The movement in healthcare design toward patient-centered care and healing environments is often reflected in healthcare facility features meant to mitigate the stressful nature of serious illness. Preliminary research has shown that providing space for families in patient rooms and ambient features such as natural light, views, water features, and healing gardens may reduce stress and speed physical healing in patients.1-4

It is not well understood, however, how the medical staff uses these types of features and whether they may be beneficial to the staff. Healthcare workers face both physical and emotional stress and strain as a result of their work.5 This increased stress may inevitably lead to negative consequences for the healthcare provider, including high turnover and sick-day rates, difficulty competing for new doctors or patients, decreased quality of care, increased medical error, and decreased quality of life for staff.6 Good healthcare cannot be administered without well- supported healthcare professionals, and job stress and burnout can impair both the physical and psychological health of staff. Factors such as stress and negative staff perceptions of their work environment may be related to both job strain and poor environmental quality.7

Parrish Medical Center (PMC) in Titusville, FloridA&Mdash; one of the first healthcare providers to participate in The Center for Health Design's Pebble Project— recently conducted an exploratory, qualitative study on how its staff perceive the healing environment.7 Published in the Fall 2005 volume of Health Care Manager, the study's goal was to lend proof to the idea that while a supportive organizational environment is imperative, a supportive physical environment can be just as important in influencing how staff view their workplace and how this may in turn affect their health and well- being.

In 2002, PMC dedicated an $80 million replacement facility that incorporated many features designed with the intention of making Parrish a true healing environment. These features included a well-lit, four-story atrium; a courtyard with water features; a view of either the atrium or river from all patient rooms; and a resource library with access to health information.


PMC collected data in the fall of 2003 by adding a subset of questions to its annual employee satisfaction survey. The main focus of these questions was the effect that the physical aspects of the hospital had on the quality of work life for the staff (e.g., “How much impact does the increased natural light have on your quality of work life?”).

Staff were asked to visualize standing in the atrium of the hospital or walking down a patient corridor and entering a patient room. Questions focused on specific design elements at PMC, and staff were asked to indicate how strong an effect they believed each element had on the quality of their work life. A seven-point scale with responses ranging from “very positive” to “very negative” was used to rate design features. A total of 734 staff members participated in the survey.

Based on the responses, the research team made evidence-based inferences as to how staff perceptions of the physical environment affected the quality of their work life. The ideas that the physical environment does in fact make a difference in the day-to-day life of the staff and that these differences translate into health, social, and organizational outcomes were explored. These findings are currently being used to guide future research to document these relationships and the mechanisms by which they occur.


Responses to the questions did indicate that staff were positively affected by many of the design features mentioned in the survey. Natural light received the highest percentage of “very positive” ratings (43%). This is not surprising, since past research in the fields of environmental psychology and healthcare design have focused on the positive effect of natural light on the hospital patient.8, 9 Based on study responses, PMC staff are aware of the well-lit environment in the new facility and feel that they benefit from exposure to it. The design features that increase natural light in the building include a large atrium with a skylight in the lobby of the hospital, and patient rooms with a view of the river or the atrium. The operating rooms at PMC also bring in natural light, and external walls are used so that all spaces have windows, including laboratories.

Live instrumental music was also highly rated by PMC staff (30% “very positive”). Several days a week for several hours at a time, musicians (pianist, guitarist, and harp/flutist duo) provide live music in the atrium. When there are no live instruments, PMC intermittently pipes in soft, soothing music. A small body of research from environmental psychology has shown that music can have positive implications for job performance.10 Noise, on the other hand (defined as “unwanted sound,” e.g., background noise, typing, talking on the phone, fax machines, etc.), is often felt to hinder job performance.11

Other features rated highly by staff include airflow, water features, homelike patient rooms, and separation of public and patient areas. Airflow and good air quality (29% “very positive”) may be associated with perceptions of health in the workplace. A majority of respondents to the survey (78%) worked in both the old and new buildings. It is possible, therefore, that they noticed a significant improvement in the air ventilation system, which resulted in the high ratings.

Water features, like natural light, can provide a temporary escape from the stresses and strains associated with working in a healthcare facility. At PMC, these consist of a water pool that surrounds the base of a spiral staircase in the lobby and a cascading waterfall in an outdoor courtyard. These features were highly rated by PMC staff (28% “very positive”). Knowing that they have these features to enjoy if needed may be perceived as having a positive effect. Staff also rated separation of public areas from patient transport areas as having a positive effect (29% “very positive”). Keeping these areas separate also may make it easier for staff to protect the privacy of patients and families.

Homelike patient rooms received a 25% “very positive” rating. Because these rooms make patients and their families feel more comfortable and at ease, this may make it easier for staff to care for them. However, it might not have been the look of the rooms that produced the high ratings, but rather the calming and comforting effect the rooms have on the patients.

Next Steps

PMC is committed to continuing its research on the impact of the healing environment on healthcare staff. Using the aforementioned exploratory work as a springboard, the next study will be one of the first to focus on the potential restorative effect of the nursing staff break rooms.

This study will focus on nursing staff break rooms as potentially restorative spaces, meaning these spaces help to reduce stress and fatigue, as well as refreshing mental and attention capacity. Providing private spaces where staff can get away from patients and families may not be enough, however. To aid restoration, it may be important to provide spaces with views and natural light. Both of these features are accessible by the use of windows and have been shown to lead to positive health outcomes for hospital patients.12-14 Yet, no study has examined whether a window with access to natural light or a nature view may be restorative for nursing staff.

This new study is guided by two assumptions, both of which are grounded in the literature. First, the study assumes that the healthcare environment is stressful.2, 15-18 Second, the study assumes that nursing is a stressful occupation.5,19-21 It is possible that breaks are restorative in and of themselves, but it may also be that natural light and views will heighten and enhance this restoration. Break rooms with higher degrees of restorativeness-as characterized by the degree of natural view and amount of natural light-are expected to support increased attention function and lower perceived stress and fatigue after a break.

By showing that break rooms can be restorative for nursing staff, PMC hopes to show that while patients are at the center of the healing environment, design elements can impact staff and caregivers, as well. Ensuring that staff are well supported is central to the functioning of any healthcare facility. Hopefully, in the future the healthcare industry will continue to consider the caregiver in the context of the healing environment through good design that is based on research and translated into practice. Incorporating design features that are sensitive to the entire building population can make for an environment that meets the needs of all those who live and work within its walls. HD

Jana Mroczek has a master's degree in environmental psychology from the City University of New York Graduate Center. Her research interests center on the effect of the physical environment on health and well- being, with a focus on the impact of healthcare design on physical and psychological health outcomes for all healthcare facility user groups. She is a member of The Center for Health Design's Environmental Standards Council and is a research consultant to the Pebble Project.


  1. Williams MA. The physical environment and patient care. Annual Review of Nursing Research 1988; 6:61–84.
  2. Sloan-Devlin A, Arneill AB. Health care environments and patient outcomes: A review of the literature. Environment & Behavior 2003; 35:665–94.
  3. Schweitzer M, Giplin L, Frampton S. Healing spaces: Elements of environmental design that make an impact on health. Journal of Alternative and Complementary Medicine 2004; 10 (suppl 1): s71–s83.
  4. McCarthy M. Healthy design. Lancet 2004; 364:405–6.
  5. McVicar A. Workplace stress in nursing: A literature review. Journal of Advanced Nursing 2003; 44:633–42.
  6. Ulrich RS, Quan X, Zimring C, et al. The role of the physical environment of the hospital of the 21st century: A once-in-a-lifetime opportunity. Report funded by the Robert Wood Johnson Foundation for The Center for Health Design, 2004.
  7. Mroczek J, Mikitarian G, Vieira EK, Rotarius T. Hospital design and staff perceptions: An exploratory analysis. Health Care Manager 2005; 24:233–44.
  8. Beauchemin KM, Hays P. Sunny hospital rooms expedite recovery from severe and refractory depressions. Journal of Affective Disorders 1996; 40:49–51.
  9. Walch JM, Rabin BS, Day R, et al. The effect of sunlight on postoperative analgesic medication use: A prospective study of patients undergoing spinal surgery. Psychosomatic Medicine 2005; 67:156–63.
  10. Fox JG.Industrial music. In: Oborne DJ, Gruneberg MM, eds. The Physical Environment at Work. New York:John Wiley & Sons, 1983.
  11. Gifford R. Environmental Psychology: Principles and Practice. Colville, Wash.:Optimal Books, 2002.
  12. Keep P, James J, Inman M. Windows in the intensive therapy unit. Anaesthesia 1980; 35:257–62.
  13. Ulrich RS. View through a window may influence recovery from surgery. Science 1984; 224:420–1.
  14. Verderber S. Dimensions of person-window transactions in the hospital environment. Environment & Behavior 1986; 18:450–66.
  15. Malkin J. Creating excellence in healthcare design. Journal of Health Care Interior Design 1991; 3:27–43.
  16. Ulrich RS, Simons RF, Losito BD, et al. Stress recovery during exposure to natural and urban environments. Journal of Environmental Psychology 1991; 11:201–30.
  17. Ulrich RS. Wellness by design: Psychologically supportive patient surroundings. Group Practice Journal 1991; July/August:10–19.
  18. Ulrich RS. How design impacts wellness. Healthcare Forum Journal 1992; 35:20–5.
  19. Healy C, McKay M. Identifying sources of stress and job satisfaction in the nursing environment. Australian Journal of Advanced Nursing 1999; 17:30–5.
  20. Healy C, McKay M. Nursing stress: The effects of coping strategies and job satisfaction in a sample of Australian nurses. Journal of Advanced Nursing 2000; 31:681–8.
  21. McGowan B. Self-reported stress and its effects on nurses. Nursing Standard 2001; 15:33–8.


The Pebble Report focuses on the research efforts and interests of The Center for Health Design's Pebble Project partners, a project that began in 2000 with one provider and has grown to more than 30.