MAKING HEALING AS IMPORTANT AS CURING
An Optimal Healing Environment is one that supports and stimutates patient healing by addressing the social, psychological, physical, spiritual and behavioral components of health care and enabling the body’s capacity to heal itself.
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the elements of the caregiver and the care provided are even more critical than the physical place or space. Today, there is a better understanding and rigorous research that describes how to choose elements of place that support and enable an OHE.
The primary emphasis of this volume of Complementary & Alternative Therapies in Nursing is on the evidence and clinical applications of comple-mentary and alternative therapies that nurses can use to enhance their prac-tice. This chapter focuses on the dimension of place or space—the physical environment in which care is provided and the ways in which evidence can be used to create environments that contribute to positive health outcomes.
SCIENTIFIC BASIS
There is a growing body of evidence that links the physical environment to health outcomes. According to a review of the research literature on evidence-based health care design (Ulrich et al., 2008), there have been more than 1,000 rigorous empirical studies published that link the design of a hospital’s physical environment with health care outcomes. The stud-ies cover a broad scope, with evidence linking:
■ Single-bed rooms with reduced hospital-acquired infections, reduced medical errors, reduced patient falls, improved patient sleep, and increased patient satisfaction
Source: Reprinted from Zborowsky and Kreitzer (2009).
People
Process Place
OHE
Exhibit 5.2. People, Place, and Process: The Role of Place in Creating OHEs
5. creatInG oPtIMaL HeaLInG enVIronMents 59
■ Decentralized supplies with increased staff effectiveness
■ Appropriate lighting with decreased medical errors and decreased staff stress, and
■ Ceiling lifts with decreased staff injuries
Although many of the studies focus on such topics as infection control, patient falls, staff productivity, and staff injuries, a growing number of studies focus on other aspects of the environment that contribute to healing.
As described by Malkin (2008), design strategies that focus on creat-ing healcreat-ing environments have in common the goal of reduccreat-ing stress and include:
■ Connections to nature—artwork with a nature theme, views to the out-side, interior gardens, plants
■ Options that give patients choices and control—room-service menu, choice of music and art, ability to control lighting and temperature
■ Spaces that provide access to social support—family zones within patient rooms that offer sleeping space, storage, and adequate seating
■ Positive distractions—music, water features, aviaries, videos of nature, aquariums, and sculpture
■ Reductions of environmental stressors such as noise and glare from direct light sources—carpet, indirect lighting, elimination of overhead paging
Theories Related to Healing Environments and Clinical Applications Biophilia is the inherent human inclination to affiliate with natural sys-tems and processes. The concept, originally proposed by eminent biolo-gist Edward O. Wilson (1984), has grown into a broader framework that increasingly is shaping the design of the man-made environment, includ-ing hospitals and other health care facilities. Biophilic design emphasizes the necessity of maintaining, enhancing, and restoring the beneficial experience of nature. It describes attempts to do so through the use of environmental features that embody such characteristics of the natural world as color, water, sunlight, plants, natural materials, and exterior views and vistas (Kellert, 2008).
The theory of biophilia has been empirically tested in clinical set-tings. Outcomes measured most often include stress and pain reduction.
For example:
■ A study of elderly residents in an urban long-term-care facility revealed that they attached considerable importance to having access to window views of outdoor spaces with prominent features such as plants, gar-dens, and birds (Kearney & Winterbottom, 2005).
■ Patients in a dental clinic reported less stress on days when a large nature mural was hung in the waiting room, compared to days when there was no nature scene (Heerwagen, 1990).
■ In a prospective randomized trial of blood donors, it was found that donors who viewed a wall-mounted television playing a nature video-tape had lower blood pressure and pulse rates than subjects who were viewing a television playing either a videotape of urban scenes or game or talk shows (Ulrich, Simons, & Miles, 2003).
■ Ulrich, Lunden, and Eltinge (1993) found that patients following heart surgery who viewed photos of trees and water required fewer doses of strong pain medication and reported less anxiety than patients who viewed abstract images or were assigned to a control group with no picture.
There is some evidence that the more engrossing a nature distraction, the greater the potential for pain alleviation. Miller, Hickman, and Lemasters (1992), in a study of burn patients, found that distracting patients dur-ing burn dressdur-ings by havdur-ing them view nature scenes, accompanied by music, on a bedside television lessened both pain and anxiety. In a ran-domized prospective trial of patients undergoing bronchoscopy, those who viewed a ceiling-mounted nature scene and listened to nature sounds reported less pain than subjects in the control group who looked at a blank ceiling. Following a review of the literature on the use of virtual reality as an adjunct analgesic technique, Wismeijer and Vingerhoets (2005) con-cluded that “nature exposures” might tend to be more diverting—and hence pain-reducing—if they involved sound as well as visual stimula-tion and maximized realism and immersion. There is emerging research that uses a multimethod approach to understanding the effect nature has on patients. Goto, Park, Tsunetsugu, Herrup, and Miyazaki (2013) found that exposure to organized gardens can affect both the mood and cardiac physiology of elderly individuals. Among other findings, they revealed that a subject’s heart rate was significantly lower in the Japanese garden than in the other environments studied. The individual’s sympathetic function was significantly lower as well. In this case study of 19 patients in an assisted-living facility, the multimethod approach provided both qualitative and quantitative data.
A number of studies have examined patient preferences for art and the effect of art on stress, recovery, and pain, among other outcomes.
Consistently, studies have documented that subjects prefer nature over other subject matter, and that they overwhelmingly prefer realistic art and strongly dislike abstract images (Winston & Cupchik, 1992). Findings such as these, consistent with the theory of biophilia, have led to the use of evidence-based design guidelines in health care facilities to influ-ence the selection of art. According to Ulrich and Gilpin (2003), visual art should be unambiguously positive. Recommended subject matter
5. creatInG oPtIMaL HeaLInG enVIronMents 61 includes waterscapes with calm or nonturbulent water, landscapes with visual depth or openness, nature settings depicted during warmer sea-sons when vegetation is verdant and flowers are visible, garden scenes, outdoor scenes in sunny conditions, and avoidance of overcast or fore-boding weather.
Pati and Nanda (2011) utilized a quasiexperimental design to exam-ine pediatric patients’ behavior during five distraction conditions ranging from a slide show to video with music. All distraction conditions were created on one flat-screen plasma television monitor mounted on a stand in the waiting areas. Data analysis showed that the introduction of distrac-tion condidistrac-tions was associated with more calm behavior and less fine and gross movement, suggesting significant calming effects associated with the distraction conditions. Data also suggested that positive distraction condi-tions were significant attention grabbers, and could be an important con-tributor to improving the waiting experience for children in hospitals by enhancing environmental attractiveness. Nanda, Zhu, and Jansen (2012) conducted a systematic review of neuroscience articles on the emotional states of fear, anxiety, and pain to understand how emotional response is linked to the visual characteristics of an image at the level of brain behav-ior. Findings indicated there is a paucity of research in this area; and this is a compelling field for future research on the direct impact that imagery of artwork can have on emotional processing centers in the brain.
Chronobiology
Chronobiology is an interdisciplinary field of inquiry that focuses on biological rhythms. Discoveries in chronotherapeutics have documented that time patterning of medications in synchrony with body rhythms can enhance effectiveness and safety. Other studies have targeted the impact of environmental factors such as light and temperature on body rhythms.
There is a significant body of literature focused on the impact of light on depression. In a study of psychiatric patients, Beauchemin and Hays (1996) found that patients in sunnier rooms stayed an average of 2.6 fewer days than those in sunless rooms. A meta-analysis of 20 randomized con-trolled trials by Golden et al. (2005) on the impact of light treatment on nonseasonal and seasonal depression quantified the effect of light treat-ment as equivalent to that of antidepressant pharmacotherapy trials. Light has also been found to be related to patients’ perception of pain. In a study (Walch et al., 2005) of postspinal surgery experiences, patients who were admitted to rooms with greater sunlight intensity reported less pain and stress and took 22% fewer analgesic medications. Results such as these support careful site planning to assure adequate access to daylight, and provide justification for larger windows in patient rooms or the use of bright (but diffused) artificial light in areas where sufficient daylight is inaccessible.
Using a pretest/posttest quasiexperimental study in two intensive care units (ICUs), Shepley, Gerbi, Watson, Imgrund, and Sagha-Zadeh (2012) studied the impact of daylight and window views on patient pain levels, length of stay, staff errors, absenteeism, and vacancy rates. Researchers concluded that high levels of natural light and window views may posi-tively affect staff absenteeism and staff vacancy, although factors such as medical errors, patient pain, and length of stay still require additional research. In summary, there is growing evidence that views of nature and light are beneficial for patients as well as staff.
INTERVENTION
Case Study Applications of Optimal Healing Environment
North Hawaii Community Hospital
North Hawaii Community Hospital embodies the culture of the commu-nity in the way in which it has operationalized the concept of an optimal healing environment. The footprint of the hospital was aligned so that the front is oriented to the Kohala Mountain, and the back to the Mauna Kea Mountain. Earl Bakken, one of the founders of the hospital, had the vision that the hospital itself would be an “instrument of healing,” rather than a “warehouse for sick bodies” (E. Bakken, personal communication, January 2008). All patient rooms are private and have access to views of nature and fresh air through sliding doors that open to the outside. Art in patient rooms is culturally meaningful and can be changed. Hallways are carpeted and there is minimal overhead paging. Soft music plays in public spaces. Familiar cultural patterns, textures, and colors are used in wallpapers, carpeting, and furniture coverings. Ti plants at all entrances and corners of the building are believed to filter out bad spiritual energy.
An interior bamboo garden also offers spiritual protection and represents strength and resilience. All patient rooms have sleep chairs or extra beds for guests to stay over and there are no limits on the number of visitors or visiting hours. An ohama (Hawaiian for family) room includes a kitchen so that families can prepare special meals. Skylights in halls plus win-dows in the operating rooms were incorporated into the design to enable staff to stay attuned to day/night cycles. In addition to these and many other mechanical, architectural, and engineering adaptations, the hospital embraces a philosophy of blended medicine that encourages the integra-tion of complementary therapies and culturally based healing practices.
The vision of North Hawaii Community Hospital is to become the most healing hospital in the world.
5. creatInG oPtIMaL HeaLInG enVIronMents 63 Abbott Northwestern Hospital
The design of the Neuroscience/Orthopaedic/Spine Patient Care Center at Abbott Northwestern’s new Heart Hospital in Minneapolis, Minnesota, integrates the elements of Abbott Northwestern’s healing environment aesthetic standards, including the principles of feng shui and patient-centered care, while acknowledging the needs of staff. The 128 inpatient beds are located on two floors of the Heart Hospital, which was designed to incorporate the latest technology to aid in meeting patient and safety requirements as well as implement the organization’s holistic approach to healing. To accomplish these goals, patient rooms were zoned so that the needs of each user of the space would be addressed.
■ The patient zone provides a view to the outside from every bed, a flower/
card shelf, a private safe for valuables, artwork and care-provider infor-mation on the footwall, and a small refrigerator for favorite foods.
■ The family zone incorporates an upholstered bench seat/sleeper, a read-ing light with private switch, and a data outlet for Internet access.
■ The caregiver zone includes a bedside work area with a sink, com-puter, and—in each patient room—a ceiling-mounted patient-lift sys-tem with a custom track to assist with turning, moving, or toileting a patient.
Other family and patient amenities in the unit include access to a two-story atrium with soothing water walls, a waiting room with a panoramic view of the city, a kitchenette, and a fireplace. In addition to the bedside computer in each patient room, facilities to optimize workflow include decentralized support rooms such as clean utility, soiled utility, nutrition, and medication rooms. A staff-respite area, a private room for staff to use, includes a lounge chair, an ottoman, a phone, and an outside view. Beyond the clinical out-comes, this design provides balance for the psychological, social, and spiri-tual needs of the staff, the patients, and their families. Ultimately, the new patient care center design aspires to create a unique health care environment at Abbott Northwestern Hospital.
Regions Hospital
A primary objective of a recent building project at Regions Hospital, a large tertiary care facility located in St. Paul, Minnesota, was to replace shared patient rooms with private patient rooms. The new hospital bed tower includes an expansion of the emergency department, replacement of the operating suite, and the addition of 144 private patient rooms. Design prin-ciples included an overarching goal to enhance patient safety.
To accomplish this goal in the bed tower, many new features were built into the design:
■ Standardization of patient rooms. First, staff realized that standardiza-tion of all the patient rooms was imperative. Although each floor has a different service line—even different acuity levels that range from inten-sive care to orthopedics—all patient rooms are laid out in the same way.
■ Unique staff access and visibility. Each patient room has a separate doorway for patients and families as well as one for staff. Staff work areas directly adjacent to the patient room include a view window with an integral blind. Staff shares this alcove between two rooms, a design feature particularly important for intensive care unit staff. Patient vis-ibility and ease of access to the patient should enhance patient safety by increasing staff presence.
■ enhanced family zones. In addition, family zones in the rooms are spacious, with the intent of encouraging family-centered patient care.
Families have the ability to stay overnight in most rooms.
■ inclusion of acuity-adaptable patient rooms. Patient rooms on the cardiac unit were designed to be acuity adaptable: allowing patients to stay in the same room as their acuity level varies. This concept is based on data suggesting that decreased transferring of patients less-ens medical incidents and errors (Hendrich, Fay, & Sorrels, 2004).
■ Patient access to the toilet. Finally, because the patient rooms are mir-rored, at least one half of the rooms will have direct access to the patient toilet. No studies to date have been able to document that this is a safer layout for patients; however, with a growing number of patient rooms being designed this way, Regions provides the perfect setting to study the impact of this layout on patient safety.
University of Minnesota Amplatz Children’s Hospital
The new University of Minnesota Amplatz Children’s Hospital opened in Minneapolis in 2011 as Minnesota’s first “green” children’s hospital.
Design of the new hospital included extensive involvement on the part of staff nurses to optimize workflows as well as getting design feedback from children. Highlights of the hospital design include:
■ Natural lighting. The building was designed with walls of large win-dows allowing extensive natural lighting. Corridors are positioned to allow the natural light to flow through and across the patient care units.
Large windows are not only in patient care rooms but also in confer-ence rooms and staff break rooms to allow staff to take advantage of natural lighting as well.
■ Patient care unit layout. Design of the pediatric units optimized the concept of minimizing extraneous movement in direct patient care
5. creatInG oPtIMaL HeaLInG enVIronMents 65 areas. Patient rooms are clustered in pods of no more than six patient rooms per pod with smaller caregiver workstations and no central unit desk. Access to work rooms, supply rooms, and medication rooms are through a central nonpatient corridor with patient room access on an outer corridor reserved for movement of patients and visitors.
This minimizes noise from opening and closing of supply room doors and avoidance of extraneous noise that can occur with the gathering of caregivers at a central desk. Each patient care unit has two supply rooms and two equipment rooms to improve staff workflow efficien-cies, thereby allowing staff to be more visible to family and patients.
Cabinets were built into the walls to accommodate isolation supplies, minimizing any perceived clutter that can occur from having isolation carts in hallways. There is a greeter stationed at the entrance of each pediatric unit so a friendly, consistent face—rather than a busy central desk with multiple caregivers—greets family and visitors each time they enter the units.
■ Unit aesthetics. Each pediatric unit has a nature-based theme in the form of drawings and artwork on the walls. Team work areas face toward artwork that features nature scenes such as beautiful flowers.
Children gave input into the paint colors chosen for the units.
■ Patient rooms. All patient rooms are private and large. This allows for distinct parent/family space within the patient room with a couch/
bed for overnight stays, and Internet access. Some patient rooms have a camera in the room giving a direct view of the outside. Each room has a large-screen television, as well as one monitor where patients and fami-lies can access a GetWellNetwork—online patient education materials and music and videos to promote relaxation. In addition, some rooms also have the ability for patients and families to Skype with family members who live a distance away, maintaining a patient and family-support system through a difficult time.
■ Nature outdoors. An outdoor rooftop healing garden allows patients and families an opportunity to spend time outdoors. There is a play-ground and another garden outside the hospital on the play-ground level.
A final inclusion in this section is the application of principles for creating a healing environment in the home. These tips for well-being are straight-forward and easy to implement (see Exhibit 5.3).
CULTURAL APPLICATIONS AND PRECAUTIONS
The increased diversity of the U.S. population has added a level of com-plexity to the design of health care environments. As noted by Kopec and Han (2008), entering a health care environment can be frighten-ing and disempowerfrighten-ing, particularly when a patient’s traditional and
spiritual beliefs differ from those of the dominant culture. Thus, it is becoming increasingly important to carefully weigh all design decisions that impact the physical environment, including the use of color and cultural symbols as well as other visual, auditory, and tactile design elements.
To Asians, for example, the color red symbolizes good luck, whereas the color white is associated with mourning and death. The color green has positive associations within the Islamic tradition because it is asso-ciated with vegetation and life and is believed to have been the prophet Mohammed’s favorite color. Kopec and Han (2008) have identified a number of ways in which the needs of Muslim patients might be accom-modated. A curtain inside the door, for instance, could help patients
Exhibit 5.3. Well-Being Tips for the Home
■ Open a window. Allowing fresh air to circulate through your home lets you breathe easier. This also rids the air of pollutants, including harmful chemicals that may accumulate from products, equipment such as air conditioners, and furniture.
■ Bring the outside in. Studies have demonstrated that exposure to nature can reduce stress levels and improve well-being. Viewing nature from a window or looking at nature-related images can give a sense of retreat throughout the day.
■ Create a quiet, comfortable space that allows you to escape and reflect.
Meditation is an important part of overall well-being and has been shown to increase (hard to access) alpha-wave patterns in the brain that have been associated with less stress and anxiety.
■ Use calming colors. Color can have a wide range of effects on human mood and emotions. Colors with blue undertones have the ability to calm the mind and create a greater sense of relaxation. Light waves corresponding to the color blue are found to have the greatest effect on regulating the circadian rhythms that are directly related to our moods.
■ Avoid clutter in the home; it can create unnecessary stress! Because our brains are constantly categorizing what we see, it is important to keep the space around us organized and free of clutter.
■ Personalize your space with items, furnishings, and finishes that bring you joy and that have meaning. Personalizing one’s space gives one a sense of control and a deeper connection to a space.
■ Have a sense of control in your home environment. This can include temperature controls, space allocation and organization, noise lev-els, security, and safety. Most important, your home should function according to the way you live.
Adapted from Angelita Scott, personal communication, April 1, 2013.
5. creatInG oPtIMaL HeaLInG enVIronMents 67 maintain visual privacy and modesty, while allowing health care pro-viders on rounds to announce their presence, giving patients time to prepare themselves to be seen. Understanding that followers of Islam face the northeast when they pray could be taken into consideration when orienting the bed and furnishings in the room.
Given the diversity of spiritual, religious, and cultural beliefs and prac-tices, however, it would be nearly impossible, from a design perspective (as well as practically and financially), to accommodate all of the specif-ics and nuances of every tradition. Thus, the goal of design can only be to strive to express core, universal values while seeking to devise design elements that can be flexible. Although the main focus of this chapter has been the physical or built environment, a reminder of the foundational importance of the roles of food, family, and spirituality in the creation of a healing environment is provided in the account of creating a healing environment in Liberia, West Africa (see Sidebar 5.1).
Sidebar 5.1. Healing Environments in Liberia, West Africa Maria Keita, Liberia, West Africa
I am from the Krahn tribe, a small tribe in Liberia, West Africa, which is one of 16 tribes in Liberia. However, I am confident in saying that the healing environment I describe reflects the culture of the Liberian people in general.
When I think of the healing environment in the United States, what comes to mind are the beautiful, well-designed rooms, readily available medications, and high-tech medical devices. The healing environment in my culture consists of four major parts: family presence, food, spiri-tuality, and complementary therapies. When people from Liberia are in the hospital, it is important for staff to understand the importance of presence. Family and friends come in dozens to visit. However, there are always one or two people who stay in the room at all times to sup-port the sick person. The role of the assigned person(s) is to coordinate the care of the patient between hospital caregiver and the family and provide direct support such as encouragement and reassurance to the patient. The presence of friends and family reduces anxiety and builds trust with hospital staff. A healing environment is incomplete without the presence of a family member or a friend with the sick.
It is an expectation in my culture that people stay with one who is ill.
The role of the family is to help in the care of the sick with activities of daily living, even when in a formal hospital setting.
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