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Beyond Interior Design
Health Facilities Management, November 1993

Your challenge today is to maximize the theraputic potential of the health care environment. But do you and your staff really understand what that means?

Some call it the "doctor within" - that force that drives our bodies to heal themselves. For years, we've intuitively known that it exists; now, science is catching up to quantify the anecdotal evidence.

Researchers, for example, are learning more about how emotions are linked to disease and how healing can be promoted by surroundings that reduce stress and engage the senses in therapeutic ways. The most fascinating - and long overdue - shift in thinking is based on a recent explosion of data that indicate that the mind and body can no longer be considered as separate and autonomous systems.

Trailblazers in the new field of psychoneuroimmunology, for example, are studying mind/body interactions and how they affect well-being. Cutting-edge research is revealing how billions of neurons in the brain convert feelings of hope and confidence into chemical substances that fortify the immune system.

Scientists are discovering how belief systems can determine whether a person will get sick, contract one type of illness or another and - most crucially - be able to survive any of them.

Researchers in the emerging field of chronobiology are probing the internal body rhythms of the 24- hour cycle. They're learning that the viscosity of blood increases and decreases during the day and that certain diseases occur more frequently in one season than in others. They're finding that there is a best and worst time to administer every drug.

What it means. Knowledge that environments can enhance (or hinder) healing is likewise evolving at a quickening pace. At Sweden's Vidarkliniken Hospital, for example, physicians prescribe warm- or cool-colored rooms, based on illness and state of healing.

But a healing environment cannot be accomplished simply by superficial renovations relating to finishes and color. Nor must it be confused with what came to be known in the 1980s as "hospitality health care design."

In fact, creating a healing environment often transcends to blueprints of physical design. When beginning a new project, ask:

*What are the stressors in this environment? How can they be reduced or eliminated?

*How can we affect the minds of the patients, unleashing their own senses to promote healing?

*How can we influence patients so that they take greater measures of responsibility for their own recoveries? How can we make them want to get well?

The design of most health facilities is richly encoded with cues that predefine roles and behavior. As a result, people who enter the world of clinical jargon and unfamiliar procedures often feel that they must check their personhood at the admissions desk and suppress their needs and preferences to fit in with "the system." They experience a loss of control over their lives and bodies, causing stress and anxiety that debilitate and impede recovery.

"Traditionally, health facilities have been organized for doctors, for auxiliaries, for insurance companies - everybody but the patient," says Ron J. Anderson, M.D., president and CEO of Dallas (TX) County Hospital District / Parkland Hospital. In a healing environment, though, "the system" reduces anxiety by accommodating the patient.

The focus always remains on patients' convenience, comfort, and pleasure. Ultimately, the entire setting should support patient-centered operational protocols.

There are now numerous Planetree units in hospitals across the country. As Florence Nightingale wrote in her influential book Notes on Hospitals, more than a century ago: "The first requisite of a hospital should be that it does the patients no harm."

Nature's role. In creating healing environments, we cannot underestimate the value of nature. At a visceral level, patients respond to elements that have been important to humans throughout millennia: light, water, animals, and plants.

How can you help connect people with the world of nature? Structures must draw patients, visitors and staff into contact with the ever-changing light, sight, and sound of nature through greater use of atriums, vest-pocket gardens, greenhouses, and water elements.

The stress-reducing effects of water, for example, are well-documented. Even just viewing water in a painting or a mural can reduce the levels of catecholamines (stress hormones) released into the blood. The relaxing qualities of bubbling water over stones (or a flickering fire in a hearth) can measurably reduce muscle tension, alter galvanic skin response, lower systolic blood pressure, and change the electrical activity of the brain.

This whole process invokes a new patient-centered philosophy and requires a deep-seated commitment from every health care executive and staff member. To support this approach, these groups constantly must address the challenge of how to reduce environmentally induced stress.

Patients first. To begin creating healing environments, it helps to think like a patient. You must accept the axiom that patients always come first, with emphasis being placed on treating the whole person and not just the diseased organ.

Patients, for example, should be allowed to eat when they're hungry - not when the food-service department finds it convenient. Medical charts and resource libraries must remain readily accessible. As often as possible, services should be brought to the patients rather than the other way around.

(Viewing certain abstract or impressionist-style art, however, can bring about the opposite effects!)

A well-publicized study of patients recovering from gallbladder surgery showed that patients who were assigned to rooms with views of trees were discharged earlier, received fewer negative evaluations from nurses and required fewer painkilling medications than did similarly ill patients in rooms that faced brick walls.

Five senses. Sensory deprivation is a common tactic of torture; conversely, the healing activation of the senses is a celebration of life. Surely the lesson for medicine - and for health care designers - is to accentuate the positive.

Soothing music, for example, can stimulate the pituitary gland to release endorphins, the body's natural opiates. Music is known to lower blood pressure, heart rates and the amount of few fatty acids in the blood, potentially reducing the risks of hypertension, stroke and coronary disease.

At Kaiser Foundation Hospital, Los Angeles, patients are offered tapes that provide music or explain guided relaxation techniques. Music is used during chemotherapy and prior to cardiac catheterization. Patients who suffer from spinal injuries also receive tapes.

Certain types of so-called New Age music are extremely relaxing because they're based on natural body rhythms. Studies show that certain biological sounds, such as an adult's heartbeat, can diminish stress in infants.

Sounds of the surf, generated by electronic devices, can calm agitated pediatric patients and mask corridor traffic noise in intensive care units. Classical music that's piped into operating suites is known to reduce tension levels - and sometimes even patients' anesthesia requirements.

We also know that noise can be a most noxious stressor. That's why law-enforcement agencies often employ loud or "heavy metal" music to irritate and flush out holed-up suspects. So it's not surprising that high levels of noise adversely affects the treatment of patients who take certain antibiotics or that noise in recovery rooms can enhance the perception of pain.

Patients who get in touch with their creative selves, meanwhile, often can transcend their pain. Art therapy, such as drawing, not only helps patients to feel better about themselves but also enhances their immunologic competency.

The sense of smell is likewise a powerful factor in healing because it activated the limbic system - the brain's emotional center. Scents are often retained more acutely in memory than either visual images or sounds.

Medicinal smells, for example, can stimulate anxiety and fear, increasing heart rates and stress levels. On the positive side, essential oils of certain flowers and fruits can exert powerful calming effects, slowing respiration, lowering blood pressure, relaxing muscles and even reducing pain. "Aroma-therapy" has been widely used in health facilities in Europe and Asia.

Of course, in no way are these concepts intended to supplant or undermine the marvel of drugs and technology or the quality of the doctor/patient relationship. Their value lies in supporting orthodox medicine with the added healing power of music and art, massage, acupuncture, aromatherapy, nutrition, biofeedback, creative visualization, meditation, etc.

What's ahead. Every day, health facility design theories are being transformed by scientific evidence that reinforces the mind/body connection. Yet we still see the same design concepts repeated in health facilities over and over again, regardless of their often-negative effects on patients and staff. Unfortunately, when it comes to environmental psychology, there is a long lag between the discovery of knowledge and its application.

As a designer, I lament the rather low level of information transfer that has occurred among disciplines. We need a lot more cross-fertilization of ideas, so that health facility designers, executives and staff - and let's not forget the patients! - can all profit.

We would all benefit, for example, if the curriculum of an architect's training included a course on healing environments. Too often, health facility rooms are sized according to minimum code requirements, even though "minimum" is rarely an acceptable comfort level for patients or staff.

In the years ahead, health facility officials will demand that their consultants know how to create curative architecture, inside and out. For patients, the benefits will tip the scale in favor of health and life; for care-givers, the results will be seen in improved morale, reduced turnover and a competitive edge when it comes to recruitment. .

Although no precise set of design standards are (as yet) available for creating healing environments, there is a collective vision on the horizon. We are about to enter a new era of more enlightened approaches in medicine, health care management and institutional design. For those of us who have been in the trenches of health care facility design for many years, that time cannot come too soon.

New York City's Memorial Sloan-Kettering, in fact, employs a full-time music therapist who visits patients' rooms with a guitar and other types of musical instruments.

The benefits of pets are well-documented, too. Stroking the face of a puppy from a hospital bed can be glorious medicine!

Creating a healing environment: Sutter Cancer Center

Planning for the three-story, 155,000 square foot Sutter Cancer Center, a freestanding facility that will be linked to Sutter General Hospital, Sacramento, CA, is now under way and will incorporate many pathways to healing. The goal is to help normalize and restore equilibrium to a patient's life. One way to do this is by offering psychological escape from the traditional health care setting.

Each floor contains a spacious residential-style kitchen for patients and families. Patients can pad around in their robes and slippers, read the newspaper, sip coffee-as if they were at home. Family members can bake chocolate-chip cookies or prepare an entire meal.

Patient rooms feature neutral color palettes, with an emphasis on texture. Patients retain an array of light-control options. Windows start at the floor and go almost the full width of each room.

Fountains at nurses' stations block the distracting sound of conversations and provide a soothing background sound.

Instead of uniform, "code-minimum" 8-foot wide corridors, hallway widths vary up to 11 feet. Rather than standard fluorescent lighting, most lighting is indirect.

Linen carts, meanwhile, are stored behind wall-partition alcoves instead of cluttering up corridors. Although concealed from view, the carts are easily and quickly accessible to staff.

One of the center's three floors of nursing units will serve bone-marrow transplant patients, who may remain hospitalized 40 to 50 days. Such patients, confined to their rooms for so long, can suffer sensory deprivation. Yet any static decorative treatment may become equally boring.

The solution was to use the foot-wall as a giant video screen that can play 45-minute video tapes of different natural environments, accompanied by therapeutic music. Each room contains its own video projector, built into a cabinet at the head of the bed and positioned for viewing. With very little imagination, the patient can enter the wonder of the natural world.

When transplant patients' white-cell counts are high enough to enable them to leave their rooms, they are exposed to several other expressions of nature: The unit contains two 420-gallon saltwater aquariums and four 3-by-8-foot glass-enclosed miniature gardens, recessed in niches.

Each garden will feature a 20-minute audiotape that can be activated by the viewer. The Japanese garden-with rocks, bamboo and raked sand-will be accompanied by soothing music, for example; the sounds of birds and waterfalls will add to the magic of the miniature tropical rain forest.

Two other miniature gardens-a desert milieu and a New England autumn scene with a brook-also will be available. Each aquarium and garden will be bordered by a built-in sofa that invites patients to curl up and relax.

Opposite the nurses' station on this floor will be a thicket of preserved bamboo, backed by full-height mirrors that magnify the effect of an outdoor grove. An overhead wooden grill structure, with a deep light-well above, will make the bamboo appear as if it is growing through the ceiling.-J.M.
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November, 1993: Health Facilities Management.