Environmental Properties Found to Affect Outcome
Noise
There is considerable evidence that noise produces annoyance across different patient groups. A smaller amount of research has investigated the effects of noise on outcomes, especially in critical or intensive care units. Most studies suggest that noise detrimentally affects at least some critical care outcomes, for example, increasing sleeplessness and elevating heart rate (e.g., Hilton, 1985). Apart from patients, noise is often a major source of stress for staff and can detrimentally affect workplace performance (Evans and Cohen, 1987). There appears to be sufficient evidence on negative effects of noise to justify the recommendation that noise reduction should be a major consideration in the design of new healthcare buildings.
Music
Several studies have shown across a variety of patient groups that pleasant music, especially when controllable, often can reduce anxiety or stress and helps some patients cope with pain (e.g., Standley, 1986; Menegazzi et al., 1991).
Windows Versus No Windows
Research on intensive or critical care units strongly suggests that a lack of windows can detrimentally affect patients. Lack of windows in ICUs is associated with higher rates of anxiety, depression, and delirium compared to rates for units with windows (e.g., Keep et al., 1980). Questionnaire evidence indicates that patients in acute care consider windows to be very important, and assign especially high value to nature views (Verderber, 1986).
Regarding staff, many studies across a variety of workplaces (healthcare, office buildings) have found that employees, like patients, attach high importance to having windows, and nature views are most preferred. Further, employees with nature window views are less stressed, report better health, and higher levels of job satisfaction than comparable groups who lack nature views ñ particularly those without windows (e.g., Leather et al., 1997). A later section will discuss research suggesting that nature views also foster gains in patient outcomes.
Sunny Rooms and Views
Two studies performed in a Canadian hospital raise the possibility that patient rooms looking out on sunshine, rather than cloudy or drab conditions, are linked with more favorable outcomes (Beauchemin and Hays, 1996, 1998). The first study found that patients hospitalized for severe depression had shorter stays if assigned to a sunny rather than non-sunny room. The finding that viewing sunshine apparently alleviates depression may explain the results of the second study ñ that mortality of myocardial infarction patients was lower for patients assigned to sunny critical care rooms rather than to north-facing dull rooms (Beauchemin and Hays, 1998). Regarding staff, questionnaire studies indicate that employees likewise prefer window views of spaces illuminated by sunlight rather than cloudy conditions.
Single Rooms Versus Multi-Bed Units
There is limited evidence that infection rates in critical care units are lower in single rooms than open wards. A burn unit study, for example, found that multi-bed units were associated with increased infection occurrences (Shirani et al., 1986). A related issue that implies important advantages for single bed intensive care units is the growing concern for controlling infection with respect to antibiotic resistant pathogens (Ognibene, 2000).
Sound research is lacking that could clarify the important question of whether single occupancy rooms, compared to double rooms, are better for acute care patients from the standpoint of supportive surroundings and improved outcomes. Advocates of double rooms point to a vast body of anecdotal evidence suggesting that patients who share a room often provide each other with healthful social/emotional support. Double room proponents further contend that initial construction costs are lower for double than single room impatient units.
Single room proponents, on the other hand, point to a different but again vast anecdotal literature indicating that patients in double rooms frequently complain about roommates who have an incompatible personality, invade privacy, or disturb sleep. Single room advocates can also claim that incompatibility among roommates leads to costly room changes and patient moves that erode or even outweigh initial construction cost advantages for double occupancy rooms. (See Kirk Hamiltonís paper.) These arguments notwithstanding, more research is needed to shed light on the single versus double room debate.
Flooring Material
A small but growing body of research has compared the advantages for patients of different types of flooring materials, including carpet and "hard" or glossy materials such as vinyl composition and linoleum. A few studies have yielded a rather surprising preliminary finding: hard materials may not significantly or consistently outperform carpet with respect to epidemiological concerns and certain health-related environmental conditions ñ for example, hospital-acquired infection rates and bacteria in the air (e.g., Anderson et al., 1982).
There is growing evidence that carpet is often superior from the standpoint of several supportive or patient-centered considerations. Elderly patients walk more efficiently (have greater step length, speed) and feel more secure and confident on carpeted compared to vinyl surfaces (Wilmott, 1986). A recent study by Harris (2000) of rehabilitation patients in a telemetry unit found that visitors spent more time with patients in rooms with carpet than rooms with vinyl composition flooring. This finding is important because it raises the possibility that carpet might promote improved health outcomes via an effect of heightening social support. Harrisí study also indicated that the vast majority of patients preferred carpet to vinyl composition flooring, for reasons that included slip resistance, comfort, and perceived noise reduction. The vast majority of staff (83%), however, preferred the vinyl composition surface, primarily because of greater ease in cleaning up spills (Harris, 2000).
Furniture Arrangements
A number of studies have investigated how furniture arrangements in healthcare environments influence social interaction and eating behaviors of patients. Melin and Gotestam (1981) found that by changing ward furniture arrangements appropriately it was possible to improve eating behaviors of psychogeriatric patients. Studies of day rooms, lounges, and waiting areas have shown that social interaction falls markedly when seating is arranged side-by-side along the walls of the room. These findings indicate that levels of social interaction ñ and presumably healthful social support ñ can be considerably increased for patients in day rooms and lounges by providing comfortable, movable furniture that can be arranged in small flexible groupings (e.g., Sommer and Ross, 1958).
