Healing the healer through design

In 1999, the National Academies made headlines across the United States with a report claiming that hospital errors cause more deaths each year than AIDS, breast cancer, or car wrecks.

Faulting the healthcare system as a whole rather than the people working in it, the report put forth a number of ideas to reduce deadly mistakes. Among them: “achieving a better understanding of how the environment in which care is provided affects the ability of providers to improve safety.”

Almost two decades after the report’s publication, some progress has been made in improving the design of healthcare facilities from the staff’s perspective — but there’s still a long way to go. Today’s hospital designers think a great deal about improving patient outcomes, but most of their work is grounded in patient-centered (and even family-centered) care models. While these efforts are critical, there are very good reasons to prioritize the needs of healthcare workers as well. In addition to putting patients directly at risk of harm or even death, poor working conditions have been shown to contribute to staff burnout and turnover — a very serious concern in an industry where 80-hour work weeks are common. Moreover, in a competitive business environment, staff members’ well-being has been shown to affect how patients perceive their own care, which influences hospital ratings.

Credit: Wellcome (image manipulated)

The bottom line: as designers look for ways to improve patient outcomes in hospitals, creating a better working environment for those on the front lines of care is a must.

I contacted a few doctors and doctors-in-training to ask how their work environment could be improved. A third-year student at the Albert Einstein College of Medicine in the Bronx put views at the top of her list. “A lot of the resident rec rooms where I go to eat on short breaks are windowless rooms, which can be very depressing,” she wrote. “Seeing the outside world, even if it’s nighttime and you just see cars and street lights, is far better than nothing!”

This common-sense observation is in fact one of the foundational insights of the discipline known as evidence-based healthcare design. In 1984, a Science article entitled “View through a Window May Influence Recovery from Surgery” set off a new wave of interest in hospital design. After examining data from surgical patients in a Pennsylvania hospital, its author, Roger Ulrich, observed that patients whose rooms looked out onto trees had better medical outcomes than those who faced a brick wall. “It is possible that a hospital window view could influence a patient’s emotional state and might accordingly affect recovery,” he wrote.

Ulrich remains a leading figure in evidence-based design, which relies on research to inform the creation of healthcare environments. This approach isn’t a complete break with the past, of course: over the centuries, hospital design evolved along with breakthroughs in understanding of issues like the spread of infection. But serious study of the more subjective qualities of hospital environments — whether a room has pleasant views, for instance — is relatively recent.

Stress and sterility

Increased awareness of the harmful effects of stress is largely responsible for the growing interest in holistic hospital design. As Dr. Esther Sternberg, an expert in mind/body interaction who has advised the American Institute of Architects and U.S. Green Building Council, wrote, “Understanding and reducing stress in the hospital environment is to twenty-first century medical care what understanding germ theory and reducing infection were to nineteenth-century care.”

Sternberg’s book Healing Spaces: The Science of Place and Well-Being describes how the historical trajectory of healthcare design has made hospital environments sterile in both the positive and negative senses of the term. Over time, hospitals evolved to meet two main goals: minimizing the spread of germs and accommodating medical equipment. While this approach saved lives, too often the design strategies employed to achieve it created environments that heighten rather than reduce stress.

Credit: National Archives and Records Administration (image manipulated)

For example, while a dominant palette of hard, easy-to-clean materials makes sense from a clinical and operational perspective, it can reinforce the impression of a cold institutional setting. Hard surfaces also amplify sound, which has been shown to be particularly problematic for medical staff. Studies have linked high noise levels to emotional exhaustion and burnout among healthcare workers, along with elevated stress, increased fatigue, and difficulty in communication, which can increase the risk of error.

Design strategies

So how can design help healthcare workers help their patients? Low noise levels are important, as are pleasing visual stimuli: exterior views, artwork, greenery, and good light quality (particularly during night shifts). Personalized temperature control in staff areas can increase comfort levels.

In a profession that requires long hours of standing, ergonomics make a big difference. Soft flooring lessens strain on feet, legs, and backs. Equipment that helps lift patients in and out of beds can prevent injuries. Adjustable desks and chairs reduce musculoskeletal pain, while generous provision of electrical outlets throughout patient and staff areas allows for different ways of working.

Zooming out from interior details, space planning also shapes the experience of healthcare staff. Careful consideration of how they will move throughout the facility can simplify wayfinding, increase privacy, and reduce the amount of time spent traveling from room to room.

Rethinking staff-only areas could improve workers’ ability to cope with difficult situations and refresh themselves during long shifts. There’s no reason for these spaces to feel institutional; instead, they could follow the lead of hospitality or high-end office design. Incorporating amenities like on-site fitness centers and improving the quality of staff lounges and on-call rooms — stocking them with healthy food and beverages, for example, and flooding them with natural light — would be a significant step in the right direction. (Case in point: a recent Arup project provided balconies in all staff lounges, allowing clinical staff to feel as if they’re taking a therapeutic break from the hospital without venturing far from their patients.)

Credit: National Archives and Records Administration (image manipulated)

WELL for healthcare

A new rating system called WELL could help make these and complementary design strategies standard in hospitals around the world.

Following the success of systems like LEED and BREEAM, WELL aims to broaden the understanding and application of design for building occupant wellness. While the WELL approach to certifying healthcare projects is currently under development, Arup’s London office has started to apply its lessons to healing environments.

My colleague Emely Broeker recently worked with the Chelsea + Westminster Health Charity to develop design principles for healthcare facilities, taking into account staff, patient, and visitor needs. Her work provides an overview of opportunities to raise worker satisfaction by improving thermal comfort, using circadian lighting to help staff adjust to night shifts, and selecting materials that are healthy, cleanable, and aesthetically pleasing. It also identifies ways to prevent employee stress by eliminating negative noise, incorporating nature, integrating clear wayfinding and art, including spaces for privacy and dignity, and creating a customized staff health and well-being strategy.

Next steps

Refocusing hospital design on people and experience is a form of proactive medicine for staff and patients alike. In the future, I hope to see healthcare organizations take this a step further. Aligning built environment decisions with overall hospital strategy will likely require an entirely new skill set. Just as sustainability departments have become common at many large companies, in the future we may see hospitals appointing Chief Wellness Officers.


Comments or questions for Mallory Taub? Contact mallory.taub@arup.com.

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