Healing environment

in this paragraph a more detailed explanation of the healing environment concept and its
aspects are given.

Healing environment definition

A healing environment is commonly considered as one that contributes to patients’ health

and well-being. This idea is not new. Florence Nightingale (1863) wrote already in the
nineteenth century about the positive effects of daylight and ventilation on patients’ health.
In fact, the concept of healing environment can be traced back to ancient Greece where
nature was used in the healthcare environment for its positive effect on patients (Van
den Berg, 2005). Although the term healing environment is used often, a precise and
generally accepted definition seems to be lacking (Van den Berg, 2005). Bovenberg et
al. (2010) describe a healing environment as an environment that contributes to the
well-being, recovery and healing of a client and can reduce patient stress and
stimulates the self-recovering ability of the patient. In most studies on healing
environment, the environment is operationalised through physical aspects such as daylight
and nature that have proven their positive effect on patients’ health and well-being. The
physical environment includes all physical entities that are in and around
organisations (Mobach, 2009). Evidence-based research on positive effects of
environmental aspects in healthcare settings often refers to Ulrich (1984), studying the
effect of patients view in hospital rooms. This research showed that patients that had a
view of trees, needed less pain medication and had a shorter length of stay compared to
patients viewing a brick wall. This is one of the first studies related to evidence-based
design (EBD) of hospital environments. In EBD, decisions are made on the basis of
credible research and evaluations of projects (Hamilton, 2003). Often one of the
physical aspects of EBD is studied in an intervention study (e.g. Wakamura and
Tokura, 2001; Swan et al., 2003; Altimier et al., 2005). All these aspects contribute to the
creation of a healing environment.

The physical environment can be defined as all tangible physical entities in and around
organisations (Mobach, 2009). A healing environment is considered a holistic entity
wherein different components all play a synergistic role (Fottler et al., 2000).
Therefore, healing environment from a holistic point of view considers these tangible
physical entities of the physical environment as related having an intertwined effect on
its users. In definitions of healing environment from this holistic perspective, the focus is
not only on physical aspects, but also on social and psychological aspects. Jonas and Chez
(2004) for example define an optimal healing environment as: “one in which the social,
psychologic, spiritual, physical, and behavioral components of health care are oriented
toward support and stimulation of healing and the achievement of wholeness” (p. 1).
The social aspect of the healing environment is the possibility to immerse in healing
relationships, primarily with family, friends and community (Jonas and Chez, 2004).
Psychological aspects that are influenced by environmental stimuli are of a cognitive or
emotional nature, for example the presence of plants in a patient room that give the
patient a more homely feeling which results in less anxiety (Dijkstra et al., 2006).
According to Jonas and Chez (2004), a spiritual aspect concerns spiritual and
traditional religious practices and is about experiencing being connected to
something greater than one’s individual self. Behavioural aspects concern
actions taken by individuals and groups that affect their health, for example physical
exercise and addictive behaviour (Jonas and Chez, 2004). Because spiritual and behavioural
aspects do not necessarily relate to physical aspect in a patient’s room, these are not taken
into account.

Social and psychological aspects however are relevant, because they are often related to
physical aspects and are closely related to well-being. For example, privacy, which can be
seen as a basic element of healing environment (Wesa and Culliton, 2004), can be related to
physical aspects (e.g. single patient rooms) but also to psychological aspects (e.g. the feeling
of privacy) and social aspects (e.g. privacy in conversations with others).

For the purpose of this study a healing environment is defined, using Bovenberg et al.
(2010), as an environment in which physical, psychological and social aspects contribute to
the well-being, recovery and healing of a client and can reduce patient stress and stimulates
the self-recovering ability of the patient.

Aspects of healing environment from a patient’s perspective

As shown in the previous section, different types of aspects can be distinguished in relation
to healing environment: physical, psychological and social. In this paragraph first of all the
physical aspects are explained: their effect on patients’ well-being and how they should be
designed in order to achieve this effect. Hereafter the psychological and social aspects are
explained: their effect and which physical aspects are involved.

Physical aspects of the environment

The following physical elements are explained: spatial layout, lighting, scent, nature and
natural elements, art, colour, acoustic comfort, aesthetics and ambient conditions.

• Spatial layout

• Single patient room

Having a room for their own has a lot of advantages for patients. First of all, it is more safe,
because infections can be prevented: there are less people in the room (fewer patients,
family and staff present) which reduces the risk of spread of infections and single patient
rooms are more easy to clean which also reduces the risk on infections (Ulrich et al., 2006).
Single patient rooms may reduce the number of medical errors because it is more calm and
quiet in the room (Van de Glind et al., 2007). In addition, single patient rooms are associated
with better communication between staff members, less transfers of patients and fewer
medication errors and thereby decrease the number of medical errors (Ulrich et al., 2008).
Because there are less patients in the room there is also less equipment in the room;
therefore, there is less noise and patient sleep improves (Devlin and Arneill, 2003).

Also for family a single patient room is more satisfying because they can stay unlimited
(Ulrich et al., 2008), they have a larger, more comfortable zone (McCullough et al., 2010 in:
Herweijer-van Gelder, 2016, p. 103) and communication between the family and staff
improves (Ulrich et al., 2006). Finally, single patient rooms ensure both speech and visual
privacy, confidentiality and leads to a higher patient satisfaction (Ulrich et al., 2008).
To conclude, patients having a room for their own can improve patients’ privacy, safety and
sleep.

• Bathrooms

According to Ulrich et al. (2008) research showed that shared bathrooms are an important
factor in the spread of an infection; through private bathrooms this risk can be reduced. In
addition, patients’ privacy increases when they have a private bathroom (Ulrich et al., 2008).

To conclude, the privacy of patients can be increased and the risk of infection can be
reduced through a private bathroom.

• Windows

Windows can be seen as decoration and allow patients to mentally escape spaces that are
crowded or unpleasant (Herweijer-van Gelder, 2016). According to Ulrich et al. (2008)
windows should be large so that bedridden persons can look outside onto sunny nature
spaces which help to reduce pain. Thereby they state that large windows might help
alleviate depression because of increased exposure to daylight. A study of Wilson (1972)
showed that the presence of windows may reduce the chance of getting a delirium (in:
Mobach, 2009, p. 277). For patients to be able to look down from the window, adequate
low parapet needs to be ensured (Van den Berg and Van Winsum-Westra, 2006). Through
low parapet (or breastwork) the window becomes larger and lower which enables the
patient to look down whereas high parapets may restrict the view outside.

Through large windows with low parapets, depression may be alleviated and can distract
patients.

To conclude, the spatial lay-out can influence how patients feel and also may influence their
health. The number of patients in one room, the number of patients that have to share a
bathroom and the presence, height and size of windows are herein important.

• Lighting

Adequate lighting is identified as one component that leads to patient satisfaction (Ulrich et
al., 2008). Three types of lighting can be distinguished: artificial light, daylight and sunlight.
When there is appropriate artificial lighting, less medication errors occur, herein a
luminance of 1570 lx shows a significant lower error rate (Buchanan et al., 1991). Bright
artificial light is also effective in improving mood and reducing depression (Ulrich et al.,
2008). Artificial lighting can also contribute to an aesthetically pleasing environment; in
general, bright indirect lighting is recommended to prevent glare (Devlin and Arneill, 2003).
The presence of daylight reduces pain and the incidence of depression (Ulrich et al., 2008).
Ulrich et al. (2008) also state that the length of stay of patients suffering from depression
 can be reduced through morning daylight. The presence of daylight can be ensured through
large windows and by avoiding that other buildings block light for others (Ulrich et al.,
2008). Windows should not have awnings or permanent immovable obstructions to
sunlight, ample window areas and skylights should be used as much as possible and also
accessible outdoor areas can contribute to getting enough daylight for patients (Rubin et al.,
1998).

Besides daylight, also sunlight is important. Research has shown that patients suffering from
depression had a shorter length of stay when they stayed in sunny rooms (Beauchemin and
Hays, 1996). The same applied for cardiac patients that suffered from depression but also
the mortality rate was lower with patients that stayed in sunny rooms (Beauchemin and
Hays, 1998). Walch et al. (2005) found that patients that had spinal surgery and were
exposed to increased amounts of natural sunlight, had a decreased level of stress, pain and
analgesic medication use which also resulted in lowered pain medication costs.

Lighting also has an effect on patients sleep. Through exposure to daylight or bright artificial
lighting during the day and dimmed light in the patients’ rooms at night, patients have a
natural day/night rhythm which helps to ensure good sleep but also prevents patients from
additional stress, a weakened immune system, stress and deliriums (Ulrich et al., 2008).

As described above, patients may feel better with appropriate lighting and lighting also has
a positive effect on health. This involves artificial light, daylight and sunlight.

• Scent
According to Herweijer-van Gelder (2016) there are two reasons for the use of odour: it has
a calming effect and can mask unpleasant hospital odours. Unpleasant odours can lead to
increased heart rate and breathing, whereas specific flower and fruit scents calm breathing
and reduce blood pressure and heart rate (Herweijer-van Gelder, 2016).

• Nature
Nature has always been a key component of healing environments (Van den Berg, 2005). It
reduces stress (Van den Berg, 2005), it reduces negative emotions (Ulrich et al., 2006), it can
enhance positive emotions (Ulrich et al., 2006), it can reduce anxiety of patients and family
(Smith, 2007), it can improve health outcomes linked to post-operative complications that
are coupled to stress such as headaches, it can help dealing with pain, it can lower the use
of analgesic medication and it can heighten the pain tolerance (Ulrich et al., 2008).
The first research associated with evidence-based design showed that patients that
had a view of trees needed less pain medication and had a shorter length of stay
compared to patients viewing a brick wall (Ulrich, 1984). Also the presence of plants
and flowers in patient rooms proved to lead to higher satisfaction and reduced stress,
anxiety, pain and fatigue (Park and Mattson, 2009).
 Besides the presence of real nature, also images of nature and murals depicting natural
scenes can reduce anxiety and stress (Ulrich, 1991). In addition, providing television screens
to simulate (visual and audible) nature in areas where patients undergo painful procedures
can reduce severe pain (Ulrich et al., 2008). Also, the use of natural colours and natural
materials such as wood and natural stones can increase the satisfaction of patients in
hospitals (McCullough et al., 2010 in: Herweijer-van Gelder, 2016, p. 109).

To conclude, the positive effects of nature on patients’ well-being can be achieved through
views of nature through windows, images of nature on walls or displayed using technology,
the use of natural materials and plants in patient rooms.

• Art

The presence of art can be a positive distraction for patients (Herweijer- van Gelder, 2016).
Art stimulates the senses (Dilani, 2001), it can enhance positive feelings, hold attention and
interest of patients without requiring any effort and therefore it may block or reduce
worrisome thoughts (Ulrich, 1992 in: Devlin and Arneill, 2003, p. 682). Installing
psychologically appropriate artwork may reduce stress of patients and improve pain relief
(Ulrich and Giplin, 2003 in: Huisman et al., 2012, p. 75). Hathorn and Nanda (2008)
recommend involving nature in art because patients preferred this relative to an urban
environment, images of people, architectural interiors, still life, abstract images and sport
scenes. They mention the following elements of art to be appropriate in healthcare
environments: waterscapes with calm or non-turbulent water, landscapes with visual depth
or open foreground, trees with broad canopy, savannah landscapes, verdant vegetation or
positive cultural artefacts. Flowers in the artworks should look healthy, fresh and familiar
and gardens should have an open foreground; figurative art should be diverse, leisurely and
have emotionally positive faces (Hathorn and Nanda, 2008).

However, art should be selected carefully in order to have its positive effects; therefore the
following guidelines should be taken into account (Hathorn and Nanda, 2008):

o Art should be located in the sightlines of patients;

o The needs of special patient populations should be taken into account (e.g. no images of
water in areas where patients need to have a full bladder for a medical procedure or
impressionistic images in areas where patients have vision problems);
o The demographic aspects of the location of the environment should be taken into account
(e.g. ethnicity, gender and age) and artwork should be chosen accordingly.

It can be concluded that the presence of art may have a positive effect on patients’ well-
being, if the art is selected carefully.

• Colour

Colours have a strong impact on our emotions and feelings (Kaya and Epps, 2004 in:
Herweijer-van Gelder, 2016, p. 119). However, a lot of contrasting theories and
 contradictions can be found in literature and research on colour (Dalke et al., 2006).
Thereby, the emotions associated with certain colours differ per gender, age, culture,
religion and education level (Nemsciscs, 1993 in: Herweijer-van Gelder, 2016, p. 119).
Therefore, the application of colours must be designed taking into account the context.
Also, other practical or diagnostic reasons should be taken into account; red and orange
makes patients in dermatology departments feel itchy and is therefore not convenient
whereas in maternity units the colour yellow makes diagnoses for jaundice more difficult
(Dalke et al., 2004). In general, harmonious colours and a unified colour scheme with warm
and cool colours are appropriate (Herweijer-van Gelder, 2016).

To conclude, the colours used in the design of the environment may influence patient’s
emotions and feelings and should be selected carefully.

• Acoustic comfort

Noise is defined as unwanted sound (Blomkvist et al., 2005) and can be a cause of stress by
patients and medical mistakes (Herweijer-van Gelder, 2016). Thereby patient sleep and
satisfaction is negatively influenced by noise (Ulrich et al., 2008). According to Bell et al.
(2001), noise is perceived as annoying, depending on the volume, predictability and
perceived control over it. High levels of noise can lead to stress but also low intensive
recurrent sounds can be harmful for health and mood (Bell et al., 2001).

Noise can be reduced or prevented in several ways. First of all, noise of other patients,
medical staff and visitors can be prevented through single-patient rooms (Ulrich et al.,
2008). Also, furniture with sound absorbing fabric can reduce noise (Rubin et al., 1998) and
sound absorbing materials such as ceiling and wall tiles can reduce sound, reverberation
time and echo (Ulrich et al., 2008). Thereby noise can be prevented by the choice of medical
equipment; pagers, curtain rails and various models of drip stands and carts with squeaky
wheels producing unnecessary noise. In addition, the presence of music can shut out
unwanted sounds but it also can reduce anxiety, stress and pain (Devlin and Arneill, 2003).

As described above, the sounds of the environment influence patient’s mood and health.
Herein noise, music and the possibility to take distance of other people can be taken into
account.

• Aesthetics

Herweijer-van Gelder (2016) mentions that making the environment more comfortable and
aesthetically pleasing reduces patient stress and that it increases patient satisfaction with
the quality of healthcare. McCullough defines aesthetic as a visual quality; herein the
application of the design principles and the orchestration of individual components of
colour, light, finish and texture, which is employed in an effective combination provide the
viewer a coherent visual story (Herweijer-van Gelder, 2016). Swan et al. (2003) found that
patients were more satisfied with their attending physicians, food-service staff and
housekeeping and rated the food and hospital better when they stayed in a hotel-like room,
compared to a standard room with typical hospital beds, no artwork and inexpensive family
sitting chairs. In addition, a positive treatment by the staff, showing concern, kindness and
 sympathy also improves patient satisfaction (Attree, 2001). Other elements that contribute
to the institutional character of healthcare environments are the sterile environment and
uniformity of the used materials and furniture (Herweijer-van Gelder, 2016). Elements of
the environment that are found aesthetically pleasing are: functional equipment (e.g.
telephones, televisions), comfortable furnishings and the use of colour, artwork, wallpaper,
carpeting and other homelike décor (Harris et al., 2002). In addition, a room should look
clean, tidy and neat (Lawson, 2010 in: Herweijer-van Gelder, 2016).

As described above, creating a home- or hotel-like environment with a positive attitude of

the staff is satisfying for patients. In addition, properly working multimedia equipment such
as telephones and televisions should be offered in a clean room. However, decisions that
should be made on materials that are appropriate and which type and style of furniture are
suited to create such an environment may vary from setting to setting (Harris et al., 2002).

• Ambient conditions

Poor ambient conditions, which concerns temperature, air quality and light, is an
environmental factor often associated with stress (Ulrich et al., 2008). It is assumed that
patients in general feel comfortable with a stable temperature between 21,5 °C and 22 °C
and humidity level between 30 and 70 percent (Prevosth and Van der Voordt, 2011). Good
air quality can be achieved through effective ventilation and filtration and appropriate air
flow direction and pressure (Ulrich et al., 2008). Also, individual thermostats can help
improve the ambient conditions (Harris et al., 2002).

Psychological and social aspects of the environment Several studies have reviewed the
research literature on healing environment and evidence-based design (e.g. Ulrich et al.,
2008; Huisman et al., 2012; Herweijer-van Gelder; 2016). In these reviews, it becomes clear
that the physical, social and psychological aspects of healing environment need to be taken
in account. They also show that physical aspects or the application of several physical
aspects together may contribute to the psychological and social aspects. For example, the
aspect of privacy can be achieved through single-patient rooms and sanitary and ensuring
the appropriate acoustics (Herweijer-van Gelder, 2016). The following psychological and
social aspects are explained: control, privacy, safety and social support. These aspects are all
explained in several literature reviews (e.g. Ulrich et al., 2008; Huisman et al., 2012;
Herweijer-van Gelder, 2016). For every aspect, it is made clear what physical aspects
contribute.

• Control

Control is the opportunity to decide what to do or what others do with us (Herweijer-van

Gelder, 2016). A lack of control is often associated with depression, passivity, reduced
immune system functioning, elevated blood pressure and these situations are often
stressful (Ulrich, 1991). In addition, the feeling of control is often associated with the feeling
of well-being (Bell et al., 2001 in: Herweijer-van Gelder, 2016, p. 92). According to Ulrich
(1991), patients in healthcare facilities have a low sense of control through noisy
environments wherein their privacy is invaded and have no control over lighting and
temperature. Through psychologically supportive design that increases control and thereby
 reduces stress, this can be mitigated (Ulrich, 1991). Huisman et al. (2012) describes self-
supporting systems such as control over the position of the bed, temperature, lights, sound
and natural light. The availability of facilities such as food and beverages and furniture also
impact the level of control (Williams et al., 2008). In addition, single patient rooms enhance
the level of control of patients (Devlin and Arneill, 2003); they feel more secure and have
more control over social encounters (Firestone et al., 1980 in: Huisman et al., 2012, p. 74).
Thereby, there is less uncontrollable noise of other patients in single patient rooms (Ulrich
et al., 2006).

Patients stress reduces when patients have an increased feeling of control. The feeling of
control can be increased by enhancing control over the bed, lighting, sound, temperature
and air quality. In addition, the provision of food and beverages and providing single patient
rooms also influences patients feeling of control.

• Privacy

Privacy is having the opportunity and choice to be alone or with other people, the possibility
to withdraw from an unwanted situation visually and audibly and the possibility to not share
information (Herweijer-van Gelder, 2016). Privacy is very important for patients when
talking to staff, but also in conversations with family and friends. In a study on patients in
emergency departments, patients indicated that a lack of privacy was the reason that they
withheld personal information or refused part of their physical examination (Barlas et al.,
2001). A study on patients in haemodialysis units showed that a lack of privacy led to
additional stress (Steptoe and Appels, 1989 according to Devlin and Arneill, 2003). Physical
aspects that can enhance privacy are: single patient rooms (Devlin and Arneill, 2003), high-
performance sound-absorbing ceiling tiles (Ulrich et al., 2008) and private discussion rooms
or spaces (Ulrich et al., 2008).

Privacy may reduce patients stress and can be ensured through sound absorbing materials
and single patient rooms or other private rooms or spaces.

• Safety

Safety means feeling or knowing that we are protected against danger or negative
influences and has a physical or psychological component (Prevosth and Van der Voordt,
2011). Physical safety concerns an environment that is designed in such a way that it can be
used safely, whereas psychological safety is about feeling protected against intruders and
knowing that help will be there if necessary. Physical safety concerns healing environment
aspects that are related to physical health, e.g. the prevention of infections and the
prevention of patient falls (Huisman et al., 2012). As explained in the introduction, these are
not taken into account in this study. Psychological safety however is relevant. In several
studies, the hierarchy of needs of Maslow is related to what is important to patients
(Liberakis, 1971 in: Devlin and Arneill, 2003, p. 671; Cortvriend, 2005). According to Maslow,
feeling safe is one of the basic physiological needs that are required to function effectively.
Being able to see the nursing station or seeing nursing staff walking down the hallway, gives
patients a feeling of safety (Vos, 2004 in: Herweijer-van Gelder, 2016, p. 83). In addition, the
cleanliness of a room (Harris et al., 2002; Herweijer-van Gelder, 2016) and the presence of
 lockers to store personal belongings (Vos, 2004 in: Herweijer-van Gelder, 2016, p. 84) can
also enhance feelings of safety.

Feeling safe is important for patients to function effectively and this can be enhanced
through a visible hygienic room, the presence of lockers and visible nursing staff.

• Social support
Social support is the emotional, informational and tangible support that a patient receives
and which is normally received from family and people in the social network (Ulrich et al.,
2008). When an individual is hospitalised and therefore is in an unexpected situation or
stressful event, the need for social support increases; however, when in a hospital, the
contacts with one’s social network are limited (Ulrich et al., 2008). According to Herweijer-
van Gelder (2016), the recovery process of patients is promoted by social support in three
ways: emotional components (warmth, support), practical components (time, capacity) and
informative components (advice and assistance). In addition, patients experience less fear
and anxiety when they have a lot of social support, patients are more relaxed and distracted
by social communication and it reduces the effects of a stressful situation (Herweijer-van
Gelder, 2016). The communication between family, patients and the care team can be
ensured by offering space for family wherein privacy is maintained and noise is minimised
(Sadler et al., 2009). In the physical environment, several arrangements in the design and
layout can be made to enhance social support. First of all, single-bed rooms can increase the
social support because they offer privacy, often have a larger area for family and make it
possible for family and friends to stay longer (Ulrich et al., 2008). In the case of multi-bed
rooms, offering private areas for patients and families can increase social support, for
example through lounges and rooms for group consultation (Herweijer-van Gelder, 2016).
Also, comfortable and movable furniture can facilitate social interaction and the use of
carpet can increase the length of family stays; however the latter can have a negative
impact on infection control and cleaning and therefore should be applied with
comprehensive consideration (Ulrich et al., 2008). Besides the design of the physical
environment, the provision of additional services should be considered to foster family
support, for example the opportunity for family to use the phone and the internet and
offering them facilities such as the provision of decent meals and the opportunity to stay
overnight (Vos, 2004 in: Herweijer-van Gelder, 2016, p. 104).
Social support has an effect on patient’s emotions and stress and can be increased through
single patient rooms, private areas, comfortable and moveable furniture and the provision
of additional services.