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Why should I design for a western hospital that has a high range of resources and money available when I could be designing for a healthcare centre in a developing nation?


Understanding Healing Environments: Effects of Physical Environmental stimuli on Patients’ Health and Well-being By Karin Dijkstra

“It is most likely that you experience a sense of depersonalization: you do not have control over you own body, you cannot control who enters your room, and you must fully rely on people you have never met, the healthcare professionals.” (pg 11)

“Encounters with healthcare situations are generally characterized by fear, anxiety, stress, and

uncertainty (Mason, Sachar, Fishman, Hamburg & Handlon, 1965; Newman, 1984; Pride,


“How well these healthcare environments satisfy the psychological needs of patients?”

“how can healthcare facilities be designed that create spaces for the delivery of high quality medical care and are at the same time pleasant, in order to assist rather than hinder healing?”

“Well-designed facilities may increase positive emotions, which in turn could positively affect patients’ health and well-being (Malkin, 2008). This presents an opportunity to comfort patients; physical surroundings can be designed in a way that is psychologically supportive (Ruga, 1989). The use of this knowledge on psychologically supportive healthcare environments is defined as evidence-based design (Hamilton, 2003). Evidence-based design, based on its medical equivalent, evidence-based medicine, refers to guiding design decisions by scientific evidence in order to promote health and well-being. Use of the evidence-based design of healthcare environments might impact health-related outcomes such as length of stay, pain, medication intake, stress, arousal, mood, or environmental appraisals. These variables are all considered to be relevant outcome measures in assessing the effects of the physical healthcare environment, but most research in this field focuses on stress (Ulrich, 1995).” (pg 11)

“Stress can result in more pain and slower wound healing, but it also impacts the immune system (Rabin, 1999). These are convincing reasons to design healthcare environments that reduce stress and address patients’ needs for relaxation and comfort (Malkin, 2008).” (pg 11)

It is difficult for patients to evaluate, the clinical competence of their physician and the outcome of the service because they lack the required knowledge or skills. (pg 11)

“People tend to base their evaluations of a service on three types of clues (Berry, Wall & Carbone, 2006). They use functional clues that concern the technical quality of the service, humanic clues, which relate to the behaviour and appearance of service providers, and mechanic clues, which refer to aspects of the physical environment. These clues create the service experience by influencing people’s rational and emotional perceptions of service quality.” (pg 13) 

“Berry et al. (2006) state that the more complex and personal a service is, the more customers act as detectives to unravel all of the available clues. Healthcare services are clearly one of the most personal, important, and complex services; therefore, patients will act in a detective-like manner because they are eager to obtain any evidence of the service provider’s competence and caring. Patients will rely on all clues that are available to them to form an impression of this competence or lack thereof. Both interactions with the physician and other staff members as well as clues from the built environment will be assessed in such cases to assist this impression formation.” (pg 13)

“When ill, people tend to be uncertain, anxious, concerned, and in pain. Under such circumstances, people will be imbalanced more easily by distressing environmental stimuli. This suggests that they could also benefit more from calming, relaxing, and positive environments. The impact of the physical environment could, thus, be of greater importance in healthcare settings than in other settings.” (pg 13)

“Hospitalization is generally associated with feelings of fear, uncertainty, and anxiety (Mason et al., 1965; Pride, 1968). These feelings may affect the healing process. Volicer and Volicer (1978) found that hospital stress was positively correlated with changes in heart rate and blood pressure.” (pg 15)

“Rabin (2004 in Malkin 2008; personal communication 2008) proposed that pleasant healthcare environments are those that are perceived by the brain as calming, meaning that the stress reactive areas of the brain decrease their activity with a resultant decrease in the concentration of cortisol and norepinephrine in the blood. This results in patients experiencing less pain, having more restful sleep, less anger, less muscle tension, and a lower risk of stroke. Furthermore, Kaplan and Kaplan (1989, p.189) states that “the nervous system seems to be structured in such a way that pleasure and pain tend to inhibit each other”. A more pleasant healthcare environment could, therefore, result in less stress and anxiety in patients and this should lead to better health and increased feelings of well-being.” (pg 15)

“When speaking about a more pleasant healthcare environment, a wide variety of environmental characteristics come to mind. Variables such as indoor plants, colors, and music could help create environments that generate positive feelings and, as a consequence, reduce negative outcomes.” (pg 15)

The physical healthcare environment is comprised of ambient, architectural, and interior design features (Harris et al., 2002). Ambient features include, for example, lighting, noise levels, odors, and temperature. The architectural features are the relatively permanent aspects of the physical healthcare environment, such as the spatial layout of the hospital, the size and shape of rooms, and the placement of windows. Interior design features can be defined as the less permanent aspects of the healthcare environment, such as furnishings, colours, interior plants, and artwork. 

“Research shows that hospitals are noisy places and that these noises create discomfort and stress (see Rashid & Zimring, 2008 for a review). These negative effects can be reduced by adding sound-absorbing tiles to Lighting Music Sound / noise Scents Windows Room size Spatial layout Coloring Artwork Furniture Carpeting Natural elements ` Personality traits Preferences Demographic & cultural variables Cognitive Affective Health Well-being Behavior 18 the ceiling (Hagerman et al., 2005). Environmental stimuli can also be added to the environment to influence the patient in a positive way. The environment may elicit positive feelings, hold attention and interest, and block or reduce negative thoughts, for example, by the presence of art or a view from a window (Ulrich, 1991). The purpose of the present studies is to improve health and well-being by either adding positive elements to existing healthcare environments, such as interior plants or music, or by making changes in existing environmental characteristics, for example, changing wall colours.” (pg 16-17)

“Understanding the effects of physical environmental stimuli in healthcare facilities will allow us to create environments that positively affect the health and well-being of patients. In addition, understanding the underlying processes that cause these effects may help in designing healing environments more efficiently.” (pg 21)

The effects of colour, music, and interior plants were studied in the context of treatment areas, waiting rooms, and patient rooms. Moreover, the studies aim to reveal possible underlying mechanisms that cause these effects, and to gain insight in individual differences in reactions to the physical healthcare environment. 

The available studies support the general notion that the physical healthcare environment affects the well-being of patients. Predominantly positive effects were found for sunlight, windows, odor, and seating arrangements.

“In Chapter 3, two field studies that investigate the effects of music in a waiting room are reported. Most research in this field involved inpatients in acute and psychiatric settings. Waiting areas, however, may play an important role in reassuring or distressing ambulant patients. The first study demonstrates that playing classical music in a dentist’s waiting room results in reduced feelings of stress and anxiety, as well as higher perceived attractiveness and professional quality of the waiting room. The second study replicates the beneficial effects of classical music in the waiting room of a general practitioner. Moreover, this study demonstrates that the calming effects of classical music are the result of patients being in a more positive emotional state after being exposed to classical music.” (pg 21)

“Results of this study show that the stress-reducing effects of indoor plants are mediated by perceived attractiveness of the patient room. This study, thus, confirms the stress-reducing properties of natural elements in the built environment. Moreover, it sheds light on the underlying mechanism that causes this stress-reduction. The mediating effect of a cognitive response was replicated in a second study. This second study shows that not only is stress reduced by indoor plants, but by a painting of nature as well. Apparently, both real plants and a painting of a tree activate the concept of nature.” (pg 22)

“Ingham and Spencer (1997) created three waiting room layouts: a baseline condition, an increased décor condition, and an added comfort condition. They found that dental patients in the added comfort condition rated the practice as more considerate than patients in the increased decor condition, who rated the practice as more considerate than those in the baseline condition. The quality of the practice was rated lower by patients in the baseline condition than by those in the other conditions. Patients in the added comfort condition were more relaxed, secure and comfortable than those in the other two conditions. Leather et al. (2003) compared a redecorated environment with a more traditional waiting area. They found that both affective appraisal and satisfaction were higher for the redecorated waiting area.” (pg 38)

Rongoa Remedies – Enjoy Public Art Gallery

“The practice of medicine by Maori acknowledges all aspects of a person. The diagnosis and treatment of an illness is based not only on the physical, but on the mental, spiritual and physical equally. It is acknowledged that the origin of the illness may be due to many factors such as environment, action, thought, or injury. Mason Durie (1994) describes the principles of Maori healing as holistic, incorporating the mind, body and spirit in which the concepts of tapu (sacred/restricted) and noa (unrestricted) provide guidelines in modes of healing practices.”

Design Issues in Hospitals: The Adolescent Client

“Hospitalization and illness can present a distinct and potentially harmful threat to the biological, social, and cognitive development of adolescents (Boice, 1998). With the exception of infancy, biological changes occur more rapidly during the period of adolescence than at any other time in the life span (Dusek, 1996).” (pg 2)

The influence of environmental design is of great importance to hospitals and other health care settings. The psychological stress of poor design can contribute to feelings of hopelessness, anxiety, and frustration in patients (Ortega-Andeane, 1991). Conventional medicine and advanced technology can be combined with supportive design to contribute to the overall effectiveness of the health care provided. Ulrich’s (1991) theory of supportive design includes specific goals to provide physical features and social situations that not only avoid an increase in stress on patients but also may actually reduce the stress that patients feel. McKahan (1997) offers more specific design objectives to create hospitals that are humanistic and therapeutic; these objectives include views to nature, access to nature, ceiling design, acoustic properties, artwork, and color.

Results indicated that patients who were assigned to rooms with windows that offered views of natural elements, such as trees and bushes, had shorter postoperative stays, received fewer negative evaluations from staff, and took fewer analgesics than did patients in rooms facing brick buildings. In more recent research discussed by Ulrich (1991), open-heart surgery patients were postoperatively exposed to different scenes: a nature scene of water or trees, an abstract representation, or no scene at all. Those who viewed the nature scene of water reported less anxiety than did those exposed to the other types of scenes or no scene. Moreover, those who viewed the abstract scene reported a higher level of anxiety than did those who saw no scene at all. Regarding the selection of art for the hospital environment, Ulrich suggested that “when designers or hospital art committees select art styles or content for patient areas that would pass critical muster in, say, a New York gallery, such art in many cases will increase stress and work against wellness” (p. 106). Verderber’s (1982) work on the relationship between an adequate number of windows and higher levels of well-being also underscores the importance of vistas.

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