Atriums, artwork, and hotel-type amenities are part of a design trend in hospitals and ambulatory surgery centers. Is this a fad, or does it make a difference in patient care?

In an interview with OR Manager newsletter, Roger S. Ulrich, PhD, professor and director of the Center for Health Systems and Design at Texas A & M University, discusses his research on the relation between design and health outcomes, which he has been conducting since the early 1980s.

There is some research, not a lot, with patients in holding rooms and recovery areas. There is other evidence based on other groups who are under pain and stress that may apply to the surgical population.

A couple of years ago, we did a study with Stephen Horowitz and Yacoov Weiss, cardiologists at Beth Israel in New York City, on patients in the holding area waiting for heart catheterization. We know that anxiety in this environment further exacerbates already compromised heart oxygenation.

In the study, 80 patients were randomly assigned to one of four groups: Group 1 had an attractive picture of a mountain meadow printed on their cubicle curtain. Group 2 had no picture but a tape player with nature sounds recorded at the same scene. Group 3 had both the picture and the nature sounds, and Group 4 had neither. We administered standard anxiety questionnaires and measured physiological indicators.

The group that had the combination of the nature scene and the sounds reported they were much less anxious. This was generally echoed in the physiological measures. This study has been published in abstract form and presented at scientific meetings.

There are upwards of a dozen studies, most not on patient populations, showing that when people are experiencing acute stress, even a few minutes of exposure to a nature scene is helpful. There is an effect on the autonomic nervous system.

From surveys of patient satisfaction, we know that major factors that are important to patients and families include responsiveness of the nursing staff, the negative effect of invasions of privacy, and the need for communication and support from family.

Preoperatively, I think patients want to wait in an area where their family members can be with them. The staff often wants a big, high-tech room that is good for patient surveillance. But from a healing perspective, is it necessary to deprive patients of privacy and have them staring at a blank wall and boring curtain and ceiling tiles?

Similarly, I think the whole concept of the recovery room needs to be reexamined. With shorter-acting anesthetics, patients are waking up faster after surgery. Are there ways to avoid the psychological trauma, the invasion of privacy, and the isolation of the traditional recovery room?

We know so much about patient satisfaction, yet we often create these "ambulatory surgery factories" that are the patient’s typical introduction to the local hospital.

For outpatient surgery, my suggestions would include asking:

• Can your patients find the right entrance to the building?
• Is the parking convenient?
• Once a patient enters the facility, what is the journey like? Are the directions clear? Are the spaces inviting and comforting?
• How do patients get back to the car to go home? I hope this doesn’t mean taken in a wheelchair into a parking structure and getting dumped into the back seat.
• How does a family member who may be coming later in the day figure out where to park, how to get to the right unit, and how to find their loved one?
• Is the facility designed so your staff doesn’t waste their time and energy because patients can’t find their way around?

For family waiting areas, suggestions would include:

• small groups of comfortable chairs—not like a dentist’s office with chairs lined up along the wall
• basic comfort needs, such as a convenient bathroom, food, and drinks
• access to a telephone and places to make cell phone calls in private
• pleasant, soothing pictures on the walls

For waiting areas where long waits are anticipated, I would add:

• workstations to plug in laptop computers
• space for vigils to accommodate families and friends who may be there to support a patient who is critically ill
• a television those waiting can control and avoid if they wish.

The cost of the design and construction of a new hospital is 6% to 9% of the total cost to that hospital of providing care over a period of several years. When I hear cost-conscious CEOs saying they want to cut the design and construction budget, I tell them to think about how this might increase their operating costs long term. It could also affect their revenues if patients choose more patient-friendly facilities.

Good design is cost-effective, particularly if these features are considered early in the design process.

Staffing is a huge issue. Turnover and burnout rates are too high. I just visited a new state-of-the-art cancer unit in Europe—one third of it is closed because of a lack of staff.

We all know the cost of staff turnover is very high. Staff need a supportive environment so they can provide good care for patients. It’s all connected.

Some things to consider:

• Give a greater priority to staff lounges. Lounges speak loudly about the respect the organization accords the staff. The staff needs a place for privacy and rest. Too often, lounges are rudimentary and sterile.
• Have better designed workstations and workflows. Integrate the care process so the staff spends more time on patient care and less on fetching items.
• Provide for respite. Do workspaces have windows? Is there a place close by, maybe a garden, where a person can go for a brief yet recharging break from work? A garden doesn’t have to be big, and it should be close by. More hospitals are creating gardens, but you have to keep it from becoming a smoker’s refuge.

Of course, we think about the technical issues of lighting, ventilation, and temperature. We also are seeing more interest in acoustical quality, particularly in areas like ICUs where communication is so critical. Studies on other populations show there are more errors of comprehension when the sound reverberates. We need more research specifically on ORs.

Also, is it really necessary to have an absence of windows? We require windows for patients. What about the staff? Could we provide a view out that offers a respite, perhaps on a garden or a park? Would this help to buffer stress?

I have done research on how workplace design affects anger reactions. NASA was interested in the research and its application to the design of space stations. This research shows that if people are under stress, the intensity of an angry reaction is significantly affected by their visual surroundings—and the worst type of environment is an unembellished space, like a small office with nothing on the walls. A lot of visual clutter from equipment might also aggravate anger.

There are intriguing possibilities for improving the lot of staff—their stress, job satisfaction, and probably performance. But there has been very little serious investigation of this as yet.

Rubin H R, Owens A J, Golden G. Status report (1998): An investigation to determine whether the built environment affects patients’ medical outcomes. Martinez, Calif: Center for Health Design, 1998. Report on CD-ROM available for $199 as part of the Healthcare Design Action Kit at www.healthdesign.org

Reprinted from OR Manager newsletter. March 2002 Copyright © 2002. OR Manager, Inc. All rights reserved. Phone 800/442-9918. www.ormanager.com