While there is a large amount of research pertaining to hospitalized patients, a majority is based on the preferences and opinions of adult patients. In regards to pediatric patients, most of the existing research is predominately gathered from the opinions of the guardians or the pediatric floor nurses. In terms of total research, a small percentage actually gathers data from hospitalized children. While existing research has shown that children perceive the hospital environment as stressful, there is limited research available exploring what specifically causes the patient to feel stress and what can be done in order to reduce the perceived stress of the patient. One way that has been shown to reduce the perceived patient stress is by providing them with a number of positive distractions, including access to nature and art. The purpose of this study was to explore the relationship between altered window views and perceived stress on pediatric patients.
Decals featuring representational nature scenes were applied to windows of a local pediatric hospital, and questionnaires for the were administered evaluating their preferences and opinions of both the patient and their guardian.
ADD CONCLUSION AND FINDINGS
LIST OF TABLES
2.1
Percentage of Respondents with Specialty Construction Projects
5
2.2
Hospital-Related Fears Reported by 4 to 6-Year-Old Children
8
2.3
Common Sources of Noise in Hospitals by Category
22
2.4
Maximum Recorded Noise Levels of Equipment/Other Items
23
LIST OF FIGURES
2.1
Reasons given for liking/preferring a single room.
20
2.2
Means of color preference by group.
30
2.3
Figure 2.3 Means of Color Preference by Gender
31
CHAPTER I
INTRODUCTION
Hospitals have one key commonality with all other existing buildings: they are shaped by the users of the space and the environment has an impact on the user's behaviors (Gieryn, 2002). Architects, interior designers, and health care administrators agree that the built environment of a hospital can affect the stress levels of patients (Ulrich, 1991; Beauchemin & Hays, 1996; Whitehouse, Varni, & Seid, 2001). When a patient perceives the built environment negatively, it can act as a source of stress. In contrast, when a patient perceives the built environment positively, it has the potential to promote healing (Varni et al., 2004).
Studies involving children have shown that the built environment contributes directly to their healing processes by either preventing or facilitating stress. Research suggests that hospital environments are perceived as stressful to children because they are unfamiliar to their everyday settings and are viewed as overly complex. Perceived stress of pediatric patients has been linked to negative health outcomes including physical pain, emotional distress (Whitehouse, Varni, Seid, Cooper-Marcus, Ensberg, Jacobs, & Mehlenbeck, 2001), greater need for medication and higher rates of delirium (Douglas & Douglas, 2005).
While there is evidence showing that children find hospital environments stressful, there is limited literature available on how design can prevent or facilitate stress (Pelander, Lehtonen, & Leino-Kilpi, 2007). What can designers, architects, or hospital administration do to provide a built environment that encourages healing? Ulrich's (1991) theory of supportive design suggests that healing environments should provide physical features and social situations that will not only avoid an increase on patient stress but may even reduce the stress that patients feel.
In order for children to cope with the stresses of hospitalization, the built environment should maintain a connection with familiar environments, routines, and activities. A well planned and carefully researched hospital can support patients and families by providing a greater feeling of control, protection of confidentiality and privacy, and a design that facilitates social interaction and communication (Joseph, Keller, & Kronick, 2008) . The objective of this paper is to review existing, updated literature on the relationship between the built environment and how it relates to stress among pediatric patients, and to provide research-based knowledge for those who have an impact on the design of hospital environments. The three main areas of focus will be the stress reducing effects of control, the importance of privacy, and the implementation of social interaction.
'we know that the hospital environment is stressful to children (rutter 1982( and can have long-term effects even after only a short stay. stress is most marked in those aged 6 months to 4 years (schaffer and callender 1959, Illingworth and Holt, 1955) out of the doverty article
it has been estimated that child can be confronted by 52 new faces within the first day of admission (crocker, 1978)
Conceptual Framework
Theory of Supportive Design
The theory of supportive design states that healthcare facilities should promote wellness by providing a design that fosters the coping of stress (Ulrich, 1991). In order to do this, Ulrich states:
"Health facilities should not raise obstacles to coping with stress, contain features that are in themselves stressors, and thereby add to the total burden of illness.
Healthcare environments should be designed to facilitate access or exposure to physical features and social situations that have stress reducing influences.
Target groups should include patients, visitors, and healthcare staff."
This theory is mainly focused on the concept of stress and ways that the environment of the individual can influence general wellness. Based on research and theory from both behavioral sciences and healthcare fields, environments that will most likely support dealing with stress and therefore promote wellness will include: an element of control over the environment, access to social support, and access to positive distractions in the physical environment. Each of these three points were selected based on findings in past studies that showed these selections provided actual physiological effects and health-related indicators.
This study is specifically focused on the aspect of positive distractions in the physical environments, although it could be argued that all three are somewhat encompassed at least somewhat. Research has shown that well-being usually occurs when the built environment provides a moderate amount of positive stimulation (Wohlwill, 1986). When there is a lack of positive distraction, patients may focus on their pain, worries, or stressful thoughts which can lead to increased stress. When design exposes patients to low stimulation or sensory deprivation, patients have been shown to have increased levels of anxiety and depression and high rates of delirium and psychosis (Wilson, 1972) (Parker & Hodge, 1976) (Keep, James, & Inman, 1980).
Findings from several studies have shown that responses to positive distractions can also promote positive changes in other physiological systems (i.e. reduced blood pressure). Ulrich identifies three elements that have shown to generally be positively accepted by humans: 1) happy, laughing or caring faces; 2) animals; and 3) nature elements such as trees, plants and water.
Ulrich's Brick Wall Study
Ulrich's study (1984) is one of the most well known studies pertaining to hospitals, design, and views of nature. The records of patients in a suburban Pennsylvania hospital were kept over the period of 1972 to 1981. Twenty-three surgical patients were assigned to rooms looking out a natural scene, and twenty-three patients were assigned to similar rooms that overlooked a brick-building wall. The patients were matched based on sex, age, whether the were smokers or non smokers, weight, nature of past hospitalization, year of surgery, and floor level. Ulrich found that patients who overlooked the natural scene had fewer negative nurses comments, received fewer analgesics, had fewer minor post surgical complications, and shorter hospital stays than patients who overlooked the brick wall.
Hospital Design and the Law
All buildings, including hospitals, are mandated by a number of laws and codes, and it is an important that each of the required standards are met. The Texas Department of State Health Services states that all patient rooms in a hospital are required to have at least one operable exterior window which can readily be opened from the inside without the use of tools (NFPA 101, 2003; 18.3.8.1 and 18.3.8.2). Any request to the Texas Department of State Health Service for waivers for will not be considered as it is a Fire Safety Requirement.
Because architects and designers are required to provide patient rooms with a window, it is important that the view from the window has a positive effect on the patients during their stay at the hospital. However, it is not a realistic that every hospital room can provide an ideal nature filled, conflict-free view so it may be necessary to consider alternatives actions such as enhancing the window view with decals.
Justification for the Study
It is undeniable that there is a need for supportive hospital design for children, adolescents, and young adults. In 2009, there were over 3.1 million hospital discharges for young people aging 1-21 years of age, which equals 3.6 discharges per 100 young people (U.S. Department of Health and Human Services, 2011). Because patients find the process of being hospitalized stressful, it is important that both researchers and designers are working to gain great knowledge on ways to reduce the stress and enhance the patient experience.
This study is examines the effects of altered window views in hospitals on pediatric patients. Distinctive characteristics of this study include:
A questionnaire was developed based on research, the demands of the population, and other survey methods used in similar studies.
Window decals were developed based on research based on art preferences of children and research in the field of views from windows.
Pediatric patients and their guardians at University Medical Center were the subjects for this study.
Research Objective
The objective of this study was to understand the impact of the view from the window on pediatric patients and guardians, and whether the application of window decals effected the patients during their stay at the hospital. The patients who stayed in the rooms with the decals were compared with patients who stayed in rooms without the decals. The research addressed by this study are:
Question 1: Does the application of window decals enhance the patient experience in comparison to patients without the window decals?
Question 2: Does the subject matter of the decals have an effect on the patient experience?
Question 3: Do the applied decals affect how the patient feels?
Question 4: What are the parents perceptions of the view from their windows?
Importance of the Study
Pediatric hospitals should provide an environment that is supportive and patient-centered. Currently, there is a lack of knowledge pertaining to the preference of pediatric patients from pediatric patients about their built environments. There is also a lack in knowledge relating to ways that the views from windows can be enhanced if it is not naturally occurring. The results from this study will add to the body of knowledge by providing greater information on window views, positive distractions, and enhancing the patient experience by reducing perceived stress.
Definition of Terms
Acoustics:
Built Environment:
Children:
Elements of Design:
Environment:
Environmental Design:
Environmental psychology: the study of transactions between individuals and their physical settings (Gifford, 1987)
Hearing:
Principles of Design:
it is not realistic that every patient has a view of nature
add in chart about patients per year hospitalized
other studies that have used skylights.... should these be included in lit review? look into it.. perhaps in the first chapter
windows important in order to orient themsevles in time
include citi certification
CHAPTER II
REVIEW OF LITERATURE
Currently the United States is amidst one of the largest hospital booms recorded in history. This 'boom' is attributed to a number of factors including the need to replace the aging hospitals of the 1970's, the aging of the baby boomers, shifts in the population, and new technological advances in the healthcare setting. The hospitals that are currently being built will be utilized for decades to come, and the United States has been estimated to spend more than $20 billion per year before 2014 (Babwin, 2002).
The building boom is especially existent in the field of pediatric hospitals. In fact, the building of pediatric hospitals are second only to heart hospitals in terms of all specialty projects. Table 2.1 shows the percentage of respondents with construction projects in the following areas.
Table 2.1
Percentage of Respondents with Specialty Construction Projects:
Heart Hospital
22%
Children's Hospital
17%
Women's Hospital
15%
Rehabilitation Hospital
13%
Orthopedic Hospital
11%
Note. From Health Facilities Management/ASHE Construction Survey, 2007.
Development of Pediatric Hospitals
Within the last few decades there has been a shift in the architecture and design of pediatric hospitals. This is due in part to the movement toward evidence-based designs and in effort to make hospitals more child-friendly (Whitehouse, Varni, Seid, Cooper-Marcus, Ensberg, & Jacobs, 2001). Hospitals have made an almost unrecognizable transformation within the last century.
Post World War II, hospitals were designed to effectively and efficiently deliver clinical care. On the exterior, hospitals resembled and blended in with neighboring office buildings (Hughes, 2000). As early as the 1970's, social scientists began to recognize that the "windowless, maze-like hallways, medicalized interior landscapes and unusual 'smellscapes' could generate feelings of 'placelessness'" (Relph, 1976) and therefore contribute to young patients feeling distressed (Boyd & Hunsburger, 1998).
Beginning in the 1980's, this realization that the hospital environment has an effect on patients, specifically young patients, led architects and designers to create pediatric hospitals that "de-emphasize connotations associated with institutionalized medicine" and to create a "sense of enchantment" (Gesler, 1992). This was accomplished by providing features that promote non-threatening, therapeutic fantasy "elsewhere" (Hopkins, 1990) including "bright colors, natural light, indoor foliage, park benches, water fountains, juvenile artwork, nursery images, mascots, film and television characters, stores and fast food franchises with easily recognizable aromas" (Dalke H. , Little, Niemann, Camgoz, Steadman, & Hill, 2006); (Horsburgh, 1995); (Whitehouse, Varni, Seid, Cooper-Marcus, Ensberg, & Jacobs, 2001).
Today's hospitals feature some of the largest patient rooms ever built (some as large as 400 square feet), patient rooms that are designed to feel more like a hotel than a hospital, and feature high end amenities. Because today's hospitalized children are more likely to be repeat patients, it is necessary to deign hospitals that provide optimal support and amenities (Huff, 2007). One major gap in the current design process of today's pediatric hospitals is that the actual opinions and preference of children are commonly overlooked. Children and youth are commonly denied a voice during architectural planning, even in the planning of pediatric hospitals. When the children have been consulted, they have rarely participated in a post occupancy evaluation (Pelander, Lehtonen, & Leino-Kilpi, 2007). This underutilized source of information should be taken into consideration as children are generally able and eager participants whose experiences within the hospital and opinions and commonly very different from those of adults (commonly parents or nurses) who speak on their behalf (Christensen & Prout, 2002) (Clark & Percy-Smith, 2006) (Sinclair & Franklin, 2000).
A Child's Fear of the Hospital
Many, if not most, children find some aspect of being admitted to the hospital frightening and causes anxiety (Salmela, Salantera, & Aronen, 2009). One study, found that 83% of parents of preschool or kindergarten-aged children suffer from different kinds of anxiety symptoms related to hospital fears, this includes even minor visits (Rossen & McKeever, 1996). The more a child is repeatedly admitted to the hospital, the greater the increase in child anxiety (Brewer, Glenditsch, Syblik, Tietjens, & Vacik, 2006).
The existing research pertaining to children and their fears while in the hospital is predominately gathered from the opinions of the parents or nurses, with minimal amounts of the information actually coming from the child.
Several studies have found that preschool aged children have more hospital-related fears than other patients, which is attributed to their developmental stage (Gazal & Mackie, 2007) (Gozal, Drenger, Levin, Kadari, & Gozal, 2004). For young, pre-school aged children, it is especially difficult to separate what is real from what is imagined, as well as the fact that their ability to explain and cope with their fears is limited (Brewer, Glenditsch, Syblik, Tietjens, & Vacik, 2006). At times it is difficult to for a young child to be able to identify the difference between pain and fear, and which of the two they are experiencing (Young, 2005). Table 2.1 lists hospital-related fears that were reported by 4 to 6-year-old children.
Table 2.2
Hospital-Related Fears Reported by 4 to 6-Year-Old Children (N =90)
Single Expressions of Fear
Objects of Fear
n
%
Fears of Being a Patient
Pain
51
57
Staying in hospital
23
26
Being Admitted to hospital
17
19
Symptoms of the disease
15
17
Bodily injuries
10
11
Becoming ill
6
7
Fears Caused by the Developmental Stage of the Child
Being left alone
19
21
Imagination
13
14
Loss of autonomy
10
11
Unfamiliar people
9
10
Other fears caused by the developmental stage
9
10
Fears Caused by Unfamiliar Environment or Lack of Information
9
10
Lack of Information
18
20
New and unknown experiences
15
17
Physical Environment
Instruments and equipment
19
21
Facilities of the hospital
11
12
Noises and smells of the hospital
9
10
Social and Symbolic Environment
Separation from the family
20
22
Other fears caused by the social and symbolic environment
2
2
Child-Staff Relations
Exercise of power by adults
16
18
Doctor
13
14
Nurses
10
11
Nursing Interventions
Shots
45
50
Sample=taking and tests
29
32
Other nursing interventions
29
32
Operation
12
13
Medication
12
13
Note: From Child-reported hospital fears in 4 to 6-year-old children by M. Samela, S. Salantera, & E. Aronen, 2009, page 271.
Samela et. al (2009) found in their study there are a large number of factors in a hospital that cause a child to be fearful, and that 90% of children are afraid of at least one thing while in the hospital. When the fear of the child is taken into consideration and is supported in coping, they are more cooperative and less anxious than other comparable children (Mahajan, Wyllie, Steffen, Kay, Kitaoka, & Dettorre, 1998). These same children will also require less medication for pain and sedation, heal faster, and return home sooner (Walworth, 2005).
Control
In pediatric hospital settings, there are a very limited number of things that patients can actually control. However, the actual control has been found to be less important in regards to reducing stress than perceived control (Sherman, Shepley and Varni, 2005). Previous findings have suggested that perceived control moderates the relationship between stress and illness. In other words, when a patient feels they have greater control over their environment, stress and healing time have the opportunity to decrease. Closely related to the concepts of stress and coping are those of perceived control and learned helplessness. According to Seligman's Learned Helplessness Theory, "the experiencing of uncontrollable events can lead to an expectation that one cannot control future outcomes." Patients felt dissatisfied with environments where they felt they had no control (Sherman, Shepley and Varni, 2005).
Patient room
Sick children as well as their parents have expressed a desire to be cared for in a setting where they are treated as more than just a patient and a parent in a hospital (Coyne & Cowley, 2007). This can be accomplished by designing and providing facilities where the patient can control and adjust their individual surroundings. One key area of the built environment that patients expressed a desire to control is the patient room.
Patient rooms are the area where pediatric patients will spend the largest majority of time while they are in the hospital. The interiors of patient rooms should be designed to meet the needs of the patients and their families (Douglas & Douglas, 2005). Hospitals have begun the transformation from the cold, sterile environments of the past to much more 'homelike' environments by incorporating hardwood floors, brightly colored bedding, rocking chairs, and cabinetry that carefully masks medical equipment (Fannin, 2003). It is common to have a pediatric patient room large enough to sleep both parents (Huff, 2007)h.
The design of the room should encourage patients to personalize their space with drawings, posters, toys, mementos, artifacts and photos from home to help reduce stress and anxiety. Studies have found that this personalization is a way to connect to their social networks that exist outside of the hospital. Patients may begin to feel disconnected from this network if they experience an extended stay in the hospital (Lewis, Kerridge & Jorden, 2009). Photos, specifically, have been found to be a mean by which patients communicate about their lives, experiences, hopes, fears and values, and the relationships and social networks that matter to them (Lewis, 2007).
When children and adolescents were asked to describe their ideal patient room, it included comfortable furniture, clocks, balconies and specific design features such as shelves, bulletin boards, and lockable storage (Blumberg & Devlin, 2006). Requests also included several electronic devices such as individual televisions, access to music of their own, and headphones. Some hospitals, such as The Children's Hospital of Denver, have met the challenge of 'patient-centered' care by providing them with features such as large flat screen televisions, on-demand movies, and X-boxes (Richmond, 2008).
Studies have shown that patients would also like the ability to control the temperature of their room with a private thermostat, have the ability to entertain visitors, to control the amount of natural and artificial light (Lewis, Kerridge & Jorden, 2009), use private bathrooms, and be provided with larger amounts of storage space and areas where they can be alone with their family (Varni et. al, 2004).
Light
Studies have found that bright light, whether natural or artificial, can promote a number of improved health outcomes including depression, agitation, sleep, circadian rest-activity rhythms, as well as length of stay. In regards to natural light, morning light has been found more effective than evening light in reducing depression (Beauchemin & Hays, 1996) (Benedetti, Colombo, Barbini, Campori, & Smeraldi, 2001) (Lewy, Bauer, Cutler, Sack, Ahmed, & Thomas, 1998) (Terman, Terman, Lo, & Cooper, 2001). In fact, a study that compared the effect of morning and evening light found that morning light was twice as effective as evening light when treating patients with SAD (seasonal affective disorders) (Lewy, Bauer, Cutler, Sack, Ahmed, & Thomas, 1998)
A patient's length of stay is directly related to the amount of light the person receives. Patients in rooms that are brightly lit have a shorter length of stay than patients who stay in dimly lit rooms. One study found that patients who were hospitalized for severe depression had a shortened length of stay by 3.67 days when their rooms were sunny rather than rooms that overlooked shadowy spaces (Beauchemin & Hays, 1996).
Another study (Walch, Rabin, Day, Williams, Choi, & Kang, 2004) set out to examine whether exposure to natural daylight would have an effect on the intake of pain medication . Researchers found that patients who were exposed to an increased amount of intense sunlight experienced less perceived stress, less pain, took 22 percent less analgesic medication per hour and had 20 percent less pain medication costs.
Positive distractions
Positive distractions are a small set of environmental features or conditions that have been shown to reduce stress (Ulrich, 1991). The objective of positive distractions is to provide low levels of distraction without reaching overstimulation (Blumberg & Devlin, 2006). Common positive distractions include music, subject appropriate art, and nature. Less common, but still effective, examples include companion animals, laughter or comedy, and electronic items ( computers, television, etc.) (Ulrich, 1991).
Music
One particularly beneficial form of positive distractions is music therapy. The idea of music therapy is not new the hospital environment. In fact, after the invention of the phonograph in the 1800's music was used in hospitals to 'promote sleep and aid in surgery and anesthesia (Taylor, 1981). Beginning in the early 1900's, there was an increased interest in the idea of audio analgesia, which is the use of sound to suppress pain (Gatewood, 1921). By the 1980's, music therapy in healing environments was well established. Thus far, there have been a number of recorded benefits for children who have had the utilized music therapy. These positive benefits have assisted patients with a variety of illnesses and injuries including burn victims, pediatric cancer patients, and children who experienced anxiety while isolated in the hospital (Brodsky, 1989).
Music therapy has a number of potential therapeutic qualities, the ability to provide both physical and emotional comfort, and promotes coping. Music can affect patients differently, depending on age. One study found that that live music is generally more effective than taped music for cancer patients over the age of 17 (MacGill, 1983). Live music may be more effective because it allows for personalized expression of one's feelings. This is especially true for young pediatric patients, who establish a connection best with songs that can be made relevant to their current experiences (Stetcher, McElheny, & Greenwood, 1972).
A recent study (Barrera, Rycov, & Doyle, 2002) focused on understanding patients and the affect that interactive music therapy may have on them, with a specific focus on the differentiation between age groups. The participants were divided into three main age groups: pre-school, school age, and teenage. The patients who participated in music therapy predominately used instruments and singing. The study found that young children generally gave comments that focused on one particular instrument. For example, a typical response would include the patient saying that they really enjoyed playing with the guitar. The children in the study ranging from ages 6 to 10 focused on the pleasure they received from playing the music. The teenagers were more aware of the positive changes that occurred when exposed to music. The teenagers noted that it caused changes in their mood and comfort and would like more sessions.
Overall, when the patients evaluated their experiences many patients noted that it caused positive changes in their mood and were desirous of more sessions. The study found 64% of patients believed the music therapy provided comfort and 58% believed it reduced their anxiety. The findings showed a significant improvement in children's feelings from pre- to post-music therapy.
Art
Art is widely understood to have therapeutic and healing effects on children. Art has also been shown to reduce stress and impact negative thoughts that affect the healing process, when the art is appropriately selected. It would be beneficial if pediatric patients had the ability to choose the art that was in their patient room. While there have been numerous studies on art preference of adults, there have been minimal research efforts to understand the preference of art for children and its' effects.
A recent study (Eisen, Ulrich, Shepley, Varni, & Sherman, 2008) was conducted to determine the impact of art on stress of pediatric patients, and which art is most effective at reducing this stress. After reviewing the preferences of 129 school aged children who were both healthy and ill, the study found that a large majority (66%) of children prefer art that has a theme of representational nature. Children seemed to prefer art that was more realistic and preferred abstract images the least. Nearly all of the children (95.6%) preferred that the art be related to nature in some way.
Adults have also been found to have similar art preferences to pediatric patients. Carpman & Grant (1993) studied the preferences of 300 adult inpatients and found that patients consistently preferred nature images and strongly disliked abstract art. While it is evident that nature inspired art and other emotionally appropriate art can promote positive feelings, studies have also shown that inappropriate art can increase stress and worsen other outcomes (Ulrich, 1991). It should be understood that not all art is appropriate for healthcare settings.
Nature
The opportunity for a patient to escape to a place of nature in a healthcare environment can offer the patient a sense of control, reduce stress, and sometimes help the patients gain perspectives on life and death. There have been previous studies that indicated that in as few as three to five minutes, patients can begin to experience the positive physiological effects of nature (Parsons & Hartig, 2000). Views of nature have consistently been found that the stress-reducing benefits of simply viewing nature can have a number of positive emotional and physiological changes. While viewing nature, stressful feelings and anxiety decrease while pleasant feelings increase. Views of nature draw the patient's attention away from the pain they are experiencing and can cause a patient to have lower blood pressure and heart activity (Ulrich, Effects of interior design on wellness: theory and recent scientific research, 1991). Comparatively, patient rooms filled with views of buildings or urban areas lacking nature have been shown to increase the feelings of stress and is significantly less effective in producing restoration for the patient (Ulrich & Zimring, 2004).
Studies using questionnaires found that patients who are bedridden have an especially high preference for window views filled with nature (Verderber, 1986). As more studies are completed, more and more evidence indicates that visual access to nature provides reduced stress and pain. For example, a study in Sweden found that ICU heart patients who viewed a picture with a landscape scene filled with trees and water reported less anxiety/stress and required fewer doses of strong pain medication than patients without any form of pictures (Ulrich, Effects of interior design on wellness: theory and recent scientific research, 1991) Another group of patients were given abstract images and had reported worsened effects than the patients in the control group. Another study (Ulrich, 1984) found that patients who overlook scenes filled with nature as opposed to patients overlooking a brick wall had a better emotional-well being required less medication (Ulrich, 1984).
A number of experimental studies have provided even more convincing evidence that views of nature can reduce patient pain and stress. A study was designed using ceiling mounted nature scenes. Adult patients who had undergone a painful bronchosopy procedure and viewed the ceiling reported less pain than patients who viewed standard blank ceiling panels (Diette, Lechtzin, Haponik, Devrotes, & Rubin, 2003). Another experiment used volunteers in hospitals to examine the effect on pain on patients who viewed soundless nature scene videotapes in contrast to patients who viewed a blank, static screen television screens (Tse, Ng, Chung, & Wong, 2002). Patients who viewed the nature scenes indicated a 'higher threshold for detecting pain and had substantially greater pain tolerance.' When another study implemented videotaped scenes of nature (forest, flowers, ocean, waterfalls, etc) into the patient room while burn victims had their dressing changed, the patients reported reduced anxiety and pain intensity (Miller, Hickman, & Lemasters, 1992).
Access to nature seems especially important for hospitalized children, who experience great amounts of stress upon admittance to a hospital. Literature suggests that one reason children enjoy nature is because it provides a location for an active use of space and an opportunity for exploration. Another theory is children enjoy nature while in the hospital because hospitals are typically so complex that it is less mental chaos, more relaxing, and familiar. It was found that children enjoy gardens as a place to get "away" or provide them with a sense of refuge.
Hospital gardens offer the potential to provide restorative or calming nature views while reducing stress. Gardens also provide opportunities for social support, an area for positive escape, and a sense of control (Cooper Marcus & Barnes, 1995) (Ulrich, 1999). If a patient is not able to visit the garden, views of nature through patient room windows still provide an abundance of benefits. Patients who have views to nature as opposed to views without nature have been shown to have reduced stress, less requested medication, and shorter stay times in hospital (Ulrich, 1984). Views alone of nature may foster restoration from anxiety and help patients relate to the outside world (Douglas & Douglas, 2005). The stress reducing effects are not only enjoyed by patients. Often parents will utilize the gardens as a place of solace and relaxation in hospital gardens as having a hospitalized child is extremely stressful for parents as well (Whitehouse, Varni, Seid, Cooper-Marcus, Ensberg, & Jacobs, 2001).
Privacy
Privacy is directly related to control issues and can be defined as the selective control of social interactions (Altman, 1975). According to Shepley (2005), 'the ability to control interactions is so important that these skills may be even more important than the interactions themselves.' Children and families need a hospital environment that provides an effective balance of social interaction and privacy (visual and auditory). Patients and their families commonly express a desire to control their accessibility, and this control may be more prove more beneficial than any actual social interaction (Rollins, 2009).
Design can help patients establish personal territories and have a feeling of private space (Blumberg & Devlin, 2006). When a patient feels that the built environment does not provide them with adequate privacy, it can cause stress on pediatric patients and affect their overall perceived care. Common examples of this stress could be the fear that their conversations are being heard by other patients, the noise and difficulties of having a multipatient room, the feeling that they are being looked at in their patient room by passers-by, or the frustration that there are not facilities for patients to be alone with their parents. Because of this, single family rooms are quickly becoming the expectation of families in the United States as it provides privacy and promotes family interaction (Rollins, 2009).
Single patient rooms
Privacy is an extremely important design measure to take into consideration in a pediatric hospital environment. One way privacy can be achieved is by providing single-patient rooms. Single patient rooms provide a number of benefits, including better audible and visual privacy as well as decreased risk for hospital-acquired infections.
Audible and visual privacy in hospitals is not only a requested amenity, but it may have an actual affect on the patient and their state of wellbeing. Modern hospitals becomes an alarmingly common occurrence for physicians and nurses to breach privacy and confidentiality by talking in places where other patients or people may overhear important patient information (Ubel, Zell, & Miller, 1995).
A study (Jolly 2001) completed in 2001 compared two multi patient rooms to examine visual and auditory privacy. One of the rooms was divided by a curtain, and one of the rooms was divided by a wall. Patients with a curtain divider were found to have significantly less visual and auditory privacy than patients with walls. Not only to curtain dividers offer limited privacy, but the excess noise that occurs often causes difficulty for the patient to sleep. The study found that because of this lack of privacy, 5% of patients or parents were found to be withholding medical information or refusing some form of medical treatment which could be potentially compromising patient safety. Patients have generally been found to prefer single patient rooms. Figure 2.1 lists reasons why patient's like or prefer single patient rooms.
Within the same study, patients in the rooms with walls did not report withholding any form of information to medical personnel. Patients in single-bed rooms have been found, nationwide, to report higher satisfaction with privacy (Ulrich & Zimring, 2004), experience reduce noise (Jolley, 2005), and have an 11 percent decrease in hospital-acquired infections (Harrison, 2005).
The efforts to reduce hospital-acquired infections is pertinent due to the fact that hospital-acquired infections, along with medical errors, are among the leading causes of death in the United States and kill more Americans than AIDS, breast cancer, or automobile accidents (Institute of Medicine, 2001). Single-patient rooms, compared to multi-bed patient rooms, were less far less difficult to decontaminate after a patient is discharged, therefore greatly reducing the possibility of infections (Ulrich & Zimring, 2004).
It is important to note, at times, some patients may dislike single-patient rooms. Patients can feel "lonely, have less contact with staff and miss out on the psychological support of other patients (Jolley, 2005)". The isolation of single patient rooms may also reduce the quality of care due to the lessened contact with staff (Evans, Shaffer, & Hughes, 2003).18844318-6.jpg
Figure 2.1. Reasons given for liking/preferring a single room.
Note. From Single Rooms and Patient Choice by S. Jolley, 2005.
Adolescents
Because pediatric hospitals provide care for a variety of patients ranging in age from infants to adolescents, it is important that the built environment is flexible to meet the needs of all of the patients. Unfortunately the area of research directed specifically towards adolescents in severely underdeveloped.
As pediatric patients approach adolescence, their need for privacy changes. When a group of adolescent patients were asked what would be the most important aspect of a hospital room, 96% answered privacy or a private restroom. Adolescent patients also desired to be able to close their patient room door and 82% expressed a desire for to wear more comfortable and less revealing pajamas. Some patients even mentioned that they would like to be able to bring their own pajamas from home (Blumberg & Devlin, 2006).
Noise
As previously mentioned, it is necessary that patients are provided with adequate auditory privacy and this privacy includes protection from overheard noise. Kam et al (1994) describe noise as complex because it is 'subjective and is influenced by several factors such as cultural and social factors, individual sensitivities, sense of having control over the sound and whether it is appropriate to the situation.' Sound is typically measured in decibels (dB), a logarithmic scale expressing the ratio of sound pressure to a reference level. An increase of six dB corresponds to a doubling in sound intensity. Individuals are able to adapt to continuous or background noise, but are disturbed by intermittent noise (Kam, 1994). Noise that is found to be unpredictable is more stressful than continuous noise (Topf & Dillon, 1988).
The WHO (World Health Organization) has set guidelines for noise that is commonly found in hospitals. Background noise in patient rooms should not be louder than 35 dB, and night time peaks of should not be louder 40 dB. However, many studies have found that noises in hospitals greatly exceed these standards. Background noises in hospitals typically range from 45 dB to 68 dB, although peaks have been found as high as 90dB.
High levels of noise in hospital environments increase stress and heal time in hospital patients, and have been shown to cause a variety negative effects (Bailey & Timmons, 2005). Elevated noise levels have been found to cause decreased oxygen saturation, elevated blood pressure, increased heart and respiration rate, cause disrupted sleep, startling, reduction of digestive secretions, hearing damage, raised metabolism. It is, however, a difficult task to control the noise levels in a busy, technology dependent hospital (Brandon, Ryan, & Barnes, 2007).
Noises can predominately be categorized into three main categories: equipment noises, environmental surfaces and voices. A list of common noise sources by category can be found in Table 2.2.
Table 2.2
Common Sources of Noise in Hospitals by Category
Equipment noises:
incubators
ventilators
oxygen saturation monitors
infusion umps
Environmental noises
heating, ventilation and air-conditioning systems
plumbing lines and fixtures
door mechanisms
surface materials on floors, walls, and ceilings
overheard paging systems
overhead paging systems
locations of desks, storage units, and paths
Voices
Note:From Effect of environmental changes on noise in the NICU (2007). Neonatal Network. July/August 2007, page 5-6.
Conversation, one of the main contributors to noise within the hospital is, has been found to range in noise levels from 60dB to 90dB (Kam, 1994). These measurements are significantly higher than the WHO has established as a guideline. The study found that 50% of noise was caused by staff talking, laughing, or talking on the telephone (Philbin, Robertson, & Hall, 1999). Table 2.3 shows a number of common noises that were found in hospital environments and their maximum recorded decibel levels.
Table 2.3
Maximum recorded noise levels of equipment/other items
Activity
Decibels
Activity
Decibels
Admission
63
Moving trolley
65
Air conditioning
50
Nebuliser
65
Air shoot alarm
60
Noisy shoes
64
Apron from roll
68
Nurse handover
69
Baby crying
72
Opening crisp packet
60
Bipap vision alarm
73
Opening crisp packet
60
Changing bin bag
68
Patient having physio
60
Closing bin lid
70
Patient intervention
63
Closing door
67
Rattling of mugs
78
Closing folder
66
Rubbish into bin
62
Closing of sharps bin
83
Talking
74
Coughing
71
Talking on telephone
63
Cupboard
79
Tap running
65
Door bell
66
Telephone onto receiver
74
Door slamming
78
Telephone ringing
71
Emptying O2 cylinders
74
Testing ventilator
66
Fire alarm
62
Vent piping from O2
67
Ivac alarming
75
Ventilator alarming
63
Monitor alarming
58
Ward round
69
Moving cot sides
68
X-ray machine
65
Moving equipment
72
Note . From Bailey, E. & Timmons S. (2005). Noise levels in PICU: an evaluative study. Pediatric Nursing, 17(10), 24.
One specific pediatric population that is directly affected by noise in the hospital are the infants in NICU. Infants exposed to noises that were >80 dBA had a number of physiological responses including apnea and bradycardia as well as abrupt fluctuations in heart rate, blood pressure, respiratory rate, perfusion, and oxygen saturation. In regards to infants, changes in the noise levels have been found to cause increases and decreases in premature infants' heart and respiratory rates, decreased transcutaneous oxygen tension and increased intracranial pressure. There is concern that these fluctuations may 'negatively affect short-term pathology and long-term infant development' (Lotas, 1992).
Design solutions that could provide better auditory privacy include installing "high-performance sound absorbing ceiling tiles, eliminating or reducing noise sources, and providing single-bed rather than multibed rooms (Ulrich & Zimring, 2004)." Ways to reduce this noise would be to encourage staff to observe quiet times (specifically at night), turn off equipment when it is not being used (Bailey & Timmons, 2005), responding quickly to alarms, placing telephones away from patient beds, conducting conversations away from the patient beds and rooms, and making efforts to implement awareness programs for staff (Brandon, Ryan, & Barnes, 2007).
Social Support
Researchers (Salmela, Salantera, & Aronen, 2009) found that pediatric patients were most afraid of hospitals because they were unfamiliar and afraid of being abandoned. Having parental support and the understanding that someone is there with them can help children adjust to their new environments. Social support from caring individuals can help reduce stress in pediatric patients as well as promote faster recovery rates.
While it is well documented how important social support is for patients, specifically pediatric patients, there is only a moderate amount of research that explores how hospital design can facilitate or hinder social support. The primary source of support will always be from families and caregivers, although it should be a goal of designers to attempt to provide spaces that also support the healing process of children (Shepley, 2005). Evidence has shown that the built environment can influence "the amount and the degree" of social interaction so it is necessary that hospitals provide a balance of both privacy and social interaction (Shepley, Harris, White, & Steinberg, 2008). Social support can have positive effects on a child's ability to cope and health outcomes in children (Johnson, Jeppson, & Redburn, 1992) (Rollins J. , Tell me about it: Drawing as a communication tool for children with cancer, 2005) (Shepley, The healthcare environment, 2005). Evidence has shown that providing more lounges, day rooms, and waiting rooms with furniture that is flexible promotes social support. Single rooms facilitate more social interaction simply because there is typically more room and furniture than in multi patient rooms (Ulrich & Zimring, 2004).
Parent to child support helps maintain a "normal" routine and helps the child adjust to hospitalization. Parents typically stay in single patient rooms more than multipatient rooms, and the extended interaction between parents and patients helps foster support (Rollins, 2009). One of the simplest ways to keep parents involved is to provide them with sleeping amenities, whether it be a chair or a guest suite. Many patient rooms are advancing their design and providing colorful couches that are also beds for their parents (Blumberg & Devlin, 2006).
Benefits of Play
Play is an essential feature of social, intellectual, physical and emotional growth for children. For pediatric patients, play helps patients adjust to stress and anxiety commonly associated with the hospital (Peterson, 1989). Play is more than just a way to distract the child as it can serve as a way for a child to cope with the process of being admitted to the hospital (Delpo & Frick, 1988).
Children use a number of method's to cope with hospitalization and treatment. An analysis (Rollins J. , 2003) that explored stress and coping for pediatric cancer patients (ages 7 to 18) found four coping themes that emerged among the children:
being prepared: any behavior that the child uses or someone uses on his or her behalf to ready the child for an event such as hospitalization and procedures;
being connected: any encounter/relationship with another person that the child identifies as significant in helping him or her cope;
shutting it out: any behavior that the child uses in an attempt to ignore, avoid, blunt, or deny something he or she is, has, or will be experiencing;
working through it: any evidence that indicates the child's attempt to reflect, find meaning, think through, work through, or cheer up or cheer on himself or herself or others.
Some pediatric patients reported that seeing others with visible signs of illness distressed them, but the majority enjoyed social interactions with other patients (Adams, Theodore, Goldenberg, McLaren and McKeever, 2010). Providing ways for pediatric patients to interact or play with other pediatric patients can benefit social skills and communication skills. This interaction can also provide a greater self-confidence and independence among the patients. Play provides a child with learning opportunities in self mastery, skills in environmental experience, reality-testing, coordination versus passivity, with fulfillment and, most importantly, spontaneous free fun. Play can help a sick child adjust to stress and anxiety. MacCarthy (1979) said: "second to the continuing presence of the mother or another supporting figure, play can be an important factor in diminishing the harmful effects of stress in hospitalized children."
Peer-to-peer Contact
The benefits of peer-to-peer interaction is not limited to young pediatric patients. It is especially important for hospitalized adolescents to have access to peer-to-peer interaction (Hutton, 2002). Parents of hospitalized children also benefit from interaction with other parents of hospitalized children. Parent to parent support 'provides parents with information emotional support, a sense of being understood, friendship, mentoring, role modeling, assistance, with problem solving, and a base for advocacy efforts (Ahmann & Rollins, 2005)." In fact, parents have cited the support of other parents as a necessary aspect of successful coping in hospital environments (Johnson, Jeppson, & Redburn, 1992). Bradwell and Hawkins (2000) gathered the following quote from the mother of a hospitalized child:
During the treatment, the lives we lived on the ward, the other parents and myself, were lived in each other's pockets. Much of the time we were experiencing incredible, intense emotion, and as a result, incredibly intense friendships were formed. (p. 344)
When parents feels they are supported, they are better equipped to help their child cope with the stresses of illness, hospitalization and treatment (Rollins J. A., 2009). The ability of parents is important for all ages, but has been found to be especially important for parents of children in middle infancy to preschool year, especially children ranging in age from 15 to 30 months (Hockenberry & Wilson, 2006). For this particular age group, the greatest stressor is separation from their parent.
Color
Color is a powerful design tool in the physical environment (Olds, 2001) that, when combined with other design elements (light, shape, form, space, etc.), can transform healthcare environments and influence patient behavior. Research pertaining to color in any built environment is difficult to generalize due to the fact that color preference may vary due to the location of the building. Mahnke (1996) suggests that recommendations for colors can only be made once the specific location, climate and terrain have been taken into consideration. For example, warm, deeply saturated colors work best in temperate and tropical areas. Cooler, lighter tones along with neutral are typically more preferred in the northern climates (Olds, 2001). While color has been found to have a physical effect, it is generally only for short periods of time.
Color Preferences of Children
Many designers and health care providers desire color guidelines that is based on empirical research, but unfortunately most of the research that exists has been inconclusive (Tofle, Schwarz, Yoon, & Max-Royale, 2004). A majority of existing research has examined the color preference of healthy adults, but these findings cannot successfully be applied to environments used predominately by children (Shepley, Fournier, & McDougal, 1998). As Piaget points out, a child's way of understanding does not function the same as an adult's (Berk, 2002). Young children commonly make associations with color and shapes, and less with form (Dalke H. , et al., 2006).
The current color research literature pertaining to children has identified color generalizations, and Caples (1996) advises that it is necessary for designers and planners to select colors for children's environments according to the color's psychological impact. For example: 'hues of green and purple can have a stabilizing effect, red can create excitement, and yellow can encourage feelings of restfulness (Read, 2003).' Other studies have found a number of findings related to particular colors. For example, red was highly preferred among younger children (Adams, 1987) (Bornstein, 1975) (Zenter, 2001), but around first grade that preference changed and blue became more preferred with age (Garth & Porter, 1934). Green was found to be minimally preferred by young children, but also increased with age (Choungourian, 1969) (Dittmar, 2001) (Meerum Terwogt & Hoeksma, 1995). Boyatzis and Varghese (Boyatzis & Varghese, 1994) found that children were responded positively toward bright colors, and negatively toward dark colors. Most colors studies have not supported a gender effect in children. In adults, evidence shows that males generally find cool colors most pleasant and females find warm colors the most pleasant (Helson & Lansford, 1970).
While a number of contradictions have been found throughout the existing research, a number of trends have emerged. For example, blue is a generally preferred colors across all ages and genders, bright colors are commonly associated with happy, positive feelings, and dark colors evoke negative feelings such as being sad or bored.
Most of the existing research pertaining to color preference of children has come from the opinion's of healthy children. A recent study (Park, 2009) compared the color preferences of healthy children and pediatric patients to determine if there was a difference between the two. The study also sought to investigate the value of color as a component of a healing environment for pediatric patient rooms and to determine whether gender plays a role in preference.
The results of the study showed that generally, all patients (whether healthy, outpatients, or inpatients) had the same color preferences. One key finding indicated that both groups of the sick children preferred yellow significantly less than healthy children. The results for the three evaluated groups can be found in Table X. When evaluating the results based on gender, the study found that males prefer purple and red less than females. All of the groups reported blue and green as their most preferred, and white as their least preferred. The results for the preferences by gender can be found in Table X.
figure 4.jpg
Figure 2.2. Means of color preference by group.
Note. From color perception in pediatric patient room design: healthy children vs. pediatric patients by J. G. Park, 2002, Herd Journal, page 17.
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Figure 2.3. Means of color preference by gender.
Note. From color perception in pediatric patient room design: healthy children vs. pediatric patients by J. G. Park, 2002, Herd Journal, page 17.
Color as wayfinding
Wayfinding can be defined as 'a consistent use and organization of definite sensory cues from the external environment (Lynch, 1960).' Wayfinding issues that commonly occur in hospitals are both costly and stressful on patients and visitors, as they are typically unfamiliar with the hospital. One study conducted at a major regional hospital found that the annual cost of the wayfinding system was found to cost more than $224,000 per year. This number was calculated by examining the amount of time hospital personnel (other than information staff) used to give direction. The total amount of time was found to be more than 4,500 staff hours, which is equal to more than two full-time positions (Zimring, 1990).
Color can be used in healthcare environments for a number of applications, including wayfinding on both the interior and the exterior. Parents, patients, and caregivers are all able to benefit from wayfinding through color in healthcare environments as it can direct them from entry to their final destination. Using color for wayfinding purposes is ideal as it is easily duplicated in a number of materials and it can help create both emotional and physical responses from the users, depending on their own personal experiences (Olds, 2001).
The application of color is a way of relaying to the user environmental information in order to analyze the built environment (Mahnke, 1996). Color, whether used on a sign, a wall, or the floor, can help more clearly demarcate wayfinding cues, and greatly assist both the parent or the child in a hospital environment.
However, it has been found that as many as two thirds of coding, way-finding systems were ineffective or misunderstood (Dalke H. , et al., 2006). When selecting colors for way-finding and coding, it is important to select colors that are not easily confused with other colors or words e.g. blue, yellow, red and purple. A color such as turquoise (a color that is a combination of blue and green) could be easily confused and disputed whether it is a blue or a green. Grey is another color that is commonly confusing as it can take on other hues and shades. There is research that indicates gender can make a significant difference in color perception (BBC, 2001).
Conclusion
While it is widely accepted that children find hospitals stressful, there is a limited amount of knowledge on how the built environment can prevent or facilitate stress (Adams et. al, 2010). What can designers, architects, or hospital administration do to provide a built environment that encourages healing? Ulrich's (1991) theory of supportive design suggests that healing environments should provide physical features and social situations that not only avoid an increase in stress on patients but also may actually reduce the stress that patients feel.
This review of literature has identified that when pediatric patients are provided with control, privacy, and social interaction there is the potential for a decreased perception of pain, shorter length of stay, overall improved health and quality of care. Strong evidence and previous research shows that altering the design to meet the needs of patients can make an environment more comfortable, aesthetically pleasing, improve mood and other psychological feelings including anxiety (Ulrich & Zimring, 2004). Relieved stress among patients increases satisfaction and when a patient feels satisfaction with their built environment, they are more likely to perceive they are receiving a higher quality of care (Varni et. al, 2001).
There was an abundance of information on features of the built environment that cause stress in pediatric patients. However, one gap in research that was noted was the limited amounts of architectural features in the built environment that could promote healing, and the lack of research that is gathered from the child's perspective. Children are commonly denied opinions on the built environment, even in the built environment of pediatric hospitals (Adams et. al, 2010).
The following are design solutions that could be implemented in order to provide pediatric patients and their family with a sense of control of their environment:
allow patients the opportunity personalize their space using pictures, images, and mementos in order to maintain external relationships and provide a sense of territoriality;
allow patients to adjust electronics including televisions and music to their preference;
provide the ability to control the amount and type of light and the surrounding temperature;
utilize art carts that are filled with a number of nature inspired images in order to allow patients to select the artwork displayed in their room'
and allow patients both views and access to nature at their discrepancy.
Because research has shown privacy, both auditory and visual, to be so important in the reduction of perceived stress it is necessary that the built environment is supportive of these processes. The following are suggested design solutions to provide pediatric patients and their family with a sense of privacy:
single patient rooms equipped with private restrooms and the ability to shut the door;
provided locations for families and patients to spend private, alone time;
reduce a significant amount of noise and increase auditory privacy by having nurses utilize quiet times and zones;
and use more sound-absorbent materials for acoustics.
Finally, social interaction
