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Make it Pretty and They Will Come: The Role of Aesthetics in Patient Satisfaction

Thursday, July 8th, 2010
Woodwinds Health Campus

Garden bench at Woodwinds Health Campus, photo courtesy of Woodwinds Health Campus

Like most people, I’ve had my fair share of unpleasant experiences in doctors offices and hospitals. And looking back, I realize that many of my most worst memories had to do with the way the place looked. The one that took the cake was a doctor’s office in a windowless clinic with one potted plant in the waiting room. And that plant, a Poinsettia from Christmas-time (this was in February) was dead. Even if only on a subliminal level, we perceive that something is wrong with this picture: “If they can’t even take care of one houseplant, how the heck are they going to take care of me?” I have heard many people, when talking about the gardens in a hospital, clinic, or nursing home or other place of healing, express the opposite sentiment: “They take such good care of the gardens, and that reassures me that they will take good care of me, too.”

I’m reading an article from an old (2008) issue of Healthcare Environments Research & Design Journal (HERD), titled “Ambulatory Facility Design and Patients’ Perceptions of Healthcare Quality,” which completely reinforces what we all know in our hearts to be true: That places of healing work better when they look and feel like…places of healing. And I’m talking, of course, about a more holistic idea of healing than just “isolate, sterilize, and medicate.” Squeaky white linoleum floors that reflect buzzing fluorescent lights attached to low ceilings in long, windowless corridors is an old model that has been proven to be anything but good for our health.

So, let me just share a few nuggets from this article. First, its conclusion, as stated in the abstract: “This study is consistent with other studies that examined the relationship among the physical attractiveness of healthcare settings, patient satisfaction, and quality of care.” Patients reported better care, service, and staff and doctor interactions in the more attractive waiting rooms. The authors cite several other related studies about patient satisfaction: Leitner and colleagues (1998) found that “patients in hospital units where nurses felt that their work was meaningful were more satisfied with their hospital stay” and that “…patients on units where nurses felt more tired and more frequently expressed their intention to quit were less satisfied with their care.” Mallak, Lyth, Olsen, Ulshafer, and Sardone (2003) found that “…job satisfaction [among healthcare providers] and patient satisfaction were significantly and positively correlated with culture strength and ratings of the built environment.” They also cite interviews with patients and families about what they want. Douglas and Douglas (2004) “found that patients reported the need for personal space, a homey welcoming atmosphere, areas for visitors, access to external areas, and provision of facilities for recreation and leisure.” Gardens in places of healing can fulfill many of these criteria, and a well-designed garden should address all of them.

I once got an email from someone recommending that his local hospital’s healing gardens (Woodwinds Health Campus, pictured above) be added to the TLN’s list of exemplary gardens in healthcare facilities. The gardens made a strong positive impression on him, and influenced how he felt about the entire hospital. And it probably provided a great incentive for him to visit for regular check-ups rather than waiting for emergencies. Think about how much people’s health would improve if they adhered to the preventative care model!

The article mentioned above explores the role of the built environment in influencing patient (consumer) satisfaction. Another article, which I’ll blog about soon, discusses the role of the built environment in influencing patient health and safety. There are so many reasons for healthcare providers to focus not just on the medicines and the machines, but on the places that house what all that stuff is there for: The patients and their families. All of those places have outdoor space – be it a parking lot and drop-off area or a designed “healing garden,” and all of those outdoor spaces could and should be considered as part of the aesthetic package that influences patient satisfaction, health, and well-being.

Full citations:

Becker, Franklin, Bridget Sweeney, and Kelley Parsons (2008). “Ambulatory Facility Design and Patients’ Perceptions of Healthcare Quality.” Healthcare Environments Research & Design Journal (HERD), Vol. 1, No. 4, pp. 35-54.

Douglas, C. H., and M. R. Douglas (2004). “Patient-friendly Hospital Environments: Exploring the Patient’s Perspective.” Health Expectations, Vol. 7, No. 1, pp. 61-73.

Leiter, M. P., P. Harvey, and C. Frizzell (1998). “The Correspondence of Patient Satisfaction and Nurse Burnout,” Social Science Medicine, Vol. 47, No. 10, pp. 1611-1617.

Mallak, L. A., D. M. Lyth, S. D. Olsen, S. M. Ulshafer, and F. F. Sardone (2003). “Culture, the Built Environment and Healthcare Organizational Performance.” Managing Service Quality, Vol. 13, No. 1, pp. 27-38.

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Posted in Architecture, Bibliography, Building Design, Healing landscapes, Landscapes for Health, Research | 2 Comments »

A New Way to Improve Quality of Life for Seniors: Excellent DVD Series (with a discount for us!)

Thursday, December 10th, 2009

Five years ago, Susan Rodiek embarked on a project to create a series of DVDs about providing better access to nature for older adults. Rodiek, a professor at Texas A & M University’s Center for Health Systems & Design, specializes in senior populations, and access to nature has long been a focus for her research and teaching.

Those years of hard work have paid off. I received my “Access to Nature for Older Adults” DVDs last week and I’m truly impressed. The three-DVD series is not just instructional – it’s downright inspiring. With beautiful imagery, compelling research and interviews, easily digestible information, and a lot of real, practical solutions to common problems, it’s a must-watch and a must-have for architects, landscape architects, planners, educators, and any care provider who works with seniors in continuing care retirement communities, assisted living facilities, nursing homes, hospices, as well as acute care general hospitals.

Session One, The Value of Nature, describes how access to nature may benefit the health of seniors, from the perspective of experts and available research – addressing the role of programs, policies, and design issues.

Session Two, Improving Outdoor Access, explores how the layout of the building itself can either encourage or discourage outdoor access, and how specific areas – such as indoor-outdoor connections – can be successfully developed.

Session Three, Safe and Usable Outdoor Spaces, highlights the main outdoor features that are reported by residents to impact their outdoor usage, and how these can be improved. Seating, shade, and walkways are among the outdoor elements illustrated.

The Access to Nature website is also chock-full of good information. Some of it is accessible to everyone, and some of it is only accessible if you have the DVDs. So go ahead and buy them! You won’t be sorry.

Receive a 10% discount: Between now and the end of January 2010, Therapeutic Landscapes Network members and readers of this blog will receive a 10% a discount when you buy any or all of the Access to Nature DVDs. Just enter this promotional code in the checkout section on the Access to Nature website: TLNA2N.

Posted in Architecture, Building Design, Education, Products, Resources, Senior Housing, Seniors | 2 Comments »

Green Walls for Healing Gardens

Monday, November 9th, 2009

 

Patrick Blanc's 'Mur Vegetal' in Paris -Quai Branly

Patrick Blanc's 'Mur Vegetal' in Paris -Quai Branly

One of the key elements of a healing garden – a garden designed to facilitate and even improve people’s health and well-being – is a high ration of plant material (“softscape”) to paving, walls, stairs, etc. (“hardscape”). More plants, less paving.

And especially if we’re talking about hospitals and other healthcare facilities, which is where healing gardens are needed most, people like a lot of softness and greenery to balance out the hard, sterile surfaces indoors. People also prefer a feeling of enclosure – it makes them feel safe and secure, and can delineate spaces for private reflection and conversation.

So, what better design element than a green, living wall? Patrick Blanc made a big splash with his (absolutely gorgeous) vertical gardens a few years ago, and since then, the market for green walls has exploded. I’ve been surprised at how slowly it’s catching on in the healthcare environment. Seriously, wouldn’t it be great if all of the hospitals and clinics and hospices and nursing homes had soft, green, living vertical surfaces instead of concrete walls and vinyl fences and strange partitions that don’t really work in delineating space?

Image courtesy Annabel Harrold from Echo Studio's post on Blanc

Image courtesy Annabel Harrold from Echo Studio's post on Blanc

Another plus about vertical gardens: They are easily accessible to just about everyone. Whether you’re standing on two feet or wheeling in a wheelchair or a stroller, the plants are at your height where you can reach out to touch and smell, or even to garden in. What a fantastic tool for horticultural therapists!

Here’s an example of a custom-designed wall by Hitchcock Design Group for a continuing care retirement community (CCRC) in Hyde Park, Chicago:

Hitchcock Design Group green wall. Photo by Naomi Sachs

Hitchcock Design Group green wall. Photo by Naomi Sachs

If you’re interested in the confluence of plants and architecture, definitely check out Jason King’s blog Veg.itecture (their tagline is “investigating green architecture.”).

And if you know of any healthcare facilities with vertical green walls – fixed or freestanding – please leave a comment. We’re trying to build a list for the Therapeutic Landscapes Network.

Here’s one last image, from a new company called Woolly Pocket Garden Company. Check out their blog. I especially like the posts about the Edible Staircase and the Edible Schoolyard, two programs with kids in Los Angeles schools.

Green wall image courtesy of Woolly Pockets

Image courtesy of Woolly Pockets

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Posted in Architecture, Backyard Sanctuary, Container Garden, Gardening, Healing Garden, Horticultural Therapy, Plants and Horticulture, Products | No Comments »

The need for natural light, part III

Monday, January 5th, 2009


Let’s see, which hospital room would you rather stay in? This one (A)?


Or this one (B)?

Carson Tahoe Regional Medical Center, Carson City, NV
As for me, I’d choose B. There are lots of reasons why I think B is better than the A, but high on the list is that B has lots of windows that not only look out onto a view that even homebuyers would pay good money for, but that let in copious natural light as well. 

And so we come to the Part III of “The need for natural light.” 
The benefits of natural light - at home, at work and school, and in the healthcare setting – have been well documented. People fare better when they have access to natural light. For example, a 1998 study found that sun exposure in the workplace environment increased worker satisfaction and performance, including lowering intention to quit and reducing fatigue (that same study, by Leather et al., found that providing views of nature also increased satisfaction, particularly in high-stress environments). A landmark “Daylighting in Schools” study found that students in classrooms with more natural light scored as much as 25% higher on standardized tests than other students in the same school district (see references below for full citation and to link to the condensed study). 

As for healthcare: Roger Ulrich and colleagues have found exposure to natural light to be an important factor in environments for healing. Exposure to sunlight can reduce depression, alleviate stress, and even reduce pain. In addition to providing essential dosages of Vitamin D, sunlight increases our levels of serotonin, which in turn inhibits pain. In their recent literature review of evidence-based healthcare design, Ulrich et al. cite a study by Walch and colleagues of post-operative spinal surgery patients. Patients with sunnier rooms reported less stress and took 22% less analgesic pain relief medication (see Ulrich et al, 2008, below). 

In her new, excellent book A Visual Reference for Evidence-Based Design, Jain Malkin lists daylight as one of the key ingredients in creating a successful Environment of Care: “There is a major focus on the importance of natural light and views, access to gardens, and clarity of wayfinding.” In Chapter 4, “Incorporating Research into Design Features,” lighting is first on the list: “Lighting–both natural and electric–is the most important component of an interior environment. Adequate exposure to natural light is essential for biological health and entrainment of circadian rhythm. Research indicates that patients in rooms that receive more sunlight are less depressed and have reduced length of stay.” Malkin also mentions benefits to staff members (pp. 63-65; see full citation below). 
So what does all of this have to do with therapeutic landscapes? 

Simple: Windows that let in natural light… 

The waiting room at Santa Fe Cancer Center at St. Vincent Hospital 
looks out onto the healing garden (Santa Fe, New Mexico)

…can also offer views to the outside world (even skylights can sometimes give us views of blue sky and/or clouds). As Ulrich et al. state in their most recent (2008) literature review, “Larger windows in patient rooms not only provide natural light, but they also have the potential benefit of offering views of nature and should be considered in the design process.” 

Healing garden at St. Vincent Hospital, Santa Fe, NM 
(note the mirrored windows – they provide privacy for those inside 
while also reflecting the garden to make it appear larger).

And as we know from Ulrich’s and other studies, window views to something more interesting than a brick wall, or the building’s air conditioning system, elicit better outcomes. And the research also suggests that more naturalistic the setting, the better the outcome (again, see Ulrich et al, 2008, below).


Lobby at Carson Tahoe Regional Medical Center, Carson City, NV



All of this research notwithstanding, there are times when natural light can be too much of or not enough of a good thing.

Too much of a good thing: 

1. When light = sun = heat. In hot climates, keeping light out is one important way of regulating the temperature. Whether inside the building or out, people seek shade when temperatures rise above the human comfort zone. Though it’s beautiful and exemplary in many ways, I’m actually not sure how I’d feel in the above Carson City lobby on a hot day in August…but maybe they’ve got it all figured out with awnings, blinds, or some other technology (besides just more AC). 

2. When light = glare. For example, as I write this, the sun is starting to stream into my office, which would be lovely if it didn’t glance off of my computer screen. Time to draw the curtain. And glare can truly be a problem, especially for people like the elderly who are glare-sensitive. 

3. This last point isn’t so much to do with light as with privacy. The one drawback of a window, especially on a ground floor looking out onto a garden, is that if users inside can see out, then people outside can usually see in. Designers of hospitals with interior courtyards often grapple with the double challenge of the “fishbowl effect” (feeling like everyone can see you when you’re in the garden) and not wanting to violate the privacy of those indoors. Designers have found all sorts of clever ways to address this issue, including at St. Vincent Hospital, above, where mirrored windows allow users inside to see the garden whilst keeping their privacy intact, and users outside get the sense of an even larger and more verdant garden (yep, the old mirror trick can work in the landscape as well).

Window coverings: That 1998 workplace study I mentioned earlier also suggested providing users with ways to control the amount of light (curtains, etc.). As we also know from research, providing people with choices is another way to reduce stress and bolster a feeling of control over one’s environment. Whether those operable window coverings are used to control light for temperature regulation, glare, privacy, or just personal preference, they should be provided whenever possible.
Not enough of a good thing: Seasonal Affective Disorder and Sundowners Syndrome. Sometimes natural light has to be augmented or adjusted, as in these two examples below.

1. Another issue with natural light is that in the winter, there just isn’t enough of it. We’ve all heard of SAD – Seasonal Affective Disorder, and this is a real thing. Just as plants need grow-lights in the winter because even sitting in a sunny windowsill isn’t enough, some people need additional light, too. Full spectrum light therapy, at doses of 2500 – 10,000 lux, has been found to be as or even more effective than anti-depressants for some SAD sufferers. 

2. For people with Alzheimer’s and other forms of dementia, exposure to light and the color of light should be controlled and regulated to avoid mood changes and disruptive behaviors, particularly those brought on by “sundowners syndrome.” In two studies by Melinda La Garce, the effects of “Sundowner’s Syndrome” and other light-related problems were reduced by adding “full spectrum lighting to simulate daylight, shading devices to reduce sun angle change and shadows, and light monitors to keep the light intensity the same throughout the day and evening.” In the 2004 study, La Garce noted that the sun’s altitude, which changes over the course of the year, affects the color, intensity, and angle of daylight. She also found that the color of light seemed to play a stronger role than shadows and light intensity. 

As I’ve mentioned in the past (see, for example, “When the Weather Outside is Frightful”),  indoor atria are another great way to provide access to natural light and nature, even on days when going outside is not an option. This image is of the Fourth Floor Atrium at the University of Alberta Hospital in Canada. To see more examples, link to Shane Pliska’s article in Interiorscape Magazine.

References 

Crockett, Jim (2004). “Healthy Daylight and Healthy Darkness: What our Bodies Need.” Consulting-Specifying Engineer. Click HERE to link to the article.

Darling, Tammy (1993). “Seeing the light: why your body needs regular doses of natural light.” American Fitness, Nov-Dec. Click HERE to link to the article.

Gross, Raz, Yehuda Sasson, Moshe Zarhy, and Joseph Zohar (1998). “Healing Environment in Psychiatric Hospital Design.” General Hospital Psychiatry, Vol. 20, No. 2, pp. 108-114. Read the summary by InformeDesign.

Heschong, Lisa and Heschong Mahone Group (1999). “Daylighting in Schools: An Investigation into the Relationships Between Daylighting and Human Performance.” Commissioned by California Pacific Gas and Electric Company. Click HERE to link to the condensed report.

Horowitz, Steven G., M.D. (1998). “Design Trends: Designing for Advanced Therapeutic Outcomes – Acute Care.” Journal of Healthcare Design, Vol. 7. Read the summary by InformeDesign.

La Garce, Melinda. (2004). “Daylight Interventions and Alzheimer’s Behaviors – A Twelve-Month Study.” Journal of Architectural and Planning Research, Volume 23, Issue 3, pp. 257-269. Read the summary by InformeDesign.

La Garce, Melinda. (2002). “Lighting Affects Behavior of Alzheimer’s Patients.” Journal of Interior Design, Volume 28, Issue 2, pp. 15-25. Read the summary by InformeDesign.

Leather, Phil, Mike Pyrgas, Di Beale, and Claire Lawrence (1998). “Windows in the Workplace: Sunlight, View, and Occupational Stress.” Environment and Behavior, Vol. 30, No. 6, pp. 739-762. Read the summary by InformeDesign.

Malkin, Jain (2008). A Visual Reference for Evidence-Based Design. The Center for Health Design. 

van Bommel, W. J. M. and G. J. van den Beld (2004). “Lighting for Work: A Review of Visual and Biological Effects.” Lighting Research and Technology, Volume 36, No. 4, pp. 255-269. Read the summary by InformeDesign. 

Ulrich, R. S., Craig Zimring, Xuemei Zhu, Jennifer DuBose, and Hyun-Bo Seo, Young-Seon Choi, Xiaobo Quan, and Anjali Joseph. (2008). A Review of the Research Literature on Evidence-Based Healthcare Design. Published in Health Environments Research & Design Journal, Vol. 1, No. 3, Spring, pp. 61-125. Click HERE to read the abstract. 

Ulrich, R. S., C. Zimring, A. Joseph, X. Quan, and R. Choudhary. (2004). The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: Center for Health Design. Read the summary and access the full report at the Center for Health Design.

Walch, J. M., B. S. Rabin, R. Day, J. N. Williams, K. Choi, and J. D. Kang. (2004). “The effect of sunlight on post-operative analgesic medication usage: A prospective study of patients undergoing spinal surgery.” Psychosomatic Medicine, Vol. 67, pp. 156-163.

Posted in Architecture, Bibliography, Building Design, Built Works, Healing Garden, Interior Gardens and Atria, Research | 1 Comment »

The need for natural light, part II (and to be continued)

Monday, December 22nd, 2008

In researching for this blog posting on the need for natural light, I’ve uncovered so much good information that I wouldn’t be able to do the subject justice to try to write about it today, when I’m crunched for time. So, stay tuned while I do a little more digging and collecting thoughts. 

In the meantime, the best all-around article I’ve found so far is “A Review of the Research Literature on Evidence-Based Healthcare Design” by Roger S. Ulrich, Craig Zimring, Xuemie Zhu, Jennifer DuBose, Hyun-Bo Seo, Young-Seon Choi, Xiaobo Quan, and Anjali Joseph, published in the Spring 2008 issue of Health Environments Resarch & Design Journal, a quarterly journal published by the Center for Health Design and Vendome Group (Vol. 1, No. 3, pp. 61-125). This article (and the journal in general) is a must-read/have for anyone interested in Evidence-Based Design in healthcare. For subscription information, contact www.herdjournal.com.

Posted in Architecture, Building Design, Research, Resources | No Comments »

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