While the term “healing environment” has become familiar in recent years and it is increasingly common for hospital RFPs (requests for proposals) to require that respondents demonstrate competency in this area, the truth is that few facilities achieve this goal. Too often hospital senior management and physicians in leadership positions fail to recognize the potential of this concept, relegating it to a current “trend” of superficial significance.

This concept is so poorly understood that it is often referred to as if it were a commodity that can be bought, as opposed to a systemic approach to delivering patient care that truly regards the patient as the center of the universe-putting patients' needs first. But it also demands a physical environment that reduces stress, one that is psychologically supportive for patients and families coping with the stress of illness and also for the staff who care for them.

The Stress Factor

Stress results from any situation that requires behavioral adjustment, such as invasions of privacy, uncontrollable noise, chronic pain, separation from family and things familiar, and feelings of helplessness and general loss of control. Add to this the worries about medical errors-much in the news lately-and whether one's insurance will reimburse the costs of care, and it's easy to understand the high levels of stress and anxiety that can ensue. Under stress, muscle tension increases; blood pressure and respiration increase; all forms of pain are worsened because hormones produced during stress lower the pain threshold; and the overproduction of stress hormones can produce cardiac arrhythmias, depression and insomnia.

It's interesting to note that the negative effects of stress can be measured hours after the stressful event occurred. Worse yet, stress impacts the immune system, which is perhaps the most compelling reason to design environments that reduce stress and help patients relax and feel comfortable.

Aside from direct health effects, stress can lead to dangerous outbursts of violence directed at staff. For example, according to Roger Ulrich, a researcher at Texas A&M University, the visual work environment can trigger violent outbursts in persons who have “trait anger.”

Health Benefits

Research indicates that speedier recovery time at home can occur as a result of a less stressful hospital experience. In fact, physical comfort in the hospital setting can even reduce mortality and morbidity. Patients in such a setting might require fewer narcotic pain medications, experience less anxiety and depression, and have fewer post-surgical complications. A more comfortable, less stressful hospital experience leads to higher patient satisfaction which, in turn, is linked to increased patient compliance with drug regimens and with recommended post-surgical care, including follow-up visits. All of this, of course, potentially affects clinical outcomes.

Scientific Research

In recent years, the neurosciences have provided considerable insight into how the immune system can be experimentally suppressed or enhanced by a variety of interventions, and we have learned that feelings are inseparable from biochemistry. Clearly, our thoughts influence our physiology. What we perceive and think, and how well we cope, are all set in motion by messages from the brain to the rest of the body. One could say that our brains are writing a prescription to our bodies every minute of every day.

According to neuroscientist Candace Pert, these messages can affect cell biology. In the area of evolutionary biology, humans respond positively and negatively to elements of the natural environment in fairly predictable ways. It is this that accounts for the tremendous interest in recent years in creating healthcare facility healing gardens.

Indeed, there are five areas of research that can be used as a platform on which to design a healing environment:

1. Connection to nature. A large body of research indicates that humans are “hard-wired” to appreciate and benefit from exposure to nature. Based on our evolutionary past and the landscape features that were important for survival, research shows that humans have a deep need to connect to nature, and that even a brief view of a garden or interaction with a water element, for example, can have the immediate physiological benefits of reducing stress and anxiety.

2. Options and choices. A considerable number of studies have documented that availability of options or choices reduces patients' stress and enables them to feel more in control. A healing environment will offer as many choices and options to patients as possible, in every setting, whether it is an outpatient waiting room or critical care unit.

3. Social support. It has been well-documented that access to friends and family contributes to emotional and psychological well-being. Whether it is a social support group for breast cancer survivors or a family member sleeping overnight in a patient's room, sympathy and compassion offered by caring individuals are essential.

4. Pleasant diversions. We are multi-sensory beings; research in the neurosciences demonstrates that various types of sensory experiences can actually be therapeutic and can boost the immune system. Certain types of music, engaging moments spent in front of an aquarium or water feature, meditation, guided imagery and visualization-all provide diversions from pain and opportunities for developing coping skills.

5. Elimination of environmental stres-sors. A growing body of environmental research indicates that stressors in the built environment can add to the burden of illness. Noise is perhaps the most deleterious of these; hospital nursing units are notoriously noisy. Poor air quality and glare from direct (as opposed to indirect) light sources are other stressors. None of this is beyond the control of the owner and design team working collaboratively.

Next Step: Outcomes of “Pebble Projects”

The components of a healing environment-e.g., garden views, understandable surroundings and pleasant diversions-seem so intuitively beneficial as to need no further vindication. Certainly many healthcare organizations have embraced these concepts without randomized, double-blind, controlled studies to demonstrate their cost-effectiveness. But to mainstream these ideas and make them the standard of care will no doubt require rigorous outcomes research.

To that end, The Center for Health Design has embarked on a multiyear research effort in partnership with a number of leading healthcare institutions that are committed to improving the patient care environment. These are referred to as “Pebble Projects,” because it is anticipated that they will impact and influence the healthcare industry much the way a pebble thrown into a pond creates a ripple across the entire body of water.

Without denigrating the need for outcomes research, it is amusing to reflect that we never attempt to calculate the cost of a negative environment-one with many stressors. This, perhaps, indicates how our familiarity with the utterly depressing institutional environments that dot our healthcare landscape (figure 1) prevents us from questioning-dare I say demanding-something better. When expectations are so low, even a sleep-chair that opens to a bed in a patient room seems like a big deal. It leads to such observations as a friend, the head of customer service for a multihospital system in the Midwest, made recently: Tires Plus, a national chain known for providing customer amenities as well as shiatsu massage and nutrition classes for workers, creates a much more comfortable environment than is provided in the ER waiting rooms of most hospitals.

For all the extraordinary healthcare facilities that have been developed in recent years, the fact remains that a level of excellence in design probably represents no more than 20% of facilities in the nation; the remainder still look much as they did in the 1960s. Looked at pos-itively, this means that today's health-care architects, designers and CEOs have many opportunities to make a difference.

The crucial player here is the CEO. Would it surprise you to know that the highly respected British medical journal The Lancet recently carried a prediction by Colin Martin that “evidence-based design is poised to emulate evidence-based medicine as a central tenet for health care in the 21st century”? Design professionals know that as the evidence accumulates, the tipping point will be created by enlightened CEOs and senior healthcare executives who see the long-term benefits of deep cultural and organizational change and commit to research-informed facility design. HCD

A book could be written about President and CEO Frank Sardone's commitment to the art of healing, as expressed in a thousand ways in this extraordinary medical center that is filled with natural light, interior gardens, significant works of art and outstanding architecture (figures 2 and 3). What's more, Bronson has realized significant measurable benefits:

The Bronson Methodist Hospital, Kalamazoo, Michigan

$181 million inpatient and ambulatory care replacement facility; opened 2000

(Center for Health Design Pebble Partner)

Architecture and Interior Design: Shepley Bulfinch Richardson and Abbott

  • The nursing vacancy rate is half the state average.

  • Staff are screened for customer service orientation and sensitivity, with incentive awards tied to extraordinary service.

  • Private patient rooms have seen decreased patient transfers because of the elimination of conflicts among patients that necessitated moves. Patient sleep quality has increased and nosocomial infection has decreased.

Methodist Hospital-Clarian Health Partners, Indianapolis, Indiana

$13 million Comprehensive Cardiac Critical Care (CCCC) 56-bed demonstration project; opened 1999

(Center for Health Design Pebble Partner)

Architecture and Interior Design: BSA Design

It would be easy to look at this facility and make the superficial observation (because it is so beautiful and patient/family-centered) that it is merely an application of hospitality design to the critical care environment (figures 4 and 5). Nothing could be further from the truth. Led by Ann Hendrich, MSN, RN, senior vice-president, the design project was based on rigorous research directed at improving both clinical and economic outcomes. Based on documentation that there are 27 steps involved in moving a patient, the CCCC patient room was designed to adjust for changes in the patient's level of care, thus eliminating the need for most transfers. Methodist is now going on to study other possible outcomes of the design:

  • Based on not having to transfer patients so often, will patients have fewer complications, will the mortality index change, and will the sentinel-event index rates (falls, medication errors, complaints) decrease?

  • Will the new work environment result in higher clinician satisfaction?

  • Will nursing recruitment and retention improve?

  • Will average length of stay be reduced?

  • Will the supply and/or labor cost per patient be reduced?

  • Will multimedia patient education improve patients' readiness for discharge and caregiving at home?

Doernbecher Children's Hospital, Oregon Health Sciences University, Portland, Oregon

$61 million; opened 1998

Architecture and Interiors: Zimmer Gunsul Frasca Partnership, in association with Anshen + Allen

This is surely one of the most stellar examples of a total healing environment. It represents the highest level of achievement in healthcare architecture and interior design, as well as medical planning (figures 6 and 7). The attention to detail is remarkable as one moves through the facility, noticing the extraordinary commissioned works of art, the access to exterior views, the scale of objects geared to children, and the variety in furnishings and lighting. A unique signage system makes use of colorful icons to aid in wayfinding. This project incorporates all of the aforementioned bodies of research and, in the tradition of the best children's hospitals, embraces the entire family.

Scripps Breast Care Center, La Jolla, California

10,000 sq. ft., $1 million project; opened 2000

Architecture and Interior Design: Jain Malkin, Inc.

Tension runs high for women visiting a breast care center, and that's why this design taps into the five bodies of research previously mentioned to offer women the widest number of stress-reducing amenities. Passing through the rotunda, women are greeted by Hygeia and Panacea, daughters of Asclepius, the god of healing in 4th-century BC Greece (figure 8). Together, they underscore the dual functions of the Center: prevention and treatment. Curved walls and other features keep energy flowing according to the principles of feng shui; patients have a choice of five pleasant diversions while waiting; and the East of the Sun waiting lounge for symptomatic patients is dedicated to the summer solstice, deemed to be the peak of women's energy and healing. Architectural features of the room correlate to the solstice and lead the eye to a niche containing a sundial sculpture marking the path of the sun on June 21 in this locale. The West of the Moon waiting lounge (figure 9) for patients undergoing mammogram screening introduces the Triple Goddess of the Moon legend celebrating the three stages of a woman's life: the young maiden, the nurturing mother and the wise elder, which are represented by a sculpture of the moon in its phases of full, waxing and waning. A series of paintings facing this lounge reiterates the theme of the stages of a woman's life.

Although the outcomes have yet to be investigated formally, anecdotally it seems that the design features have greatly reduced stress for patients, judging by the letters that have been received.

Jain Malkin is president of Jain Malkin, Inc., healthcare design and interior ar-chitecture consultants based in La Jolla, California.


and now for the ture…

The start of a new century captivates our imagination and challenges us to reinvent the patient care environment. It is time to embrace a new generation of healthcare facilities that look very different from familiar institutional models. Committed to healing the whole person and to honoring the vital link between mind, body and spirit, the facilities featured on the following pages empower patients by partnering with them and by providing options and choices. These new health centers are spiritual sanctuaries, not grim, scary places. These “temples of healing” have gardens, fountains and natural light, and are filled with art and music-they embrace the joy of living and are a celebration of wellness. Let us make this a blueprint for the multitude of hospitals that will be built in the next 10 years as the nation's inventory of 1960s-era facilities is replaced.