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DOI: 10.1177/0013916503255102 2003; 35; 665 Environment and Behavior

Ann Sloan Devlin and Allison B. Arneill Health Care Environments and Patient Outcomes: A Review of the Literature

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10.1177/0013916503255102ARTICLEENVIRONMENT AND BEHAVIOR / September 2003Devlin & Arneill / HEALTH CARE ENVIRONMENTS AND PATIENT OUT-COMES

HEALTH CARE ENVIRONMENTSAND PATIENT OUTCOMESA Review of the Literature

ANN SLOAN DEVLIN is the May Buckley Sadowski ‘19 Professor of Psychology atConnecticut College. She received her B.A., M.A., and Ph.D. degrees in psychologyfrom the University of Michigan. Her current research interests involve personal-ity differences in perceptions of health care architecture; gender and correlates ofway finding, such as mental rotation; and the environmental design of way-findingsystems.

ALLISON B. ARNEILL received her B.A. and M.A. in psychology from Connecti-cut College. She currently works at the Harvard University Development Office as astaff assistant specialist. She has a long-standing interest in health care architectureand interior design as they relate to wellness.

ABSTRACT: This review of the literature on health care environments and patientoutcomes 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.,Alzheimer’s patients). The article also describes the challenges presented in doinghigh-quality research focused on health care environments and contrasts the contribu-tions made by two different traditions: architecture and behavioral science. The impli-cations of managed care and opportunities for research are considered.

Keywords: health care architecture; managed care; ambient environment; patient-centered care; postoccupancy evaluations (POEs)

The role of the environment in the healing process is a growing concernamong health care providers, environmental psychologists, consultants, andarchitects (Devlin, 1992, 1995; Martin, Hunt, & Conrad, 1990; Ruga, 1989;

665

AUTHORS’NOTE: Address correspondence to Ann Sloan Devlin, Box 5448, Depart-ment of Psychology, Connecticut College, 270 Mohegan Avenue, New London, CT06320.

ENVIRONMENT AND BEHAVIOR, Vol. 35 No. 5, September 2003 665-694DOI: 10.1177/0013916503255102© 2003 Sage Publications



Ulrich, 1992, 1995). Moreover, the belief that the traditional, institutionallydesigned health care facility has no bearing on the wellness of its patients aslong as the level of care is superb is in question (Ulrich, 1992). Researchersare finding that changes and additions made to the health care facility’s physi-cal and social environment with the patient in mind can positively influencepatients’ outcomes (Davidson, 1994; Ulrich, 1984; Verderber & Reuman,1987). Likewise, health care professionals are finding that “sensitive designcan enhance recovery [and] shorten hospital stays” (Lemprecht, 1996,p. 123). At the same time, the role of the physical environment and facilitiesthemselves are not universally included in routine patient satisfaction assess-ments. For example, in a survey measuring whether patients were satisfiedwith their hospital experience, no items directly related to the physical envi-ronment were included (Harris, Swindle, Mungai, Weinberger, & Tierney,1999). Yet patients mention the importance of such aspects of the environ-ment 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 environmentof health care settings can affect patient health, and articles linking healthcare design and well-being appear with more frequency in design journals.For example, the September/October 2002 issue ofArchitecture Bostonwasdevoted to the topic of health. Ulrich (1991) contended that “research haslinked poor design to such negative (patient) consequences as anxiety, delir-ium, elevated blood pressure levels, and an increased intake of pain drugs”(p. 97). Unfamiliar environments in clinics, hospitals, and nursing homes canproduce psychological stress that can negatively affect healing and wellness(Ulrich, 1991). Today, designers and planners of health care facilities face anenormous challenge. To be successful, they must accommodate sophisticatedclinical interventions and complex medical technology while providing ahumane, therapeutic environment. They must also respond to rapid change atmultiple 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 envi-ronments and their impact on patient outcomes. This body of literature isdiverse in terms of focus and findings. Although the early research focusedon the hospital environment, more recent research has examined a range offacilities from ambulatory care centers to Alzheimer’s units. Researchershave examined the influence of such topics as ambient stressors (e.g., noise),nature, and patient control. The research has been done by leaders in manyfields including architecture, consulting, health care, and psychology.

666 ENVIRONMENT AND BEHAVIOR / September 2003



Despite the progress that is being made, with some foundations supportingthe process (Beatrice, Thomas, & Biles, 1998), the research is still accumu-lating and gaps do exist—some of them related to the difficulty in doing thisresearch. Before discussing the environmental influences that are known, it isimportant to discuss both the challenge of doing this research and the recentchanges in health care that involve its physical design.

THE CHALLENGES OFRESEARCH IN HEALTH CARE SETTINGS

A number of researchers have commented on the limited number of stud-ies dealing with person-environment fit in hospitals. “Apart from issues oflifestyle, aesthetics, or their specific relation to the reconstituted hospital andmedical center, the field of health architecture had not fostered a tradition ofresearch” (Verderber & Fine, 2000, p. 190). There is a “paucity of nursingresearch 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 aremuch discussed, but infrequently tested empirically” (p. 231). Another pleais for more sophisticated approaches to research. As Epstein (2000) noted,“Future studies of patient-centered care will require more than just the appli-cation of quantitative ratings to observational data” (p. 806).

Rubin and Owens (1996) combed through more than 38,000 articles tofind those even remotely related to patient outcomes that are influenced byvariables in the environment. Just fewer than 50 articles met their criteria, andmost of those were poorly designed from a methodological standpoint. Eventwo well-known studies, those by Ulrich (1984) about the positive effect ofviews of nature for patients recovering from surgery and by Miller, White,Whitman, O’Callaghan, and Maxwell (1995) about premature babies whogained more weight when their hospital stay used light cycled on diurnal pat-terns, were subject to criticism (Weber, 1996).

A number of problems explain why this research has been slow to accu-mulate. These include the fact that architecture lacks a tradition of research,that medicine has overlooked the role of the physical environment in patientwell-being, and that the research process in health care settings is exceed-ingly difficult. Regarding architecture’s lack of power to make an impact,“The criteria upon which far-reaching decisions are based too often rest uponflawed assumptions and a lack of ‘hard data.’ This statement of course is old

Devlin & Arneill / HEALTH CARE ENVIRONMENTS AND PATIENT OUTCOMES 667



news (perhaps the oldest news) indeed to environmental design researchersand research-based designers” (Verderber & Refuerzo, 1994, p. 281).Regarding research, Malkin (1992) commented on the difficulty of doinggood research because of the problems with experimental control and alsostated, “For many design questions, there is no sound research yet available toinform the designer’s personal intuition, sensitivity, and experience”(Malkin, 1991, p. 28).

Another problem sometimes cited is the difficulty practitioners have withunderstanding research that appears in academic journals. Increasingly,though, researchers recognize the need to make their findings available innonacademic journals. As an example, the summer 2002 issue ofCureincluded an article on healing environments with an overview of Ulrich’s re-search on the benefits of good health care design (Steele, 2002). Anotherexample of the move to make findings more available is a new database proj-ect entitled InformeDesign (where research informs design). This Internetproject is a collaboration between the University of Minnesota and the Amer-ican Society of Interior Designers (ASID). Although not limited to researchon health care, the Internet Web site, to be launched in the fall of 2003, willdisseminate research-based design criteria in a way that is interpretable to anonresearch trained audience (Martin & Guerin, 2002).

Another area in which progress can be made is the use of research to eval-uate the impact of finished projects. Few firms routinely incorporate whatare calledpostoccupancy evaluations(POEs) in their work (Shumaker &Pequegnat, 1989). POEs evaluate how well facilities perform the functionsfor which they were intended. But the firms of Kaplan, McLaughlin, andDiaz (K/M/D) and Caudill, Rowlett, and Scott are cited as those that value theinformation that POEs can provide (Shumaker & Pequegnat, 1989).Verderber and Refuerzo (1994, 1999) also put forward the concept ofresearch-based design or design that is driven by research. Translating theinformation from 25 POEs, they formulated 40 guidelines for communityhealth care centers in Louisiana. Findings from their research were used toplan the West Monroe Community Health Center. These included the factthat no single footprint fits all needs, the necessity of zoning based on func-tion for interior spaces, the importance of natural daylight (including the useof 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 listedthe importance of using residential imagery, legible entrances, and separateentrances for patients and staff. Verderber and Refuerzo suggested that,rather than beginning the design process from scratch each time, one mightbetter ask, “How do we want to adapt this body of knowledge to our newclinic?” (1999, p. 238).




Members of the health care profession who make design decisions need torecognize the benefit that POEs can feed into future designs (Zimring &Welch, 1988). As an example, Zimring and Welch (1988) cited K/M/D whoevaluated a psychiatric hospital to prepare for another project with the sameclient. In fact, McLaughlin of K/M/D has been credited with establishing theimportance 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 nurs-ing unit and with refining the concept of the single-bed hospital room.

THE EVOLUTION OF HEALTH CARE DESIGN

The evolution of health care architecture has led to research on specificbuilding types that differ in many ways from the general hospital. As early asthe 1970s, designers were considering the challenge of hospital design in anera of increasing technology and rapid change. McLaughlin (1976) foundmany problems with what is called thematchbox-and-muffin scheme(patienttowers arising from supporting services). In McLaughlin’s view, the hospitalis “the most changing of building types, and its physical life is uniquely char-acterized by modification” (p. 118). Hospitals with a radial corridor designwere popular beginning in the 1960s and were recommended for staffing effi-ciencies and reduced walking distance for staff as well as more opportu-nity 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 surpassedthe radial design in popularity because the triangular design created fewerirregularly shaped spaces and offered more privacy for patients. Nesmith(1995) also discussed the fact that hospitals must constantly be concernedwith designing for change in the future. As an alternative to the matchbox-and-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 thematchbox-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 charac-terized the transformation of health care. These are (a) bigness versus small-ness, (b) compactness versus linearity, (c) low-rise versus mid- or high-risedesign, and (d) centralized versus decentralized approaches. They furthernoted that the single-family detached home, the roadside hotel, and the sub-urban shopping mall have also influenced the way we conceptualize healthcare design. Nesmith (1995) also cited the shopping mall as a building typefor health care that makes patients comfortable because of its familiarity.




Ultimately, the decentralization of health care came to dominate buildingform, and this decentralization, especially within separate building types,provided the chance to create a less forbidding image for the architecture ofhealth care (Verderber & Fine, 2000). “The termfunctional deconstruction,as used here in the context of health architecture, consists of the dissection ofexisting internal components and their redistribution either within the medi-cal center or elsewhere in the community landscape” (Verderber & Fine,2000, p. 135). The dramatic atrium (influenced by the architecture of hotelsand malls) was described as the defining characteristic of the hospital in thelate 1980s, but, according to Verderber and Fine (2000), this dominance wasbrief because cost containments led to a variety of consequences. With fewerchoices for patients because of HMO or PPO restrictions, hospitals did notneed to try as hard to attract patients. By the mid-1980s, in their argument,there were pleas to attend to regional characteristics. Finally, the decons-tructedhealth villageemerged as a solution to the conflict between modern-ism and postmodernism (Verderber & Fine, 2000). The work of K/M/D iscited as pivotal in changing the function and appearance of health care archi-tecture (Verderber & Fine, 2000). Specifically, in the St. Vincent Hospital inSanta Fe, Verderber and Fine talked about K/M/D’s horizontal as opposed tovertical emphasis, which created the possibilities for courtyards, and the low-rise approach with irregularly shaped space, which, in turn, permits futuregrowth. This project is described as a “compact, changing village”(McLaughlin, cited in Verderber & Fine, 2000, p. 94). The emphases thatemerged were (a) horizontality, (b) expandability, and (c) regionalist appear-ance (Verderber & Fine, 2000).

In the last 10 years, a number of authors in addition to Verderber and Finehave traced the evolution of priorities in health care design. Nesmith (1995)said that the 1970s and 1980s emphasized change related to growth and tech-nology, whereas the mid-1980s to early 1990s stressed creating a more wel-coming environment for the patient. During this time, health care focused onspecialized populations (e.g., the cancer patient, the Alzheimer’s patient, thewoman as patient, the rehabilitation patient). Entire books have been devotedto specialized kinds of units (Rostenberg, 1986). In response to the questionof what is next, Nesmith stated that the next concern will be value: “By this Imean the planning and design of health systems and facilities which mosteffectively deliver actual and perceived quality care” (p. 6). A second princi-ple she identified involves the facility astool and healer:

The second principle combines two philosophies: that the physical settings ofhealth care delivery support productivity and effectiveness, and that they are anend in themselves—aiding in the healing and wellness process through psycho-




physiological effect.. . . Important elements of this approach will include morecomprehensive 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 isthe growth in the number of ambulatory care centers and outpatient care facil-ities. Because of the differences in the strictness of building codes in acute-care hospitals, ambulatory care facilities are seen as an opening for more pro-gressive and sensitive design (Nesmith, 1995).

An overview of the elements in supportive health care is also provided byWilliams (1988) who listed unit design, spatial considerations, sound, light,color, thermal considerations, and weather. What is important to the patienthas even been related to Maslow’s hierarchy of needs (Liberakis, 1971).Beatrice et al. (1998) cited seven areas of patient-centered care: (a) respect forpatients’values, preferences, and expressed needs; (b) coordination and inte-gration of care; (c) information and education; (d) physical comfort; (e) emo-tional support and alleviation of fear and anxiety; (f) involvement of familyand friends; and (g) transition and continuity of care. Malkin (1991) pointedto the following dimensions that are important to consider in health caredesign: scale, relationship of indoor and outdoor space, materials, acoustics,lighting, legibility, variety, and special population needs. The 1990s, accord-ing to Malkin, were to present two challenges: (a) how to create a healingenvironment, and (b) how to design for special patient populations. In addi-tion, because what will be a healing environment for one person may not beidentical to the form needed for another, “The most important thing is to pro-vide 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 architec-ture with a high-tech image seems to attract patients and instill confidence inthe hospital’s ability to provide the latest medical procedures. At the sametime, people are attracted to healthcare environments that are reassuringlyfamiliar” (p. 11). Verderber and Fine’s (2000) recent book, updating an ear-lier treatise on the hospital by Thompson and Golden (1975), nicely capturedthe 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, ontraditional building massing and internal configuration through more legibleinterior spaces and circulation patterns (even at times recalling Florence Night-ingale’s provisions), and on the reincorporation of nature as a therapeuticdesign 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)

SUMMARY

With regard to the research on the physical environment and patient out-comes, 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.

PATIENT-CENTERED CARE

One response to the pressures in health care has been to emphasize whathas been called patient-centered care. What has emerged as a priority inhealth care is providing the patient with choice—a concept that is fundamen-tal to environmental psychology (Proshansky, Ittelson, & Rivlin, 1970); thebelief that giving patients control may influence their medical outcomes isgrowing. In fact, a primary goal of patient-centered care is to increase thepatient’s control over his or her environment (Birdsong & Leibrock, 1990;Sherer, 1993; Ulrich, 1992; Weber, 1996). Individuals who believe that theyhave control over situations are more resistant to life’s hassles (Raybeck,1991). In the hospital setting, lack of control is a major problem, and it canincrease stress and affect wellness (Ulrich, 1992). Lack of control has alsobeen found to be associated with depression, passivity, elevated blood pres-sure, and reduced immune system functioning (Ulrich, 1991). Confusingway-finding cues, lack of privacy, noise, lack of personal control over televi-sion, and lack of a view out a window are some of the factors that contribute toa loss of sense of control in hospitals (Ulrich, 1992).

Taylor (1979) pointed out that “the hospital is one of the few places wherean individual forfeits control over virtually every task he or she customarilyperforms” (p. 157). In a discussion of how patients cope with their loss ofcontrol and depersonalization in the hospital, Taylor (1979) suggested thatpatients develop into thegood patient—the compliant one—or thebadpatient—the resistant one. She suggested that the good patient may actuallybe in a state of anxious or depressed helplessness, whereas the bad patientmay be in a state of anger and reactance against the removal of freedoms. Shefurther argued,




Both helplessness and reactance produce physiological, cognitive, behavioral,and affective consequences that can strongly interfere with the course of recov-ery and that helplessness and reactance in patients evoke reactions in hospi-tal 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 shehas in the hospital. Two ways to change the traditional patient role and toincrease patients’sense of control in the hospital environment are to increasetheir freedom of choice of daily rituals and allow them access to educationand information.

Patients’choices in the hospital can be expanded (or curtailed) in a numberof ways. For example, in a study of the effect of the inability to control theselection of television programs, blood donors in the waiting room of a bloodbank had higher stress levels on days when the television was on than on dayswhen the television was off (Ulrich, 1992). Ulrich (1992) concluded that thelack of choice of program created more stress than did not having the optionof television at all.

The issue of control was also studied when questionnaires were adminis-tered to patients in 16 hemodialysis units asking them about their perceptionsof control over four factors in their treatment environment: acoustics/noise,lighting, temperature, and privacy (Steptoe & Appels, 1989). A significantnumber of patients reported little or no control over bright lighting, uncom-fortable temperatures, irregular noise levels, and lack of privacy. Further-more, this lack of control over the environment created additional stress topatients who were already experiencing stress related to their illness.

Whether we call it functional deconstruction or new residentialism, thevillage emphasis discussed by McLaughlin (1975) and Verderber and Fine(2000) earlier gives the patient greater choice, reduces stress, and decentral-izes patient services (or centralizes them from the patient’s perspective).“Residentialism, as much an attitude as an architectural style” has been“embraced by providers, architects, and the public as a valid expression ofemerging philosophies of patient-centered care” (Verderber & Fine, 2000,p. 318).

Although the phrase is frequently heard, the meaning of patient-centeredcare is not unambiguous, and “health care executives are struggling to find aclear definition for one of the field’s hottest catchphrases” (Sherer, 1993,p. 14). Some cite an increase in the efficiency of how care is delivered and aconcomitant 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, andworkflow are designed from the perspective of the patient (Cleary et al., 1993).

Although patient-centered care is frequently mentioned as a priority in thehealth care arena, there is relatively little concrete evidence about its effects.Redman and Jones (1998) evaluated the impact of the patient-centered modelin two community hospitals. Using structured interviews of unit-based nursemanagers (n = 22) and non-nurse department heads (n = 4), a number ofthemes emerged; not all were positive responses to the changes. Many newdemands were related to the reorganization, and, even though they wereinterviewing participants 6 months after implementation, there were prob-lems related to the redistribution of the workload. This study looked at thenurse manager—a different group than had previously been examined withregard to the issue of the patient-centered model. “These findings increasethe importance of evaluating the impact of model implementation beyond theimmediate patient care units affected by the model” (Redman & Jones, 1998,p. 52). The results point to the importance of a support network for managerswhen such patient-centered models are implemented.

Despite incomplete agreement, one of the fundamental aspects appears tobe the delivery of service that is organized around patients (and, therefore, ismore decentralized) than around specialized departments. “Basic tenetsinclude decentralization of services, cross-training of employees, work rede-sign, and physical and geographical reorganization of delivery systems asthey are brought closer to the bedside” (Sherer, 1993, p. 14). J. PhilipLathrop, vice president of Booz Allen Health Care in Chicago quoted in thisarticle, stated, “Patient-centered care addresses fundamental structural prob-lems that overcompartmentalize, overspecialize, and rely on only one operat-ing approach for all patients” (p. 14). But as Sherer noted, many health careexecutives want to see the data that demonstrate the superiority of thisapproach. 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 (controlgroups are often unmatched, pretest measures are not gathered). The mostsignificant impact of patient-centered care is claimed to occur in the patientroom (size, arrangement, and décor) and in the reconfiguration and redefini-tion of the central nursing station (Sherer, 1993, p. 23).

THE PLANETREE MODEL

Among the better known, patient-centered care programs is the Planetreemodel (Martin et al., 1990), which emphasizes creating a homelike environ-




ment for patients. Two of its other goals are training patients to be partners intheir health care and increasing the satisfaction of nurses. Although rigorousoutcome studies had not been completed at the time Martin et al. (1990)wrote their article, preliminary results for a Planetree unit at the Pacific Medi-cal Center indicated greater satisfaction among Planetree patients thanpatients on a traditional medical-surgical unit with a similar length of stay.The authors noted that “the Planetree philosophy is gaining wide acceptancefrom hospital managers” (p. 600). Orr (1995) discussed the Planetree philos-ophy when reporting on a study at the University of Washington that showedthat a Planetree unit was positively evaluated by physicians who, initially,had been reticent to embrace the concept: “The physical environment trulyenhanced the physician’s perception of the quality of care that was delivered”(Orr, 1995, p. 84). But Orr, a health care consultant, claimed that the idea ofgiving patients access to information in the form of reference libraries inpatient 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 Planetreelines (to create a more comfortable, calming, and home-like environment) atthe Pacific Medical Center in California. In this randomized trial, patientswere 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) orother units (n= 333). Hypotheses were that a stay on the Planetree unit wouldimprove patient satisfaction, health education, involvement of patients intheir own care, health behaviors, perceived health status, and use of services.Patients were interviewed at admission, 1 week after discharge, and at 3months and 6 months following discharge.

Although there were some differences in the characteristics of patients onthe Planetree unit versus other units, at discharge, the Planetree patients weresignificantly 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 intheir care and with the opportunity to see their support network (family andfriends). At the same time, there were no significant differences in theinvolvement of physicians nor of patients’perceptions of the control they hadover their health, although the Planetree patients stated that they learnedmore about self-care and illness. This study is described as one of the fewmethodologically rigorous experiments dealing with hospital units that arepatient centered. The patient satisfaction and patient education aspects doappear to differ, but it is noteworthy that there were no differences in thehealth behaviors of patients in different units. The authors commented that




with relatively short hospital stays (about a week), it is difficult to changelifelong behaviors.

In a study involving two renovated (Planetree) units versus a non-renovated unit, Devlin (1995) compared patient, nursing staff, and visitorevaluations. The renovated units were designed under the Planetree modelwithin a larger general hospital. The study evaluated users’ reports with aninstrument employed by Davidson (1994) in which respondents rated fivevariables (care, being, choice, environment, and communication) on a visualanalog scale. In addition to the variables used by Davidson, Devlin addedchange(whether the patient thought that aspects of the unit should bechanged) andresponsiveness(how responsive the hospital unit was topatients’ needs). One or both of the Planetree units were evaluated signifi-cantly more positively than the unrenovated unit in terms of care, being, envi-ronment, communication, and responsiveness by patients, visitors, and staff(Devlin, 1995). However, independent of the unit they were on, nurses rated anumber of variables (the care they were able to provide, the availability ofchoice on the unit) lower than patients or visitors did. Furthermore, there wasno significant difference across units in the number of days patients spent onthe units, in the number of visits patients reported having, or in the number ofvisits family members or others reported making. Nor was there any differ-ence across units in the stress reported by nurses on the Health ProfessionsStress Inventory. Thus, the benefits of the patient-centered model of care asreflected in this study of Planetree units may be confined to the subjectiveassessment of the quality of the patients’ experience.

The effects of the patient-centered model on health care outcomes is stillunclear, although it is apparent that the idea of control can positively affecthealth outcomes by reducing stress. With regard to specific patient-centeredmodels like Planetree, the advantages that have thus far been documentedappear to be qualitative in nature in terms of patient satisfaction.

THE AMBIENT ENVIRONMENT

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 vari-able, such as sound, and examining it to see if it negatively or positivelyaffects certain aspects of patients’ outcomes.

Although not all ambient variables turn out to be stressors, many, such assound, have been examined from this perspective. Topf (1994) discussedambient stressors as those that are “chronic, negatively valued, conditions of




the physical environment that are uncontrollable (i.e., inescapable) and thatpotentially result in stress” (p. 289). Topf (1994, 2000) suggested thatresearch on environmental stress and health can effectively be addressedthrough enhancing person-environment fit, called enhancement of person-environment 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 theenvironment including noise, temperature, lighting, and density. An impor-tant aspect is perceived control and, in turn, exercised control (as in the use ofearplugs 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 maybe hazardous to one’s 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 crowdingbrought on by the presence of people who are unfamiliar, (c) smells andtactile sensations that may be unwelcome, and (d) noise from a number ofsources.

Noise. Of those four variables, the most often examined from the stand-point of research in the health care environment appears to be noise. Noise isthe 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). Annoy-ance is the term given to the psychological reaction to noise. Sound is typi-cally measured using a meter with an A-weighted scale in dB(A). Hearingloss occurs at 90 dB(A) (Baker, 1984).

Describing the noise levels recorded from 4 intensive care and 2 generalcare units of 3 hospitals in a large metropolitan area, Hilton (1985) reportedthat decibel levels from equipment were as high as 90 dB(A) at times. Abovedecibel levels of 60 dB, sounds negatively affected rest and sleep. There wasmarkedly more noise in intensive care units (ICUs) in the larger than in thesmaller hospitals, which Hilton attributed to the greater number of patientsper room in the larger hospitals. To reduce this factor in the environment, anumber of behavioral suggestions were made, including closing doors whenpossible, reducing volume on telephones, and dimming lights (which, in turn,tends to lower voices). Other suggestions included purchasing quieter equip-ment and training staff. The ratio between number of patients and equipmentper 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 thehealing process, because noise can disrupt sleep (Simpson, Lee, & Cameron,




1996). A proliferation of noises, some of which are not even identifiable byemployees, may lead to confusion and stress. In a study of 33 audiosignalscommonly heard on a ward, only half of the critical alarms and only 40% ofthose categorized as noncritical were identified correctly (Cropp, Woods,Raney, & Bredle, 1994). Cropp et al. (1994) suggested that health care pro-viders develop a system of alarms that is graded to reflect differences inimportance. They also suggested that placing doors on rooms and usingalarms that sound only in a central nursing station might buffer sound. Noisecan also be reduced by carpeting (Snyder, 1966), which also has the benefit ofreducing the likelihood of falls. The use of carpet is also part of a movementto humanize hospitals and may be appreciated more by patients than staff(Cheek, Maxwell, & Weisman, 1971), but negative staff reactions may betied 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 sub-jective quality of sleep. Volunteers were randomly assigned to hear audio-tapes of an actual critical care unit (CCU) or quiet. Experimental and controlgroups differed on a number of variables, and participants in the noise condi-tion took longer to fall asleep, spent less time sleeping, and awakened moreoften. Further, sleep deprivation may be associated with a number of negativephysiological outcomes including immunosuppression and lower proteinsynthesis (Topf & Davis, 1993). Participants in a similar experiment in asleep lab (exposure to audiotape of CCU sounds or quiet) did, in fact, havepoorer REM sleep as measured with 7 or 10 indicators (including REM activ-ity) and shorter REM durations (Topf & Davis, 1993).

And although the patient’s recovery is paramount, the effect of hospitalnoise on staff is also of concern. The statement that the guards do more timethan the inmates regarding prisons applies to health care settings, as well. In asurvey of 100 critical-care nurses involving self-report measures of stress andsensitivity to noise (Topf & Dillon, 1988), results indicated that telephones,alarms in equipment, and the beeping of monitors for patients were identifiedas annoying. A measure of burnout was correlated with the degree of noise-induced 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 criti-cal-care nurses focused on measures of health (Topf, 1988). It revealed thatnoise-induced stress could account for 6% of the independent variance inheadaches on the job and that individual differences, such as sensitivity tonoise, were also contributors. The author pointed out that this self-reportresearch needed to be confirmed by experimental studies, which, if support-




ive, may point to the need for “acoustic modifications in the structure of criti-cal care units and patient bedside equipment” (p. 33).

Music. At the other end of the spectrum from noise, the role of music toattenuate the anxiety surrounding hospitalization has been examined (White,1992). The use of music is an example of an intervention that could be part ofa holistic approach, although mixed results of its benefits have also beenreported (Davis-Rollans & Cunningham, 1987; Zimmerman, Pierson, &Marker, 1988). In one pre-post experimental design involving hospitalizedpatients (White, 1992), the experimental group was exposed to 25 minutes ofclassical music selected by the investigator, whereas the control group had a25-minute rest period without music. An anxiety measure, heart rate data,and respiratory rate were included as dependent measures. The experimentalgroup showed statistically significant improvement in all the measures, and,although the controls also had a statistically significant drop in the state ofanxiety following their rest period, the drop was greater for those exposed tomusic.

Although less convincing because no control group was used, research byUpdike (1990) also suggests that music can benefit ICU patients. Blood pres-sure, heart rate, mean arterial pressure, double product index (the product ofheart rate and systolic blood pressure divided by 100), as well as emotionalresponses were measured. Responses indicated a drop in systolic blood pres-sure when patients were exposed to music. Theoretically, this research (andothers) suggests that emotional responses can be modified when musicmoves 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 apretest/posttest experimental design in a study of patients in a CCU who wererandomly assigned to music therapy, relaxation therapy, or control groups.The relaxation (or relaxation plus music therapy) outcome measures wereapical heart rates, peripheral temperature, cardiovascular complication, andqualitative responses to sessions (i.e., “How helpful were they?”) Patientschose three music selections they wanted to hear. Results indicated that boththe relaxation group and the relaxation plus music group had significantlyfewer complications than the control group. Although the music therapyalone was more effective in raising peripheral temperatures, it is not clear thatmusic by itself is better than relaxation alone, although Guzzetta pointed outthat music may have the advantage of shutting out unwanted noise (becauseheadsets are worn). In a study discussed in Rubin and Owens’s (1996) reviewof 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 decreasedwhen they listened to music they had chosen reinforces Minckley’s (1968)theory that the ability to control environmental stimuli, such as noise ormusic, is a key component of tolerance of and positive coping with environ-mental interference. Similarly, Moss (1988) examined changes in anxietyrelated to hearing music in adults admitted for elective arthroscopic surgery.The findings showed decreases in preoperative to postoperative anxiety inpatients who listened to music compared to control groups (cited in Rubin &Owens, 1996).

The research on noise suggests that its reduction can positively affecthealth. Music also appears to have beneficial effects, and may, in turn, shutout unwanted sounds.

THE PATIENT ROOM: WINDOWS, VIEWS, AND ART

In the process of providing a more welcoming environment, the patientroom is of particular importance. The challenge for the designer is to create aresidential feel while preserving whatever technology is deemed necessary.In the evolution of health care architecture, Verderber and Fine (2000) dis-cussed the shift from a staff-centered (modern) to a patient-centered (post-modern) room. In this transformation, the role of the window and the view itaffords are of special significance.

The presence or absence of a window and the view it affords include oneaspect of the physical environment that has been demonstrated to affectpatients’ experiences in the hospital (Rubin & Owens, 1996; Ulrich, 1984;Verderber, 1982, 1986; Verderber, Grice, & Gutentag, 1987). In a study usinghospital records to examine the effects of views out of windows on patientsrecovering from gallbladder surgery, Ulrich (1984) found that patients recov-ering from surgery in rooms with a view of nature versus a view of a brickwall “had shorter postoperative hospital stays, had fewer negative evaluativecomments from nurses, took fewer moderate and strong analgesic doses, andhad slightly lower scores for minor postsurgical complications” (p. 421). In asimilar study, Wilson (1972) looked at incidences of delirium and depressionin postoperative, major surgery patients with and without windows in theirrooms. Wilson found that patients in intensive care units without windowshad significantly higher incidences of organic delirium than did patients inrooms with windows. These findings suggest that windows may have healingand stress-reducing effects on patients and should be considered in hospitaland waiting room design.




In related research by Verderber (1986), 125 staff and 125 inpatients ofphysical medicine and rehabilitation (PMR) units viewed 64 4×5-inch colorphotographs that depicted the PMR units from 11 hospitals. Rooms in patientliving areas, treatment areas, and staff areas ranged from windowed to win-dowless. 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 nature—be it ocean,sky, or forest—appears to help satisfy human informational needs” (p. 459).Keep (1977) reported that “satisfaction is generally achieved when windowarea occupies 20-30% of the window wall” (p. 600). In a study on the valueof windows, Verderber and Reuman (1987) concluded that involvement withwindows and views helps the patient develop a “perceptual and cognitive linkwith the external environment” and positively affects the therapeutic process(p. 121). Verderber (1986) also found that window conditions in most hos-pital settings often contrast with patients’ ideal window views found inresearch.

One reason windows may be of value to the patient is that they are a sourceof natural light. Heerwagen and Heerwagen (1986) examined people’s pref-erences for daylight versus electric light in office spaces and found that peo-ple preferred daylight to electric light for psychological comfort, for officeappearance and pleasantness, for visual health, and for general health. Win-dows may be of therapeutic value because they provide a soothing, peacefuldistraction. Researchers have found that people much prefer scenes of natureto cityscapes and urban environments (Kaplan, Kaplan, & Wendt, 1972), thatscenes of nature have more positive effects on physiological states (Ulrich,1981), and that scenes of nature influence faster recuperation from stress thando scenes of the urban environment (Ulrich, Dimberg, & Driver, 1990; Ulrichet al., 1991).

Now, innovative ways to bring art and nature into health care settings areavailable. These include the electronic window of nature that simulates thepassage of daylight from dawn to dusk, created by Joey Fischer/Art ResearchInstitute Limited and used first in the United States at Stanford (Seligmann &Buckley, 1990). Recent books on health care feature other examples of thissame idea such as an angiography lab that is backlit with a photograph oftrees and a waterfall on the ceiling at Grace Hospital in Detroit and a CT scan-ning suite at St. Mary’s Hospital in Grand Rapids, Michigan, where there is aphotograph on the ceiling depicting underwater scenes (Malkin, 1992;Nesmith, 1995).

Ulrich (1992) is one of a small group of researchers who regularly use out-come measures other than patient or staff satisfaction reports on the




physiological changes (e.g., lower blood pressure) that can occur through theuse of serene artwork. These scenes typically involve water or other forms ofnature. Ulrich discusses the importance of positive distraction—“an elementthat produces positive feelings, effortlessly holds attention and interest, andtherefore may block or reduce worrisome thoughts” (1992, p. 24). The mosteffective of these distractions, he claimed, are “(1) nature elements such astrees, plants, and water; (2) happy, laughing, or caring human faces; and (3)benign animals such as pets” (1992, p. 24). These elements, he argued, havean evolutionary significance.

Ulrich’s (1992) research shows that views of nature that reduce bloodpressure and increase muscle relaxation can facilitate reactions to stress in asfew as 5 minutes. Ulrich noted, “All art is not created equal” (1992, p. 25) andcited research on the psychiatric ward of a Swedish hospital where patientswere favorable toward art containing scenes of nature but less comfortablewith art that was described as abstract.

Furthermore, in another study, open-heart surgery patients postopera-tively viewed a nature scene (of either water or trees), an abstract scene, or noscene. Those exposed to the nature scene with water reported less anxietypostoperatively than did those exposed to other types of scenes or the control.In addition, those who viewed the abstract scenes reported higher anxietythan did those without any pictures (Ulrich, 1992). Beyond health care envi-ronments, studies in personality and individual differences have demon-strated 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 arton the walls. However, based on other data one can assume that detailed rep-resentational paintings or prints would be appropriate for all areas, but partic-ularly for long term use areas” (p. 34). These findings fit with the directionthat has been taken in selecting paintings for health care environments thatare representational and feature scenes of nature. The role of nature is alsobeing emphasized in the use of gardens in healing (Cooper Marcus & Barnes,1995). “Patients, visitors, and staff come to the garden to help themselves feelbetter” (Cooper Marcus & Barnes, 1995, p. 57).

Lighting and color. In health care environments, consideration needs to begiven to lighting—both its color and quality (Koch, 1991). The quality oflighting is important for populations, such as the institutionalized elderly,that spend long periods of time indoors. Chronic diseases such as cataractsand 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 man-age glare. What is recommended is bright, indirect lighting. “Hospitals arenotorious for lacking cues as to time of day, and the resulting disorientation iswell-documented” (Kolanowski, 1992, p. 12).

Benya (1989) discussed the various areas for improvements in the lightingof health care environments. Among the areas to be improved are the ways inwhich source color are rendered, the reduction of glare, more daylight, thereduction of institutional lighting, softer lighting, and an emphasis on resi-dential aspects of lighting (so that it looks more like what you would find in aresidence). At least in the opinion of some designers, lighting can play a criti-cal role in the perception of the hospital environment, and “the overall effectis far greater in both aesthetic and psychological value when weighed againstthe cost of other types of architectural improvements” (Benya, 1989, p. 58).

The use of color to enhance mood, improve way finding through colorcues, and reduce patient disorientation, has also been examined (Cooper,Mohide, & Gilbert, 1989). To attract attention to particular areas (e.g., activ-ity areas) the authors’ advice was to paint them with bright colors. Forrestricted areas, the advice was pale colors.

Color often plays an important role in way-finding systems despite theexistence of users who are colorblind. Health care environments frequentlyuse 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 indepth because many of the prescriptions for way-finding systems apply tobuilding types in general and are not specific to health care facilities. Forthose interested in reading more about the topic, a book by Carpman andGrant (1993) on health care design reviewed research and design recommen-dations for way finding in health care environments.

SPECIALIZED BUILDING TYPES AND UNITS

The third emphasis in research has been on specific building types for spe-cific patient populations. The decentralization of hospital care has beenaccompanied by an increase in units for special patient populations, and onepopulation that has been chiefly responsible for a number of health carebuilding types is the elderly. Moving beyond nursing homes, four architec-tural types of continuing-care retirement forms emerged by the mid-1990s(Verderber & Fine, 2000). Verderber and Fine described these as (a) thepastoral campus type, (b) the denser suburban type, (c) the new, urbanistvillage 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 otherpopulation, much of it by the Philadelphia Geriatric Center under the guid-ance of M. Powell Lawton. Lawton put forward the environmental pro-activity hypothesis, which suggests that environmental resources will be putto better use in people of higher competence. A second hypothesis involvesenvironmental docility, which suggests that “environmental press accountsfor a greater proportion of behavioral outcomes as personal competencediminishes” (Lawton, 1985, p. 507) and that docility will increase as limita-tions of the individual encounter environmental barriers or constraints. Thesehypotheses point to the importance of control, or of a command center, for theelderly, which supports autonomy (e.g., having a telephone or televisionwithin reach of a favored chair, much like what is depicted for Mr. Crane, theaging father on theFrasier television series). Others have demonstrated thatchanges in the physical environment of the elderly who are hospitalized canimprove their ability to perform tasks of daily living (Landefeld, Palmer,Kresevic, Fortinsky, & Kowal, 1995). Creating a home-like atmosphere thatalso addresses the sensory limitations of the elderly can additionally improveoutcomes (Alvermann, 1979).

Many of the building types address the substantial subpopulation of theelderly with dementia and Alzheimer’s disease. “Many of the problems expe-rienced by people with dementia and their caregivers are linked directly to theplanning 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 prosthetic-ally designed nursing home in the sense that it staves off further deterioration.“The open treatment area is intended to diminish the effects of disorientationand memory loss by giving residents an almost complete view of all areasfrom anywhere in the space” (Liebowitz et al., 1979, p. 59). However, whenthis research was done, a variety of changes occurred including better light-ing in bedrooms, a reduction in the number of people sharing bedrooms, andincreased programming. It, therefore, was not clear which changes wereresponsible for the fact that patients did not deteriorate.

Cohen and Weisman (1991) described the prosthetic effect for patients ofenvironments, including the Weiss Institute, designed for those with demen-tia in their book,Holding on to Home: Designing Environments for Peoplewith Dementia. Other recommendations for the physical environments ofpatients with dementia came from work by Peppard (1986) and a book byCalkins (1988). Calkins endorsed the butterfly plan in which two clusters ofbedrooms are arranged around the nursing station to permit visual monitor-ing of patients by staff members. Although design changes have received a




good deal of attention for the elderly as a patient population, the staff alsoplay a significant role, and staff training can be a significant component ofpatient-centered care for the elderly (Inouye et al., 1993). Thus, some of theprotective effects of patient-centered care for the elderly can come in theform of geriatric nursing expertise.

In terms of design for patients with dementia, what is recommended isnoninstitutional in character (including human scale, soft architecture, elimi-nating environmental barriers, use of reminders from the past, spaces forfamiliar tasks like cooking, and display areas). “The environment shouldhave sufficient cues so that people with dementia do not resort to wanderingas a consequence of disorientation” (Cohen & Weisman, 1991, p. 70). Thesuggestion is made that continuity in paths (like a loop) is useful becausedead ends cause frustration. Outdoor spaces are also helpful as are greenhouses, sunrooms, and areas for plants. Design configurations that includecentral open areas (like a widened hallway) or open activity areas (Kromm &Kromm, 1985) are popular because these spaces have been shown to reducedisorientation and lead to increased time spent in social areas with a parallelreduction in time spent in bedrooms (Liebowitz et al., 1979).

Increases in the level of functioning for patients with dementia have beenreported when patients were admitted to a unit specially designed for them.Results indicated improvements in the level of functioning for both mentaland emotional status coupled with the functions of daily living at both 4 and13 months following intervention (Benson, Cameron, Humbach, Servino, &Gambert, 1987). Additions included an orientation board and color-codingfor each patient’s door with his or her name and picture also displayed next tothe door. Although doors were not locked, they were alarmed, and a double-door knob arrangement was used because, as the authors commented, fewdementia patients can turn both knobs at once. Beyond physical changes inthe environment, each resident had an individualized treatment plan. “Ourdata suggest that a specially designed dementia unit can benefit selectedpatients within the nursing home setting” (Benson et al., 1987, p. 322). Thisresult was accomplished with the same level of nursing staff. Althoughpatients’ improvements were not cognitive, they included other importantbehaviors including social, group interaction, grooming, and eating.

However, some have questioned whether special care units (SCUs) fordementia patients that are segregated necessarily result in improvements(Mathew, Sloan, Kilby, & Flood, 1988). In a study involving 34 patients intwo comparison settings, patients in the dementia unit were not better,cognitively, than controls. But one obvious benefit in the dementia unit wasthe 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 tapeon the floor in front of a door, because many demented patients apparentlyperceive two-dimensional grid patterns as presenting a barrier (Hussian &Brown, 1987). Other research on Alzheimer’s units (Hyde, 1989) suggeststhat, although many views exist about the basic goals of such units, a sharedbelief is that the environment can help compensate for patients’cognitive andsensory deficits to encourage mastery of the environment including the activ-ities of daily living.

Other models for addressing the needs of the elderly have been createdincluding the Acute Care of Elders (ACE) units (Palmer, Counsell, &Landefeld, 1998). The goal of ACE units is to foster independent functioningin patients and to prevent a “dysfunctional syndrome.” Primary nurses alsohave an expanded role in ACE units. Covinsky et al. (1998) also describedACE units. ACE units stress enhancing personal control through (a) patient-centered nursing care, (b) prepared environments, (c) planning for discharge,and (d) medical care review. Physical changes made include carpeting incorridors and patient rooms, clocks and calendars in every room, and use ofpatterns with visual contrast in carpets and wall coverings to enhance wayfinding and orientation. Bathrooms have elevated seats; levers rather thanknobs are used for doors. Floor lighting at the bedside promotes safe transferat night. There is a large commons space for all patients that provides spacefor activities that promote socializing and exercising. Regarding the ACEunit, Covinsky et al. talked about a prepared environment in which walking isencouraged by carpeting all patient rooms. At discharge, patients on the ACEunit were more likely to improve and less likely to decline. However, 3months later, the patients from the ACE unit were similar to non-ACEpatients in their abilities to perform activities of daily living. Similar to someof the results reported earlier with regard to patient-centered units likePlanetree, some improvements of patients on units with the interventionsmay not be extended in time (Martin et al., 1998). Counsell et al. (2000), how-ever, described research on ACE units in which the decline in activities ofdaily living (ADL) was less frequent for those on the ACE unit than for othersreceiving usual care. In that study, patient and provider satisfaction improvedwithout a concomitant increase in costs.

Other types of designs for specialized patient populations include birthingcenters (Vogler, 1990) and rehabilitation centers. One design innovation forphysical rehabilitation that has been positively reviewed is called Easy StreetEnvironments, in which patients practice navigating grocery stores, bus stops,banks, and restaurants before facing the real environment (Guynes, 1990).




MANAGED HEALTH CARE,RESEARCH OPPORTUNITIES, AND NEW INITIATIVES

These specialized centers and smaller building types are, in some mea-sure, the result of the revolution in health care known as managed care. Exter-nal forces, such as legislation and changes in the insurance industry, have atremendous capacity to effect change. In particular, managed health care hassignificantly affected the architecture of the health care environment. Muchof the publicity surrounding the rise of managed health care has planted anegative image of its impact on the patient with practitioners declaring thatthey can no longer provide the services that they think their patients require.However, the gap between member satisfaction with HMOs and other typesof health plans may be narrowing (Walker, 2002), and there may be positiveaspects of managed health care in terms of its impact on the physical environ-ment. When diagnosis related groups (DRGs) increased competition, someproviders thought it possible to distinguish themselves through design(Voelker, 1994). It has been argued that a new paradigm in health care archi-tecture is needed—one that replaces the monumental and enduring withstructures that reflect caring and flexibility (Arneill & Nuelsen, 1992).

Regarding the changes that managed health care has created, BruceArneill—past president of the National American Institute of ArchitectsAcademy on Architecture for Health and chairman of the S/L/A/M Collabo-rative, an architectural firm that has done a substantial number of health careprojects—commented,

Due to competition, lower reimbursements from the government, and thedemand 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 fordiagnosis and treatment, and curing, healing, and caring have gone through ametamorphosis. (personal communication, October 16, 2002)

As an example of the change in the way health care is now approached byarchitects, Arneill stated,

Another good example of the change is the fact that the Academy on Architec-ture for Health for the American Institute of Architects has grown in the last 25years from approximately 100 members to almost 4,000.. . . Also, the Ameri-can College of Healthcare Architects has been formed to establishcredentialing for healthcare architects based on education, training, experi-ence, 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 under-gone a substantial change in status compared to its standing in the field afterWorld War II. At that time, health care architects or architectural firms had lit-tle status in design quality in the field of architecture. Now, however, not onlyare health care architects held in higher esteem, but there are those who evensubspecialize, for example, in cancer centers, women’s centers, and so forth.Arneill stated that “Ninety percent of this advancement and change has takenplace since the advent of managed care in the mid-1970s” (B. P. Arneill, per-sonal 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 imagethat providers present, attract groups of payers, and increase the share of themarket that providers control (Fitzgerald, 1996). The emphasis seems to beon satellite feeders, and these outpatient facilities and medical office build-ings are argued to provide not only greater convenience for patients but alsoeasier staff flow (Fitzgerald, 1996). Even when renovation occurs within gen-eral hospitals, the impetus seems to be the creation of units within units, suchthat intensive care and sub-acute care units form entities within the largerhospital itself. This kind of chunking or grouping has the potential to makepatients and families more comfortable because of the idea that the whole isbroken down into more manageable parts.

This new construction by the health care industry has presented environ-ment and behavior researchers with a tremendous opportunity to build on asolid foundation of research findings. Although quality research is difficult todo in the health care environment because of the many variables involved inthe challenge of experimental control (Voelker, 1994), we have an obligationto follow the advice of Kenneth Schwartz, quoted in an article about the 2ndInternational Conference on Health and Design in Stockholm, Sweden:“Design research results need to be impressive, when presented to a hard-nosed world” (Martin, 2000, p. 518). Collaborations are emerging that mayhelp to produce just this kind of hard-nosed evidence in the form of evidence-based design (Tarampi, 2002). One example is The Pebble Project (Bilchik,2002; Varni & Marberry, 2001). The Pebble Project (so named to indicatethat the work is hoped to have a ripple effect) is a collaboration between theCenter for Health Design and a number of health care organizations aroundthe country who are measuring design-based health care outcomes. Although




the research is ongoing, preliminary data indicate a variety of encouragingfindings. These include a 62% decrease in medication errors at a new unit inthe Barbara Ann Karmanos Cancer Institute in Detroit, six fewer nosocomialinfections (those caused or aggravated by hospital life) per month in privatepatient rooms at Bronson Hospital in Kalamazoo, Michigan (Bilchik, 2002),and a decrease in patient falls by 75% at the new Comprehensive CardiacCritical Care unit at Methodist Hospital, Clarian Health Partners, in India-napolis (Marberry, 2002). These findings and others reviewed in this articleindicate that we have the tools to do the kind of research that will lead toevidence-based design, and providers are becoming more willing to supportsuch efforts. More and more, they realize the potential of research to improvepatient well-being and the health care system.

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