In thinking about applying scientific research to the design process, it may seem as if the end result might have a rather institutional feel. However, nothing could be further from the truth. When considered from a purely aesthetic standpoint, healthcare facilities that employ evidence-based principles are actually warmer and more calming than the cold, sterile medical spaces of bygone eras. According to the Whole Building Design Guide, design teams are responsible for employing a number of design solutions that will help to create a therapeutic environment for patients and staff throughout the facility. Here are a few considerations it recommends (among others) to reduce stress and create a welcoming space10:
- Artwork and aesthetics can enhance the soothing and calming qualities of a space.
- Adequate space should be provided in public areas and waiting rooms to avoid crowding.
- Perceived waiting time can be mitigated by positive distractions.
- Visual and noise privacy.
- Odors that are objectionable or “medical” can create stress.
- Wayfinding—the built environment should provide clear visual cues to orient patients and families, and guide them to their destination and return. Landscaping, building elements, daylight, color, texture, and pattern should all give cues, as well as artwork and signage.
- Acoustical treatment of corridors adjacent to patient rooms (carpet tiles, rubber flooring).
- Provide lighting that supports natural circadian rhythm.
- Color, while subjective, can be a design factor in reducing environmental stress when understood and used in the context of the color preferences of a project-specific population.
While the above strategies and other EBD principles certainly make for well-designed spaces, the question is: Does design have a quantifiable result in patient outcomes? The answer, of course, lies in the data.
According to a report from the Robert Wood Johnson Foundation (RWJF), one of the nation’s largest philanthropy organizations devoted exclusively to health and healthcare, there is a direct link between patient health and quality of care and the way a hospital is designed.11 For example, the report cites a number of real-world examples where evidence-based design strategies were employed, resulting in the following outcomes12:
- Patient falls declined by 75 percent in the Cardiac Critical Care Unit at Methodist Hospital in Indianapolis, Ind., which made better use of nursing staff by spreading out their stations and placing them near patients’ rooms.
- Medical errors fell 30 percent on two inpatient units at The Barbara Ann Karmanos Cancer Institute in Detroit that allocated more space for their medication rooms, re-organized medical supplies, and installed acoustical panels to decrease noise levels.
Further, RWJF revealed that by using EBD strategies in the redevelopment of the Bronson Methodist Hospital in Kalamazoo, Mich., the design team realized measurably improved outcomes. By incorporating design features such as private rooms with rooming-in accommodations for all patients; creative use of artwork, music, light, and nature to create a more pleasant and less stressful environment; shorter walking distances for patients and families with seating along the way; and touch-screen information kiosks at every main entrance, the hospital was able to document the following results13:
- 11-percent reduction in nosocomial infections
- Nursing turnover rates below 7 percent (the national average is 20)
- 95.7 percent overall patient satisfaction
- Improved staff satisfaction
- Increase in market share
Additionally, according to an article in “Becker’s Hospital Review,” using EBD strategies benefits hospitals and other medical facilities in five ways, including enhanced patient safety, reduced medical errors, decreased need for patient medication, reduced staff injuries, and increased staff efficiency through improved workflow.14 In one case study, Clarian Health Partners in Indianapolis realized a nearly 70-percent decrease in medication errors by replacing its multi-level ICU with variable-acuity adaptable rooms. “Variable-acuity rooms provide different levels of care in one room to minimize patient transfers from one space to another, which can occur as often as three to six times in a patient’s hospital stay,” the article stated. “The 90-percent reduction in transfers at Clarian decreased hospital expenses and reduced medical errors while boosting patient satisfaction and staff productivity.”
As the body of available, credible research grows, EBD continues to inform the way not only hospitals are designed and constructed, but it is also making inroads into being part of the process for designing schools, office spaces, hotels, restaurants, museums, prisons, and even residences, according to the International Interior Design Association (IIDA).15 “It makes sense that EBD has its roots in healthcare, where lives are at stake and legal implications are palpable, outcomes are fragile, and decisions need to be justified by hard data,” the association observes. “[However] this need for justification is becoming more commonplace in most other building designs.”
Clearly, the data reflects the reality that evidence-based design practices have a direct impact on the people who inhabit the built environment. As such, design practitioners and healthcare professionals should consider looking to organizations like the Center for Health Design, which houses a repository of knowledge and thousands of research studies, to begin employing EBD principles. One such approach involves providing positive distractions for patients in healthcare settings—and utilizing effective artwork programs, as well as innovative material solutions to employ them—which will be examined in the following sections.
Art: The Power of Positive Distraction
Among the many tenets of evidence-based design is to provide positive distractions in healthcare facilities through appropriate art, restful views, and access to nature, thus relieving unnecessary stress and improving patient satisfaction. “Positive distraction” is a term used to describe the belief that environmental features can elicit positive feelings, hold attention and interest and, therefore, reduce stressful thoughts.16 Research demonstrates that when used appropriately, artwork can have a positive effect on medical outcomes of patients, especially as it relates to stress reduction.
NOTE OF CAUTION: While positive distraction and artwork are an essential component of EBD, it is crucial to note here that simply because one or more strategies are used in conjunction with a healthcare (or any other) project does not mean it has been founded upon credible research. In other words, beware of false claims. As Malkin warns in her book:
“[P]rojects have sometimes been labeled a healing environment based on an art program (possibly not even one based on research) or a number of cosmetic changes in interior finishes. Healing environments sounds so nice, who wouldn’t want to make a claim like this? However, several questions should be asked: Why would a specific design be expected to improve outcomes? Is the project anchored in research about reduction of stress for patients? Has anyone developed a hypothesis and attempted to measure outcomes before and after the interventions? Similar claims may, in the near future, be made about a project having been evidence-based. Articles are already starting to appear in magazines making this claim, and sometimes it is based on one or two research-based elements, but the project overall may miss the boat on many important issues. The evidence-based designation should be applied only when research has impacted the design with sufficient scope and hypotheses are tested in the process.”17
With that being said, how is art being used in healthcare spaces as one part of a broader evidence-based approach to design? First and foremost, art serves as a contrast to the often somber work being done in many healthcare settings. “Art is a counterpoint to the complexity of healthcare design,” said Cheryl S. Durst, executive vice president and CEO of IIDA. “Incorporating art and artisanal pieces into healthcare environments humanizes the experience, creates a sense of calm, and presents an opportunity to welcome others into these spaces.”18
Further, by connecting communities, supporting local artists, creating healing environments, and celebrating identity, art is often used by healthcare designers to fulfill many goals for multiple populations while still satisfying the complex design needs of healthcare spaces. For example, healthcare facilities are increasingly designed to shed the identity of being a place for those who are ailing; instead, these environments are built to be gathering places by providing programming for the public as well as event spaces and auditoriums that can be used for various community purposes. Using local artwork offers the community an opportunity to be involved with a healthcare project and provides an incentive to visit or use the facility for purposes unrelated to illness.19
Additionally, the American Society of Interior Designers (ASID) recently noted that design practitioners, in particular, feel the need to support creativity in tangible terms that move beyond technology and functional planning. In other words, they seek materials and products that “not only make sense from a design perspective, but also feed our creative soul,” noted Sandy Gordon, FASID, LEED AP, and chair of the Board of Directors for ASID. “We are committed to uniting art and space. Without a doubt, art and interior design are inextricably linked. Interior design is, in itself, an art form, bringing beauty and functionality seamlessly together in residential and commercial spaces.”20
There’s no doubt that art stimulates the visual senses and helps in the creation of aesthetically pleasing environments, but does it really have a measurable impact in healthcare settings? While the arts and sciences are often seen as divergent disciplines, data from credible research claims otherwise.
In the peer-reviewed Journal of the Royal Society of Medicine (JRSM), researchers of one published article cite a well-known scientific study of the visual environment and health outcomes which found that levels of depression and anxiety were lower in patients undergoing chemotherapy when exposed to visual art than in patients not exposed to visual art.21 Further, researchers discovered that patients recovering from open heart surgery who were exposed to an image of nature experienced less postoperative anxiety than other groups who were exposed to an abstract image or no image at all. (Interestingly, the study concluded that patients experienced greater levels of anxiety when exposed to abstract art than those with no image, suggesting that art selection is very significant; see related sidebar for guidelines.)22
Also, the JRSM article noted that the use of appropriate art in hospitals is viewed positively by both patients and staff, and had a positive effect on morale.23 In fact, 43 percent of frontline clinical staff believed that the arts had a positive effect on healing and 24 percent felt that the arts improved clinical outcomes. Further, considerable evidence has shown that mental health can be improved by participation in arts projects.24