Therapeutic Environments

from the Therapeutic Environments Forum, AIA Academy of Architecture for Health
Ron Smith, AIA, ACHA, Senior Associate, HOK | Healthcare, Facilitator
Nicholas Watkins, Ph.D., Director of Research and Innovation, HOK | Healthcare, Contributor

Last updated: 12-03-2008

Overview

Healthcare facilities 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 affects patient outcomes, patient satisfaction, patient safety, staff efficiency, 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

Research on completed projects by organizations including the Center for Health Design, Texas A&M University's Center for Health Systems Design, the Academy of Neuroscience for Architecture, and by a growing number of architectural firms and their clients shows measurable benefits to patient outcomes, safety, and quality of care, from such factors.

The application of these factors has been focused on the patient and patient's family. However, there are also recognized potential benefits for staff and caregivers in terms of satisfaction, effectiveness, and staff retention, from environmental factors such as:

• Noise reduction
• Same-handed patient rooms
• Access to daylight
• Appropriate lighting
• Providing 'off-stage' areas for respite
• Proximity to other staff
• Appropriate use of technology
• Decentralized observation, supplies, and charting

The benefits staff receive from these environmental factors may impact the quality of care patients experience. (For more information on design of effective workplaces, see WBDG Productive Branch.)

In general, 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
• Architecture and the Mind, John Eberhard, FAIA
• Exploring Pathology: Relationships between Clinical and Environmental Psychology, Kathryn H. Anthony and Nicholas Watkins. From Handbook of Environmental Psychology (pp. 129-146), R. Bechtel and A. Churchman (Eds.) New York: John Wiley & Sons, 2002.
• 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.
• Humanscape: Environments for People by Stephen Kaplan, and Rachael Kaplan. Ann Arbor, MI: Ulrich's Books, Inc.
• Inquiry by Design, John Zeisel, 2006 Edition.

B. Practice

To create a therapeutic environment, all members of the design team—medical planner, architect, engineer, interior designer, site and landscape 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 design criteria that are used or are being studied:

Reduce or Eliminate Environmental Stressors

For example:

• Artwork and aesthetics can enhance the soothing and calming qualities of a space
• Adequate space should be provided in public areas and waiting rooms to avoid crowding
• Perceived waiting time can be mitigated by positive distractions
• Visual and noise privacy
• Odors that are objectionable or 'medical' can create stress
• 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, daylight, color, texture, and pattern should all give cues, as well as artwork and signage
• Reduce or eliminate sources of noise; other patients, public address systems, equipment 'clatter', loud conversations at nurse stations
• Acoustical treatment of corridors adjacent to patient rooms; carpet tiles, rubber flooring
• 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.)
• Maintain good indoor air quality; 100% outside air where climatic conditions allow
• Color, while subjective, can be a design factor in reducing environmental stress when understood and used in the context of the color preferences of a project-specific population.

Additional Information on Reducing Environmental Stressors

• Adaptable Patient Room Study Graduate Studies in Architecture + Health, Clemson University, 2003-2004.
• Ambulatory Facility Design and Patients' Perceptions of Healthcare Quality, Franklin Becker, Ph.D., B. Sweeney, K. Parsons. Health Environments Research and Design Journal, August 2008.
• "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
• Mental health and the built environment: More than bricks and mortar?, David Halpern. Bristol, PA: Taylor & Francis Ltd., 1995.
• "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, Preventative Medicine, Volume 30, Number 4, April 2000 , pp. 339-345
• When buildings don't work: The role of architecture in human health, Gary W. Evans and Janetta M.M. Journal of Environmental Psychology, 18, 85-94, 1998.

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 gardens: Therapeutic Benefits and Design Recommendations, C.C. Marcus and M. Barnes (Eds.) New York: John Wiley & Sons, Inc., 1999.
• 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 appropriate environments
• Consider sociopetal versus sociofugal spaces: Sociopetal spaces facilitate social behaviors and the development of social groups (nonfixed seating, round tables, etc); see Sommer, R. below

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
• Personal Space: The Behavioral Basis of Design by Robert Sommer. Englewood Cliffs, NJ: Prentice-Hall, Inc., 1969
• 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)
• The Design of Psychologists Offices; A Qualitative Evaluation of Environment - Function Fit by Kathryn H. Anthony and Nicholas Watkins. Academy Journal, 2007.
• Through the Patient's Eyes: Understanding and Promoting Patient-Centered Care by Margaret Gerteis. Jossey-Bass, 1993.

Give a Sense of Control

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.

For example:

• Private patient rooms result in better outcomes, according to recent studies commissioned by the Facilities Guidelines Institute and conducted for CHER (see below)
• 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, daylight, 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
• Storage area for patient belongings

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" (PDF 1.08 MB), by Habib Chaudhury, Atiya Mahmood and Maria Valente, Simon Fraser University, November 20, 2003. Submitted to The 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. Design goals that are set and clearly defined at the beginning of a project can serve as research questions to be answered by Post-Occupancy Surveys, data collection, and evaluation.

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
• Create your own and share it...!

D. Operational Models

Aligning the healthcare organization's operational model with the design goals early in the process is a key to success in creating a collaborative, emotionally, spiritually, and socially supportive environment.

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, and identifying opportunities to make it an active agent for healing. 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, for example:

• 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 behavior

• 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."

Holistic Model: there is a movement toward research "that embraces an organization and its facility in its entirety. This research considers several design features at once, how they interact, and how their interactions impact several patient and staff outcomes" (N. Watkins), for example:

• "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.
• "Lost in Translation: Bridging the Gaps Between Design and Evidence-Based Design", Nicholas J. Watkins, A. Keller. Health Environments Research Journal, 2008.
• 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.
• "Color in Healthcare Environments; a Critical Review of the Research Literature" by the University of Missouri, Columbia, Department of Environmental Design
• 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
• Sustainable Design movement as it applies increasingly to Healthcare facilities; e.g., Green Guide for Healthcare, USGBC LEED-HC
• The journal HERD (Health Environments Research and Design)
• The Institute of Medicine (IOM) and its emphasis on the improvement of quality and patient safety
• CMS and its 'pay for performance' policy
• 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 growing number of 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: multidisciplinary studies in the fields of neuroscience and architecture

Links to Additional Information on Market Forces and Future Influencers

• Institute of Medicine
• Institute for Healthcare Improvement

Application

Examples

Community Hospital of the Monterey Peninsula; healthcare in a natural setting with innovative daylighting, views of nature for patients and staff, water features, and healing gardens.

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.

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) Artwork
• 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.
• Inquiry by Design by John Zeisel, 2006.
• 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.
• Visual Reference for Evidence Based Design by Jain Malkin, 2007.

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.