Easy on the eye, warm in the heart
Some of the best practice we’ve seen has been in some of the worst designed environments we’ve seen. But, the staff have to put vast effort into counter-acting the safety, social and therapeutic impact of inappropriate environments. Hospitals burdened by old buildings (even the 1970s produced what are now recognised as hopeless environments) can nevertheless make wards look much lovelier and operate more effectively with some relatively inexpensive changes. Happily, the new generation of hospitals have individual ensuite bedrooms, layouts which help rather than hinder staff being connected to patients, style, delightful artwork and the strong sense that patients are cared about and for. Harrison House in Grimsby exemplifies the 21st century approach to mental health hospital design.
Here’s how Enhancing the Healing Environment put it:
“The environments in which we live and work have a profound influence on our physical and psychological well-being. In health care settings the environment can support recovery and well-being and has a real effect on patients’ perception of the care they receive. This goes beyond the necessity for cleanliness, infection control and the preservation of an individual’s privacy and dignity, to creating spaces that are fit for purpose and comfortable. Research has repeatedly confirmed that a supportive and welcoming environment can have positive effects on both those who visit hospitals – whether as patients or visitors – and those who work in them”.
It’s often possible to detect, before being informed, if a hospital has been blessed with an Enhancing the Healing Environment (EHE) make-over. The distinctive features are style, boldness, visual pleasure and artwork. Whether it’s an entrance, a waiting area, a ward or a garden, it will be attractive, welcoming and above all conveys the strong impression that people using the space are valued.
EHE’s main criteria (or ‘themes’) for design are:
- Humanising the hospital environment
- Community involvement
- Sense of arrival
- Clear sense of identity
- Legibility and wayfinding
- Children’s themes (for kids’ areas….)
- Welcoming and reassuring
- Privacy and distraction
- Visual calmness and educational benefits
- Stress relieving
- Specific patient needs
- Making breathing space
Great list! All very obvious and essential when stated, but their list of benefits includes a few, valuable, surprises:
- Clinical impact
- Communication and information
- Reductions in vandalism
- Positive distraction
- Perceptions of patients and staff (and presumably visitors?)
- Heritage and culture
- Patient and staff involvement and development
Although to a large extent staff teams and patients are lumbered (or lucky) with the environments they’ve inherited, choices can be made about:
- How rooms are used – the classic being converting the smoking room into a gym or pampering room
- How rooms, corridors etc are decorated and visually enhanced. (We’re of course not going to be referring to pimp your ward.) It’s amazing what a difference a few stylish scatter cushions and some classy paintings can make. (Also see Ideas #18 Landscape Paintings and #51 Personalising Bedrooms)
- Signage. This goes way beyond helping people (including visitors) navigate the ward, avoid barging into the wrong room etc. The look, ‘personality’, tone etc of signs conveys strong messages about how patients are valued and included – for example, what sign, notice or information is on the staff office? Does it encourage or dissuade patients from finding a member of staff when they need one? We’ve seen fantastic examples of creative signage. How much easier, more pleasurable and generally uplifting must it be for an elderly person with dementia to find their way to this room in Ramsey Ward, Kent than if it just had dull (and tiny!) standard NHS sign. More on Ramsey later in this feature!
- The ward was designed in such a way that our personal space was protected and respected yet it still felt inclusive and almost homely.
- When I walked onto the ward I thought I was in the wrong place and had been checked into some lovely health spa. It was designed to be a calm, relaxing, welcoming place. The staff don’t disappoint either!
- Some of the ward went on a trip to the garden centre. We bought plants for the ward. It looks so much nicer. I have my own ward plant to look after. It’s now flowering!
- Every time there was something to celebrate we would decorate the ward in a theme. We even used to have competitions between wards on who could do it the best.
- I found myself always sitting in the same chair in the lounge so I moved around to different chairs. It got me out of my comfort zone and got to know others.
- The ward was great; it was very modern, and fresh. The rooms were en-suite with a lot of space. Feeling at home is important and telling staff if you don’t is crucial.
- I was surprised (in a good way) that the ward was nothing like One Flew Over the Cuckoo’s Nest! And no padded cells, straightjackets or men in white coats!
- The lounge is cosy and has comfy sofas and chairs and a widescreen TV with Freeview. Perfect for chilling.
- The ward was a kind of sanctuary for me when I most needed it.
- I think private space is important.
A little note from Marion
- Staff rest room and hand-over room but no office.
- The Nursing station has high, attractively curved wooden front with 2 see-through panels for the vertically challenged.
- Tribunal/meeting room.
- Lovely art room with windows right along the curved wall.
- Reminiscence room.
- Sanctuary – relaxation room. Window has one of the water photos transposed on it. Will be a blind for night with night-time version of photo! Ceiling has fiber optic lights, which change colours gently. sounds and visuals can be personalised. Impact of colour. Plasma screen TV for relaxation DVDs etc. Wall includes glass brick cubes.
- Conservatory for family visiting room.
- Nappy change facilities in loo next to family room. Now being included in all new builds.
- A ward for elderly patients has an open plan kitchen in the central area of the ward.
- In the resource room (and how fab that is), a staff nurse created a Wall of Information including community resources and women-specific resources. The Wall of Information has a big sign: Services you may need after discharge and a series of laminated A4 posters, each with information, created by staff, about local and national services. The room also has a PC for staff to use to help with relevant information gathering. Other wards take samples of the info to benefit their patients.
- The smoking room has been converted to a very mellow, spa-feeling massage and complementary therapies room.
- The ward had benefited from a fabulous make-over courtesy of the King’s Fund’s Enhancing the Healing Environment. The overarching themes were ‘warmth and calm’, although one of the improvements was to make the ward less stiflingly hot in the summer. An increased sense of space was achieved by knocking three rooms into one lovely, open plan space, with dining, lounge/TV, hot drinks and pool table areas.
- The ward has a room that provides tranquillity and relaxation during times of distress. Patients have helped decorate the room with an image of a lake and mountains and an ‘under the water’ theme. Once completed, this room will be an area that patients can use readily for reflection, relaxation and therapy sessions.
- There are various ‘chill out rooms’ including lounges and visitors rooms and an open recreational area.
- Fabulous art-work everywhere, including individual pieces in each bedroom. Different sizes (including huge) and all done collaboratively with patients, with some being joint projects with local artists.
- As well as a patient-designed motif within the laminate flooring, there are several pieces of furniture which are as much sculptures as things upon which to sit and have a sarnie. The entrance area has a breathtakingly beautiful series of connected seats, sculpted from wood by designers whose work is in the V&A! There are other trendy seats in the garden, with blue and green swirly metal sides. And in keeping with the generally arty theme, one of the courtyards is… a sculpture courtyard!
- Lovely art in corridors, and immediately you come in front entrance.
- Men’s ward has signed football shirts framed on the walls; dementia ward has a magnificent interior design based on films of the 40s
- Ward is decorated with glamour pictures of ladies’ fashion from the 30s and 40s and staff were actively involved with those patients who were awake, doing jigsaws or looking through magazines together.
- Nursing assistant is talented photographer and ward is decorated with beautiful water-themed photos.
- The first thing that greets you is a lovely framed local photo, with an accompanying narrative about the photo. The ward has a smart, hotel-like feel, with large pieces of stylish art, from specially commissioned local photos of nature. There are cleverly designed transparencies (taken from the commissioned photos) on some of the glass external doors and a few windows to increase privacy. Refreshingly, wards aren’t named after trees but after local ships (the marina is right by the hospital) and ward doors have a photo of the ship and a short description of it.
- There were two stunning embroideries, one which featured the first hand-sewn DH logo I’ve seen. Doesn’t sound too promising, but this certificate celebrating the newly Enhanced Healing Environment was magnificent partly because of the bold, incongruous, post-modern fusion of officialdom and art. The artist, former patient Louise Jessup, also contributed a large, long landscape (predominantly in green and purple of course), combining embroidery, quilting and other fabric techniques.
- Challenging estates’ department – not prescription flooring or magnolia paint. Lovely colours on walls and seating.
- Senior ward staff and patients painted the walls, and made their own fabric ‘painting’ on canvas to co-ordinate with cushions beautifully made by a member of staff.
- Everything is glamorously colour co-ordinated, suffragette green and purple, including the deeply hip, curvy (Bonio-shaped) dining tables and matching padded dining chairs.
- The ward feels very light and spacious. Colour changing mood lighting set into huge skylight in centre of ward. The ward benefitted from the King’s Fund’s Enhancing the Healing Environment initiative, with new furniture, redecoration and artwork. One of the walls was painted in a colour chosen by patients – counter-intuitively it’s red! Apparently this did stimulate quite a bit of ‘discussion’ but it looks really good (it’s an orangey rather than scarlet red) and modern and bright, and is enjoyed by patients and staff.
- Ward signs – instead of dull, standard NHS ones, there’s lively, attractive font chosen by patients painted above doors. (Interestingly, the font is a Disney one – perhaps they love Fred Lee’s If Disney ran your hospital as much as we do.)
- The male/female ‘spokes’ have 4 bedrooms between them, and two sets of connecting doors can be locked to make the rooms part of one side or the other.
- The ward is (invisibly) zoned to reflect levels of care needed; one end is for more intensive care. They use a traffic light concept on admission – eg a red zoned patient will be allocated a nurse for the shift, green (near discharge) patient is supported by an HCA. This is a simple and excellent concept.
- Beautiful white light in ward using new technology, and get as much natural light as possible into corridors.
Furniture and equipment
- Groovy dining room chairs were custom-made by the building contractor, and are cleverly designed to enable people to sit together but with more personal space than on traditional tables. I was told this is particularly helpful for many psychotic patients who find it hard to sit too close to others, and also conducive to people doing different activities (eg one person reading and another painting) at the same time.
- A fantastic solution to so many of the fiddly and risky problems of patients making their own hot drinks. The same hot drinks machine the canteen has. There’s also a milk machine, which avoids milk in cartons left out of the fridge gently turning into cheese, or those yucky little cartons of white liquid vegetable fat masquerading as milk.
- A Zip Tap. The water it produces is hot enough for tea/coffee but not riskily boiling.
- They have devised a Home Planning project. This is designed to help clients pan and budget for setting up home. They cut out ideas from magazines and plan a design canvas, they research budget, sourcing using the internet, and visiting relevant shops. They get a certificate on completion.
Other great ideas
- Have decided not to have noticeboards as these were felt to give too institutionalised a feel. Leaflets etc are on display on sideboard.
- Repositioning a bed to give better view of outside.
- A ‘wandering path’, a route around an inside or outside area which is continuous rather than having an end as this ‘block’ can be distressing for confused patients.
- Music in unit reception area! Lovely. Very welcoming.
- #15 Sanctuaries
- #39 Café
- #41 Shopping
- # 50 Electronic door access
- #51 Personalising bedroom
- #61Kids Visiting
Ramsey Ward, St Martin’s Hospital, Canterbury
There are beautiful pictures everywhere, from the entrance to the ward right through to the magnificent seascape mural in the bathroom. The photo shows part of the mural, which the nursing team not only painted but meticulously cut out the birds, penguins etc for and arranged these on the scene. (The whole mural was then glazed to meet infection control requirements.)The two main ward design themes are celluloid stars of the past and planes. There are wonderful strips of pictures of planes, which the staff resourcefully acquired from the nearby Manston airforce museum. (Particularly enjoyed by the male patients.) And for the ladies, a truly remarkable border stretching right round the (big!) ward, which the staff created frame by frame, including punching out hundreds of the little holes that provide film-strip authenticity. And the team even did the fundraising to be able to buy all the decorations.
Patients were actively involved in the process and in doing so feel they have more of an onus on both rooms. The activity room has been painted and patients have started to undertake art work to be put on the walls. The new activity room has become a relaxed environment with a dedicated resource area with patient information and resources.
which includes mind, journeys, healthy lifestyle and community resources information.
The room also has a dedicated multi faith area which is work in progress.
The Feelings Tree
Healthcare support worker Louise Williams has green fingers not because she likes gardening but due to the painting of a feelings tree. The tree is enthusiastically used by patients to add their feelings on leaf shape paper with the aim of the leaf moving up the tree as the person gets better. It is hoped that newly admitted patients can see from other patient’s comments higher up the tree that there is light at the end of the tunnel! The tree was painted by patients and staff of Dinas female ward.
The physical environment and patient wellbeing
The full article is well worth reading, and is available from here
Patients can spend many hours in bed or sitting, with little to do. The influence of the immediate environment on their sense of wellbeing and actual recovery was the subject of a 2003 report from NHS Estates. The study indicates that the architectural environment can contribute to the treatment of patients and significantly affect their health outcomes, concluding that:
- patients are sensitive and articulate about their architectural environment
- patients make better progress in purpose-designed modern buildings than in older ones
- better designed hospitals create an overall improved atmosphere, leading to patients with mental health problems being less confrontational and general patients requiring less analgesic medication.
Environmental and Therapeutic Issues in Psychiatric Hospital Design: Toward Best Practices
Full article available from here
One of the most consistent recommendations in the body of literature on psychiatric hospital design is the importance of reducing the institutional feel of the facility and incorporating a homelike environment whenever possible. This type of atmosphere has been associated with enhanced emotional and intellectual well-being and improved patient behavior. Medical staff have also been noted to prefer non-institutional environments.
Familiarity. Patient rooms should have a familiar tone. Research reveals that people prefer familiar rooms over decorative or stylish rooms. Upholstered furniture should be included whenever feasible. Although furniture can be used as a weapon and should not be easy to lift or throw, it should not be too heavy to allow for easy movement. Flexible design for interchanging pieces and resistance to damage are also important. Artwork (soothing, not exciting) is recommended. Images of nature can reduce anxiety. Some authors have suggested installing carpeting to enhance comfort and appearance, although this must be balanced against the likelihood of soiling. Above all, the decision to install carpeting should be made in consultation with nursing and housekeeping staff.
Several authors have suggested incorporating color in the interior design. Studies of wall color choice have yielded inconsistent results. However, there are some fairly consistent general recommendations. First, monochromatic, bland color schemes and fashionable or trendy palettes or pastels should be avoided. Brighter colors may be preferred for patients with depression and some older adults, but they could be overstimulating for highly agitated patients. Second, warm blue tones often have a soothing or sedating effect, presumably because of their shorter wavelengths, and they may be particularly suitable for the calmest areas. Using closely related colors of the same value and intensity also has been reported to have a calming effect. Third, blue-green colors can have a negative effect on mood for patients with depression and less energy. And finally, seclusion room walls should be a “calm, but definitive color, not white or gray” (1).
Other interior design considerations
Unit design must accommodate the competing goals of stimulating patients who are withdrawn and depressed without overstimulating patients who are manic and agitated, while simultaneously fostering a sense of optimism about hospitalization.
Different functional areas may be differentiated through color, lighting, carpeting, wall graphics, and furnishings.
Inclusion of natural plants has been recommended by several authors and has been found to be preferred by staff. Devlin (2) found that the addition of plants was the feature rated most positively overall in his investigation of the redesign of multiple psychiatric units.
Open versus closed nursing stations. Open nursing stations have been recommended by several sources. Edwards and Hults (3) found significant positive psychological, behavioral, and social effects after the removal of glass partitions from psychiatric unit nursing stations at a VA hospital. Patient requests of nurses at nursing stations were dramatically reduced, as were negative beliefs of patients. Improvements in ward milieu and patient-staff communication were also noted. Closed nursing stations, which were more typical before the development of psychoactive drugs, often convey an image of staff inaccessibility and are not welcoming to patients and visitors.
Available reports of experiences with open nursing stations do not support concerns of patient abuse of increased access to nurses, although additional empirical research on this issue is needed. Contiguous, secure space, closed to patients, is recommended to maintain confidentiality of patient records.
Special considerations with older patients. There are unique issues and recommendations for designing facilities for older psychiatric patients, which were incorporated into the design of a geropsychiatric unit at the VA Palo Alto. Because of the decline in selective attention in late life and reduced stimulation among many older patients, it is especially important that moderate environmental stimulation be provided to older adults in careful balance. Glare and noise are particularly aggravating environmental factors, especially for those with sensory or cognitive impairment. Moreover, high levels of illumination are needed for older patients, particularly those with dementia. Low levels of light not only decrease visibility but can also promote agitation. In a study examining the effects of intra-institutional relocation on older long-term care residents, residents identified brighter lights as positive changes (4).
Pictures of familiar images and eras and a familiar dining experience can stimulate memory and enhance meaning and adjustment among older patients. Opportunities for exercise or other physical activity may also enhance personal well-being and provide energy outlets to reduce negative behaviors associated with dementia.
Furthermore, shorter corridors are easier for older patients to navigate and limit reverberation. Sufficient visual cues can promote orientation and reduce wandering.
- Gutheil TG, Daly M: Clinical considerations in seclusion room design. Hospital and Community Psychiatry 31:268–270,1980
- Devlin AS: Psychiatric ward renovation: staff perception and patient behavior. Environment and Behavior 24:66–84,1992
- Edwards J, Hults MS: “Open” nursing stations on psychiatric wards. Perspectives in Psychiatric Care 8:209–217,1970
- Moye J, Domingos K, Pittman R, et al: When environmental re-design creates autonomy hindrance: learning from the investigation of local detail in the study of institutional relocation. Clinical Gerontologist 18:15–31,1997
’Inspiring Design Excellence and Achievements’ (IDEAs) toolkit
The Department of Health’s ’Inspiring Design Excellence and Achievements’ (IDEAs) toolkit is a design tool to aid Trusts, and their architects and design consultants, to develop their design ideas. IDEAs is intended to help create aspirations towards good design from the beginning of the process and direct attention towards qualities that otherwise are often lost in highly technical healthcare environments. IDEAs treats both interior and exterior spaces as ’places’ where a number of activities commonly take place. It works by understanding these activities and the functional and emotional needs of the people involved. IDEAs can be used either as a standalone tool within a workshop context or as a web-enabled integrated tool by individuals.
IDEAs deals with activities rather than individual spaces or rooms. Examples of activities that occur in healthcare places include:
- bed rest
EHE Assessment Tool
The EHE Assessment Tool and Developing supportive design for people with dementia: design principles are the first in a series of tools and resources to be developed and produced by The King’s Fund to help individuals and organisations develop more supportive design for people with dementia, particularly in hospital settings.
A Staff and Patient Environment Calibration Tool (ASPECT)
ASPECT is based on a database of over 600 pieces of research. That research deals with the way the healthcare environment can impact on the levels of satisfaction shown by staff and patients and on the health outcomes of patients and the performance of staff.
The ASPECT toolkit addresses eight key headings:
- Privacy, company and dignity
- Nature and outdoors
- Comfort and control
- Legibility of place
- Interior appearance
ASPECT can be used as a stand-alone tool, or it can be used to support AEDET Evolution to provide a more comprehensive evaluation of the design of healthcare environments.
When used to support AEDET Evolution, it enables the user to score the Staff and Patient Environment Heading of AEDET Evolution in a more detailed, accurate way.
PEAT (Patient Environment Action Teams)
PEAT is self assessed and provides a framework for inspecting standards to demonstrate how well individual healthcare organisations believe they are performing in key areas including:
- infection control
- patient environment (including bathroom areas, lighting, floors and patient areas)
Resources and references
Enhancing the Healing Environment
In particular, their Enhancing the Healing Environment – guide for NHS Trusts is excellent.
Enhancing the Healing Environment
Inspiring Design Excellence and Achievements http://www.kingsfund.org.uk/current_projects/enhancing_the_healing_environment/ehe_design.html
Fabulous hospitals and wards
Ramsey Ward, St Martin’s Hospital, Canterbury http://www.starwards.org.uk/newsletters?start=18
The psychological and social needs of patients. BMA. 2011.
Environmental and Therapeutic Issues in Psychiatric Hospital Design: Toward Best Practices by Bradley E. Karlin, Ph.D. and Robert A. Zeiss, Ph.D.
A Staff and Patient Environment Calibration Tool (ASPECT)
‘It’s the sort of place I would not mind going on holiday’ by Adam James.
Great article on design basics.
Fascinating and handy chart showing the relationship between colour and mood.