offbeat character to the Symposium as well. There were musicians and early-morning yoga sessions. There were some presentations, such as one about the effects of certain colors on patients, that today would be regarded as soft and unscientific. It was a creative, “anything-goes” atmosphere, but the powerful concept that brought people together was the shared belief that hospitals were poorly designed and worsened patient stress, and that things could be much better.
Marberry: Where are we today in regard to research in the field?
Ulrich: Great progress has been made, but far more progress is needed. The research on a few topics, such as infection, has grown exponentially. And there has been broad improvement in the rigor and quality of studies. Evidence-based design now has an international profile and is affecting projects worth billions of dollars. But there are still many issues for which we lack sound knowledge, and there are still many hospitals built that are inadequate because only lip service is given to evidence-based design.
It's still easy to find, unfortunately, hospital buildings that are noisy, where wayfinding is confusing, or where ward layouts force nurses to needlessly walk long distances every shift. But more people and decision-makers get the concept of evidence-based design, more governments are getting it, and it's showing up internationally in the design requirements for new projects. More design firms have acquired skill in evidence-based design. Many firms still have a long way to go, but it wasn't too many years ago that relatively few design professionals practiced and really understood the evidence-based design process. That has improved, and the Evidence-based Design Accreditation and Certification (EDAC) program has helped. But, there's always room for improvement.
Marberry: What would you say to the evidence-based design naysayers who say, “Oh, well, it's just a marketing buzzword, there's not enough substance”?
Ulrich: One can always point to deficiencies in any area, but I would ask the naysayer, “How could you responsibly and ethically ignore evidence that is sound, where findings have accumulated from multiple strong scientific studies showing that a given intervention or design approach can have important effects on the health of the patient or the safety of the patient?”
Naysayers have emphasized there is a lack of randomized controlled trials, or randomized controlled trials (RCTs). If they examine the research literature, they will soon find many randomized controlled trials in the evidence-based design area. For example, there are several RCTs published in prominent medical journals showing that nature distraction reduces pain.
Some critics, to my knowledge, lack research training or experience, and this is evident in their comments. I have planned and carried out RCTs, and agree that such studies are rigorous and important. But so are other types of studies using other methods-such as epidemiological studies-that also can produce good evidence. Experienced researchers consider several factors in evaluating the quality of evidence. Is there a control group of patients or comparison environmental condition? Are findings from different studies concerning an environmental factor such as noise generally consistent? If so, the pattern of consistency strengthens validity and signals that the evidence should be taken more seriously. Is the study published in a peer-reviewed research journal? An important point is that the quality of EBD research has been strengthened by advances in understanding mechanisms or pathways by which environmental factors affect outcomes.
Marberry: What are some examples of this?
Ulrich: Well, studies of the effects of design factors on infection, pain, depression, patient satisfaction, or staff lifting injuries.
I believe that those who narrowly insist on randomized controlled trials paint themselves into a small corner, which forces them to criticize not only parts of evidence-based based design, but also most engineering and green building standards in healthcare. By rigidly insisting on RCTs, it follows that naysayers must consign to the rubbish heap LEED's criteria or green building design measures, because RCTs and other well-controlled studies are lacking. Their position also slams many engineering or mechanical system-design standards because of the absence of RCTs showing what specific degree of improvement in, say, air quality or air changes should be implemented to produce such-and-such significant improvement in clinical outcomes. Are the critics-some of whom are engineers-also saying that engineers engage in marketing flim-flam when they endorse healthcare standards not grounded on rigorous RCTs showing impacts on clinical outcomes and costs? And from their critique of evidence-based design, it follows, for instance, that the air-quality control measures during hospital construction in the Guidelines for Design and Construction of Health Care Facilities should be disregarded because they are based mainly on uncontrolled, rather weak case studies of infection outbreaks.
Marberry: Are you saying that they have “tunnel vision” when it comes to research quality?
Ulrich: Yes, and I strongly disagree with it. A narrow and rigid insistence on RCTs is not consistent with mainstream views in medical research. In the case of environmental factors such as ventilation and air filtration, yes, most outcome studies are poorly controlled and do not randomly assign patients to different air conditions. But this does not justify denigrating standards or dismissing them as marketing ploys. An informed quality assessment should also recognize there is pattern across many studies indicating that infection rates are lower when there is very good air quality. And air-quality studies gain scientific credibility from the fact the findings are reasonable and broadly consistent with well-established knowledge concerning airborne transmission of pathogens.
If one insists on randomized clinical trials for all healthcare design or medical research, then one quickly encounters major ethical objections. Could a researcher get the ethics or review board to approve an RCT on infection rates where one group of patients was randomly assigned to multibed rooms with patients who were known to be infected, while the other group was assigned to single rooms? Of course not, because there would be a strong chance that patients would be seriously harmed. Parachutes have been used for many decades around the world, despite the fact there are no RCTs whatsoever on their effectiveness. How could there be? Can you imagine proposing to randomly assign some pilots or passengers to have real parachutes and others to have placebo backpacks, or fakes, then telling them to jump out the airplane and using the number of deaths as the outcome measure? But this is the kind of blind alley position that follows from a rigid insistence on RCTs.
Marberry: Some of those who are criticizing evidence-based design don't understand that it's not prescriptive. It's a process, right?
Ulrich: Yes, and perhaps the most difficult aspect of the evidence-based design process is to take the evidence and understand it, critically interpret it, and then interpret its relevance for the unique context of each project. EBD is not about rigid rules. The same evidence can help designers create quite different approaches for addressing similar issues or objectives.
To read the second installment of Sara O. Marberry's conversation with Roger Ulrich, don't miss the December issue of HEALTHCARE DESIGN.
Sara O. Marberry is the executive vice president of The Center for Health Design, which is located in Concord, California. She has worked in the healthcare building and design industry since 1988 as a marketing consultant, speaker, and nonprofit executive. For more information, go to www.healthdesign.org. Healthcare Design 2010 November;10(11):40-49
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