Therapeutic Environments

from the Therapeutic Environments Forum, AIA Academy of Architecture for Health
Ron Smith, AIA, ACHA, Hellmuth, Obata + Kassabaum, L.P., Facilitator

Last updated: 04-03-2007

Overview

Healthcare facilities today are designed not only to support and facilitate state-of-the-art medicine and technology, patient safety, and quality patient care, but to also embrace the patient, family, and caregivers in a psycho-socially supportive therapeutic environment. The characteristics of the physical environment in which a patient receives care, do affect patient outcomes, patient satisfaction, staff satisfaction, and organizational outcomes. The effects can be positive or negative. No environment is neutral.

A healthcare environment is therapeutic when it does all of the following:

• Supports clinical excellence in the treatment of the physical body
• Supports the psycho-social and spiritual needs of the patient, family, and staff
• Produces measurable positive effects on patients' clinical outcomes and staff effectiveness

Description

A. Theory / Background

Therapeutic Environment theory stems from the fields of environmental psychology (the psycho-social effects of environment), psychoneuroimmunology (the effects of environment on the immune system), and neuroscience (how the brain perceives architecture). Patients in a healthcare facility are often fearful and uncertain about their health, their safety, and their isolation from normal social relationships. The large, complex environment of a typical hospital further contributes to the stressful situation. Stress can cause a person's immune system to be suppressed, and can dampen a person's emotional and spiritual resources, impeding recovery and healing.

Healthcare architects, interior designers, and researchers have identified four key factors which, if applied in the design of a healthcare environment, can measurably improve patient outcomes:

• Reduce or eliminate environmental stressors
• Provide positive distractions
• Enable social support
• Give a sense of control

Evidence gathered from research on completed projects is demonstrating measurable benefits to patient outcomes, safety, and quality of care, from such factors. Recent initiatives by the Academy of Neuroscience for Architecture (ANFA) are bringing neuroscientists and architects together for further research that will "provide hard evidence on how these experiences are formed in the brain and why our minds perceive them as positive" (John Eberhard, FAIA). The ANFA intends to pursue research on subjects such as:

• Windows and their impact on patient experiences
• Calming environments for patients and staff
• Wayfinding in complex buildings
• Privacy issues in healthcare settings
• Interior environmental impacts on people, equipment, and space utilization
• Contribution of certain colors to patient recovery in hospital settings

While the application of these factors is primarily focused on the patient and family, there are also recognized potential benefits for staff and caregivers in terms of satisfaction, effectiveness, and staff retention, from environmental factors such as:

• Appropriate lighting
• Providing 'off-stage' areas for respite
• Proximity to other staff
• Appropriate use of technology

(For more information on design of effective workplaces, see WBDG Productive Branch.)

Therapeutic Environments have been proven to be cost-effective by improving patient outcomes, reducing length of stay, and by enhancing staff satisfaction, recruitment, and retention of staff.

Additional Information on Theory/Background

• AIA Academy of Architecture for Health
• Hospital Interior Architecture: Creating Healing Environments for Special Patient Populations by Jain Malkin. New York: John Wiley & Sons, Inc., 1992.
• "How Design Impacts Wellness" by Roger Ulrich, Ph.D.. Healthcare Forum Journal, 1992.
• Architecture and the Mind, John Eberhard, FAIA

B. Practice

To create a therapeutic environment, all members of the design team—site and landscape designer, medical planner, architect, engineer, and interior designer—are responsible for using the power of design to find solutions that will affect the patients and staff in positive ways, throughout the facility; from the parking lot, approach, and entry, to the public spaces, clinical spaces, and ultimately the patient room. Following are some specific features that are commonly used under each of the four key factors:

Reduce or Eliminate Environmental Stressors

For example:

• Acoustical separation from sources of noise; other patients, mechanical noises, public address systems
• Acoustical treatment of corridors adjacent to patient rooms
• Acoustical separation of staff work areas from patient rooms; "even low noise levels (40-58 dB) combined with poor acoustics can reduce sleep quality and negatively affect other outcomes" (Roger Ulrich, Ph.D., Healing Environments Virtual Seminar, AIA, 2003)
• Appropriate lighting systems; "lighting can be a stressor that alters mood, increases stress, disrupts daily rhythms, and modulates hormone production" (J. Roberts, Ph.D.)
• Provide lighting that supports natural circadian rhythm; "Provide natural daylighting where possible, or bright white lights (400-600nm) in the daytime. Ensure absolute darkness in the evening; for nighttime movement only red lights (650-700nm) should be present in the rooms." (J. Roberts, Ph.D.)
• Provide comfortable furnishings and comfortable layouts
• Maintain good indoor air quality
• Appropriate use of color

Additional Information on Reducing Environmental Stressors

• Adaptable Patient Room Study Graduate Studies in Architecture + Health, Clemson University, 2003-2004.
• "Color in Healthcare Environments; a Critical Review of the Research Literature" Coalition for Health Environments Research
• "Light and Immunomodulation" by Joan E. Roberts, Ph.D. New York Academy of Sciences—impact of light on the immune system
• "Reducing noise pollution in the hospital setting by establishing a department of sound: a survey of recent research on the effects of noise and music in health care." Cabrera, IN; Lee, MH, Prev Med. 2000 Apr; 30(4):339-45.

Provide Positive Distraction

For example:

• Views of nature, from patient rooms, and wherever possible in lobby, waiting, and other 'high stress' areas
• Access to nature, healing gardens
• Chapel, meditation room, and meditation gardens
• Artwork depicting nature, including back-lighted photographs of nature
• Music; live piano in public area, recorded music in patient room when programmed specifically to create a healing environment
• Mild physical exercise; corridors, public spaces, and gardens that invite walking when appropriate
• Pets and other activities or elements that allow for a sense of stimulation that help nurture a patient's sense of positive well-being

Additional Information on Providing Positive Distraction

• Art for Health Care; American Art Resources
• Distinctive Art Source
• Healing Healthcare Systems—music programming
• Sky Tiles, Luminous Sky Tiles—scenes of nature
• Society for the Arts in Healthcare (SAH)
• Virtual Windows—scenes of nature
• "Windows on Nature" by Joey Fischer, Art Research Institute

Enable Social Support

For example:

• Family zone in patient room; with furniture for sleeping, phone and internet connection, reading light with separate control, and out of the way of staff
• Provide places where patients can engage socially with family and other caregivers, such as the Planetree feature of a Family kitchen on inpatient units where family members can prepare food for patients and families to eat together
• Provide accommodation for accompanying family member to be with patient throughout the examination and treatment process
• Organize Family Focus Groups and Patient and Family Advisory Councils to be an active part of the design process, tuning in to the specific needs of the population and community to be served, as recommended by the Institute for Family-Centered Care
• Ensure culturally sensitive environments

Additional Information on Enabling Social Support

• Caring for Patients from Different Cultures by Geri-Ann Galanti. University of Pennsylvania Press, 2003.
• Institute for Family Centered Care
• Putting Patients First: Designing and Practicing Patient-Centered Care by Susan Frampton. New York: John Wiley & Sons, Inc., 2003. (2004 ACHE Book of the Year)
• Through the Patient's Eyes: Understanding and Promoting Patient-Centered Care by Margaret Gerteis. Jossey-Bass, 1993.

Give a Sense of Control

For example: the ability of the patient to control the environment directly contributes to successful patient outcomes. A sense of control extends from privacy and lighting to choosing artwork being hung in the patient's bedroom during the hospitalization, to ordering meals from room service.

• Private patient rooms result in better outcomes, according to recent studies by Roger Ulrich, Ph.D. and CHER
• Give the patient as much privacy and control over it, as is consistent with the need for nursing supervision
• Give the patient control over the immediate environment; i.e., radio, TV, reading light, night light
• Wayfinding; the built environment should provide clear visual cues to orient patients and families, and guide them to their destination and return. Landscaping, building elements, color, texture, and pattern should all give cues, as well as artwork and signage
• Provide mini-medical library and computer terminals so patients can research their conditions and treatments—as in the Planetree model
• Choice of lighting; patients and staff can benefit from personal dimming controls
• Choice of artwork
• Volume and programming control of televisions in waiting areas
• Room service/menu selection

Additional Information on Giving a Sense of Control

• Clanton & Associates,—information on lighting controls
• Planetree
• St. Charles Medical Center—examples from their successful programs and facilities
• "The Use of Single Patient Rooms vs. Multiple Occupancy Rooms in Acute Care Environments", Coalition for Health Environments Research

C. Tools

Every healthcare project should begin with a review of existing available literature on design interventions that have been proven to improve patient outcomes, staff effectiveness and patient safety, and a decision made with the users as to how each one might apply to the project, and what outcomes / benefits would be expected. Checklists can assist designers and users in evaluating existing conditions and in setting goals for new facilities planning and design.

Additional Information on Tools

• Center for Health Design; the Picker Institute's checklist for patient-centered care is available as part of a design action kit, "Through the Patient's Eyes"
• "Healing Environments" by Barbara J. Huelat, ASID. Medezyn, 2003.—The author shares several of her checklists for designing for the body, mind, and spirit.
• Institute for Family Centered Care—resources for design planning

D. Operational Models

A physically enriched therapeutic environment is of no support where there does not exist the collaborative, emotionally, spiritually, and socially supportive environment. Aligning the healthcare organization's operational model with the design goals early in the process is a key to success.

Additional Information on Operational Models

• Healthcare Design Magazine, "Relating Facility Design to Organization Design" by Kirk Hamilton, FAIA, FACHA. September 2003.

E. Research and Evidence

Research plays an important role in helping us continue to better understand the effects of the healthcare environment. A growing body of evidence is emerging from research in several fields. Three kinds of research are being pursued:

Medical Model: evaluates environmental effect using biologically measurable data

• Stress and Surgery Recovery "Psychological Influences on Surgical Recovery" by Janice Kiecolt-Glaser, Ph.D. American Psychologist, Nov. 1998. pp.1209-1218.
• Joan E. Roberts, Ph.D., Department of Natural Sciences, Fordham University, NY, at JRoberts@fordham.edu, research on "Light and Immunomodulation". Her research focuses on the central impact of light on the immune system, which is susceptible to a variety of stresses.

Social Science Model: evaluates user perception and quality

• Press Ganey Associates "is the health care industry's top satisfaction measurement and improvement firm with 33% of all hospitals, and 44% of all hospitals of more than 100 beds, relying on our services."

Multidisciplinary Model: evaluates the whole environment

• "The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity", a survey of literature that identifies more than 600 research studies linking the built environment to healthcare outcomes.
• Roger Ulrich, Ph.D., Texas A&M University
• Mardelle McCuskey Shepley, D.Arch., AIA, Associate Director of the Center for Health Systems & Design, College of Architecture, Texas A&M University
  • Nursing Unit Configuration and Its Relationship to Noise….
• Pebble Projects; Center for Health Design
• The Coalition for Health Environments Research (CHER) funds research through grants for investigations into the "humane, effective, and efficient environments through multidisciplinary collaboration dedicated to quality healthcare for all".
  • "The Use of Single Patient Rooms vs. Multiple-Occupancy Rooms in Acute Care Environments" by Habib Chaudhury, Ph.D. Simon Fraser University, 2003.—initial phase due to be published mid-year 2004
  • "Color in Healthcare Environments; a Critical Review of the Research Literature" by the University of Missouri, Columbia, Department of Environmental Design; due to be published mid-year 2004
• The Academy of Neuroscience for Architecture—AIA architecture-neuroscience research initiative
• Lisa Heschong, Heschong Mahone Group, Sacramento, CA Architect and researcher; daylighting and productivity studies

F. Market Forces and Future Influencers

Factors likely to influence the design of therapeutic environments in the foreseeable future:

• Evidence-Based Design: the increasing ability to base design goals and decisions on the measured results of outcomes from real projects
• The Institute of Medicine (IOM) and its emphasis on the improvement of quality and patient safety
• The aging baby boomer generation will continue to have increased market influence toward greater quality and choice
• Technology and the need for flexibility
• The Center for Health Design "Pebble Projects": results of the early projects are being published; a total of 18 projects (Pebble Partners) are currently underway and will produce further evidence in support of the design of therapeutic environments
• The Academy of Neuroscience for Architecture: a large body of results will be forthcoming from multidisciplinary studies in neuroscience and architecture

Links to Additional Information on Market Forces and Future Influencers

• Institute of Medicine
• Institute for Healthcare Improvement

Application

Examples

St. Charles Medical Center, Bend, Oregon. This site contains a good description of the key features that make up the healing environment of this award-winning 'total healing hospital'.

Griffin Hospital, Derby, Connecticut. This is a facility which has experienced significant success and growth since it underwent major renovation and became a Planetree affiliate.

Woodwinds Health Campus, St. Paul, Minnesota, where "healing is an art as well as a science".

Children's Hospital and Health Center, San Diego, California. This site includes descriptions and details of the healing environment of this 'Pebble Partner' facility.

Toronto General Hospital, Toronto, Ontario. New Clinical Services building is designed to provide a supportive patient experience within a technologically advanced environment.

Children's Hospital at Montefiore, Bronx, New York, where "Inspiration trumps adversity".

Clemson University, Department of Architecture, Graduate Studies in Architecture + Health. An ongoing project evaluating innovations in patient room design, based on therapeutic environment principles.

Academy Journal, a peer-reviewed publication of the AIA Academy of Architecture for Health.

Vidar Clinic, Jarna, Sweden. A convalescent facility designed by Erik Asmussen on the principles of anthroposophic medicine, where the built environment is an active agent in the healing process through the use of specific color, architectural forms, and spaces. Go to the 'arkitektur och omgivning' (architecture and environment) section of this site to view images.

Relevant Codes and Standards

• Department of Veterans Affairs (VA), Office of Construction & Facility Management (CFM) Technical Information Library—guides and standards for planning departments and clinics
• Guidelines for Design and Construction of Hospital and Health Care Facilities
• Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)
• NFPA 101 Life Safety Code

Additional Resources

WBDG

Building / Space Types

Health Care Facilities, Hospital, Nursing Home, Outpatient, Psychiatric, Clinic / Health Unit

Design Objectives

Accessible, Aesthetics, Cost-Effective, Cost-Effective—Consider Non-Monetary Benefits such as Aesthetics, Historic Preservation, Security, and Safety, Functional / Operational, Historic Preservation, Productive, Secure / Safe, Sustainable, Sustainable—Enhance Indoor Environmental Quality (IEQ)

Products and Sytems

Federal Green Construction Guide for Specifiers

• 07 55 63 (07530) Vegetated Membrane Roofs
• 08 14 00 (08210) Wood Doors
• 08 50 00 (08500) Windows
• 12 10 00 (12100) Art
• 12 59 00 (12700) Systems Furniture
• 26 50 00 (16500) Lighting

• Executive Order 13423 Technical Guidance for Implementing the Guiding Principles for Federal Leadership in High Performance and Sustainable Buildings—Daylighting

Publications

• Architecture of Erik Asmussen by Susanne Siepl-Coates. Kansas State Univ.
• Caring for Patients from Different Cultures by Geri-Ann Galanti. University of Pennsylvania Press, 2003.
• Design That Cares: Planning Health Facilities for Patients and Visitors, 2nd Edition, by Janet Carpman, Myron Grant, and Deborah Simmons. New York: John Wiley & Sons, Inc., 2001.
• Healing Environments by Barbara J. Huelat, ASID. Medezyn Publishing, 2003.
• Healthcare Design Sarah O. Marberry editor. New York: John Wiley & Sons, Inc., 1997.
• Healthcare Design—A quarterly magazine
• Hospital Interior Architecture: Creating Healing Environments for Special Patient Populations by Jain Malkin. New York: John Wiley & Sons, Inc., 1992.
• Medical and Dental Space Planning: A Comprehensive Guide to Design, Equipment, and Clinical Procedures, 3rd Edition, by Jain Malkin. New York: John Wiley & Sons, Inc., 2002.
• Putting Patients First: Designing and Practicing Patient-Centered Care by Susan Frampton. New York: John Wiley & Sons, Inc., 2003. (2004 ACHE Book of the Year)
• Through the Patient's Eyes: Understanding and Promoting Patient-Centered Care by Margaret Gerteis. Jossey-Bass, 1993.

Organizations

• Academy of Architecture for Heath
• Center for Health Design
• Coalition for Health Environment Research (CHER)
• Environmental Design Research Association (EDRA)
• Institute for Family Centered Care
• Institute for Healthcare Improvement (IHI)
• Institute of Medicine (IOM)
• International Academy for Design & Health
• Planetree
• Society for the Arts in Healthcare

Websites

• Green Guide for Health Care™—A best practices guide for healthy and sustainable building design, construction, and operations for the healthcare industry.