To use an evidence-based design process, you have to know what the best available evidence is. But research is published faster than anyone can read it. In this blog series, The Center for Health Design’s research team will provide insight into a few healthcare design research matters through a snapshot of 10 studies published since the 2016 Healthcare Design Expo & Conference. Serving as an inside look at a session held at the 2017 HCD Expo, the blogs will identify why this research matters and help readers ride the waves of an ocean of research without drowning.

The research
A 2017 article by Andrade and colleagues, who tested Roger Ulrich’s theory of supportive design, offers findings that suggest how certain design elements may reduce patient stress.

Why does it matter?
There is mounting evidence of the link between the physical environment and health outcomes. Stress is a particular outcome of interest in the healthcare setting because reduced stress has been linked to improved patient satisfaction and recovery. There is no “magic bullet” design solution for stress reduction, but a better understanding of the link between design and stress can help healthcare leadership make better design decisions.

While there are many assumptions about how the environment affects patient stress, there are few formal theories to help us understand the mechanisms--or underlying psychological processes--behind the effect. There are also few studies that test existing theories, which makes it hard for designers to know if they should rely on these theories or not.

This study is important because it helps to fill that gap by testing Ulrich’s theory of supportive design. This theory suggests that there are three ways a healthcare setting can reduce patient stress: by providing a sense of control over the environment, by facilitating social support, and by serving as a positive distraction from some of the negative circumstances surrounding the patient experience. This study is also unique in its cross-cultural approach, which the authors used to explore how design affects stress depending on culture.

How was the study done?
In a nutshell, the researchers predicted that hospital rooms affect patient stress and that the effect can be explained by the number of desirable elements in a room: more desirable elements equals less stress. To test this, researchers counted the number of favorable design elements in each patient room (defined through a refined measurement of quality developed in earlier research by Andrade and Devlin) and classified them in terms of positive distraction, perceived control, and social support. Researchers then surveyed 236 patients recovering in the rooms, using a questionnaire about those three factors.

Additionally, patients reported their anxiety level (stress). The researchers collected data at hospitals in both the United States and in Portugal to see if there were any cultural differences.

What was learned?
The findings support part of Ulrich’s theory. Desirable elements in the patient room had a significant effect on stress and the effect can be partially explained (mediated) by how much social support and positive distraction the room provided. But the effect was not explained by the level of perceived control. In other words, if you are a patient and the room you’re recovering in has numerous features that make it easy for you to get support from friends and family and gives you positive things to be distracted by, you may feel less stressed. However, features in the room that give you a sense of control over what happens in your room may not make a difference in your stress level.

Additionally, the findings show a cultural difference in how the features affect patient stress. U.S. patients tend to value conditions for control and social support more than Portuguese patients do, while conditions for positive distraction are more important for Portuguese patients.   

Are the results definitive?
While the findings give us better insight into the relationship between design and stress, there are many challenges in field research, and the authors point out that there may be other variables beyond those included in the study that explain the entire effect. Additionally, while the findings show that desirable elements have a positive impact on stress, the authors acknowledge the complexity of the healthcare environment, and how there may be a certain point at which there is too much of a good thing (Doherty & Stavropoulou, 2012). That is, filling a room with desirable elements may reduce stress to a certain point, but there may be a threshold at which numerous desirable elements become chaotic and overstimulating.

Findings from this study showed that stress was not influenced by elements that facilitate environmental control; however, this does not mean that sense of control is not important to recovering patients. Patients in this study participated at least 24 hours after orthopedic surgery, but were still in a state of recovery. The authors mention that there were varying levels of fatigue and in a few instances participants had to stop in the middle of the survey because they were not feeling well. Active control over the environment is not likely top of mind during early recovery, but in later stages this could change. Healthcare designers shouldn't discount the importance of providing the option for control to address the needs of patients at varying stages of recovery.

The inclusion of both Portuguese and U.S. patients provides some helpful insight into the effect of culture in this relationship, but each sample size was small, and larger samples in a greater number of countries would help to better understand the role of culture.

The takeaway
This research shows that when the environment enables social support and positive distractions, patients experience less stress. Culture plays an important role in how the patient room affects patient stress, indicating that different cultural values or expectations may produce different perceptions of healthcare environments.

Many of the design elements included in this study (e.g., television, paintings, windows, whiteboards, an extra table, chairs for visitors, WiFi) are relatively inexpensive and do not require major renovation. Decision-makers should consider the cost-benefit of these interventions when working towards improved patient satisfaction and health outcomes.

Interested in the topic? Visit The Center for Health Design Knowledge Repository for more.

Summary of: Andrade, C. C., Devlin, A. S., Pereira, C. R., & Lima, M. L. (2017). Do the hospital rooms make a difference for patients’ stress? A multilevel analysis of the role of perceived control, positive distraction, and social support. Journal of Environmental Psychology, 53, 63–72. https://doi.org/10.1016/j.jenvp.2017.06.008