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and Behavior

Health Care Environments and Patient Outcomes: A Review of the Literature

Ann Sloan Devlin and Allison B. Arneill
Environment and Behavior 2003 35: 665
DOI: 10.1177/0013916503255102
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& Arneill / HEALTH
/ September 2003


A Review of the Literature

ANN SLOAN DEVLIN is the May Buckley Sadowski 19 Professor of Psychology at

Connecticut College. She received her B.A., M.A., and Ph.D. degrees in psychology
from the University of Michigan. Her current research interests involve personality differences in perceptions of health care architecture; gender and correlates of
way finding, such as mental rotation; and the environmental design of way-finding
ALLISON B. ARNEILL received her B.A. and M.A. in psychology from Connecticut College. She currently works at the Harvard University Development Office as a
staff assistant specialist. She has a long-standing interest in health care architecture
and interior design as they relate to wellness.

ABSTRACT: This review of the literature on health care environments and patient
outcomes considers three research themes: patient involvement with health care (e.g.,
the role of patient control), the impact of the ambient environment (e.g., sound, light,
art), and the emergence of specialized building types for defined populations (e.g.,
Alzheimers patients). The article also describes the challenges presented in doing
high-quality research focused on health care environments and contrasts the contributions made by two different traditions: architecture and behavioral science. The implications of managed care and opportunities for research are considered.
Keywords: health care architecture; managed care; ambient environment; patientcentered care; postoccupancy evaluations (POEs)

The role of the environment in the healing process is a growing concern

among health care providers, environmental psychologists, consultants, and
architects (Devlin, 1992, 1995; Martin, Hunt, & Conrad, 1990; Ruga, 1989;
AUTHORSNOTE: Address correspondence to Ann Sloan Devlin, Box 5448, Department of Psychology, Connecticut College, 270 Mohegan Avenue, New London, CT
ENVIRONMENT AND BEHAVIOR, Vol. 35 No. 5, September 2003 665-694
DOI: 10.1177/0013916503255102
2003 Sage Publications




Ulrich, 1992, 1995). Moreover, the belief that the traditional, institutionally
designed health care facility has no bearing on the wellness of its patients as
long as the level of care is superb is in question (Ulrich, 1992). Researchers
are finding that changes and additions made to the health care facilitys physical and social environment with the patient in mind can positively influence
patients outcomes (Davidson, 1994; Ulrich, 1984; Verderber & Reuman,
1987). Likewise, health care professionals are finding that sensitive design
can enhance recovery [and] shorten hospital stays (Lemprecht, 1996,
p. 123). At the same time, the role of the physical environment and facilities
themselves are not universally included in routine patient satisfaction assessments. For example, in a survey measuring whether patients were satisfied
with their hospital experience, no items directly related to the physical environment were included (Harris, Swindle, Mungai, Weinberger, & Tierney,
1999). Yet patients mention the importance of such aspects of the environment as cleanliness, comfort, and privacy when asked about their rooms
(Bruster et al., 1994).
Although this gap exists between research findings and applications,
increasingly, health care providers understand that the physical environment
of health care settings can affect patient health, and articles linking health
care design and well-being appear with more frequency in design journals.
For example, the September/October 2002 issue of Architecture Boston was
devoted to the topic of health. Ulrich (1991) contended that research has
linked poor design to such negative (patient) consequences as anxiety, delirium, elevated blood pressure levels, and an increased intake of pain drugs
(p. 97). Unfamiliar environments in clinics, hospitals, and nursing homes can
produce psychological stress that can negatively affect healing and wellness
(Ulrich, 1991). Today, designers and planners of health care facilities face an
enormous challenge. To be successful, they must accommodate sophisticated
clinical interventions and complex medical technology while providing a
humane, therapeutic environment. They must also respond to rapid change at
multiple levels in technology, care and treatment methods, reimbursement,
regulation, and demographic trends in health status, among other factors
(Allison & Hamilton, 1997).
The purpose of this article is to explore the literature on health care environments and their impact on patient outcomes. This body of literature is
diverse in terms of focus and findings. Although the early research focused
on the hospital environment, more recent research has examined a range of
facilities from ambulatory care centers to Alzheimers units. Researchers
have examined the influence of such topics as ambient stressors (e.g., noise),
nature, and patient control. The research has been done by leaders in many
fields including architecture, consulting, health care, and psychology.



Despite the progress that is being made, with some foundations supporting
the process (Beatrice, Thomas, & Biles, 1998), the research is still accumulating and gaps do existsome of them related to the difficulty in doing this
research. Before discussing the environmental influences that are known, it is
important to discuss both the challenge of doing this research and the recent
changes in health care that involve its physical design.


A number of researchers have commented on the limited number of studies dealing with person-environment fit in hospitals. Apart from issues of
lifestyle, aesthetics, or their specific relation to the reconstituted hospital and
medical center, the field of health architecture had not fostered a tradition of
research (Verderber & Fine, 2000, p. 190). There is a paucity of nursing
research that focuses on congruous person-environment interactions; that is,
environmental patterns that promote harmony within the individual
(Kolanowski, 1992, p. 10). Similarly, Lawton, Liebowitz, and Charon (1970)
commented, The merits of the physical design of a treatment setting are
much discussed, but infrequently tested empirically (p. 231). Another plea
is for more sophisticated approaches to research. As Epstein (2000) noted,
Future studies of patient-centered care will require more than just the application of quantitative ratings to observational data (p. 806).
Rubin and Owens (1996) combed through more than 38,000 articles to
find those even remotely related to patient outcomes that are influenced by
variables in the environment. Just fewer than 50 articles met their criteria, and
most of those were poorly designed from a methodological standpoint. Even
two well-known studies, those by Ulrich (1984) about the positive effect of
views of nature for patients recovering from surgery and by Miller, White,
Whitman, OCallaghan, and Maxwell (1995) about premature babies who
gained more weight when their hospital stay used light cycled on diurnal patterns, were subject to criticism (Weber, 1996).
A number of problems explain why this research has been slow to accumulate. These include the fact that architecture lacks a tradition of research,
that medicine has overlooked the role of the physical environment in patient
well-being, and that the research process in health care settings is exceedingly difficult. Regarding architectures lack of power to make an impact,
The criteria upon which far-reaching decisions are based too often rest upon
flawed assumptions and a lack of hard data. This statement of course is old



news (perhaps the oldest news) indeed to environmental design researchers

and research-based designers (Verderber & Refuerzo, 1994, p. 281).
Regarding research, Malkin (1992) commented on the difficulty of doing
good research because of the problems with experimental control and also
stated, For many design questions, there is no sound research yet available to
inform the designers personal intuition, sensitivity, and experience
(Malkin, 1991, p. 28).
Another problem sometimes cited is the difficulty practitioners have with
understanding research that appears in academic journals. Increasingly,
though, researchers recognize the need to make their findings available in
nonacademic journals. As an example, the summer 2002 issue of Cure
included an article on healing environments with an overview of Ulrichs research on the benefits of good health care design (Steele, 2002). Another
example of the move to make findings more available is a new database project entitled InformeDesign (where research informs design). This Internet
project is a collaboration between the University of Minnesota and the American Society of Interior Designers (ASID). Although not limited to research
on health care, the Internet Web site, to be launched in the fall of 2003, will
disseminate research-based design criteria in a way that is interpretable to a
nonresearch trained audience (Martin & Guerin, 2002).
Another area in which progress can be made is the use of research to evaluate the impact of finished projects. Few firms routinely incorporate what
are called postoccupancy evaluations (POEs) in their work (Shumaker &
Pequegnat, 1989). POEs evaluate how well facilities perform the functions
for which they were intended. But the firms of Kaplan, McLaughlin, and
Diaz (K/M/D) and Caudill, Rowlett, and Scott are cited as those that value the
information that POEs can provide (Shumaker & Pequegnat, 1989).
Verderber and Refuerzo (1994, 1999) also put forward the concept of
research-based design or design that is driven by research. Translating the
information from 25 POEs, they formulated 40 guidelines for community
health care centers in Louisiana. Findings from their research were used to
plan the West Monroe Community Health Center. These included the fact
that no single footprint fits all needs, the necessity of zoning based on function for interior spaces, the importance of natural daylight (including the use
of full-height windows), and the creation of room-to-room transparency
(being able to see from one room to the location of another). They also listed
the importance of using residential imagery, legible entrances, and separate
entrances for patients and staff. Verderber and Refuerzo suggested that,
rather than beginning the design process from scratch each time, one might
better ask, How do we want to adapt this body of knowledge to our new
clinic? (1999, p. 238).



Members of the health care profession who make design decisions need to
recognize the benefit that POEs can feed into future designs (Zimring &
Welch, 1988). As an example, Zimring and Welch (1988) cited K/M/D who
evaluated a psychiatric hospital to prepare for another project with the same
client. In fact, McLaughlin of K/M/D has been credited with establishing the
importance of the POE in the health care arena (Bobrow & Van Gelder,
1980). The firm of K/M/D is also credited with the design of a triangular nursing unit and with refining the concept of the single-bed hospital room.

The evolution of health care architecture has led to research on specific

building types that differ in many ways from the general hospital. As early as
the 1970s, designers were considering the challenge of hospital design in an
era of increasing technology and rapid change. McLaughlin (1976) found
many problems with what is called the matchbox-and-muffin scheme (patient
towers arising from supporting services). In McLaughlins view, the hospital
is the most changing of building types, and its physical life is uniquely characterized by modification (p. 118). Hospitals with a radial corridor design
were popular beginning in the 1960s and were recommended for staffing efficiencies and reduced walking distance for staff as well as more opportunity for observing patients, among other advantages (Trites, Galbraith,
Sturdavant, & Leckwart, 1970; Verderber & Fine, 2000). Verderber and Fine
(2000) argued that the triangular or saw-tooth design ultimately surpassed
the radial design in popularity because the triangular design created fewer
irregularly shaped spaces and offered more privacy for patients. Nesmith
(1995) also discussed the fact that hospitals must constantly be concerned
with designing for change in the future. As an alternative to the matchboxand-muffin design, McLaughlin selected the village as a prototype
something that is being hailed today with the decentralization of services.
The village approach makes the addition of services much easier than in the
matchbox-and-muffin scheme.
In their extensive review of the evolution of health care architecture,
Verderber and Fine (2000) discussed a number of tensions that have characterized the transformation of health care. These are (a) bigness versus smallness, (b) compactness versus linearity, (c) low-rise versus mid- or high-rise
design, and (d) centralized versus decentralized approaches. They further
noted that the single-family detached home, the roadside hotel, and the suburban shopping mall have also influenced the way we conceptualize health
care design. Nesmith (1995) also cited the shopping mall as a building type
for health care that makes patients comfortable because of its familiarity.



Ultimately, the decentralization of health care came to dominate building

form, and this decentralization, especially within separate building types,
provided the chance to create a less forbidding image for the architecture of
health care (Verderber & Fine, 2000). The term functional deconstruction,
as used here in the context of health architecture, consists of the dissection of
existing internal components and their redistribution either within the medical center or elsewhere in the community landscape (Verderber & Fine,
2000, p. 135). The dramatic atrium (influenced by the architecture of hotels
and malls) was described as the defining characteristic of the hospital in the
late 1980s, but, according to Verderber and Fine (2000), this dominance was
brief because cost containments led to a variety of consequences. With fewer
choices for patients because of HMO or PPO restrictions, hospitals did not
need to try as hard to attract patients. By the mid-1980s, in their argument,
there were pleas to attend to regional characteristics. Finally, the deconstructed health village emerged as a solution to the conflict between modernism and postmodernism (Verderber & Fine, 2000). The work of K/M/D is
cited as pivotal in changing the function and appearance of health care architecture (Verderber & Fine, 2000). Specifically, in the St. Vincent Hospital in
Santa Fe, Verderber and Fine talked about K/M/Ds horizontal as opposed to
vertical emphasis, which created the possibilities for courtyards, and the lowrise approach with irregularly shaped space, which, in turn, permits future
growth. This project is described as a compact, changing village
(McLaughlin, cited in Verderber & Fine, 2000, p. 94). The emphases that
emerged were (a) horizontality, (b) expandability, and (c) regionalist appearance (Verderber & Fine, 2000).
In the last 10 years, a number of authors in addition to Verderber and Fine
have traced the evolution of priorities in health care design. Nesmith (1995)
said that the 1970s and 1980s emphasized change related to growth and technology, whereas the mid-1980s to early 1990s stressed creating a more welcoming environment for the patient. During this time, health care focused on
specialized populations (e.g., the cancer patient, the Alzheimers patient, the
woman as patient, the rehabilitation patient). Entire books have been devoted
to specialized kinds of units (Rostenberg, 1986). In response to the question
of what is next, Nesmith stated that the next concern will be value: By this I
mean the planning and design of health systems and facilities which most
effectively deliver actual and perceived quality care (p. 6). A second principle she identified involves the facility as tool and healer:
The second principle combines two philosophies: that the physical settings of
health care delivery support productivity and effectiveness, and that they are an
end in themselvesaiding in the healing and wellness process through psycho-



physiological effect. . . . Important elements of this approach will include more

comprehensive application of recent research findings on the effects of color,
light quality, acoustics, outlook, air quality, and individual control. (p. 7)

She also claimed that one of the most notable trends in the health care field is
the growth in the number of ambulatory care centers and outpatient care facilities. Because of the differences in the strictness of building codes in acutecare hospitals, ambulatory care facilities are seen as an opening for more progressive and sensitive design (Nesmith, 1995).
An overview of the elements in supportive health care is also provided by
Williams (1988) who listed unit design, spatial considerations, sound, light,
color, thermal considerations, and weather. What is important to the patient
has even been related to Maslows hierarchy of needs (Liberakis, 1971).
Beatrice et al. (1998) cited seven areas of patient-centered care: (a) respect for
patients values, preferences, and expressed needs; (b) coordination and integration of care; (c) information and education; (d) physical comfort; (e) emotional support and alleviation of fear and anxiety; (f) involvement of family
and friends; and (g) transition and continuity of care. Malkin (1991) pointed
to the following dimensions that are important to consider in health care
design: scale, relationship of indoor and outdoor space, materials, acoustics,
lighting, legibility, variety, and special population needs. The 1990s, according to Malkin, were to present two challenges: (a) how to create a healing
environment, and (b) how to design for special patient populations. In addition, because what will be a healing environment for one person may not be
identical to the form needed for another, The most important thing is to provide control, so that the patient has options and is able to decide what is best
(Malkin, 1991, p. 35).
What do patients want? Nesmith (1995) suggested that hospital architecture with a high-tech image seems to attract patients and instill confidence in
the hospitals ability to provide the latest medical procedures. At the same
time, people are attracted to healthcare environments that are reassuringly
familiar (p. 11). Verderber and Fines (2000) recent book, updating an earlier treatise on the hospital by Thompson and Golden (1975), nicely captured
the current trends in health care architecture:
The bases for postmodern reactionism in the healthcare milieu were, besides
patient-centered care, a new emphasis on surface, texture, and ornament, on
traditional building massing and internal configuration through more legible
interior spaces and circulation patterns (even at times recalling Florence Nightingales provisions), and on the reincorporation of nature as a therapeutic
design element, and on the degree to which the building was attractive, up-



lifting, and comprehensible in the eyes of the patient. (Verderber & Fine, 2000,
p. 7)

With regard to the research on the physical environment and patient outcomes, three broad themes emerge from the authors discussed thus far: (a)
patient involvement in their health care, (b) the ambient environment (i.e.,
sound, light, nature), and (c) special populations.


One response to the pressures in health care has been to emphasize what
has been called patient-centered care. What has emerged as a priority in
health care is providing the patient with choicea concept that is fundamental to environmental psychology (Proshansky, Ittelson, & Rivlin, 1970); the
belief that giving patients control may influence their medical outcomes is
growing. In fact, a primary goal of patient-centered care is to increase the
patients control over his or her environment (Birdsong & Leibrock, 1990;
Sherer, 1993; Ulrich, 1992; Weber, 1996). Individuals who believe that they
have control over situations are more resistant to lifes hassles (Raybeck,
1991). In the hospital setting, lack of control is a major problem, and it can
increase stress and affect wellness (Ulrich, 1992). Lack of control has also
been found to be associated with depression, passivity, elevated blood pressure, and reduced immune system functioning (Ulrich, 1991). Confusing
way-finding cues, lack of privacy, noise, lack of personal control over television, and lack of a view out a window are some of the factors that contribute to
a loss of sense of control in hospitals (Ulrich, 1992).
Taylor (1979) pointed out that the hospital is one of the few places where
an individual forfeits control over virtually every task he or she customarily
performs (p. 157). In a discussion of how patients cope with their loss of
control and depersonalization in the hospital, Taylor (1979) suggested that
patients develop into the good patientthe compliant oneor the bad
patientthe resistant one. She suggested that the good patient may actually
be in a state of anxious or depressed helplessness, whereas the bad patient
may be in a state of anger and reactance against the removal of freedoms. She
further argued,



Both helplessness and reactance produce physiological, cognitive, behavioral,

and affective consequences that can strongly interfere with the course of recovery and that helplessness and reactance in patients evoke reactions in hospital staff that also have undesirable consequences for treatment and recovery.
(Taylor, 1979, p. 157)

The role the patient plays, therefore, strongly influences the control he or she
has in the hospital. Two ways to change the traditional patient role and to
increase patients sense of control in the hospital environment are to increase
their freedom of choice of daily rituals and allow them access to education
and information.
Patientschoices in the hospital can be expanded (or curtailed) in a number
of ways. For example, in a study of the effect of the inability to control the
selection of television programs, blood donors in the waiting room of a blood
bank had higher stress levels on days when the television was on than on days
when the television was off (Ulrich, 1992). Ulrich (1992) concluded that the
lack of choice of program created more stress than did not having the option
of television at all.
The issue of control was also studied when questionnaires were administered to patients in 16 hemodialysis units asking them about their perceptions
of control over four factors in their treatment environment: acoustics/noise,
lighting, temperature, and privacy (Steptoe & Appels, 1989). A significant
number of patients reported little or no control over bright lighting, uncomfortable temperatures, irregular noise levels, and lack of privacy. Furthermore, this lack of control over the environment created additional stress to
patients who were already experiencing stress related to their illness.
Whether we call it functional deconstruction or new residentialism, the
village emphasis discussed by McLaughlin (1975) and Verderber and Fine
(2000) earlier gives the patient greater choice, reduces stress, and decentralizes patient services (or centralizes them from the patients perspective).
Residentialism, as much an attitude as an architectural style has been
embraced by providers, architects, and the public as a valid expression of
emerging philosophies of patient-centered care (Verderber & Fine, 2000,
p. 318).
Although the phrase is frequently heard, the meaning of patient-centered
care is not unambiguous, and health care executives are struggling to find a
clear definition for one of the fields hottest catchphrases (Sherer, 1993,
p. 14). Some cite an increase in the efficiency of how care is delivered and a
concomitant increase in the quality of service coupled with a decrease in cost



as the goals of patient-centered care (Cleary, Edgman-Levitan, Walker,

Gerteis, & Delbanco, 1993). In patient-centered care, services, roles, and
workflow are designed from the perspective of the patient (Cleary et al., 1993).
Although patient-centered care is frequently mentioned as a priority in the
health care arena, there is relatively little concrete evidence about its effects.
Redman and Jones (1998) evaluated the impact of the patient-centered model
in two community hospitals. Using structured interviews of unit-based nurse
managers (n = 22) and non-nurse department heads (n = 4), a number of
themes emerged; not all were positive responses to the changes. Many new
demands were related to the reorganization, and, even though they were
interviewing participants 6 months after implementation, there were problems related to the redistribution of the workload. This study looked at the
nurse managera different group than had previously been examined with
regard to the issue of the patient-centered model. These findings increase
the importance of evaluating the impact of model implementation beyond the
immediate patient care units affected by the model (Redman & Jones, 1998,
p. 52). The results point to the importance of a support network for managers
when such patient-centered models are implemented.
Despite incomplete agreement, one of the fundamental aspects appears to
be the delivery of service that is organized around patients (and, therefore, is
more decentralized) than around specialized departments. Basic tenets
include decentralization of services, cross-training of employees, work redesign, and physical and geographical reorganization of delivery systems as
they are brought closer to the bedside (Sherer, 1993, p. 14). J. Philip
Lathrop, vice president of Booz Allen Health Care in Chicago quoted in this
article, stated, Patient-centered care addresses fundamental structural problems that overcompartmentalize, overspecialize, and rely on only one operating approach for all patients (p. 14). But as Sherer noted, many health care
executives want to see the data that demonstrate the superiority of this
approach. Sherer acknowledged the difficulty in assessing the outcomes.
Much of the research involves subjective measures of satisfaction, and,
within that category, very little can be called good research design (control
groups are often unmatched, pretest measures are not gathered). The most
significant impact of patient-centered care is claimed to occur in the patient
room (size, arrangement, and dcor) and in the reconfiguration and redefinition of the central nursing station (Sherer, 1993, p. 23).

Among the better known, patient-centered care programs is the Planetree

model (Martin et al., 1990), which emphasizes creating a homelike environ-



ment for patients. Two of its other goals are training patients to be partners in
their health care and increasing the satisfaction of nurses. Although rigorous
outcome studies had not been completed at the time Martin et al. (1990)
wrote their article, preliminary results for a Planetree unit at the Pacific Medical Center indicated greater satisfaction among Planetree patients than
patients on a traditional medical-surgical unit with a similar length of stay.
The authors noted that the Planetree philosophy is gaining wide acceptance
from hospital managers (p. 600). Orr (1995) discussed the Planetree philosophy when reporting on a study at the University of Washington that showed
that a Planetree unit was positively evaluated by physicians who, initially,
had been reticent to embrace the concept: The physical environment truly
enhanced the physicians perception of the quality of care that was delivered
(Orr, 1995, p. 84). But Orr, a health care consultant, claimed that the idea of
giving patients access to information in the form of reference libraries in
patient units is one few hospitals appear to embrace (quoted in Sherer,
1993, p. 24).
Following their earlier article (Martin et al., 1990), Martin et al. (1998)
discussed the renovation of a 13-bed medical-surgical unit along Planetree
lines (to create a more comfortable, calming, and home-like environment) at
the Pacific Medical Center in California. In this randomized trial, patients
were either randomly assigned to a Planetree unit (n = 129) or other units (n =
112) or assigned to the only available bed in the Planetree unit (n = 186) or
other units (n = 333). Hypotheses were that a stay on the Planetree unit would
improve patient satisfaction, health education, involvement of patients in
their own care, health behaviors, perceived health status, and use of services.
Patients were interviewed at admission, 1 week after discharge, and at 3
months and 6 months following discharge.
Although there were some differences in the characteristics of patients on
the Planetree unit versus other units, at discharge, the Planetree patients were
significantly more satisfied with their stay than were those on other units.
This satisfaction involved architectural aspects as well as technical aspects.
They were more satisfied with the extent to which nurses were involved in
their care and with the opportunity to see their support network (family and
friends). At the same time, there were no significant differences in the
involvement of physicians nor of patientsperceptions of the control they had
over their health, although the Planetree patients stated that they learned
more about self-care and illness. This study is described as one of the few
methodologically rigorous experiments dealing with hospital units that are
patient centered. The patient satisfaction and patient education aspects do
appear to differ, but it is noteworthy that there were no differences in the
health behaviors of patients in different units. The authors commented that



with relatively short hospital stays (about a week), it is difficult to change

lifelong behaviors.
In a study involving two renovated (Planetree) units versus a nonrenovated unit, Devlin (1995) compared patient, nursing staff, and visitor
evaluations. The renovated units were designed under the Planetree model
within a larger general hospital. The study evaluated users reports with an
instrument employed by Davidson (1994) in which respondents rated five
variables (care, being, choice, environment, and communication) on a visual
analog scale. In addition to the variables used by Davidson, Devlin added
change (whether the patient thought that aspects of the unit should be
changed) and responsiveness (how responsive the hospital unit was to
patients needs). One or both of the Planetree units were evaluated significantly more positively than the unrenovated unit in terms of care, being, environment, communication, and responsiveness by patients, visitors, and staff
(Devlin, 1995). However, independent of the unit they were on, nurses rated a
number of variables (the care they were able to provide, the availability of
choice on the unit) lower than patients or visitors did. Furthermore, there was
no significant difference across units in the number of days patients spent on
the units, in the number of visits patients reported having, or in the number of
visits family members or others reported making. Nor was there any difference across units in the stress reported by nurses on the Health Professions
Stress Inventory. Thus, the benefits of the patient-centered model of care as
reflected in this study of Planetree units may be confined to the subjective
assessment of the quality of the patients experience.
The effects of the patient-centered model on health care outcomes is still
unclear, although it is apparent that the idea of control can positively affect
health outcomes by reducing stress. With regard to specific patient-centered
models like Planetree, the advantages that have thus far been documented
appear to be qualitative in nature in terms of patient satisfaction.

In the comments of Nesmith (1995), Williams (1988), Beatrice et al.

(1998), Topf (2000), and others, the ambient environment, in terms of sound,
views, and lighting, has been the subject of a significant amount of research.
Typically, the research approach involves isolating an environmental variable, such as sound, and examining it to see if it negatively or positively
affects certain aspects of patients outcomes.
Although not all ambient variables turn out to be stressors, many, such as
sound, have been examined from this perspective. Topf (1994) discussed
ambient stressors as those that are chronic, negatively valued, conditions of



the physical environment that are uncontrollable (i.e., inescapable) and that
potentially result in stress (p. 289). Topf (1994, 2000) suggested that
research on environmental stress and health can effectively be addressed
through enhancing person-environment fit, called enhancement of personenvironment compatibility (EP-EC). Reminiscent of the work of Lynch
(1981), who described the performance dimensions for good city form, Topf
(1984) offered a framework for studying the negative physical factors in the
environment including noise, temperature, lighting, and density. An important aspect is perceived control and, in turn, exercised control (as in the use of
earplugs to attenuate unwanted noise).
Sensory overload is particularly acute in the intensive care unit (Baker,
1984, 1993), and there has even been a suggestion that critical care units may
be hazardous to ones health (Dracup, 1988) because of the stress they create.
Baker (1984) identified four variables that may negatively affect the patient:
(a) lighting that alters circadian rhythms, (b) the perception of crowding
brought on by the presence of people who are unfamiliar, (c) smells and
tactile sensations that may be unwelcome, and (d) noise from a number of
Noise. Of those four variables, the most often examined from the standpoint of research in the health care environment appears to be noise. Noise is
the presence of unwanted sound. Describing the physical properties of noise,
Baker (1984) stated that it is nonperiodic waveforms, random in fluctuation,
not harmoniously related, that interfere with desired signals (p. 69). Annoyance is the term given to the psychological reaction to noise. Sound is typically measured using a meter with an A-weighted scale in dB(A). Hearing
loss occurs at 90 dB(A) (Baker, 1984).
Describing the noise levels recorded from 4 intensive care and 2 general
care units of 3 hospitals in a large metropolitan area, Hilton (1985) reported
that decibel levels from equipment were as high as 90 dB(A) at times. Above
decibel levels of 60 dB, sounds negatively affected rest and sleep. There was
markedly more noise in intensive care units (ICUs) in the larger than in the
smaller hospitals, which Hilton attributed to the greater number of patients
per room in the larger hospitals. To reduce this factor in the environment, a
number of behavioral suggestions were made, including closing doors when
possible, reducing volume on telephones, and dimming lights (which, in turn,
tends to lower voices). Other suggestions included purchasing quieter equipment and training staff. The ratio between number of patients and equipment
per room suggests that one-person rooms are preferred to reduce noise.
Not only is noise an annoyance, but it also has the potential to affect the
healing process, because noise can disrupt sleep (Simpson, Lee, & Cameron,



1996). A proliferation of noises, some of which are not even identifiable by

employees, may lead to confusion and stress. In a study of 33 audiosignals
commonly heard on a ward, only half of the critical alarms and only 40% of
those categorized as noncritical were identified correctly (Cropp, Woods,
Raney, & Bredle, 1994). Cropp et al. (1994) suggested that health care providers develop a system of alarms that is graded to reflect differences in
importance. They also suggested that placing doors on rooms and using
alarms that sound only in a central nursing station might buffer sound. Noise
can also be reduced by carpeting (Snyder, 1966), which also has the benefit of
reducing the likelihood of falls. The use of carpet is also part of a movement
to humanize hospitals and may be appreciated more by patients than staff
(Cheek, Maxwell, & Weisman, 1971), but negative staff reactions may be
tied to the process of inadequate consultation about such change.
Using a posttest-only experimental design with volunteers in a sleep lab,
Topf, Bookman, and Arand (1996) examined the effects of noise on the subjective quality of sleep. Volunteers were randomly assigned to hear audiotapes of an actual critical care unit (CCU) or quiet. Experimental and control
groups differed on a number of variables, and participants in the noise condition took longer to fall asleep, spent less time sleeping, and awakened more
often. Further, sleep deprivation may be associated with a number of negative
physiological outcomes including immunosuppression and lower protein
synthesis (Topf & Davis, 1993). Participants in a similar experiment in a
sleep lab (exposure to audiotape of CCU sounds or quiet) did, in fact, have
poorer REM sleep as measured with 7 or 10 indicators (including REM activity) and shorter REM durations (Topf & Davis, 1993).
And although the patients recovery is paramount, the effect of hospital
noise on staff is also of concern. The statement that the guards do more time
than the inmates regarding prisons applies to health care settings, as well. In a
survey of 100 critical-care nurses involving self-report measures of stress and
sensitivity to noise (Topf & Dillon, 1988), results indicated that telephones,
alarms in equipment, and the beeping of monitors for patients were identified
as annoying. A measure of burnout was correlated with the degree of noiseinduced stress. The study also pointed out that the sounds that disturb staff
(e.g., beeping alarms) may differ from those reported to disturb patients (e.g.,
loud talking in the hallway). Another report involving this research on critical-care nurses focused on measures of health (Topf, 1988). It revealed that
noise-induced stress could account for 6% of the independent variance in
headaches on the job and that individual differences, such as sensitivity to
noise, were also contributors. The author pointed out that this self-report
research needed to be confirmed by experimental studies, which, if support-



ive, may point to the need for acoustic modifications in the structure of critical care units and patient bedside equipment (p. 33).
Music. At the other end of the spectrum from noise, the role of music to
attenuate the anxiety surrounding hospitalization has been examined (White,
1992). The use of music is an example of an intervention that could be part of
a holistic approach, although mixed results of its benefits have also been
reported (Davis-Rollans & Cunningham, 1987; Zimmerman, Pierson, &
Marker, 1988). In one pre-post experimental design involving hospitalized
patients (White, 1992), the experimental group was exposed to 25 minutes of
classical music selected by the investigator, whereas the control group had a
25-minute rest period without music. An anxiety measure, heart rate data,
and respiratory rate were included as dependent measures. The experimental
group showed statistically significant improvement in all the measures, and,
although the controls also had a statistically significant drop in the state of
anxiety following their rest period, the drop was greater for those exposed to
Although less convincing because no control group was used, research by
Updike (1990) also suggests that music can benefit ICU patients. Blood pressure, heart rate, mean arterial pressure, double product index (the product of
heart rate and systolic blood pressure divided by 100), as well as emotional
responses were measured. Responses indicated a drop in systolic blood pressure when patients were exposed to music. Theoretically, this research (and
others) suggests that emotional responses can be modified when music
moves through the auditory cortex, activates the limbic system, and, in turn,
affects emotional reactions. Music therapy effectively reduces anxiety,
stress and the experience of pain (Guzzetta, 1989, p. 610). Guzzetta used a
pretest/posttest experimental design in a study of patients in a CCU who were
randomly assigned to music therapy, relaxation therapy, or control groups.
The relaxation (or relaxation plus music therapy) outcome measures were
apical heart rates, peripheral temperature, cardiovascular complication, and
qualitative responses to sessions (i.e., How helpful were they?) Patients
chose three music selections they wanted to hear. Results indicated that both
the relaxation group and the relaxation plus music group had significantly
fewer complications than the control group. Although the music therapy
alone was more effective in raising peripheral temperatures, it is not clear that
music by itself is better than relaxation alone, although Guzzetta pointed out
that music may have the advantage of shutting out unwanted noise (because
headsets are worn). In a study discussed in Rubin and Owenss (1996) review
of the literature, patients exposed to music that they chose during laceration



repair reported less pain during the surgical procedure (Menegazzi, Paris,
Kersteen, Flynn, & Trautman, 1991). The fact that patients pain decreased
when they listened to music they had chosen reinforces Minckleys (1968)
theory that the ability to control environmental stimuli, such as noise or
music, is a key component of tolerance of and positive coping with environmental interference. Similarly, Moss (1988) examined changes in anxiety
related to hearing music in adults admitted for elective arthroscopic surgery.
The findings showed decreases in preoperative to postoperative anxiety in
patients who listened to music compared to control groups (cited in Rubin &
Owens, 1996).
The research on noise suggests that its reduction can positively affect
health. Music also appears to have beneficial effects, and may, in turn, shut
out unwanted sounds.

In the process of providing a more welcoming environment, the patient

room is of particular importance. The challenge for the designer is to create a
residential feel while preserving whatever technology is deemed necessary.
In the evolution of health care architecture, Verderber and Fine (2000) discussed the shift from a staff-centered (modern) to a patient-centered (postmodern) room. In this transformation, the role of the window and the view it
affords are of special significance.
The presence or absence of a window and the view it affords include one
aspect of the physical environment that has been demonstrated to affect
patients experiences in the hospital (Rubin & Owens, 1996; Ulrich, 1984;
Verderber, 1982, 1986; Verderber, Grice, & Gutentag, 1987). In a study using
hospital records to examine the effects of views out of windows on patients
recovering from gallbladder surgery, Ulrich (1984) found that patients recovering from surgery in rooms with a view of nature versus a view of a brick
wall had shorter postoperative hospital stays, had fewer negative evaluative
comments from nurses, took fewer moderate and strong analgesic doses, and
had slightly lower scores for minor postsurgical complications (p. 421). In a
similar study, Wilson (1972) looked at incidences of delirium and depression
in postoperative, major surgery patients with and without windows in their
rooms. Wilson found that patients in intensive care units without windows
had significantly higher incidences of organic delirium than did patients in
rooms with windows. These findings suggest that windows may have healing
and stress-reducing effects on patients and should be considered in hospital
and waiting room design.



In related research by Verderber (1986), 125 staff and 125 inpatients of

physical medicine and rehabilitation (PMR) units viewed 64 45-inch color
photographs that depicted the PMR units from 11 hospitals. Rooms in patient
living areas, treatment areas, and staff areas ranged from windowed to windowless. Photographs with highest preference were of trees and lawns,
neighborhoods surrounding the hospital, people outside the unit, and vistas
(both near and far). In hospitals, the representation of naturebe it ocean,
sky, or forestappears to help satisfy human informational needs (p. 459).
Keep (1977) reported that satisfaction is generally achieved when window
area occupies 20-30% of the window wall (p. 600). In a study on the value
of windows, Verderber and Reuman (1987) concluded that involvement with
windows and views helps the patient develop a perceptual and cognitive link
with the external environment and positively affects the therapeutic process
(p. 121). Verderber (1986) also found that window conditions in most hospital settings often contrast with patients ideal window views found in
One reason windows may be of value to the patient is that they are a source
of natural light. Heerwagen and Heerwagen (1986) examined peoples preferences for daylight versus electric light in office spaces and found that people preferred daylight to electric light for psychological comfort, for office
appearance and pleasantness, for visual health, and for general health. Windows may be of therapeutic value because they provide a soothing, peaceful
distraction. Researchers have found that people much prefer scenes of nature
to cityscapes and urban environments (Kaplan, Kaplan, & Wendt, 1972), that
scenes of nature have more positive effects on physiological states (Ulrich,
1981), and that scenes of nature influence faster recuperation from stress than
do scenes of the urban environment (Ulrich, Dimberg, & Driver, 1990; Ulrich
et al., 1991).
Now, innovative ways to bring art and nature into health care settings are
available. These include the electronic window of nature that simulates the
passage of daylight from dawn to dusk, created by Joey Fischer/Art Research
Institute Limited and used first in the United States at Stanford (Seligmann &
Buckley, 1990). Recent books on health care feature other examples of this
same idea such as an angiography lab that is backlit with a photograph of
trees and a waterfall on the ceiling at Grace Hospital in Detroit and a CT scanning suite at St. Marys Hospital in Grand Rapids, Michigan, where there is a
photograph on the ceiling depicting underwater scenes (Malkin, 1992;
Nesmith, 1995).
Ulrich (1992) is one of a small group of researchers who regularly use outcome measures other than patient or staff satisfaction reports on the



physiological changes (e.g., lower blood pressure) that can occur through the
use of serene artwork. These scenes typically involve water or other forms of
nature. Ulrich discusses the importance of positive distractionan element
that produces positive feelings, effortlessly holds attention and interest, and
therefore may block or reduce worrisome thoughts (1992, p. 24). The most
effective of these distractions, he claimed, are (1) nature elements such as
trees, plants, and water; (2) happy, laughing, or caring human faces; and (3)
benign animals such as pets (1992, p. 24). These elements, he argued, have
an evolutionary significance.
Ulrichs (1992) research shows that views of nature that reduce blood
pressure and increase muscle relaxation can facilitate reactions to stress in as
few as 5 minutes. Ulrich noted, All art is not created equal (1992, p. 25) and
cited research on the psychiatric ward of a Swedish hospital where patients
were favorable toward art containing scenes of nature but less comfortable
with art that was described as abstract.
Furthermore, in another study, open-heart surgery patients postoperatively viewed a nature scene (of either water or trees), an abstract scene, or no
scene. Those exposed to the nature scene with water reported less anxiety
postoperatively than did those exposed to other types of scenes or the control.
In addition, those who viewed the abstract scenes reported higher anxiety
than did those without any pictures (Ulrich, 1992). Beyond health care environments, studies in personality and individual differences have demonstrated that subjects like nature paintings that are complex, free of tension,
and representational rather than expressionistic or semi-abstract
(Zuckerman, Ulrich, & McLaughlin, 1993). Commenting on a POE,
McLaughlin (1975) stated, None of the hospitals studied had extensive art
on the walls. However, based on other data one can assume that detailed representational paintings or prints would be appropriate for all areas, but particularly for long term use areas (p. 34). These findings fit with the direction
that has been taken in selecting paintings for health care environments that
are representational and feature scenes of nature. The role of nature is also
being emphasized in the use of gardens in healing (Cooper Marcus & Barnes,
1995). Patients, visitors, and staff come to the garden to help themselves feel
better (Cooper Marcus & Barnes, 1995, p. 57).
Lighting and color. In health care environments, consideration needs to be
given to lightingboth its color and quality (Koch, 1991). The quality of
lighting is important for populations, such as the institutionalized elderly,
that spend long periods of time indoors. Chronic diseases such as cataracts
and glaucoma, in tandem with senile miosis (in which less light reaches the



retina), point to the importance of light for the institutionalized elderly

(Kolanowski, 1992). At the same time, precautions must be taken to manage glare. What is recommended is bright, indirect lighting. Hospitals are
notorious for lacking cues as to time of day, and the resulting disorientation is
well-documented (Kolanowski, 1992, p. 12).
Benya (1989) discussed the various areas for improvements in the lighting
of health care environments. Among the areas to be improved are the ways in
which source color are rendered, the reduction of glare, more daylight, the
reduction of institutional lighting, softer lighting, and an emphasis on residential aspects of lighting (so that it looks more like what you would find in a
residence). At least in the opinion of some designers, lighting can play a critical role in the perception of the hospital environment, and the overall effect
is far greater in both aesthetic and psychological value when weighed against
the cost of other types of architectural improvements (Benya, 1989, p. 58).
The use of color to enhance mood, improve way finding through color
cues, and reduce patient disorientation, has also been examined (Cooper,
Mohide, & Gilbert, 1989). To attract attention to particular areas (e.g., activity areas) the authors advice was to paint them with bright colors. For
restricted areas, the advice was pale colors.
Color often plays an important role in way-finding systems despite the
existence of users who are colorblind. Health care environments frequently
use color to direct patients (e.g., Take the green elevators to the third floor.).
Although important, the literature on way finding is not reviewed here in
depth because many of the prescriptions for way-finding systems apply to
building types in general and are not specific to health care facilities. For
those interested in reading more about the topic, a book by Carpman and
Grant (1993) on health care design reviewed research and design recommendations for way finding in health care environments.

The third emphasis in research has been on specific building types for specific patient populations. The decentralization of hospital care has been
accompanied by an increase in units for special patient populations, and one
population that has been chiefly responsible for a number of health care
building types is the elderly. Moving beyond nursing homes, four architectural types of continuing-care retirement forms emerged by the mid-1990s
(Verderber & Fine, 2000). Verderber and Fine described these as (a) the
pastoral campus type, (b) the denser suburban type, (c) the new, urbanist
village type, and (d) the urban high-rise type. More research has probably



been done on outcomes for the elderly in their buildings than on any other
population, much of it by the Philadelphia Geriatric Center under the guidance of M. Powell Lawton. Lawton put forward the environmental proactivity hypothesis, which suggests that environmental resources will be put
to better use in people of higher competence. A second hypothesis involves
environmental docility, which suggests that environmental press accounts
for a greater proportion of behavioral outcomes as personal competence
diminishes (Lawton, 1985, p. 507) and that docility will increase as limitations of the individual encounter environmental barriers or constraints. These
hypotheses point to the importance of control, or of a command center, for the
elderly, which supports autonomy (e.g., having a telephone or television
within reach of a favored chair, much like what is depicted for Mr. Crane, the
aging father on the Frasier television series). Others have demonstrated that
changes in the physical environment of the elderly who are hospitalized can
improve their ability to perform tasks of daily living (Landefeld, Palmer,
Kresevic, Fortinsky, & Kowal, 1995). Creating a home-like atmosphere that
also addresses the sensory limitations of the elderly can additionally improve
outcomes (Alvermann, 1979).
Many of the building types address the substantial subpopulation of the
elderly with dementia and Alzheimers disease. Many of the problems experienced by people with dementia and their caregivers are linked directly to the
planning and design of the environment (Cohen & Weisman, 1991, p. 20).
The Abram and Helen Weiss Institute (Lawton, Fulcomer, & Kleban, 1984;
Liebowitz, Lawton, & Waldman, 1979) is what has been called a prosthetically designed nursing home in the sense that it staves off further deterioration.
The open treatment area is intended to diminish the effects of disorientation
and memory loss by giving residents an almost complete view of all areas
from anywhere in the space (Liebowitz et al., 1979, p. 59). However, when
this research was done, a variety of changes occurred including better lighting in bedrooms, a reduction in the number of people sharing bedrooms, and
increased programming. It, therefore, was not clear which changes were
responsible for the fact that patients did not deteriorate.
Cohen and Weisman (1991) described the prosthetic effect for patients of
environments, including the Weiss Institute, designed for those with dementia in their book, Holding on to Home: Designing Environments for People
with Dementia. Other recommendations for the physical environments of
patients with dementia came from work by Peppard (1986) and a book by
Calkins (1988). Calkins endorsed the butterfly plan in which two clusters of
bedrooms are arranged around the nursing station to permit visual monitoring of patients by staff members. Although design changes have received a



good deal of attention for the elderly as a patient population, the staff also
play a significant role, and staff training can be a significant component of
patient-centered care for the elderly (Inouye et al., 1993). Thus, some of the
protective effects of patient-centered care for the elderly can come in the
form of geriatric nursing expertise.
In terms of design for patients with dementia, what is recommended is
noninstitutional in character (including human scale, soft architecture, eliminating environmental barriers, use of reminders from the past, spaces for
familiar tasks like cooking, and display areas). The environment should
have sufficient cues so that people with dementia do not resort to wandering
as a consequence of disorientation (Cohen & Weisman, 1991, p. 70). The
suggestion is made that continuity in paths (like a loop) is useful because
dead ends cause frustration. Outdoor spaces are also helpful as are green
houses, sunrooms, and areas for plants. Design configurations that include
central open areas (like a widened hallway) or open activity areas (Kromm &
Kromm, 1985) are popular because these spaces have been shown to reduce
disorientation and lead to increased time spent in social areas with a parallel
reduction in time spent in bedrooms (Liebowitz et al., 1979).
Increases in the level of functioning for patients with dementia have been
reported when patients were admitted to a unit specially designed for them.
Results indicated improvements in the level of functioning for both mental
and emotional status coupled with the functions of daily living at both 4 and
13 months following intervention (Benson, Cameron, Humbach, Servino, &
Gambert, 1987). Additions included an orientation board and color-coding
for each patients door with his or her name and picture also displayed next to
the door. Although doors were not locked, they were alarmed, and a doubledoor knob arrangement was used because, as the authors commented, few
dementia patients can turn both knobs at once. Beyond physical changes in
the environment, each resident had an individualized treatment plan. Our
data suggest that a specially designed dementia unit can benefit selected
patients within the nursing home setting (Benson et al., 1987, p. 322). This
result was accomplished with the same level of nursing staff. Although
patients improvements were not cognitive, they included other important
behaviors including social, group interaction, grooming, and eating.
However, some have questioned whether special care units (SCUs) for
dementia patients that are segregated necessarily result in improvements
(Mathew, Sloan, Kilby, & Flood, 1988). In a study involving 34 patients in
two comparison settings, patients in the dementia unit were not better,
cognitively, than controls. But one obvious benefit in the dementia unit was
the lack of restraints. Other researchers have avoided the use of restraints by



successfully incorporating visual barriers to conceal doorknobs (Namazi,

Rosner, & Calkins, 1989). Some have tried grid patterns created with tape
on the floor in front of a door, because many demented patients apparently
perceive two-dimensional grid patterns as presenting a barrier (Hussian &
Brown, 1987). Other research on Alzheimers units (Hyde, 1989) suggests
that, although many views exist about the basic goals of such units, a shared
belief is that the environment can help compensate for patientscognitive and
sensory deficits to encourage mastery of the environment including the activities of daily living.
Other models for addressing the needs of the elderly have been created
including the Acute Care of Elders (ACE) units (Palmer, Counsell, &
Landefeld, 1998). The goal of ACE units is to foster independent functioning
in patients and to prevent a dysfunctional syndrome. Primary nurses also
have an expanded role in ACE units. Covinsky et al. (1998) also described
ACE units. ACE units stress enhancing personal control through (a) patientcentered nursing care, (b) prepared environments, (c) planning for discharge,
and (d) medical care review. Physical changes made include carpeting in
corridors and patient rooms, clocks and calendars in every room, and use of
patterns with visual contrast in carpets and wall coverings to enhance way
finding and orientation. Bathrooms have elevated seats; levers rather than
knobs are used for doors. Floor lighting at the bedside promotes safe transfer
at night. There is a large commons space for all patients that provides space
for activities that promote socializing and exercising. Regarding the ACE
unit, Covinsky et al. talked about a prepared environment in which walking is
encouraged by carpeting all patient rooms. At discharge, patients on the ACE
unit were more likely to improve and less likely to decline. However, 3
months later, the patients from the ACE unit were similar to non-ACE
patients in their abilities to perform activities of daily living. Similar to some
of the results reported earlier with regard to patient-centered units like
Planetree, some improvements of patients on units with the interventions
may not be extended in time (Martin et al., 1998). Counsell et al. (2000), however, described research on ACE units in which the decline in activities of
daily living (ADL) was less frequent for those on the ACE unit than for others
receiving usual care. In that study, patient and provider satisfaction improved
without a concomitant increase in costs.
Other types of designs for specialized patient populations include birthing
centers (Vogler, 1990) and rehabilitation centers. One design innovation for
physical rehabilitation that has been positively reviewed is called Easy Street
Environments, in which patients practice navigating grocery stores, bus stops,
banks, and restaurants before facing the real environment (Guynes, 1990).





These specialized centers and smaller building types are, in some measure, the result of the revolution in health care known as managed care. External forces, such as legislation and changes in the insurance industry, have a
tremendous capacity to effect change. In particular, managed health care has
significantly affected the architecture of the health care environment. Much
of the publicity surrounding the rise of managed health care has planted a
negative image of its impact on the patient with practitioners declaring that
they can no longer provide the services that they think their patients require.
However, the gap between member satisfaction with HMOs and other types
of health plans may be narrowing (Walker, 2002), and there may be positive
aspects of managed health care in terms of its impact on the physical environment. When diagnosis related groups (DRGs) increased competition, some
providers thought it possible to distinguish themselves through design
(Voelker, 1994). It has been argued that a new paradigm in health care architecture is neededone that replaces the monumental and enduring with
structures that reflect caring and flexibility (Arneill & Nuelsen, 1992).
Regarding the changes that managed health care has created, Bruce
Arneillpast president of the National American Institute of Architects
Academy on Architecture for Health and chairman of the S/L/A/M Collaborative, an architectural firm that has done a substantial number of health care
Due to competition, lower reimbursements from the government, and the
demand by educated, computer-literate clients for better quality care, curing,
and healing, the behavior of doctors, nurses, and administrations has changed.
Also, the demands for functionally and aesthetically better environments for
diagnosis and treatment, and curing, healing, and caring have gone through a
metamorphosis. (personal communication, October 16, 2002)

As an example of the change in the way health care is now approached by

architects, Arneill stated,
Another good example of the change is the fact that the Academy on Architecture for Health for the American Institute of Architects has grown in the last 25
years from approximately 100 members to almost 4,000. . . . Also, the American College of Healthcare Architects has been formed to establish
credentialing for healthcare architects based on education, training, experience, and exams and assures that good programming, planning, and design is



carried out for top drawer healthcare facilities. (personal communication,

October 16, 2002)

Arneill explained that the profession of health care architecture has undergone a substantial change in status compared to its standing in the field after
World War II. At that time, health care architects or architectural firms had little status in design quality in the field of architecture. Now, however, not only
are health care architects held in higher esteem, but there are those who even
subspecialize, for example, in cancer centers, womens centers, and so forth.
Arneill stated that Ninety percent of this advancement and change has taken
place since the advent of managed care in the mid-1970s (B. P. Arneill, personal communication, October 16, 2002).
The monolithic hospital is being replaced by a variety of buildings types,
including ambulatory care centers, primary care centers, outreach facilities,
and wellness centers. These now constitute the majority of new construction
(Fitzgerald, 1996). Such new construction is argued to enhance the image
that providers present, attract groups of payers, and increase the share of the
market that providers control (Fitzgerald, 1996). The emphasis seems to be
on satellite feeders, and these outpatient facilities and medical office buildings are argued to provide not only greater convenience for patients but also
easier staff flow (Fitzgerald, 1996). Even when renovation occurs within general hospitals, the impetus seems to be the creation of units within units, such
that intensive care and sub-acute care units form entities within the larger
hospital itself. This kind of chunking or grouping has the potential to make
patients and families more comfortable because of the idea that the whole is
broken down into more manageable parts.
This new construction by the health care industry has presented environment and behavior researchers with a tremendous opportunity to build on a
solid foundation of research findings. Although quality research is difficult to
do in the health care environment because of the many variables involved in
the challenge of experimental control (Voelker, 1994), we have an obligation
to follow the advice of Kenneth Schwartz, quoted in an article about the 2nd
International Conference on Health and Design in Stockholm, Sweden:
Design research results need to be impressive, when presented to a hardnosed world (Martin, 2000, p. 518). Collaborations are emerging that may
help to produce just this kind of hard-nosed evidence in the form of evidencebased design (Tarampi, 2002). One example is The Pebble Project (Bilchik,
2002; Varni & Marberry, 2001). The Pebble Project (so named to indicate
that the work is hoped to have a ripple effect) is a collaboration between the
Center for Health Design and a number of health care organizations around
the country who are measuring design-based health care outcomes. Although



the research is ongoing, preliminary data indicate a variety of encouraging

findings. These include a 62% decrease in medication errors at a new unit in
the Barbara Ann Karmanos Cancer Institute in Detroit, six fewer nosocomial
infections (those caused or aggravated by hospital life) per month in private
patient rooms at Bronson Hospital in Kalamazoo, Michigan (Bilchik, 2002),
and a decrease in patient falls by 75% at the new Comprehensive Cardiac
Critical Care unit at Methodist Hospital, Clarian Health Partners, in Indianapolis (Marberry, 2002). These findings and others reviewed in this article
indicate that we have the tools to do the kind of research that will lead to
evidence-based design, and providers are becoming more willing to support
such efforts. More and more, they realize the potential of research to improve
patient well-being and the health care system.

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