The physical environment and patient wellbeing

Patients can spend many hours in bed or sitting, with little to do. The influence of the immediate environment on their sense of wellbeing and actual recovery was the subject of a 2003 report from NHS Estates. The study indicates that the architectural environment can contribute to the treatment of patients and significantly affect their health outcomes, concluding that:

• patients are sensitive and articulate about their architectural environment
• patients make better progress in purpose-designed modern buildings than in older ones
• better designed hospitals create an overall improved atmosphere, leading to patients with mental health problems being less confrontational and general patients requiring less analgesic medication [i].

Studies have shown that poor design works against the wellbeing of patients and in certain instances can have negative effects on physiological indicators of wellness [ii]. Research has linked poor design to anxiety, delirium, elevated blood pressure, and increased intake of analgesics [iii]. Healthcare building design should extend beyond functional efficiency, marketing and cost. It should promote wellness by creating physical surroundings that are psychologically supportive. It should ensure that patients are not overcrowded or over concentrated, provide a variety of spaces such as a big day room, a dining room that is well lit and ventilated and a spacious lobby and corridors and give sufficient attention to natural and artificial lighting [iv].

This may not always be possible within existing building design, but it should be a consideration in all future builds and renovations. The effects of supportive design are complimentary to the healing effects of drug treatments and other medical technology, and can foster the process of recovery [v].

Examples of environmental hospital design that can be of benefit include:

Exposure to daylight

Research indicates that exposure to light - daylight or bright, full spectrum artificial light - is effective in reducing depression even for those hospitalised with severe depression [vi]. Medical studies have reported that hospitalised patients with depression may have more favourable outcomes, including shorter and less costly stays, if they are assigned to sunnier rooms rather than rooms that receive less daylight or are always in the shade. A 2001 study by Benedetti et al found that patients hospitalised for depression stayed an average of 3.7 fewer days if they were assigned east-facing rooms exposed to morning light, compared to patients in west-facing rooms with less sunlight [vii]. Depression is a serious problem not only for mental health patients, but also for patients with cardiovascular disease or cancer. A Canadian investigation of myocardial infarction patients in an intensive care unit suggested that female patients had shorter stays if their rooms were sited to provide higher daylight exposure [viii]. In the same study, mortality in both sexes was lower in sunnier rooms than in north-facing rooms.

Reduced noise

Studies have documented the negative effects of noise on patient outcomes. Several studies focusing on neonatal intensive care units, have found that higher noise levels decreased oxygen saturation increasing the need for oxygen support therapy, elevated blood pressure, increased heart and respiration rate, and worsened sleep [ix]. Lack of adequate sleep results in poor physical and mental function [xiv]. Sleep is important for immune, endocrine and metabolic functions and insufficient or poorly timed sleep has a negative affect on health and wellbeing [xv][x]. Studies have also shown that noise increases stress in adult patients and can heighten blood pressure and heart rate [xi][xii]. When high performance ceiling tiles were installed in a coronary critical care unit (CCU) in a hospital in Sweden, noise levels declined and patients reported that they were significantly more satisfied with care quality compared to when low performance ceiling tiles were in place [xiii]. Research on adults and children has shown that noise is a major cause of sleep deprivation. L

Ward layouts and way-finding

Ward layouts in older hospitals generally provide long corridors organised around a central nursing station, where medication and charts are located. Research has shown that nurses spend much of their time (more than 40 per cent in older UK NHS hospitals) walking up and down halls increasing fatigue and stress and sharply cutting the time available for observing patients and delivering direct care [xvi][xvii]. Way-finding problems in hospitals are costly and stressful and affect patients who may be unfamiliar with the hospital and are stressed and disorientated. This is worsened as most hospitals have existing complex buildings upon which they impose a signage system.. This strategy is usually ineffective. If people get lost, they may get stressed, which raises cortisol levels and lowers immune system functioning [xviii]. Evidence based design (EBD) is an effective solution and involves designing better signage including optimal spacing and location of signage.

Single sex accommodation

The importance of single sex accommodation, toilet and washing facilities was a recurrent theme in the responses to the 2008 Royal College of Nursing dignity survey. Respondents viewed single sex provision as a significant contributing factor to providing dignified care [xix].

Single sex accommodation can dramatically improve how patients feel about their care and help ensure that everyone is treated in privacy with the dignity they deserve [xx]. Being in mixed-sex hospital accommodation can affect a patients’ health at a time when they may already feel vulnerable. The most common concerns include physical exposure, being in an embarrassing or sexually threatening situation, noise, and the possibility of other patients overhearing conversations about their condition. These worries can disrupt a patient’s recovery [xxi].

Women, older people and some ethnic minority groups are more likely to worry about being in mixed-sex accommodation. Older people represent the largest users of NHS services and account for two-thirds of NHS hospital admissions. They are most likely to find mixing 'not at all acceptable’ [xxii]. Patients talk about feeling more relaxed and comfortable in same-sex accommodation. Some believe that the greater sense of ease helps them to recover more quickly [xxiii][xxiv].

Social interaction

Patient studies have indicated that social support reduces stress and improves recovery outcomes. Hospital design can facilitate or hinder access to social interaction [1]. Levels of social interaction can be increased by providing lounges, day rooms, and waiting rooms with comfortable movable furniture arranged in small flexible groupings. Studies in psychiatric wards and nursing homes have found that appropriate arrangement of movable seating in dining areas enhances social interaction and also improves eating behaviours, including increasing the amount of food consumed by geriatric patients [xxv]. Renovating a traditional waiting area in a neurology clinic by making small changes to the general layout, colour scheme, floor covering, curtains, and providing informational material and information displays resulted in more positive environmental appraisals, improved mood, altered physiological state, and greater reported satisfaction among patients[xxvi].

Nature and hospital gardens

Laboratory and clinical studies have shown that viewing nature produces stress recovery, evident in physiological changes, such as in blood pressure and heart activity [xxvii]. A picture with a landscape scene reported less anxiety/stress and needed less analgesics than a control group [xxviii]. A study of blood donors in a waiting room found that blood pressure and pulse were lower on days when a television played a nature videotape, compared to days with continuous daytime television programmes [xxix]. Hospital gardens not only provide restorative or calming nature views, but can also reduce stress and improve outcomes through other mechanisms, including fostering access to social interaction and providing opportunities for positive escape and a sense of control with respect to stressful clinical settings [xxx]. A study by Whitehouse et al in 2001 indicates that patients and families who use hospital gardens report positive mood changes and reduced stress [xxxi]. Research has demonstrated that looking at built scenes lacking nature (rooms, buildings, and parking lots) is significantly less effective in fostering restoration and may worsen stress. Visual exposure to nature improves outcomes such as stress and pain. A study in a Swedish hospital found that heart-surgery patients in intensive care units who were assigned

For information on what is happening in the UK please see Appendix 1.

References
[1]Professor Sir Michael Marmot looked at the social gradient in health concluding that the higher the social position, the better the health. He labelled this 'the status syndrome’. According to Marmot, the better health enjoyed by higher status people was due to their greater social participation and autonomy

[i] Lawson B, Phiri M, Wells-Thorpe J (2004) The architectural healthcare environment and its effects on patient health outcomes a report on an NHS Estates funded research project. The Stationery Office (TSO).

[ii] Ulrich R (1991) Effects of Interior design on wellness: Theory and recent scientific research. Journal of Health Care Interior Design 3: 97-109.

[iii] Ulrich R (1984) View through a window may influence recovery from surgery. Science:224: 420-21

[iv] Gross R, Sasson Y, Zarhy M et al (1998) Healing environment in psychiatric hospital design. General Hospital Psychiatry 20: 108-14.

[v] Ruga W (1989) Designing for the Six Senses. Journal of Health Care Interior Design 1: 29-34.

[vi] Golden et al (2005) The efficacy of light therapy in the treatment of mood disorders: A review and meta-analysis of the evidence. American Journal of Psychiatry 162:656-62

[vii] Benedetti et al (2001) Morning sunlight reduces length of hospitalisations in bipolar depression. Journal of Affective Disorders, 62:221-23.

[viii] Beauchemin K,Hays P (1998) Dying in the dark: Sunshine, gender and outcomes in myocardial infarction. Journal of the Royal Society of Medicine 91: 352-4.

[ix] Johnson A (2001). Neonatal response to control of noise inside the incubator. Paediatric Nursin, 27: 600-5.

[x] Slevin M, Farrington N, Duffy G et al (2000). Altering the NICU and measuring infants’ responses. Acta Paediatrician, 89(5): 557-81.

[xi] Morrison W, Hass E, Shaffner D et al (2003) Noise, stress, and annoyance in a paediatric intensive care unit. Critical Care Medicine 31:113-119.

[xii] Topf M, Thompson S (2001) Interactive relationships between hospital patients’ noise-induced stress and other stress with sleep. Heart & Lung 30: 237-43.

[xiii] Hagerman I, Rasmanis G, Blomkvist V et al (2005) Influence of intensive coronary care acoustics on the quality of care and physiological state of patients. International Journal of Cardiology 98 : 267-70.

[xiv] Pilcher J & Huffcut A (1996). Effects of sleep deprivation on performance: A meta-analysis. Sleep; 19, 318-26.

[xv] Åkerstedt T & Nilsson PM (2003) Sleep as restitution: an introduction (Minisymposium). Journal of Internal Medicine; 254: 6-12.

[xvi] Hendrich A (2003) Optimizing physical space for improved outcomes: Satisfaction and the bottom line. Paper presented at the Impact Conference, Institute for Healthcare Improvement and The Centre for Health Design, Atlanta, GA.

[xvii] Ulrich R, Zimring C, Quan X et al (2006) The environment’s impact on stress. In S Marberry (Ed.), Improving healthcare with better building design. Chicago: Health Administration Press, 37-61.

[xviii] Zeisel J, Silverstein N, Hyde J et al (2003). Environmental correlates to behavioural outcomes in Alzheimer’s special care units. The Gerontologist 43: 697-711.

[xix] Royal College of Nursing (2008) Defending Dignity: Challenges and Opportunities for Nursing. Royal College of Nursing: London

[xx] Maxwell S. Sigsworth J.(2009) Eliminating mixedsexaccommodation in hospital to improve patient experience. Nursing Times. 105:12-4

[xxi] Department of Health (2009) Putting an end to mixed sex hospital accommodation. London: DH.

[xxii] Healthcare Commission (2007) Caring for dignity A national report on dignity in care for older people while in hospital. Healthcare Commission: London

[xxiii] Ulrich R S (2004) The role of the physical environment in the hospital of the 21st century: a once-in-a-lifetime opportunity. New York: Robert Wood Johnson Foundation.

[xxiv] Dowdeswell B, Erskine J and Heasman M (2004) Hospital Ward Configuration Determinants Influencing Single Room Provision, [Online] AReport for NHS Estates England, by the European Health Property Network.

[xxv] Bechtel R,Churchman A (2002) Handbook of environmental psychology. New York: Wiley.

[xxvi] Leather P, Beale D, Santos A et al (2003) Outcomes of environmental appraisal of different hospital waiting areas. Environment & Behaviour, 35: 842-69.

[xxvii] Ulrich R (1991) Effects of interior design on wellness: Theory and recent scientific research. Journal of Health Care Interior Design 3: 97-109.

[xxviii] Ulrich R (1991) Effects of interior design on wellness: Theory and recent scientific research. Journal of Health Care Interior Design, 3: 97-109.

[xxix] Ulrich R, Simons R, Miles M (2003) Effects of environmental simulations and television on blood donor stress. Journal of Architectural & planning research 20, 38-47.

[xxx] Ulrich R (1999) Effects of gardens on health outcomes: Theory and research. Cooper Marcus & Barnes (Eds.), Healing Gardens: New York: Wiley.

[xxxi] Whitehouse S, Varni J, Seid M et al (2001). Evaluating a children’s hospital garden environment: Utilization and consumer satisfaction. Journal of Environmental Psychology21: 301-14.