AIA Academy Journal Healthcare Design article by Kathy Anthony Nov. 1st, 2007 anthony nov 1, 2007 by STUDIO SELWA LLC / ARCHITECTURAL DESIGNER

Academy Journal

November 1, 2007

Letter from the Editor This is the 10th edition of the Academy Journal, published by the AIA Academy of Architecture for Health (AAH) knowledge community.

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Letter from the Editor

The Design of Psychologists' Offices: A Qualitative Evaluation of Environment-Function Fit Nicholas J. Watkins, PhD, Cannon Design Kathryn H. Anthony, PhD, University of Illinois at Urbana-Champaign Abstract | Article

Historical Hospital Buildings: Should They Be Reused? H. James Henrichs, AIA, Hobbs+Black Associates Abstract | Article Rebranding Services and Facilities at a Community Hospital for Improved Satisfaction Greg Heiser, AIA, OWP/P Jocelyn Stroupe, IIDA, AAHID, OWP/P Abstract | Article

Historical Hospital Buildings: Should They Be Reused? H. James Henrichs, AIA, Hobbs+Black Associates Abstract | Article

Designing for Family-Centered Care in the Newborn Intensive Care Unit: Designing for the Future James F. Padbury, MD, Women & Infants Hospital and Brown University Johan Verspyck, AIA, Anshen+Allen+Rothman Abstract | Article Sound Practices: Noise Control in the Healthcare Environment Roger B. Call, AIA, ACHA, LEED AP, Herman Miller for Healthcare Abstract | Article

Rebranding Services and Facilities at a Community Hospital for Improved Satisfaction Greg Heiser, AIA, OWP/P Jocelyn Stroupe, IIDA, AAHID, OWP/P Abstract | Article Designing for FamilyCentered Care in the Newborn Intensive Care Unit: Designing for the Future James F. Padbury, MD, Women & Infants Hospital and Brown University Johan Verspyck, AIA, Anshen+Allen+Rothman Abstract | Article Sound Practices: Noise Control in the Healthcare Environment Roger B. Call, AIA, ACHA, LEED AP, Herman Miller for Healthcare Abstract | Article

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November 1, 2007

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Letter from the Editor

This is the 10th edition of the Academy Journal, published by the AIA Academy of Architecture for Health (AAH) knowledge community. As the official publication of the Academy, the Journal electronically publishes articles of particular interest to AIA members and the interested public involved in the fields of healthcare architecture, planning, design, research, and construction. The goal has always been to promote awareness and educational exchange between architects and healthcare providers and to broaden our base of understanding about our clients.

Articles are submitted to, and reviewed by, a nationally diverse Editorial Review Committee (ERC). Over the years, the committee has reviewed over 150 submitted articles, responded to countless writers’ inquiries, and encouraged and assisted numerous writers in achieving publication. The Journal has provided valuable opportunities for new and seasoned authors from the architecture and healthcare professions. With this issue, 85 articles have been selected and printed supporting the enhancement of the built environment for healthcare. Throughout the 10-year history of the Journal, the authors have included architects, physicians, nurses, other healthcare providers, academics, research scientists, and students from the United States and many foreign countries. Published articles have explored a broad range of medical topics, including the trends and future of healthcare architecture, cardiac care, future and evolving technology, patient rooms and patient safety, lighting design for healthcare, psychology, workplace design, cancer care environments, emergency care, women’s and children’s care, and various healthcare project delivery methods. Visit the Academy Journal archives for earlier articles you may have missed. We plan to build upon our success by encouraging more graduates who have received healthcare research scholarships and others involved with research within the architecture for healthcare fields to submit their research to the Journal for publication. We will continue to develop a cross-referenced article index and a broader base of writers and readers. The deadline for the 2008 Call for Papers is May 30, 2008. My special thanks to the AIA for its continued support and hard-working staff and to the many volunteers who have contributed to our growing and continued success. I especially want to thank the members of the 2007 ERC: James G. Easter Jr., FAAMA, Assoc. AIA(Tenn.); Ed Jakmauh, AIA, ACHA, LEED AP (Pa.); Joyce Redden (Tenn.); John Sealander, AIA, ACHA (Calif.); and Professor Kent Spreckelmeyer, PhD, FAIA (Kan.). As always, we appreciate your feedback, comments and suggestions by calling AIA Professional Practice Project Manager Jennifer Barry at 202-626-7366 or me at 631-246-5660. Orlando T. Maione, AIA, ACHA, NCARB Editor, Academy Journal October 2007

Historical Hospital Buildings: Should They Be Reused? H. James Henrichs, AIA, Hobbs+Black Associates Abstract | Article

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November 1, 2007

The Design of Psychologists' Offices: A Qualitative Evaluation of Environment-Function Fit Abstract | Article Psychologists’ offices have been largely absent from contemporary theoretical and methodological discussions of therapeutic environments. Research on environmental stressors, healing environments, psychiatric facilities, and the transactions between a psychologist and client during a therapy session suggest that psychologists’ offices are significant for the psychologists who work there daily and the clients who visit them. To address the gap in the literature, we examined the relationship between psychologists and their office environments in an exploratory, qualitative study using interviews and projective measures. Projective measures included cognitive mapping exercises and photographs taken of the psychologist’s and client's views of each office. We interviewed 10 licensed psychologists about how they perceived—and how they believed their clients perceived— their office environments. Content analyses of the interviews revealed that the environmental responses psychologists used in their office designs met the needs imposed by therapeutic transactions. In addition, environmental responses helped psychologists adapt difficult spaces to the ongoing needs of therapy. Implications include design recommendations for psychologists and designers. The training of psychologists also should give greater consideration to office design. Sensitivity to office design could differentiate psychologists from their competitors. This is especially important in contemporary healthcare, where healing designs offer a competitive advantage.

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Letter from the Editor The Design of Psychologists' Offices: A Qualitative Evaluation of Environment-Function Fit Nicholas J. Watkins, PhD, Cannon Design Kathryn H. Anthony, PhD, University of Illinois at Urbana-Champaign Abstract | Article Historical Hospital Buildings: Should They Be Reused? H. James Henrichs, AIA, Hobbs+Black Associates Abstract | Article Rebranding Services and Facilities at a Community Hospital for Improved Satisfaction Greg Heiser, AIA, OWP/P Jocelyn Stroupe, IIDA, AAHID, OWP/P Abstract | Article Designing for FamilyCentered Care in the Newborn Intensive Care Unit: Designing for the Future James F. Padbury, MD, Women & Infants Hospital and Brown University Johan Verspyck, AIA, Anshen+Allen+Rothman Abstract | Article Sound Practices: Noise Control in the Healthcare Environment Roger B. Call, AIA, ACHA, LEED AP, Herman Miller for Healthcare Abstract | Article

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November 1, 2007

The Design of Psychologists' Offices: A Qualitative Evaluation of Environment-Function Fit Abstract | Article Researchers have investigated the therapeutic value of institutional healthcare environments such as hospitals and Alzheimer’s facilities in fostering positive medical outcomes and recovery from stress (McCormick and Shepley 2003). Several researchers have discussed the lack of research about psychologists’ offices (Anthony 1998; Anthony and Watkins 2002a; Anthony and Watkins 2002b). Experimental research lacks external validity because actual psychologists, psychologists’ offices, and clientele have not been used (Miwa and Hanyu 2006). As such, psychologists’ offices have been largely absent from contemporary theoretical and methodological discussions of therapeutic environments. Psychologists recognize that their clients suffer from stressors related to mental illness and daily routines. Clients also suffer stress from making a life transition involving discomfort and disclosure of private information within an unfamiliar setting (Demick and Andreoletti 1995; McLoughlin 1995; Spivack 1984). Consequently, how, if at all, do psychologists believe that their office designs contribute to the therapeutic process? How do psychologists compensate for the inadequacies of their therapeutic environments? Answers to these questions could guide future research on and design of psychologists’ offices. Environments for the treatment of mental illness When an imbalance exists between the demand posed by a stressor and a person’s perceived resources to adaptively respond to the stressor, stress occurs (Stokols 1979; Stokols et al. 2000). A stressor might overwhelm a person’s physical and psychological resources and, as a result, cause a person to feel incompetent (Stokols et al. 2000). Evans and McCoy (1998) identify negative, stressful experiences resulting from the relationship between physical environments and a person’s psychology. These concepts include overstimulation resulting from crowding and ambiguous spatial configurations. Researchers and designers have long expressed interest in creating healthcare environments that mitigate stress. Healing gardens, views of nature, and legible building plans and signage have been well documented as design features that contribute to positive psychological and physiological

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health (Evans and McCoy 1998; Ulrich 1999; Ulrich et al. 2003). Researchers have extensively investigated institutions such as psychiatric facilities and their possible negative effects on mental health. Their research reveals that the design of a psychiatric facility can reinforce rigid social programs and patterns of behavior among patients and staff (Bechtel 1997; Goffman 1961; Schefflen 1965; Stevenson 2000). Consequently, the design of an institution reflects its philosophy of care (Bechtel 1997; Stevenson 2000; Williams 1994). For instance, in the 19th century, Thomas Kirkbride designed mental hospitals for the humane treatment of patients. His designs required one room for each patient, double-loaded main corridors, wards terminating with sunlit bays, and access to natural settings (Good et al. 1965; Sachs 1999). Critics warn that the physical designs of many mental institutions exacerbate patients’ conditions. Fortress-like facades reinforce the larger community’s stigma of the mentally ill (Ittelson et al. 1970; Stevenson 2000). Commons areas equipped with fixed seating inhibit social interaction (Osmond 1957; Sommer 1969). Spaces efficient for staff, such as radial plans and long corridors lined with easy-to-clean surfaces, convey a sense of sterility and distort patients’ already disturbed perceptions with illusions and glare (Ittelson et al. 1970; Spivack 1984). Ironically, the design of mental institutions can undermine the competence of the patient, thereby worsening the patient’s illness (Moos 1973; Timko et al. 2000). Similarly, a psychologist’s office both communicates and facilitates communication. People imbue the environment with psychosymbolic meaning formed through interactions with the environment (Lawrence and Low 1990). Likewise, office features and psychologist-client transactions have psychosymbolic importance. Obvious symbolic cues include artwork, desks, and diplomas (Pressly and Heesacker 2001). Less obvious forms of communication include those physical features that reflect the psychologist-client transaction and those integral to treatment and diagnosis. In general, the therapeutic setting should be a holding environment; psychologists and their offices should provide comfortable and secure environments within which clients feel free to communicate sensitive information (Saari 2002; Winnicott 1986). Clients and psychologists communicate through transference relationships (Wachtel and Messer 1997; Saari 2002). Horvath and Lubrosky (1993) state that a transference “implies that emotions and thoughts associated with the unresolved relationships with significant others are bound to be displaced (transferred) onto the relationship with the therapist” (p. 562). Transferences are imbued with feelings that the client and psychologist hold for each other and for inanimate objects (Winnicott 1953). From positive transferences, the psychologist and client develop a “working alliance” to relieve the client of distress (Pipes and Davenport 1999;

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Horvath and Lubrosky 1993). Saari’s (2002) concept of interpsychic space is the nonverbal, spatial expression of positive and negative transferences through proxemics and personal space. For Stern (1997), an interpersonal field opens a context for disclosure between a psychologist and a client. Similarly, Satir (1964), Shefflen (1973), and Sommer (1969) have all demonstrated that in mental health settings, clients communicate psychological states nonverbally with seating arrangements and the manipulation of nonfixed physical features. Psychologists can influence transferences through their intentional manipulations of space. For instance, Henry Stack Sullivan sat across a desk from his schizophrenic clients because such an arrangement focused their attention on therapy (Goodman 1962). Psychologists record transferences with the physical manipulation of their therapeutic environments. In the process, psychologists use space to treat and diagnose clients. Klein (1949) used play therapy with children so that transferences between psychologist and client were expressed through toys. Lowenfield adapted Klein’s play therapy to trays of sand. Play with sand trays enabled a healing connection with natural elements, while helping the psychologist reach a diagnosis (Mitchell and Friedman 1994). Peled and Ayalon (1988) analyzed attachments to home as part of family therapy. As is the case with other therapeutic environments, psychologists’ offices must also alleviate and adapt to stressors. Psychologists’ offices should convey holding environments within which psychologist-client transactions are accommodated. Also, they should empower psychologists to perform transactions necessary for maintaining a holding environment. Therefore, they should provide psychologists with the resources necessary to adapt to the ongoing needs of therapy. Environment-function fit A traditional measure of compatibility between an environment and the activities performed within is environment-function fit (Alexander 1970; Sherrod and Cohen 1982). A derivation of environment-function fit, person-environment congruency measures the relationships between a person’s perceptions and the demands exerted by a sociophysical environment (Lawton 1989). Researchers have applied person-environment congruency to measure fit between the elderly and nursing home facilities and the mentally ill and psychiatric facilities (Kristoff 1996; Lawton 1989; Moos 1973; Timko et al. 2000). Lawton theorized that congruency occurred when a demand fell into a person’s perceived competency to meet that demand. If so, either a person’s perceived control or actual control over the demand increased. The built environment is a resource that people use to exert control over demands and increase competency (Alexander 1970). Flexible environments made of nonfixed features can create greater opportunities for fit (Lang

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1987). At the other extreme, negative fit decreases competency (Alexander 1970). Lower competency also results in decreased performance, increased stress, negative affect, and a lack of control (Lawton 1989). Just as stress exacerbated by the environment of mental institutions and other therapeutic environments reduces the competency of users, we suggest that the design of a psychologist’s office provides a resource for mastery over the demands of psychotherapy. Therefore, environmentfunction fit could be a paradigm for understanding psychologists as users of design, and consequently, the function of design in psychologists’ offices. Methodology Participant sample Ten psychologists agreed to participate in a study of their office environments under the condition that clientele were not to be included or discussed. Participants were all: (1) licensed counseling or clinical psychologists; (2) employed in private practice or by a healthcare facility; (3) practicing within the city where the researchers were located. Subjects varied in psychotherapeutic philosophy from psychoanalytic to cognitive-behavioral. Six had a private practice, and four worked for a healthcare facility. The sample’s composition conformed to principles of strategic nonrepresentative sampling formulated by Trost (1986) and used in prior research of built environments (Gustafson 2001). Nonrepresentative sampling allows researchers to determine a sample reflective of the breadth of the topic under study without overrepresentation by any one characteristic of the sample. Each psychologist represented one private practice or healthcare facility. Conveniently, this prevented overrepresentation from any facility. Procedures and measures The exploratory nature of the study and the sample size warranted an antipositivitic research approach emphasizing on-site research, richness of data, smaller sample size, less emphasis on generalizability, and identification of contextual factors and information specific to each subject’s unique experience (Mazumdar and Geis 2001; Mazumdar 2002). Interviews were conducted within the therapeutic setting so that the researchers could see firsthand and discuss the unique design features of each office and so that psychologists could describe their offices in detail. Researchers used techniques of questioning described by Carspecken (1996) and Kvale (1996): specifically, descriptive questions, nonleading leads, and low-inference paraphrasing. After each interview, the researcher and psychologist reviewed the topics discussed on the interview guide to assess verification between the researcher’s and psychologist’s interpretations of questions (Carspecken 1996). Such “member checking” ensured the

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“trustworthiness” and validity of the data (Lincoln and Guba 1985). All interviews were transcribed verbatim. Analyses Grounded theory was used to identify categories within each interview and across interviews (Mazumdar and Geis 2001; Strauss and Corbin 1998). The diversity of the sample controlled for theoretical sampling, during which collection and analyses of data coincide to fill gaps in the data revealed during analyses (Noonan et. al. 2004; Patton 1990). Extensive auditing ensured the dependability and confirmability of the results (Lincoln and Guba 1985). Concepts representing discrete parts of the interviews emerged through a process of open coding. Then, concepts were synthesized into larger categories. Axial coding further synthesized categories and revealed dimensions (“not valued” to “highly valued”). Also, axial coding identified connections between categories, revealing novel interpretations of the data. Selective coding isolated two core categories as nuclei of the subjects’ experiences. Theoretical redundancy and saturation were achieved when the subjects’ transcribed interviews failed to generate categories beyond those already existing from the analyses. To assess the reliability and validity of the categories, the researchers asked an impartial, independent researcher— blind to the analyses and the coding of the categories—to code random samples from the transcripts. Results The content analysis produced two core categories important to the design of psychologists’ offices. Consistent with theories of person-environment congruence, categories of needs and responses emerged (Kristoff 1996). As shown in Table 1, the first category included therapeutic needs identified by the psychologists, i.e., criteria that they believed were necessary for successful psychotherapy. The second category consisted of environmental responses that psychologists implemented in response to therapeutic needs. Both the therapeutic needs and environmental responses express psychologists’ desire to accommodate their clientele and relieve stressors imposed by therapy. All 10 psychologists stressed the importance of therapeutic needs but differed with respect to what environmental responses were highly valued in meeting those needs.

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Table 1. All 10 psychologists identified several therapeutic needs as well as environmental responses to meet those needs. The value placed on each environmental response varied by psychologist.

Therapeutic needs included practicality, control, cueing of appropriate social roles, security, comfort, adaptability, privacy, order, and empathy. Environmental responses to therapeutic needs consisted of clocks, lighting, proxemics, seating, windows, color, staffing, thermal comfort, genderfriendly dĂŠcor, location, noise control, nonfixed features, room size, and plants. If environmental responses could not be met adequately, psychologists adapted the best they could. They valued therapeutic spaces that were flexible. Psychologists stressed that their offices needed to be both economical and functional. Many of the therapists engaged in private practice shared an office space with a colleague to cut the cost of rent. The functional necessities of an office were illustrated by a case where the office did not accommodate the special needs of a psychologist with a disability. The psychologist adapted to the space by placing all furniture to the exterior of the room and turning drawers into desks. Many psychologists expressed a strong need for control. Psychologists seek not onlyÂ to have a sense of control of their clients but also control of the context for therapy. As a consequence, all psychologists interviewed described design strategies purposefully implemented for therapy sessions. Most design strategies consisted of controlling what people could or could not see. Psychologists spoke of positioning clocks and how it was important that clients http://info.aia.org/journal_aah.cfm?pagename=aah_jrnl_20071101_watkins&dspl=1&article=article[11/22/2010 11:18:47 AM]

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could or could not see them. Psychologists managed to divvy up the counseling room into multiple visual fields by privileging themselves with views that only they could observe. For example, some therapists had images of personal significance mounted on the wall above their clients’ heads. These images were intentionally mounted in such a manner so the client would not notice them. One psychologist intentionally located his offices on the second floor of a building because all the windows on that level were reflective. The tint and reflectivity of the windows prevented individuals on the street from seeing a therapy session in progress.

In this psychologist's office, clients can see out, but outsiders cannot see in due to the reflective windows. This helps protect clients' privacy.

Diffuse spot lighting was a common technique used to focus a session and encourage clients to disclose sensitive information. Floor lamps lit up corners and framed seating areas during later hours. A clear need for all psychologists was that an office communicates the appropriate social scripts necessary for a successful therapeutic session. In this regard, the design of psychologists’ offices varied according to the guiding philosophy and associated social role of each psychologist. Psychologists who were inclined to take a psychoanalytic and humanistic philosophy offered seating that was warm and comforting. In addition, psychologists made an effort to imply that the psychologist-client relationship was that of a team. The psychologist did not sit any higher than the client, and both often sat in similar seats with the psychologist’s chair facing the client. Yet on occasion, stepping outside the designated social roles implied by the design of the therapeutic setting did have its consequences: “A client picked the hard, straight-back chair. So I fell into the beanbag chair, and it really, really upset her.” (Psychologist No. 5)

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Client's view of the psychologist's office. Note the full-length view of a private garden, making this by far one of the most user-friendly office environments for both therapist and clients

Psychologists had to rely on security methods when presented with a potentially harmful client. A common measure used to mitigate a confrontation between a psychologist and a client was to provide an easy means of egress for clients in case they became upset. Also, psychologists placed their chairs away from the path leading to the doorway, believing that anxious clients felt comforted by having a clearly defined exit. Psychologists emphasized a desire to keep a client’s attention on the session at hand. Windows were beneficial in anchoring a client to the therapeutic setting by offering natural views onto greenery. Even though psychologists favored having the natural light from a window looking onto a street or sidewalk, they listed drawbacks such as sporadic cars and passersby diverting a client’s focus. In addition, windows looking out onto public areas threatened the privacy of clientele. As a result, many psychologists kept blinds drawn over their windows, causing offices to be dimly lit. One psychologist avoided such problems with the use of clerestory windows. Plants and small items were also used to keep the client focused on the therapy session at hand. Two female psychologists catering to a female clientele displayed collections of figurines and stuffed animals. Male psychologists often presented gender-neutral objects and those reflecting sporting interests such as photographs of motorcycles and bicycles and prints of natural scenery. Many psychologists emphasized the need for an office with a warm, home-like appearance—comfortable chairs, framed pictures, wood shelving, plants, soft colors, and lamps.

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A psychologist's visual image of her office. It featured the comfort associated with a homelike interior.

Thermal conditions of a therapeutic space were often troublesome. Many psychologists struggled with thermal control when neighboring businesses shared the same thermostat. Certain seasons and times of day when window exposures were hit hard by the sun caused overheating and discomfort. One psychologist used a space heater to compensate for the drafty winter air leaking through his windows. Psychologists favored spaces with neutral colors, believing that these had a calming effect. Creams and whites were common. Carpets often were soft green or maroon. Shelves and furniture were often made of stained wood and upholstered with patterned fabrics. One of the most critical needs for psychologists’ offices was the ability to adapt to ongoing change. Whether moving into a new office or taking on additional clientele (in, say, shifting focus to family therapy), psychologists required spaces that would easily respond to their needs. In new offices, places to sit had to be negotiated to accommodate previously practiced social roles. If necessary, a few psychologists were even willing to rearrange furniture for specific clients. Flexible, sizable rooms were favored in this regard. Privacy was another need that psychologists felt their office environments should reflect. Many offices had their own adjoining waiting rooms. Some psychologists staggered appointments with those of their colleagues so that clients would not run into each other. Psychologists who shared offices with other units in mental health centers or other businesses in an office building often could rely on anonymity to protect any given client’s privacy:

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"Having our own waiting room is certainly a privacy issue. But the location of the office is not as much of an issue [because] itâ&#x20AC;&#x2122;s a building that has a variety of businesses in it. Anyone coming into the building isnâ&#x20AC;&#x2122;t necessarily seeing a therapist." (Psychologist No. 2)

This busy intersection was adjacent to a mental health facility. Clients had to park on one side of the intersection and then wait to cross. Psychologists felt it overexposed clientele and threatened confidentiality.

Psychologists often cited noise as a threat to privacy. They complained of thin walls and hollow-core doors that bled conversations through to the adjoining waiting room. They used radios and indoor water features to provide white noise. Insulated interior walls and those constructed with concrete or brick were effective. Psychologists believed that their clientele already dealt with too much chaos outside of the therapeutic setting. Accordingly, most believed it necessary to keep their offices in good order for therapy sessions. However, psychologists in both administrative and counseling positions who accumulated large volumes of paperwork often found it difficult to portray a sense of order. Some of their desks conveyed a sense of disorder and disarray.

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In this office, the client's view consists of the psychologist's computer and a messy desk. This office also lacked windows.

Often, psychologists made their empathetic intentions clearer by displaying positive images on walls for a client’s easy view, maintaining a comfortable proximity in relation to the client, maintaining healthy plants, and showcasing items such as signs with healing phrases and small angel statuettes. The cumulative effect of satisfying all the needs listed above was that of an empathetic and caring holding environment—one reflecting a psychologist's desire to foster positive therapeutic transactions with clientele. Conclusion and discussion This study explored psychologists as users of design with an environment-fit paradigm. Its goal was to identify ways in which psychologists use their offices to reinforce their competency and control over therapeutic transactions with clients. In-depth interviews and content analyses revealed that physical features of psychologists’ offices provide resources for what psychologists perceived were their own needs as well as those of their clients. Several environmental responses facilitated the meeting of needs and, in turn, a fit or congruency between an office and a psychologist. Given the importance of physical features in the designs of psychologists’ offices to meet therapeutic needs, designers and researchers should expand upon the repertoire of healthcare environments to include psychologists’ offices. Such an enhanced definition would accommodate issues unique to psychologists’ offices and allow comparisons between psychologists’ offices and other therapeutic environments. Psychologists whose offices did not meet their needs perceived these spaces as satisfactory for their clientele but not ideal. Most of the psychologists were housed in

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office space that they defined as less than ideal for therapeutic transactions. Consequently, relationships between therapeutic needs and environmental responses fluctuated. For example, some offices were too small and required rearrangement of furniture to suit the demands of an upcoming therapy session. Psychologists considered certain design features prerequisites for a healthy, therapeutic environment and for positive outcomes among clients. The important physical features of psychologists’ offices were analogous to those identified by Evans (2003) for most therapeutic settings and those suggested by Pressly and Heesacker (2001) and Goldstein (1998) specific to psychologists’ offices. For example, psychologists believed that a quiet environment, control over the design of the office, views of nature including water and trees, indoor plants, and landscape paintings were restorative, reduced stress, and facilitated therapeutic transactions. Fluorescent lighting should be avoided as it leads to clients' discomfort and anxiety. Abstract works of art whose content is deliberately ambiguous and can be subject to potentially negative interpretations should not be displayed (Ulrich 1999). Comfortable seating arrangements must meet proxemic requirements but not be so comfortable as to induce sleepiness. Several psychologists preferred neutral colors so as not to provoke anxiety associated with vibrant colors such as red and orange. In most cases, psychologists’ offices engaged clients’ sense of vision. Consequently, the designs of many offices were underused as tactile, auditory, and olfactory components within treatment and diagnosis. In contrast to Klein (1949), the physical design of psychologists’ offices was also underused as an indicator of transferences. Consistent with prior literature, many psychologists would use the nonverbal behaviors of clients’ seating habits as indicators of a therapeutic session’s progress (Saari 2002; Satir 1964; Shefflen 1973). One cognitive-behavioral psychologist used a dinner table around which he and his clients sat to fill out tests and negotiate homework tasks. Another used clients’ attachments to stuffed animals as indicators of unconscious, underlying feelings. However, treatment and diagnosis were usually relegated to talking and sitting, not playing or acting. Psychologists must recognize the discrepancies between their own viewpoints of their offices and those of their clients. Their photographs and drawings revealed that they and their clients have dramatically different perspectives of the same office. Many psychologists had views of bookshelves and framed images, while clients faced a blinking computer screen and a desk cluttered with paper. Many of the psychologists were not aware of this discrepancy between viewpoints until they were asked to take the client’s perspective. The dynamics between therapeutic needs and environmental responses varied depending upon whether the psychologist was engaged in private practice or was a

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team member of a consortium or a mental health center (Luhrman 2000). For example, many large healthcare facilities frequently relocate their counseling departments to accommodate the changing needs of other departments. As a result, counseling offices are often housed in windowless basements and cramped quarters.

This plan for a hypothetical Psychological Services Center at a university shows clear separation between the research staff, support, and therapeutic areas. It allows clients to exit inconspicuously after therapy without parading through the waiting room and allows therapists and research staff to circulate without clients seeing them. Privacy concerns like these are paramount and must be integrated sensitively into the design of therapeutic environments.

Source: Cannon Design Healthcare Design Studio participants Coral Brandt, Jill Kirchherr, and Selwa Nadhimi

Psychologistsâ&#x20AC;&#x2122; offices serve as workspaces laden with the territoriality and symbolism associated with other office environments (Joiner 1971; Sundstrom 1986). Ironically, some mental health facilities force psychologists to work in deplorable offices that inhibit personalization and territoriality. Several psychologists spoke of dissatisfying internships in inadequate offices. Many recalled windowless rooms with little privacy. One psychologist recalled an internship spent in a former gynecologistâ&#x20AC;&#x2122;s office. The psychologist was forced to meet clientele with a decrepit gynecologist's chair positioned in the center of the room. Whether they are clinicians at mental health centers, private clinicians, or interns, psychologists should receive some opportunity and adequate resources to select and design spaces for therapy. Psychologists seem to take a trial-and-error approach when designing their offices. None of the psychologists interviewed had been taught how to design their offices. None used professional interior designers. Graduate schools

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of clinical and counseling psychology ought to train future clinicians on the importance of the office environment in the therapeutic process. Students could be informed about where to place lamps and clocks and how to personalize a space without intruding on a client's field of vision. Graduate training could address how and where to set up office environments with adequate views, lighting, and seating. Indeed, the discrepancies between clients’ versus psychologists’ viewpoints of psychologists’ offices underscore that good design practices are not intuitive. Conducting a qualitative study was advantageous given the exploratory nature of the research. Psychologists welcomed one-on-one interviews to discuss their offices, procedures that were compatible with those used daily when treating clients. In the future, the needs and responses revealed by the researchers in this study could be used in the development of a questionnaire. Future research could isolate one specific need (e.g., privacy) or response and examine it in detail. Researchers could study the relationship between a specific therapeutic approach and the design of psychologists’ offices. Further studies could focus specifically on either psychologists in private practice or those working for mental health centers. More important, future research can underscore that psychologists’ offices are not only workspaces but also therapeutic environments affecting how well therapy might or might not be performed. In an era of competitive healthcare, clients who have a choice might gravitate to psychologists’ offices that appear restorative and uplifting. REFERENCES Alexander, C. (1970). The goodness of fit and its source. In H.M. Proshansky, W.H. Ittelson, & L.G. Rivlin (Eds.), Environmental psychology: Man and His Physical Setting. New York: Holt, Rinehart, and Winston. Anthony, K. H. (1998). Designing for psychotherapists’ offices: Reflections of an environment-behavior researcher. Presentation as part of a symposium on environments for psychotherapy—problems in office design at the national convention of the American Psychological Association, San Francisco, August. Anthony, K.H., and N.J. Watkins (2002a). Exploring pathology: Relationships between clinical and environmental psychology. In R. Bechtel and A. Churchman (Eds.), Handbook of Environmental Psychology. New York: John Wiley & Sons. ______ (2002b). Safe havens or perilous ports? The design of psychotherapists’ offices. In P. Hecht (Ed.), Community: Evolution or revolution? Proceedings of the 33rd annual conference of the Environmental Design Research Association (EDRA), Edmond, Okla.: EDRA. Bechtel, R.B. (1997). Environment and Behavior: An Introduction. Thousand Oaks, Calif.: Sage Publications.

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Carspecken, P.F. (1996). Critical Ethnography in Educational Research: A Theoretical and Practical Guide. New York: Routledge. Demick, J., and C. Andreoletti (1995). Some relations between clinical and environmental psychology. Environment and Behavior, 27, 56–72. Evans, G.W., and J.M.M. McCoy (1998). When buildings don’t work: The role of architecture in human health. Journal of Environmental Psychology, 18, 85–94. Evans, G.W. (2003). The built environment and mental health. Journal of Urban Health, 80, 536–554. Goffman, I. (1961). Asylums. Garden City, N.Y.: Doubleday. Goldstein, W.N. (1998). A Primer for Beginning Psychotherapy. Washington, D.C.: Brunner/Mazel. Good, L.R, S.M. Siegel, and A.P. Bay (1965). Therapy by Design: Implications of Architecture for Human Behavior. Springfield, Ill.: CC Thomas. Goodman, P. (1962). Utopian Essays and Practical Proposals. New York: Random House. Gustafson, P. (2001). Roots and routes: Exploring the relationship between place attachment and mobility. Journal of Environmental Psychology, 33, 667–686. Horvath, A.O., and L. Luborsky (1993). The role of the therapeutic alliance in psychotherapy. Journal of Consulting and Clinical Psychology, 61, 561–573. Ittelson, W.H, H.M. Proshansky, and L.G. Rivlin (1970). The environmental psychology of the psychiatric ward. In H.M. Proshansky, W.H. Ittelson, W.H., Rivlin L.G. (Eds.), Environmental Psychology: Man and His Physical Setting. New York: Holt, Rinehart, and Winston. Joiner, D. (1971). Office territory. New Society, 7, 660– 663. Klein, M. (1949). The Psychoanalysis of Children. London: Hogarth. Kristoff, A.L. (1996). Person-organization fit: An integrative review of its conceptualizations, measurement, and implications. Personnel Psychology, 49, 1–51. Kvale, S. (1996). Interviews: An Introduction to Qualitative Research Interviewing. Thousand Oaks, Calif.: Sage. Lang, J. (1987). Creating Architectural Theory: The Role of the Behavioral Sciences in Environmental Design. New York: Van Nostrand Reinhold. Lawrence, D.L., and S. Low (1990). The built environment and spatial form. Annual Review of Anthropology, 19, 453– 505.

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Lawton, M.P. (1989). Behavior-relevant ecological factors. In K.W. Schaie, & C. Schooler (Eds.), Social Structure and Aging: Psychological Processes. Hillsdale, N.J.: Lawrence Erlbaum Associates. Lincoln, Y.S., and E.G. Guba (1985). Naturalistic Inquiry. Beverly Hills, Calif.: Sage. Luhrman, T.M. (2000). Of Two Minds: An Anthropologist Looks at American Psychiatry. New York: Vintage. Mazumdar, S., and G. Geis (2001). Case study method for research on disability. In B.N. Altman, & S. Barnartt (Eds.), Research in Social Science and Disability. New York: Elsevier. Mazumdar, S. (2002). “Qualitative” research methods: An introduction and inquire into Its scientific qualities. Journal of Asian Urban Studies, 3, 21–28. McCormick, M., and M.M. Shepley (2003). How can consumers benefit from therapeutic environments? Journal of Environmental Psychology, 20, 4–15. McLoughlin, B. (1995). Developing Psychodynamic Counselling. London: Sage. Mitchell, R.R., and H.S. Friedman (1994). Sandplay: Past, Present, and Future. London: Routledge. Miwa, Y., and K. Hanyu (2006). The Effects of Interior Design on Communication and Impressions of a Counselor in a Counseling Room. Environment and Behavior, 38, 484– 502. Moos, R.H. (1973). Conceptualization of human environments. American Psychologist, 28, 652–665. Osmond, H. (1957). Function as the basis of psychiatric ward design. Mental Hospital, 8, 23–30. Peled, A., and O. Ayalon (1988). The role of the spatial organization of the home in family therapy: A case study. Journal of Environmental Psychology, 8, 87–106. Pipes, R.B., and D.S. Davenport (1999). Introduction to Psychotherapy: Common Clinical Wisdom. 2nd ed. Boston: Allyn and Bacon. Pressly, P.K., and M. Heesacker (2001). The physical environment and counseling: A review of theory and research. Journal of Counseling and Development, 79, 148– 160. Saari, C. (2002). The Environment: Its Role in Psychosocial Functioning and Psychotherapy. New York: Columbia University Press. Sachs, N.A. (1999). Psychiatric hospitals. In C.C. Marcus, & M. Barnes (Eds.), Healing Gardens: Therapeutic Benefits and Design Recommendations. New York: John Wiley & Sons.

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Satir, V. (1964). Conjoint Family Therapy: A Guide to Theory and Technique. Palo Alto, Calif.: Science and Behavior Books. Scheflen, A.E. (1965). The institutionalized, the institutionprone and the institution. Psychiatric Quarterly, 39, 203– 219. _____ (1973). Communicational Structure: Analysis of a Psychotherapy Transaction. Bloomington: Indiana University Press. Sherrod, D.R., and S. Cohen (1982). Density, personal control, and design. In S. Kaplan, & R. Kaplan (Eds.), Humanscape: Environments for People. Ann Arbor, Mich.: Ulrich’s Books. Sommer, R. (1969). Personal Space: The Behavioral Basis of Design. Englewood Cliffs, N.J.:Prentice Hall. Spivack, M. (1984). Institutional Settings: An Environmental Design Approach. New York: Human Sciences Press. Stern, D. B. (1997). Unformulated Experience: From Dissociation to Imagination in Psychoanalysis. Hillsdale, N.J.: The Analytic Press. Stevenson, C. (2000). Medicine and Magnificence: British Hospital and Asylum Architecture, 1660–1815. New Haven: Yale University Press. Stokols, D. (1979). A congruence analysis of stress. In I. Saranson, & C. Spielberger (Eds.), Stress and Anxiety, Vol. 6. New York: Hemisphere. Stokols, D., H.C. Clitheroe Jr., and M. Zmuidzinas (2000). Modeling and managing change in people-environment transactions. In W.B. Walsh, K.H. Craik, and H.R. Price (Eds.), Person-Environment Psychology: New Directions and Perspectives. 2nd ed. Mahwah, N.J.: Erlbaum. Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Techniques and procedures for developing grounded theory. London: Sage. Sundstrom, E. (1986). Work places: The psychology of the physical environment in offices and factories. New York: Cambridge University Press. Timko, C., Moos, R.H., & Finney, J.W. (2000). Models of matching patients and treatment programs. In B.W. Walsh, & K.H. Craik (Eds.), Person-environment psychology: New directions and perspectives. 2nd ed. Mahwah, NJ: Erlbaum. Trost, J. (1986). Statistically nonrepresentative stratified sampling: A sampling technique for qualitative studies. Qualitative Sociology, 9, 54-57. Ulrich, R.S. (1999). Effects of gardens on health outcomes: Theory and research. In C.C. Marcus, & M. Barnes (Eds.), Healing gardens: Therapeutic benefits and design http://info.aia.org/journal_aah.cfm?pagename=aah_jrnl_20071101_watkins&dspl=1&article=article[11/22/2010 11:18:47 AM]

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recommendations. New York: John Wiley & Sons. Ulrich, R.S., Simons, R.F., & Miles, M.A. (2003). Effects of environmental simulations and television on blood donor stress. Journal of Architectural and Planning Research, 20, 38-47. Wachtel, P.L., & Messer, S.B. (1997). Theories of psychotherapy: Origins and evolution. American Psychological Association, Washington, DC. Williams, S.M. (1994). Environment and mental health. John Wiley & Sons. Winnicott, D.W. (1953). Transitional objects and transitional phenomena. International Journal of Psychoanalysis, 34, 89-97. _____. (1986). Holding and interpretation: Fragment of an analysis. New York: Grove Press. Nicholas J. Watkins, PhD, is the director of research for Cannon Design in St. Louis. He earned his doctorate in social and cultural factors in design from the University of Illinois at Urbana-Champaign. Kathryn H. Anthony, PhD, is a professor in the School of Architecture, Department of Landscape Architecture, and Gender and Women’s Studies Program at the University of Illinois at Urbana-Champaign. She earned her doctorate in architecture from the University of California at Berkeley.

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November 1, 2007

Historical Hospital Buildings: Should They Be Reused? Abstract | Article

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Letter from the Editor

Healthcare architects and administrators are faced with the question of whether an existing older building on a hospital campus can be reused. Frequently, the building in question is an original hospital building that may feature a historically significant façade, or it may be a building completely embedded in prior additions and expansions to the point that the original building is no longer recognizable.

As the preservation of historic structures, sustainability, and adaptive reuse become broader public concerns, the question of demolition versus rehabilitation can become a heartfelt topic within the local community and hospital staff.

Historical Hospital Buildings: Should They Be Reused? H. James Henrichs, AIA, Hobbs+Black Associates Abstract | Article

By investigating the various ways in which existing structures can be reused, this article discusses first steps such as approaching the project, ensuring the building can accommodate the intended functions, and addressing structural issues. Additional topics include determining appropriate space needs, façade enhancement or replacement, and the importance of long-range facility master planning.

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November 1, 2007

Historical Hospital Buildings: Should They Be Reused? Abstract | Article Healthcare architects often face the question of whether an existing older building on a hospital campus can be reused. Frequently, the building in question is an original hospital building that was constructed in a bygone era. This type of building may be freestanding with impressive detailing on a historically significant façade, or it may be a building that has become completely embedded in prior additions and expansions to the point that the original building is no longer recognizable. As the preservation of historic structures, sustainability, and adaptive reuse become broader public concerns, the question of demolition versus rehabilitation can become a heartfelt topic within the local community and hospital staff. Sorting through the pros and cons of such issues is a complex process that involves both critical thinking and sensitivity to sentiments and emotions of those involved. Working without preconceived notions and remaining impartial and objective are of paramount importance to the design professional. The scope of this subject is so broad that this paper can only touch on a few important points. The architect, planner, or facility manager must raise the following questions: What approach should be taken to reusing an historic hospital building? The Secretary of the Interior has established standards for evaluating historic resources located in historic districts. These standards and a detailed explanation for their use are available online at the Web site for The Secretary of the Interior's Standards for the Treatment of Historic Properties. While most hospital structures are outside historic districts and, therefore, outside the purview of historic district regulations, the same general concepts can be voluntarily applied when asked to evaluate such a building. The Secretary of the Interior divides work on historic structures into four categories: preservation, rehabilitation, restoration, and reconstruction. Rehabilitation is the preferred approach because more latitude is given in repairing or replacing the existing historic fabric. Also, only rehabilitation includes an opportunity to “make possible an efficient contemporary use through alterations or additions.”

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A common misunderstanding is that additions to historic buildings should match or attempt to closely resemble the original structure. Actually, the Secretary of Interiorâ&#x20AC;&#x2122;s standards for rehabilitation indicate that a false historic appearance should not be created and that additions, if absolutely necessary, should be clearly differentiated from the historic building. Can this building dimensionally accommodate the intended functions? Many older institutional buildings were constructed prior to modern air conditioning and ventilation requirements. This fact alone created several generations of buildings with low vertical floor-to-floor heights because little or no overhead ductwork was required when the building was originally constructed. The dimensional requirements for overhead mechanical systems must be carefully analyzed when assessing the possible reuse of an existing building. Similarly, the use of modern communication and other low-voltage systems have expanded exponentially in the last few decades, placing additional demands on the available interstitial space. Does the building in question have an automatic fire suppression system? In most cases, significantly altered or renovated hospital buildings are now required by code to be fully sprinklered, which may require additional space above the ceiling. To thoroughly understand whether vertical dimensional criteria can be met requires a comprehensive code analysis, engineering studies that yield enough specific information to determine depths for overhead components and systems, and a strong understanding of vertical requirements for medical equipment and clinical uses. In addition to vertical dimensional requirements, the building must also be weighed against other criteria: Is the existing building code-compliant or can it be readily made code-compliant? Are the existing stairs adequate in width and in number? Is the level of exit discharge compliant? Will the building superstructure need to be fireproofed to meet the two-hour requirement for I-2 occupancies? Does the existing column spacing work for the intended clinical spaces? Many buildings constructed in the late-19th or early-20th centuries have closely spaced or irregularly spaced columns that may impose additional constraints on medical planning efforts. Can the existing superstructure carry the anticipated structural loading? Obviously, any significant alteration to an historic building should include analysis by a registered structural engineer. The http://info.aia.org/journal_aah.cfm?pagename=aah_jrnl_20071101_henrichs&dspl=1&article=article[11/22/2010 11:19:47 AM]

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availability of original structural design drawings is critical to this effort. If no such drawings are available, alternative means of analyzing the existing structure may need to be pursued. The outcome of such an assessment or feasibility study, as outlined above, may be clear-cut in favor of either saving the building or removing the building. Examples of both outcomes are located in southeast Michigan.

The original entrance of Henry Ford Hospital is maintained to reflect the historic structure of the institution. Photo courtesy of Hobbs+Black

At the Henry Ford Hospital in Detroit, a successful effort has been made to maintain the original and update the original structure on an ongoing basis. Conversely, at Mercy Memorial Hospital in Monroe, Mich., the original hospital building was deemed unusable and was recently demolished to make way for a major reconstruction program.

Original entrance of Mercy Memorial Hospital Photo courtesy of Hobbs+Black

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Artist's rendering of the reconstructed entrance of Mercy Memorial Hospital Rendering courtesy of Hobbs+Black

Is the structure reusable, but the façade needs to be replaced? Reskinning of an existing hospital building may be a viable, even desirable, option in some cases. The existing structure may be sound and reusable, but the façade may be thermally inefficient, leaking, or outdated. This situation, combined with budget and schedule constraints, may lead to the logical conclusion to reskin an existing building. The design options for the type of façade, however, may be limited by the structure itself, which may not be able to withstand significant additional weight. In some cases, this may prohibit the use of heavy skin elements in favor of lighter materials. Reskinning can be an opportunity to update the appearance of an otherwise marginal or outdated façade, improve energy efficiency, improve natural daylighting, and complement an otherwise state-ofthe-art medical campus. From a design perspective, replacing the façade can also be an opportunity to develop a more contextually consistent or complementary theme throughout an existing healthcare facility. Reskinning an existing building, however, would usually not qualify as a rehabilitation effort under the Secretary of the Interior’s standards. An example of a recent proposal to reskin an existing healthcare structure was recently developed for the Detroit Medical Center Sinai-Grace Hospital.

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FaĂ§ade improvements at the Detroit Medical Center's Sinai-Grace Hospital Rendering courtesy of Hobbs+Black

Another successful outcome of reuse and rehabilitation comes from a building in Southfield, Mich. In need of significant renovation, the original Great Lakes Rehabilitation Hospital had slipped into a state of disrepair and had received a number of violations from the State of Michigan. Most systems in the existing building had reached the end of their useful lives and required replacement. Additionally, the exterior of the building needed refurbishing. The renovation addressed the entire existing facility, from structure to all building systems; issues relating to code; and all building finishes, both interior and exterior. The existing site was improved for paving, lighting, and landscape as well. The result has brought all systems, finishes, and building conditions up to current standards and has made the hospital a marketable entity, able to succeed in todayâ&#x20AC;&#x2122;s heavily competitive healthcare market.

Great Lakes Rehabilitation Hospital before renovation Photo: Contracting Resources

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The facility, renamed Oakland Regional Hospital following the massive transformation into a state-of-the-art rehabilitation and surgery center Photo: Lazslo Regos Photography

Is the façade valuable but the supporting structure unusable? Conversely, a much more challenging situation may exist when the opposite is true: The façade is a valuable piece of architectural history, but the superstructure is unusable due to dimensional limitations, deterioration, or structural issues. Rarely have such buildings had new superstructures installed behind existing façades. One option available to the design professional in this situation is to treat components of the original façade as archeological relics, which are incorporated into the design of the new replacement facility. This type of “museum” approach has the potential to satisfy a wide range of otherwise conflicting interests. However, it should also be pointed out that this type of solution in most cases also would not qualify as a rehabilitation effort under the Secretary of the Interior’s standards. Long-range facility master planning can be a vital tool in developing solutions that allow buildings of historic interest to remain intact. Through the planning process, less demanding clinical functions such as administration, physician office suites, and the like can be located in structures that lack the physical characteristics needed for more intense medical uses. Careful analysis of engineering criteria, building code requirements, and the demands of medical equipment can help yield solutions that are sensitive to healthcare providers, to the community at large, and to the built environment. H. James Henrichs, AIA, is senior vice president and studio head in charge of program management, healthcare studio, for Hobbs+Black Architects in Ann Arbor, Mich. This article was originally published in Study to Solutions: Vol. III, published by the Hobbs+Black Health Research Initiative. Henrichs can be reached at jhenrichs@hobbs-black.com .

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November 1, 2007

Rebranding Services and Facilities at a Community Hospital for Improved Satisfaction Abstract | Article Healthcare providers face many challenges in today’s healthcare environment. Patients behave as consumers when selecting healthcare providers, creating increased competition among hospitals for market share. Rapid advances in technology and treatment protocols create new demands for space and infrastructure within aging campuses. Physicians, driven to offer comprehensive care and the latest treatment protocols to their patients, are hungry for the creation of specialty centers of excellence. Nursing shortages and an aging nursing population are causing hospitals to reevaluate their approach to space— both operationally and aesthetically—to improve safety and satisfaction. In light of these issues, healthcare executives are embracing the role of design in differentiating and marketing services, creating a strong brand statement, impacting operations, and improving overall experience. Quality design—planning, architecture, interiors, and landscape—is now accepted as an investment that offers long-term payback. Whether improving patient outcomes and satisfaction, attracting qualified personnel, or reinforcing a hospital’s commitment to its community, good design is helping healthcare organizations redefine themselves and improve the delivery of state-of-the-art services. Advocate Lutheran General Hospital in Park Ridge, Ill., used a new capital project, The Center for Advanced Care, as an opportunity to update its image, create a marketable healthcare destination, and improve the quality of care for patients.

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November 1, 2007

Rebranding Services and Facilities at a Community Hospital for Improved Satisfaction Abstract | Article A Case Study: Advocate Lutheran General Center for Advanced Care, Park Ridge, Ill. The Mission In early 2004, Advocate Lutheran General Hospital (ALGH) set out with a vision to create "a comprehensive, state-ofthe-art outpatient facility that is recognized as a regional leader for patients seeking multidisciplinary cancer, advanced imaging, or breast-health services." The Site ALGH’s master facility plan identified a significant shortfall in the space available for diagnostic imaging, breast-health services, and convenient visitor parking. The plan also highlighted the need to plan for emerging cancer services through improved adjacencies and synergy between areas for diagnosis and treatment. Considering competitors' recent facility investments, ALGH anticipated a negative impact on patient volumes if it did not improve facilities in a way that would better position them in the marketplace.

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Image 1. ALGH site plan Source: OWP/P

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An existing building on the campus, the West Pavilion, was identified as the ideal site. Its location near the existing entrance to the hospital offered substantial visual presence and an opportunity to create a signature destination on the campus (Image 1). The building housed an oncology practice, radiation oncology, and mental health services prior to the renovation but was underused. Originally designed as an alcohol-treatment hospital, the building needed substantial infrastructure improvements. Given the two existing, highly used outpatient radiation oncology vaults, the building could not be razed and would need to be kept in operation, along with the medical oncology practice, during the renovation and new construction work.

Image 2. ALGH existing facade Photo: OWP/P

Despite its prime location, the existing structure presented a number of challenges. The image of the building was of the Hill-Burton era: uninviting and institutional (Image 2). The floor-to-floor heights were far from todayâ&#x20AC;&#x2122;s standard for high-technology medical spaces. Most important, the building would need to remain operational during the construction schedule. The Service Line Strategy A leadership team for the project brought together key physicians and staff from each service line. The team created a set of strategic project goals to be realized in the expanded building.

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Image 3. First-floor plan for the new ALGH Center for Advanced Imaging Source: OWP/P

The new Center for Advanced Imaging (Image 3) would be a regional leader in technology and quality and would successfully compete with freestanding imaging centers on service and accessibility. State-of-the-art digital imaging technology would be featured, including CT scanners, MRI, nuclear medicine, a PET CT scanner, ultrasound, digital radiography, and dexascan. The Center needed to be conveniently accessible for outpatient diagnosis and near the Cancer Institute and Breast Health Center to ensure seamless care coordination. Patient privacy and dignity were to be respected through the use of private changing and waiting facilities with access to natural daylight. For the MRI and CT modalities, where outpatient procedure volumes were seeing double-digit growth, a modality module would be developed and planned. The module plan would allow for these modalities to grow within the existing footprint with only minor disruption to existing services during renovation. With the future growth in mind, beyond the internal expansion, external growth avenues for expansion were needed in the event that volumes exceed the internal renovation capacity. The modalities also had to be designed to share technical support space for operational efficiency and for modality cross-training of staff. The existing Cancer Institute (Image 4) would be reconfigured and expanded to house a comprehensive, multidisciplinary outpatient cancer program. The major services would include radiation oncology physicians who would work closely with other specialists, medical oncologists, and surgeons to ensure the best treatment plans and support for the patients. Oncology specialists would also offer a component of care to the existing oncology services and therapy for all cancers and diseases of the blood. Through its research institute initiatives, oncology specialists would conduct and participate in http://info.aia.org/journal_aah.cfm?pagename=aah_jrnl_20071101_heiser&dspl=1&article=article[11/22/2010 11:20:42 AM]

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cutting-edge clinical trials for a wide range of cancers and blood disease. The inclusion of a gynecologic oncology interdisciplinary practice would provide a continuum of comprehensive care to women who have been diagnosed with pelvic malignancy or who have benign or malignant breast cancer. The Caldwell Breast Health Center would provide comprehensive womenâ&#x20AC;&#x2122;s health services. The renovation would allow these multidisciplinary services to come together to offer a continuum of care as well as a new Resource Center for patients and families. The Resource Center would be part of the American Cancer Society's Patient Navigation Services.

Image 4. Floor plans for the Cancer Institute at the Center for Advanced Care and the Caldwell Breast Health Center Source: OWP/P

The Caldwell Breast Health Center (Image 4) was to be developed into a comprehensive, regional, multidisciplinary Breast Health Center providing screening, diagnosis, treatment, and counseling services. The Center would triple in size at the new location. It would be designed around three clinical modules that separate screening from diagnosis and treatment, and it would provide shorter wait times for patients. Its proximity to the Center for Advanced Imaging would reduce the wait times between initial visit and diagnosis. Located on the third level of the Center for Advanced Care, a clinic module concept for organization of the exam and consult pods would be used. These pods would promote patient comfort and confidentiality while also enhancing staff and operational efficiencies through proximity to decentralized tech work areas and physician reading rooms. The design team worked with the hospital to identify these modules of services: screening, diagnostics, and consultation. The modules can be quickly staffed to efficiently support both screening or diagnostic

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functions when volume dictates, and additional modules can be added in the soft zone designed for the future expansion. In addition, if future patient volumes dictate, an expansion to double the floor could occur to the south over the Advanced Imaging Center. The Design This revitalization project was viewed as a change catalyst—an opportunity to redefine the hospital’s image and set the tone for future campus development. This high-volume outpatient facility needed visibility from the campus entrance, but a recently built parking structure blocked it from view. By stretching the envelope and celebrating the main corner, this liability became a clear asset (Image 5). In addition, the team aligned the Center for Advanced Care with the existing parking structure; which allowed direct and convenient patient access to the Center for Advanced Care floors— addressing one of the project goals for patient access and convenient parking.

Image 5. The exterior design stretched the envelope at the main corner to make the facility visible from the campus entrance.

With a 10' 3” floor to floor and a bar-joist structural system in the James Steinkamp, Steinkamp existing structure, the team was Photo: Photography challenged to develop a solution that incorporated a state-of-the-art ventilation system. The design team reviewed several options to solve infrastructure issues such as the ventilation scheme. Ultimately, a central air handling unit system with VAV for rooms was selected, which required accommodating all the ductwork in limited ceiling space. The solution was to run the ductwork mains perpendicular to the corridors and soffit down to a 7’2” height, which also was used as a design element to break up the corridor. The building also required an upgrade to current fire codes, which entailed a new fire restive construction and a new fire suppression system. The transparent and expressive quality of the envelope assists wayfinding upon entry as a clear, day-lit guide to the many services offered at the Center for Advanced Care. Each major department—Cancer Institute, Center for Advanced Imaging, and Caldwell Breast Health Center—has its own entry and designated area, organized by a main circulation spine with a three-story atrium. This alignment also was defined by a simple wayfinding element with the patient and visitor traffic corridor along this leading edge of the new addition with daylight and exterior views to help with wayfinding from entry to services and to vehicular parking.

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Image 6. Each of the three service lines at the ALGH Center for Advanced Care has its own entry and reception area. Photo: James Steinkamp, Steinkamp Photography

The center expresses its three major service lines as separate areas, each with its own distinct entry that responds to the needs of the patients it serves (Image 6), yet each department is connected vertically by the atrium, which creates a sense of community within the building. It uses overall horizontality and overlapping elements to join them into one composition. It revels in the tension between parts and the unified whole, between the individual patient and the community of care. In addition, community-focused activities occur on the first floor: A Resource (education) Center provides patient and family with access to disease, diagnostic, and treatment information to empower them in the health and treatment of their loved ones. A meditation room and a community conference room allow for a variety of needs, from spiritual reflection to support groups and classes. Unlike any other building on the campus, the Center for Advanced Care allows light, color, and nature to reach into the clinical environment to nurture patients, families, and staff. This project represents the beginning of a new branding statement by ALGH and is a major departure from the character of the existing buildings on campus. The Center for Advanced Care is focused on expressing a sense of optimism and hope by emphasizing transparency between exterior and interior. The organization supports a new commitment to a stewardship relationship between patients and staff. Its geometry and materials allow light, color, and nature to interact and penetrate deep into the clinical spaces. It is fresh, open, and inviting. The design embraces, nurtures, and respects the patients, their families, and staff in unassuming yet profound, ways. The interior color palette and finish materials are inspired by nature. Color selected for the departments are based on the hues of spring in the Illinois prairie, providing an impression of new life, freshness, and optimism as well as

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a familiar connection to place. The use of patterned glass allows natural light to enter interior departmental spaces and, at the same time, provides privacy. The continuity of natural materials throughout the building adds warmth and texture while offering a cohesive image. The extensive use of glass opens the programmatic elements to natural light, creating a pleasant experience for patients and staff. The Impact By locating all the services in the new Center for Advanced Care, ALGH now offers a multidisciplinary, team-centric approach for preventive care, diagnostics, treatment, and follow-up care. By addressing issues related to convenience and creating a welcoming environment for staff and visitors, the hospital is witnessing increases in patients, revenue, and customer satisfaction. Staff productivity has increased by integrating services into one site.

Image 7. Source: Advocate Lutheran General Hospital

In the Caldwell Breast Center, the new care-delivery model and space design provides state-of-the-art technology that substantially increases productivity and improves reportturnaround time. In the six months since its opening, the Breast Center has seen patient satisfaction soar by more the 40 percent (Image 7). The Center for Advanced Imaging, in addition to enhanced productivity from the digital platform, has seen increased patient satisfaction increase by more than 30 percent (Image 8) due to patient convenience, broader service hours, natural daylight, and quicker throughput.

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Image 8. Source: Advocate Lutheran General Hospital

The hospital now has a marketable destination for its imaging, oncology, and breast center-related services—a building that improves the caliber of care available to its patients; an expression of how it would like to be perceived in the years to come; and a space where physicians, staff, and patients can thrive (Image 9).

Image 9. Exterior of ALGH Center for Advanced Care Photo: James Steinkamp, Steinkamp Photography

Greg Heiser, AIA, is a principal and operations leader of the healthcare practice at OWP/P in Chicago. He can be reached at 312-960-8048 or by e-mail at gheiser@owpp.com. Jocelyn Stroupe, IIDA, AAHID, is director of healthcare interiors at OWP/P in Chicago. She can be reached at 312-

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960-8202 or by e-mail at jstroupe@owpp.com.

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November 1, 2007

Designing for Family-Centered Care in the Newborn Intensive Care Unit: Designing for the Future Abstract | Article Changing patterns of care in high-risk maternal-fetal medicine drive this major project. The hospital currently has a cramped open bay neonatal intensive care unit (NICU) of 60 beds. The new addition adds 140,000 square feet to the existing Women & Infants Hospital in Providence, including a new 80-bed NICU comprising 70 private rooms totaling 56,000 square feet; a floor of 30 ante-partum beds totaling 24,000 square feet; and a new lobby with retail space, social services, a conference center, and chapel. We defined design strategies to support the premise that the single-room NICU care model is the optimal model to improve neonatal infant outcome and the best way toward a family-centered healing environment. The intent of the architecture is to support the mission and guiding principles established by the Design Committee early in the design process. The challenge for the architect is to understand the relationship between design of physical space and the influence it has on the outcome of patient care, as it affects the neonates, their families, and caregivers. Through a highly participatory design process with the Design Committee. the architects could fully comprehend the complexities of this relationship. The hospital anticipates a NIH research grant to measure the relationship between the single-room NICU design and infant and neurodevelopmental outcome. The results of this study will contribute to the growing body of evidencebased medicine that builds foundations for evidence-based design.

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November 1, 2007

Designing for Family-Centered Care in the Newborn Intensive Care Unit: Designing for the Future Abstract | Article Introduction At the groundbreaking ceremony for the new Woman & Infants Hospital addition were some of the parents and their children who had graduated from the hospital’s existing neonatal intensive care unit (NICU). The parents delivered emotional testimonies about their experiences in the NICU, stressing the value of their participation in the caring process of their newborn and how the collaboration between caregiver and parents had been vital to their children’s long term future development once the child had been released from the NICU. This inclusive and holistic philosophy towards delivering care is the fundamental premise for the design of the new NICU. How an owner and its architect address the design of future facilities for premature newborn infants under intensive medical care that emphasizes family centered care is the subject of this paper and the building currently under construction. Women & Infants Hospital, a Brown Medical School teaching hospital, serves the women of Rhode Island, northeastern Connecticut and southeastern Massachusetts for gynecology, maternal-fetal medicine, oncology and other women’s health needs. The changing patterns of care in high-risk maternal-fetal medicine are the drivers of this major project. The hospital currently has an open bay NICU of 60 beds in very cramped conditions. Adding 140,000 square feet to the existing hospital, the new addition includes a new 80 bed neonatal intensive care unit (NICU) comprised of 70 private rooms totaling 56,000 square feet (the balance of ten beds will be in multi-bed rooms for multiple birth newborns), a floor of 30 ante-partum beds totaling 24,000 square feet, and a new lobby with retail space, social services, a conference center, and chapel. The intent of the architecture is to support, in every way possible, the mission and guiding principles that had been established by the design committee early on in the design process. The challenge for the architect is to understand the relationship between the design of physical space and the influence it has on outcome of patient care, as it affects the patients, their families, and the caregivers. Only through a highly participatory design process with the design committee was it possible for the architects to fully comprehend the complexities of this relationship. This process included site visits to existing facilities and

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attending professional conferences to learn about the state of the art of neonatal care. The lessons learned will be evaluated after the facility is open and functioning. We have applied for a research grant with the NIH to measure the relationship between the single room NICU design and infant neurodevelopmental outcome. The results of this study will become a valuable contribution to the growing body of knowledge that builds upon the foundations for “Evidence Based Design”. In this paper, we will attempt to define the design strategies that have been implemented to support the premise that the single room NICU care model is the optimal model to improve patient outcome and the best way to create a healing environment that focuses on family centered care. The chosen model of care While it was clear that new physical space for the NICU was needed in the new hospital addition, it was not clear what physical design and what “model of care” should be pursued. As the specialty of newborn intensive care evolved, so have the models of care. “Model of care” refers to the physical space for the patient and the principle that the design of space surrounding that care is intimately related to outcomes. We identified several contemporary “models of care.”

Figure 1. Single-family room model

These models include open bays where infants are cared for in a large open space, or in a modification of the open plan called a “Pinwheel.” These models are similar to the existing NICU at Women & Infants Hospital, albeit with new construction a much larger open bay would be needed. A rapidly emerging approach to newborn intensive care involves “single-family rooms,” Figure 1. This model of care recognizes that caring for critically-ill patients (especially the very young and the very old) in an open bay is often disruptive. The clinical instability of children in shared space often leads to disruption of their neighboring

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partners. This is most apparent in newborn intensive care units where stability of heart rate and breathing is precarious. Even minimal visual, auditory and/or tactile stimulation can result in cessation of breathing (“apnea”) or in a decrease in the baby’s heart rate (“bradycardia”). The single-family room design has garnered widespread acclaim for its many distinct advantages.1 Patients cared for in individual rooms are less likely to be disturbed by their neighbors, the staff or other activities related to adjoining patients. This model of care also allows for better isolation of patients from nosocomial infections. This model of care provides for the only form of privacy that is consistent with federal regulations in the United States known as the “HIPPA Regulations.” Lastly, the single family room allows for a truly family-centered approach wherein the families can be present throughout much of the hospitalization and really become partners in care of their infants rather than episodic “visitors.” After completion of numerous site visits across the country, we convened the entire group to synthesize our experiences into a list of “Guiding Principles” and “Design Principles.” These are shown in Tables 1 and 2. While there was some concern that the single-family room model of care was beyond the scope of the large service at a facility like Women & Infants Hospital, after visiting these constructed nurseries there was clear consensus that it was the only model of care that should be considered. We believe that, before this decade is completed, this will be the dominant model of care in NICU design. In the fall of 2006 the American Institute of Architects made this very recommendation.

Table 1. Guiding principles for design of new NICU

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Table 2. Design principles for design of new NICU

Evidence-based practice Our conclusions are based on the results of the experiences of the people at the sites we visited. We have also examined published and unpublished data from centers that have recently changed to different models of care. They are summarized in the next few paragraphs. At the outset we should note that there are no data which conform to the “gold standard for evidenced-based practice” which is a randomized, controlled “head-to-head” trial comparing single family rooms to other models of care. The information to date is either anecdotal or based on retrospective, historical comparisons. In 1997 Vanderbilt University embarked on a major construction project to build a new children’s hospital and to re-design the critical care services. Considering the data reviewed above, the Division of Newborn Medicine at the Vanderbilt Children’s Hospital adopted the single-family room model of care. They replaced their 44-bed, open-bay neonatal intensive care unit with a NICU with 65 single-family rooms. Data were collected after moving to the NICU on outcomes, staff satisfaction and safety-related issues. Staff satisfaction is an important consideration in the successful evaluation of this single family model of care. Professional staff, especially nurses, have a wellestablished and honored tradition of advocacy for patient outcomes and in recognition of details and design that improve outcome. The preceding figures show that the overwhelming majority of staff feels that the single-family room unit is better than the group setting regardless of the illness severity or acuity. Moreover, staff feels the single family room is better for growing premature infants and also for critically ill infants who are on mechanical ventilation Likewise, a staff survey demonstrated significant preference for the new design, a greater ease in providing developmentally appropriate care, improved family interactions and generally improved outcomes. These http://info.aia.org/journal_aah.cfm?pagename=aah_jrnl_20071101_padbury&dspl=1&article=article[11/22/2010 11:21:29 AM]

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experiences were compelling in our decision to exclusively employ the single family room model of care in our NICU. Nonetheless, documentation according to the best standards for “evidence-based practice” is still lacking. Women & Infants Hospital and Brown University are in the midst of conducting a prospective, longitudinal study of the impact of this model of care on outcomes. The interdisciplinary research team includes PhD trained developmental specialists, neonatologists, neonatal nurses, OT and PT specialists and, of course, parents. The theoretical model underlying our study is shown in Table 3.

Table 3. Theoretical model

Physical environment in the intensive care setting Numerous studies have been published which demonstrate that environmental conditions in the Intensive Care Unit can have significant effect on outcome. For caregivers, the environment influences their work performance, their satisfaction and their health.2-4 For patients, the physical environment can have a profound effect on rate of recovery, and/or development of what is commonly known as “the ICU syndrome”. The ICU syndrome is a transient psychosis that is seen in patients who are subjected to long periods of invariant lighting, sleep deprivation and/or auditory disruption. While these observations are best documented in adult patients, it is clear that physical and environmental conditions also affect the outcome of critically-ill newborn infants. Optimal lighting for babies in Newborn Intensive Care Units has been studied extensively.5-6 It is clear that fetuses and newborns have well defined circadian rhythms by their third trimester. These are entrained by maternal activity, temperature and hormones. Likewise, the visual and hypothalamic tracts of newborns are functional by 28 to 32 weeks. Given these significant developmental milestones, it is not surprising that alternating lighting between day and http://info.aia.org/journal_aah.cfm?pagename=aah_jrnl_20071101_padbury&dspl=1&article=article[11/22/2010 11:21:29 AM]

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night has been shown to be better than continuous light in newborns in neonatal intensive care units.7-8 This has been shown to benefit postnatal growth, developmental milestones and establishment of circadian rhythm. Preterm infants born at less than 31 weeks gestation have improved growth in cycled light compared with continuous near darkness. Similarly, varying light levels are beneficial to the providers. Numerous studies have documented the effect of light on mood, attitude, performance and overall psychological well-being of adults in healthcare workplace settings. Nightshift workers become drowsy and lower their body temperature during the night. This is mediated by melatonin. This can be modified by exposure to bright light for as little as 15 minutes. It is clear that different intensities are needed in intensive care settings, whether for procedures, paperwork or computer use. Likewise, there is significant interaction between light and noise levels, often referred to as the “library effect”. In order to provide optimal care for the newborn, individualized settings are preferred where the light levels can be adjusted to the child’s developmental level, illness level and personal care needs throughout the day. Noise is another significant environmental variable in the newborn intensive care unit. In low birth weight infants, it has been demonstrated that intermittent loud noises increase intracranial pressure and decrease oxygen levels.10 Loud noises also interfere with the establishment of sleep patterns.11 Sound levels in neonatal intensive care units frequently exceed 75-90 decibels, levels considered safe for later auditory development. As already noted, there is a substantial interaction between light and noise, and this is particularly acute during caregivers’ activities such as rounds, changes of shift and unit maintenance. Infection control is a critical issue that can be supported or obfuscated by the physical plant. At least one episode of bacterial infection (“sepsis”) was observed in 15-33% of extremely low birth weight newborn infants in the Neonatal Research Network of the National Institutes of Health.12 It is clear that overcrowding increases the risk of nosocomial infection. Design flaws including improper sink placement and poor airflow have been associated with nosocomial outbreaks in newborn infants in newborn intensive care units. The layout and design of the NICU can also contribute to inappropriate physical contact between providers and patient care areas and thus, an increased risk of spreading infections. This is particularly common in open bays where inadvertent casual contact with the isolettes, the patient’s records and/or supplies in individual areas leads to poor quality of infection control. The infant’s room The NICU room is the building block for the new facility. Each room is 175 net square feet (nsf) and has three distinct zones: Patient, Staff, and Family, Figure 2. Each room provides an opportunity to individualize and personalize the space according to each baby’s developmental needs. The NICU room provides the privacy and separation that is necessary to perform critical

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procedures with restricted admissions, without impacting other infants. It significantly displaces the existing and obsolete open bay NICU.

Figure 2. Patient zone, staff zone, and family zone in each room

Each caregiver/staff zone has a sink, refrigerator and storage cabinets for needed supplies. The patient zone headwall provides medical gases and electrical services for the hookup of equipment, including ventilators, pumps, monitors and other developmental equipment, as needed. Family space accommodates a sleeper for a parent, desk and storage which can be separated by a privacy curtain. Every room has indirect dimmable lighting that can be adapted to individual needs related to circadian rhythm and delivery of services. Every room has a heating, ventilation and air conditioning (HVAC) system that facilitates procedures being performed within the room. The new NICU at Women & Infants Hospital of Rhode Island In order to incorporate all of the clinical programs within 80 single family rooms, a new NICU requires more than 56,000 departmental gross square feet (dgsf). Compared to the existing open ward NICU, this represents a significantly larger floor plate. While the single room NICU is undeniably the preferred model of care, the design challenge is in how to configure 80 patient rooms so that there can still be a strong sense of community, in an environment that fosters interaction between family and staff, and where the family can feel at ease in a welcoming environment despite the intensity of the clinical setting. A key requirement for the new NICU was to locate it next to the existing Labor and Delivery Suite. Initially, the goal was to locate all beds and core programs on one floor. An advantage to having all programs on one floor was that all

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support spaces could be centrally located. A disadvantage of the one-floor scheme was that the floor plate was too broad, restricting the opportunity to bring natural daylight to interior areas, with long distances creating isolated zones. Furthermore, one large floor versus two smaller floors would be more expensive to build. For these reasons, and in order to preserve more land for future hospital expansion, the NICU was located on two floors. Because the Labor and Delivery Suite is located on the second floor of the existing hospital, required adjacency dictated that the NICU be located on floors 2 and 3. Thirty ante-partum beds are located on floor 4; and a new entrance lobby that includes retail space, a resource center, chapel, and conference center occupies the first floor. Maintenance and support services are located in the basement, with a tunnel connection to the existing hospital, Figure 3.

Figure 3. Stacking diagram for new NICU

Site design and massing The new wing is sited along the western edge of the property, creating an urban edge along Gay Street and defining a new entrance forecourt off Dudley Street, the principle direction of travel for arriving patients, Figure 4. Secondary entrances, one off Gay Street, and another off the ED drop-off area, are oriented towards longer term parking areas for visitors and staff.

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Figure 4. Site plan

Figure 5. Massing model

The massing for the new addition is configured in such a way as to maximize potential daylight to interior spaces, Figure 5. A maximum perimeter of building envelope benefits from east-west orientations, without blocking views out from the patient floors of the existing hospital. The new wing bends gently at its mid-point, a strategy that not only serves as a

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way to break up the perceived length of the structure, both from inside and out, but also locates the main family lounges of the NICU at the bend, an important visual cue from the exterior. It furthermore helps to spatially define the forecourt, like an extending arm that embraces arriving patients and their families. The main structure is connected to the existing building by a two story link. Clad by a tilted glass plane, it articulates the joint between old and new, defining the new main entrance, with a light filled lobby serving both the existing and new buildings. A central reception desk controls all entry points into the building and a public concourse has been created with a cafe, retail spaces and social service, bisecting the ground floor along the east-west axis connecting Gay Street with the existing hospital, Figure 6.

Figure 6. Section through main lobby

The second floor of the link serves as the connector between the NICU and the Labor and Delivery Suites, as well as housing staff lounge and locker facilities, equipment storage and sterilization. The roof of this link building is designed to receive a healing garden, accessible from the second floor of the NICU, and visible from the upper floors of both buildings. The new wing is clad in traditional materials such as red and beige brick to provide unity with the hospital campus. The architecture responds in an open and dynamic way to the site, expressing a certain confidence and hope about the future, Figure 7.

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Figure 7. Perspective view from Dudley Street

Plan organization To minimize duplication and to unite the two NICU floors as much as possible, the design includes a vertical connection at the center of the building, utilizing an open atrium and open stair interconnecting the two floors. This architectural design allows for visible and direct access to program spaces that includes the family center and staff lounge. Clustering specific programs around the atrium clarifies wayfinding, and enhances physical and visual communication between floors, Figure 8.

Figure 8. Atrium at family lounge

Each floor of the new NICU is organized into two 20-bed zones, totaling 80 beds. Each floor is supported by one medical team, the central team room located at the center of the building, at the juncture of two bed zones. Figure 9 Patient and service elevators are located at the north end,

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as close as possible to the Labor & Delivery Suite, thus providing the shortest possible travel access to Floor 3 NICU. Isolation rooms have been designed with separate air systems in the event of an outbreak of airborne infection. A 10-bed area has been designed with both positive and negative air pressure flow. Negative pressure is activated to evacuate air-borne pathogens.

Figure 9. Second-floor plan of new addition, showing location of NICU

Each 20-bed pod is designed with core support elements that include a charting station between each two rooms, clean supplies, soiled utility, equipment room and a family space that intimately accommodates several people. Each pod is organized with two blocks of rooms that are highly visible from one another to allow for staff communication and interaction. Each zone has two rooms for twins and three single rooms that are connected and can accommodate triplets. There are no rooms anywhere on the floor that are physically isolated, a feature very important for staff. Families access the NICU via public elevators located off the main lobby, bringing them directly to family reception lounges located on each floor. Family participation Because family participation is one of the principle goals of the family centered care clinic, space is required for the family both in individual rooms and in space outside the NICU room on the same floor. It is important that family members have a place to congregate with other parents or otherwise find respite from the stressful NICU environment. In addition to smaller family rooms located at the end of corridors in each pod, we have created a family space with a comfortable lounge, kitchenette, sibling play area, conference and resource space. It is centrally located with a communicating open stair in the â&#x20AC;&#x153;open atriumâ&#x20AC;? previously described, Figure 8, and within close proximity

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to the central team room. Staff retention Staff support spaces, access to daylight, and a less stressful environment are of great importance for the well-being and retention of staff, as well as for the overall ambiance of the NICU. Although it was not possible to locate all staff work rooms and stations next to a window, the design provides interior glazed partitions, Figure 10. Staff can view out: daylight is transmitted through adjoining spaces, while allowing staff discreet visual control over the family lounges. The importance of locating the staff lounge remote from the workspace should not be overlooked. It is crucial that this space be comfortable, have natural lighting, and be a location Figure 10. Lines of sight from where staff are able to reduce staff, family, and lounge areas stress from the highly charged NICU environment. At Women & Infants’, the lounge is designed to support alternative activity arrangements with plenty of natural lighting. Its position above the main lobby offers respite from the intensity of the NICU environment, offering views out to the entry forecourt and the passing activity below. Summary and recommendations Women and Infants Hospital design principles reflect a commitment to family centered care which is at the heart of the Hospital’s Building For The Future programs. Our goal has been to create a welcome and reassuring environment with a sense of openness, along with provision of privacy for patients and their families There has emerged among the staff and administration the unanimous view that only within a single-family room model of care will we be able to provide the benefits noted above. Families and patients’ well being and outcome are clearly at the center of our professional goals. We recognize the importance of a balance between staff and family needs in achieving those optimal outcomes. We have paid careful attention to providing adequate support areas for our professional staff and for ancillary professionals who contribute so much to the newborn outcome. Our design will maintain the clinical excellence that the Hospital has demonstrated in the past and of which we are proud. More importantly, we recognize the significance of design in creating a holistic environment that seeks the right balance between the technical demands of the clinical environment and the qualitative needs for creating family centered care. REFERENCES

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1. Walsh WF, McCullough KL, White RD. Room for improvement: nurses' perceptions of providing care in a single room newborn intensive care setting. Adv Neonatal Care. 2006 6:261-70. 2. Copyright 2005 Meyer GS, Massagli MP. The forgotten component of the quality triad: can we still learn something from “structure”? Jt Comm J Qual Improv 2001; 27:484493. 3. Fottler Eisenberg JM, Bowman CC, Foster NE. Does a healthy health care workplace produce higher-quality care? Jt Comm J Qual Improv 2001; 27:444-457. 4. Ford RC, Roberts V, et al. Creating a healing environment: the importance of the service setting in the new consumer-oriented healthcare system. J Healthc Manag 2000; 45:91-107, 5. Mirmiran M, Ariagno RL. Influence of light in the NICU on the development of circadian rhythms in preterm infants. Semin Perinatol 2000; 24:247-257, 6. Rivkees SA, Hao H. Developing circadian rhythmicity. Semin Perinatol 2000; 24:232-242. 7. Mann NP, Haddow R, Stokes L, et al. Effect of night and day on preterm infants in a newborn nursery: randomized trial. BMJ 1986; 293:1265-1267. 8. Miller CL, White R, Whitman T, et al. The effects of cycled vs noncycled lighting on growth and development in preterm infants. Infant Behav Dev 1995; 18:87-95. 9. Brandon DH, Holditch-Davis D, Belyea M. Preterm infants born at less than 31 weeks’ gestation have improved growth in cycled light compared with continuous near darkness. J Pediatr 2002; 140:192-199. 10. Long JG, Lucey JF, Philip AG. Noise and hypoxemia in the intensive care nursery. Pediatrics 1980; 65:143-145. 11. Philbin MK. The influence of auditory experience on the behavior of preterm newborns. J Perinatol 2000; 20:S7787. 12. Stoll BJ, Hansen N. Infections in VLBW infants: studies from the NICHD Neonatal Research Network. Semin Perinatol 2003 27:293-301. James F. Padbury, MD, is pediatrician-in-chief, Women & Infants Hospital, and professor and vice chair of pediatrics at the Warren Alpert Medical School of Brown University. He can be contacted at JPadbury@wihri.org . Johan (Jay) Verspyck, AIA, is project architect and associate principal of Anshen+Allen+Rothman in Boston. He can be reached at jv@anshen.com

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November 1, 2007

Sound Practices: Noise Control in the Healthcare Environment Abstract | Article Unwanted sound can have a negative impact on patient outcomes and caregiver effectiveness. Speech privacy is crucial to protecting patient rights under the Health Insurance Portability and Accountability Act (HIPAA). Recent studies, however, show that hospital noise levels have increased significantly over the past five decades. Understanding the basics of sound transmission and measurement is essential to a realistic assessment of a facility's sound environment. Environmental design strategies for noise reduction and sound management include the maintenance and replacement of hospital equipment; the layout and acoustical treatment of patient rooms, nurses' stations, and corridors; and the implementation of emerging technologies to mask sound, reduce speech intelligibility, and introduce healing sound into the environment.

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November 1, 2007

Sound Practices: Noise Control in the Healthcare Environment Abstract | Article “Unnecessary noise is the most cruel abuse of care which can be inflicted on either the sick or the well,” Florence Nightingale wrote in her 1859 book, Notes on Nursing. 1 Despite—or, to some extent, because of—incredible advances in medical technology over the past century and a half, noise remains a large and largely unsolved problem in healthcare environments. In fact, a new study by acoustical engineers at Johns Hopkins University found that hospital noise levels have increased steadily over the past 50 years. Since 1960, average daytime hospital sound levels have risen from 57 decibels to 72 dB, while average nighttime levels have jumped from 42 to 60 dB—all far exceeding the World Health Organization’s recommendation of 35 dB as a top measure for sound levels in patient rooms. 2 The Johns Hopkins researchers reported that medical and communications technologies were major culprits behind increasing noise levels. Communications devices like overhead pagers and cell phones fill the air with that most distracting of sounds—human speech —and patients and healthcare workers find themselves raising their voices ever louder in an effort to be heard over the din. Within patient rooms, monitoring and life-sustaining equipment continually beeps and whooshes around patients’ beds, occasionally erupting into alarming warning signals. 3 “These noises are concentrated around the patient’s head,” notes Linda Greenberg, clinical consultant for Herman Miller for Healthcare, “because that’s where caregivers naturally tend to position equipment so it’s easier to use with the patient.” 4 Effects on patient outcomes Modern research suggests that Florence Nightingale wasn’t exaggerating when she referred to hospital noise as “abuse.” Studies show that high levels of sound have negative physical and psychological effects on patients, disrupting sleep, increasing stress, and decreasing patients’ confidence in the competence of their clinical caregivers. 5 A considerable body of research has documented the effects of noise on patient outcomes. For example, exposure to sudden, unexpected noise raises patient heart rates and has been proven to have a negative influence on patient recovery times.6 Chronically high levels of sound, on the other hand, tend to increase blood pressure levels; a new study by University of Michigan researchers found a direct correlation between overall decibel levels and blood pressure levels.7 Higher blood pressure leads to a higher risk of cardiac problems, and a team of European researchers, in a study of 4,115 patients in 32 Berlin hospitals, found that chronic noise increased the risk of heart attacks by 50 percent for men and 75 percent for women. 8 In a hospital environment, where people are already ill and psychologically stressed, unnecessary noise can be harmful. Impact on staff effectiveness Although the effects of noise on those working to care for patients in hospital environments are less well documented, hospital staff is clearly affected in many of the same ways. “People who work in noisy environments for long shifts, day in and day out, also have similar stress-induced experiences,” says Susan Mazer, president of Healing Healthcare Systems. “They report everything from exhaustion to burnout, depression, and irritability expressed at home.”9 Recent findings in the field of cognitive science show that mental activities requiring a lot of working memory, such as paying attention to a variety of different cues or performing a complex analysis, are especially noise-sensitive. 10 The frequent interruptions and distractions noise causes often result in medication errors, one of today’s most challenging issues in delivering care, according to clinical consultant Greenberg. “Since noise breaks concentration, it can contribute to the number of medication errors that is becoming a costly and dangerous situation in many healthcare facilities.”11 When a sudden loud noise causes an involuntary reflex reaction in a surgeon or when a nurse fails to hear a warning signal over the general sound

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level in a chronically noisy ICU, performance suffers and accidents can result. Swedish researchers studying a coronary critical care unit found that healthcare workers exposed to different levels of noise over the workday reported higher levels of stress and tension during periods defined as acoustically “bad “ (as measured by sound pressure levels, reverberation time, sound propagation, and speech intelligibility). During acoustically “good” periods, staff perceived the work environment more favorably, and patients correspondingly judged staff attitudes and care to be better than during the “bad” acoustical periods. 12

Considerations of privacy Interfering and distracting sounds can contribute to medical and nursing errors, and the Joint Commission on Accreditation of Health Care Organizations (JCAHO) standards state that “ambient sound environments should not exceed the level that would prohibit clinicians from clearly understanding each other.” 13 On the other side of this acoustical coin, however, is the issue of patient privacy, brought to the forefront in recent years by the Health Insurance Portability and Accountability Act (HIPAA). Speech privacy is important in any healthcare setting. Patients know that if they can overhear conversations in nearby rooms or nursing stations, others can overhear their conversations as well. A lack of auditory privacy can make people uncomfortable and less likely to discuss private matters with their caregivers. Why it’s so noisy Former patients often note the supreme irony in the fact that the hospital environment, the place where quiet is most essential, is the one place it’s least likely to be found. There are reasons for this, of course, most of which have to do with concern for patient health and safety. In addition to the sound emanating from all the machines and human beings working to monitor and promote patient health, a major cause of noisy hospital environments is the built environment itself. Hospital interiors and furnishings are typically made of hard, reflective materials that won’t harbor infectious organisms and are easily cleaned. All these soundreflecting surfaces propagate noise down hallways and into patient rooms, causing sounds to echo, overlap, and linger.14 Rolling equipment such as procedure carts and housekeeping dollies moving across uncarpeted floors add to the din, as do pneumatic tube systems, metal chart holders, and elevator doors and alarms. The sheer number of people required to care for hospitalized patients—nurses, physicians, technicians, and maintenance and housekeeping staff—contributes to the sound level, and the ratio of staff to patients rises with acuity levels. “Inpatient centralized nurse stations have the highest concentration of people in the smallest footprint,” notes clinical consultant Greenberg.15 “While smaller, decentralized stations where two to three caregivers work are becoming common, the problem of noise can still persist. Even with staff dispersed in decentralized substations, small groups of people frequently congregate in the areas just outside patient rooms.” 16 During shift changes and physician rounds, these gatherings create peak times of occupancy and noise.

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Basics of sound and noise Sound is the effect of vibration on air. Vibration—of vocal cords, of a ringing alarm bell, of a cart wheel that hasn’t been oiled—creates sound waves that transmit the energy of the vibration away from its source. The human ear is sensitive to both the rate of vibration (the frequency of the sound waves) and its intensity. The intensity, the physical pressure of vibrating air particles on the ear drum, is experienced as loudness and measured in decibels. To give an idea of the magnitude of sounds that can be found in hospital environments, the decibel level of a portable X-ray machine is roughly equivalent to that of motorcycle; a bedside monitor alarm approaches the intensity of sound created by heavy truck traffic.17 While sound can be measured objectively, noise is a subjective phenomenon and not an acoustic property. The Environmental Protection Agency defines noise as “any sound that may produce an undesired physiological or psychological effect in an individual or group.” The Occupational Safety and Health Administration’s definition is simply “unwanted sound.” Since there’s no way to measure noise empirically, it must be assessed in relation to other factors—decibels in context, in other words. At the wrong time or place the sound of laughter may be more disturbing than the louder but more appropriate sound of an infusion pump or heart monitor. 18 It’s also important to understand, acoustics experts say, that when it comes to sound management silence is not golden—or the goal. If the level of continuous sound or noise floor of a space is too low, conversations can be easily overheard and sharp sounds like a cabinet door slamming or a glass breaking can startle people unnecessarily. Noticeable changes in sound levels over time and in different areas of the hospital facility make it harder for patients and caregivers to block out unwanted sound. A continuous and consistent noise floor ranging between 42 and 48 dBA can help preserve speech privacy and protect concentration.19 All noise is sound, but all sounds are not necessarily noise. The sound of caregivers moving quietly through the corridors can be reassuring to patients in their rooms. The sound of a harp playing in the background can be soothing, even healing. Assessing and managing the sound environment Hospitals need auditory environments that promote clear and timely communication while also protecting proprietary information from being overheard and possibly misused or misunderstood. Closed doors and other visual barriers can hamper staff accessibility without assuring that patients and their families won’t hear proprietary information or preventing nurses and physicians from exchanging critical information at the right time but in the wrong place. Designing sound environments for hospital facilities, then, must include considerations of intelligibility levels as well as decibel levels. The first step in reducing noise in hospital environments is identifying its sources. A digital decibel meter is an effective tool for measuring the sound levels of specific areas of the hospital at different times of day. The “Sound Quality Committee” at an Atlanta area hospital measured the decibel levels of 238 pieces of equipment, from rolling carts to monitors to communication devices, finding that different mixes of sound sources contributed to the noise levels at different times of day. 20 In addition to quantitative measurements, of course, it is important to assess the perception of noise by patients and their families. This can be accomplished by reviewing patient satisfaction survey results on issues related to disturbances caused by noise. Once noise sources have been identified, a variety of noise-abatement strategies, from sophisticated sound-masking systems to “Quiet, Please!” signs, may be employed. In general, studies of the effectiveness of different measures suggest that design interventions are more successful than organizational or behavioral interventions.21

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However, policy changes regarding use of communications devices can be effective. Switching from loudspeaker paging to vibrating beepers and setting standards governing the use of cell phones, nurse call systems, and the discussion of confidential information in public spaces can go a long way toward reducing unwanted sound and protecting patient privacy. Environmental design strategies for noise reduction include the maintenance and replacement of hospital equipment, the layout and acoustical treatment of patient rooms, nurses’ stations, and corridors, and the implementation of emerging technologies to mask sound, reduce speech intelligibility, and introduce healing sound into the environment.

Equipment repair and replacement With all the rolling carts and machines in hospitals today, considerable noise reduction can be achieved by simply fixing or replacing squeaky wheels and scheduling regular maintenance to keep mobile equipment in quiet working order. The noise level of heavy rolling equipment can be reduced by as much as 30 decibels just by lubricating the moving parts.22 Other effective strategies include padding chart holders and pneumatic tube systems, and lowering volume levels on clinical and communication equipment. Making purchasing choices that are based on auditory performance—selecting folded towel dispensers over roll-type dispensers, for example, or choosing cleaning and maintenance equipment not only for its price and function but also for its decibel output—can contribute to quieter environments. As hospitals adopt Electronic Medical Records (EMRs), they significantly reduce paper charts. However, during the transition to electronic records, charts, with the noises that result from handling them, will persist. Another problem—noise from overhead paging systems—won’t recede until more facilities adopt nurse call systems that use wireless technology. Design of patient rooms and adjacent areas Walls are still the first line of defense in acoustic design. Physical barriers between patients and noise sources will block sound movement fairly effectively if they are of the proper height and constructed of sound-absorbing materials. However, the floor and ceiling can do more to collar noise. Together they typically account for 70 percent to 80 percent of the acoustical properties of a patient room. Noise levels are obviously much lower in single-bed rooms than in shared rooms or bays. Studies consistently show that most of the noise in a shared room is associated with the presence of another patient. One survey of more than two million patients receiving care in 2003 found that patient satisfaction with hospital noise levels was over 11 percent higher in single rooms than doubles. 23 In new hospital construction, there is already a trend toward standardizing on single-bed private rooms. In areas like ICUs and nurses’ stations, where visual access is essential, clear plexiglass or nonbreakable glass is a workable alternative to architectural walls or freestanding partitions. While naturally more sound-reflective than acoustically treated opaque sound baffles, transparent barriers between patient rooms and corridors or nurses’ stations can provide a level of noise control and speech privacy while maintaining an open line of sight. 24 Of course, it’s impossible to erect barriers of any kind between patients and the sound sources within their rooms. Here, the replacement or treatment of hard, reflective surfaces with soundabsorbing materials can dramatically reduce noise levels. Experts recommend materials with a Noise Reduction Coefficient (which measures ability to absorb sound) above .85 and a Ceiling Attenuation Class (measuring ability to block sound) of at least 35. Hospitals that have replaced “hard-lid” ceilings with high-performance acoustical tiles and tiled floors with sound-absorbing carpet report that they have been able to reduce decibel levels and improve patient sleep without sacrificing cleanliness or infection control.25

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Distance is another separation strategy that can be employed. Sound intensity decreases by 6 decibels every time the distance between the sound source and the listener doubles. 26 Locating noisy equipment like ice machines or printers as far as possible from patient rooms (and acoustically treating those locations and connecting corridors to prevent their racket from reverberating its way back to patient rooms) is an obvious but often overlooked plan of action. The location of nurses’ stations is also an important design consideration. Especially during shift changes, the activity level in a central nurses’ station can create decibel levels that approach or even exceed those of a motorcycle or a jack hammer. 27 Decentralizing nurses’ stations, if space allows, disperses people and reduces the concentration of sound emanating from their activities. However, central workstations are likely to remain for several functions on the nursing unit, even with the use of decentralized nurses’ stations. To keep noise in check, careful planning of work zones and locating equipment according to who uses it must be considered. “As part of studying the workflow in these areas,” says clinical consultant Greenberg, “we have the staff look at different ways of organizing functions. The unit secretary has specific needs that are very different than the nurses’. Dispersing the noise created by crowded stations helps everyone concentrate. Because working with medical records and entering and checking physician orders happens in these areas, they are critical places for creating an environment for accurate documentation.” 28

Adding sound to reduce noise Another method for controlling noise involves actually adding sound to the environment. Soundmasking systems work to reduce the distance over which speech and other distracting sounds can be heard by raising the decibel level of the “noise floor” in a controlled fashion.29 A series of speakers installed in the ceiling distributes electronically generated background sound that serves to cover or reduce the impact of noise spikes. This specially engineered sound creates an ambient environment that is perceived to be quieter and that enhances speech privacy in healthcare facilities. Emerging technologies that use computing technology to shape sound offer the possibility of localized sound-masking that can be customized for specific situations. Perhaps eventually individual patients and caregivers will be able to control them. These technologies are particularly effective in masking conversations. If a voice is understandable, it catches one’s attention, and that’s when confidentiality can be broken. Voice-scrambling technology, which uses a sound processor and speakers to multiply and disorder voices that come within its range, addresses this issue. The strategic placement of such devices—in nurses’ or admitting stations, for instance—could go a long way toward protecting patient confidentiality. 30 Adding soft music or nature sounds like falling water to the environment can also help to mask less pleasant sounds and may even offer a healing effect. In hospital settings, music combined with images of nature has been shown to reduce patient requests for pain medication. 31 Keeping it quiet Acoustics experts caution that noise is not a problem that can be fixed once and for all, but an ongoing issue that requires continual attention in healthcare facilities. Regular sound assessments and acoustical maintenance of equipment are essential to sustaining an auditory environment that promotes the effectiveness of caregivers and patient rest and healing. NOTES 1

Nightengale, Florence. Notes on Nursing: What It Is and What It Is Not. First American

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edition. New York: D. AppletonÂ and Co., 2006 (New York, 1860). Found at http://digital.library.upenn.edu/women/nightingale/nursing/nursing.html#IV. 2

Johns Hopkins University. "Rise in Hospital Noise Poses Problems for Patients and Staff." News release, November 21, 2005. Found at http://www.jhu.edu/news_info/news/home05/nov05/noise.html. 3

Ibid.

Greenberg, Linda. Herman Miller for Healthcare clinical consultant, phone interview, February 16, 2006. 5

Cmiel, Cheryl Ann, et al. "Noise Control: A Nursing Team's Approach to Sleep Promotion." American Journal of Nursing, February 2004. 6

Maschke, C., et al. "The influence of stressors on biochemical reactions: A review of present scientific findings with noise." International Journal of Hygiene and Environmental Health, March 2000, cited in Cole, Jasper, et al., "Impact of acoustics on staff and patients in CCU," Hospital Development, November 10, 2005. 7

University of Michigan. "Exposure to high levels of noise increases blood pressure." News release, November 18, 2005. Found at http://www.umich.edu/news/? Releases/2005/Nov05/r111805. Willich, Stefan, et al. "Noise burden and the risk of myocardial infarction." European Heart Journal, November 24, 2005. Found at http://eurheartj.oxfordjournals.org/cgi/content/abstract/ehi658v1. 8

Mazer, Susan. "Stop the Noise: Reduce Errors by Creating a Quieter Hospital Environment." Patient Safety & Quality Healthcare, March/April 2005. 10 Cole, Jasper, et al. "Impact of acoustics on staff and patients in CCU." Hospital Development, November 10, 2005. 11 Greenberg, Linda. Herman Miller for Healthcare consultant, phone interview, February 16, 2006. 12 Cole, Jasper, et al., "Impact of acoustics on staff and patients in CCU." Hospital Development, November 10, 2005. 13 Mazer, Susan. "Stop the Noise: Reduce Errors by Creating a Quieter Hospital Environment." Patient Safety & Quality Healthcare, March/April 2005. 14

Ulrich, Roger, et al. "The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity." Research report, The Center for Health Design, September 2004. 15

Greenberg, Linda. "Planning a Nurse Station for Clinical Function." Herman Miller Inc., 2000. Found at <http://www.hermanmiller.com/hm/content/research_summaries/wp_nursesstation1000.pdf> (February 16, 2006). 16 Greenberg, Linda. Herman Miller for Healthcare consultant, phone interview, February 16, 2006. 17 Cmiel, Cheryl Ann, et al. "Noise Control: A Nursing Team's Approach to Sleep Promotion." American Journal of Nursing, February 2004. 18

Mazer, Susan. "Hear, Hear." Health Facilities Management, April 2005.

Moeller, Niklas. "Sound Masking in Healthcare Environments." Healthcare Design, November 2005. 20 Mazer, Susan. "Sound Advice: Seven Steps for Abating Hospital Noise Problems." Health Facilities Management, May 2002. 21 Ulrich, Roger, et al. "The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity." Research report, The Center for Health Design, September 2004. 22 Mazer, Susan. "Sound Advice: Seven Steps for Abating Hospital Noise Problems." Health Facilities Management, May 2002.

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23 Ulrich, Roger, et al. "The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity." Research report, The Center for Health Design, September 2004. 24 Mazer, Susan. "Sound Advice: Seven Steps for Abating Hospital Noise Problems." Health Facilities Management, May 2002. 25

Dubbs, Dana. "Sound Effects." Health Facilities Management, September 2004.

26 Cmiel, Cheryl Ann, et al. "Noise Control: A Nursing Team's Approach to Sleep Promotion." American Journal of Nursing, February 2004. 27

Ibid.

28 Greenberg, Linda. Herman Miller for Healthcare consultant, phone interview, February 16, 2006. 29 Moeller, Niklas. "Sound Masking in Healthcare Environments." Healthcare Design, November 2005. 30

Markoff, John. "No Privacy in Your Cubicle? Try an Electronic Silencer." The New York Times, May 30, 2005.

Mazer, Susan. "Stop the Noise: Reduce Errors by Creating a Quieter Hospital Environment." Patient Safety & Quality Healthcare, March/April 2005. 31

Roger B. Call, AIA, ACHA, LEED AP, is director, Healthcare Architecture + Design, for Herman Miller for Healthcare, Zeeland, Mich. This article was originally published by Herman Miller for Healthcare.Â He can be reached at Â roger_call@hermanmiller.com.

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