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The Effect of the Hospital Environment on the Patient Experience and Health
Outcomes.
Professor Bryan Lawson, University of Sheffield
John Wells-Thorpe, South Downs Health NHS Trust
Trust Initiative
When self-governing NHS Trusts were set up a decade ago they were given a surprising
amount of autonomy. Hitherto, capital projects had been subject to supervision by
Regional architects and others further up the line, with local input being confined to
detail. All of a sudden the whole process of design procurement became freer and, being
one of the first formed, South Downs Health NHS Trust decided to review completely
how it handled its ongoing construction programme. Through deft financial stewardship
and the sale of surplus property the Trust was able to fund new projects independently
with only supplementary help from other quarters.
In these circumstances it was relatively easy for its first chairman, John Wells-Thorpe to
devise a new design approach that was more responsive to perceived clinical need and
patient welfare, not least of all because he was himself an architect. A number of limited
competitions were launched with the help of the RIBA Competitions Office covering, in
the first instance, a new clinic in Brighton and thereafter a hospital for the elderly
physically and mentally frail at Newhaven. In inviting architectural competitors emphasis
was placed on at least fifty per cent participation by younger practices who would not
have fallen into the category of established hospital architects. The benefit of this
approach was immediate. At briefing stage a fully inclusive dialogue engaged local users
at each level and their input was maintained throughout each project to ensure a sense of
ownership with the finished building, working alongside an enthusiastic design team.
Due to the scale and speed of the new capital programme, which subsequently involved a
new medium secure mental healthcare building to be known as Mill View Hospital Hove,
the Trust adopted a ‘competition by interview’ procedure to save time and for this project
Powell and Moya were selected as architects. And to conclude the entire programme,
MacCormack Jamieson Pritchard were selected for the new rehabilitation centre for
severely physically injured children at Chailey, East Sussex.
Building the research team
The building of Mill View Hospital involved the transfer of a group of mental healthcare
patients from an existing, converted Victorian workhouse to a brand new setting and it
seemed too good an opportunity to miss to try and measure the therapeutic benefit which
would probably ensue through moving to an enhanced environment. Coincidentally,
Poole Hospital Trust in the acute sector had moved patients from old to new
accommodation and had also made a bid for research funding from NHS Estates, so when
South Downs Health made its bid to cover a more comprehensive study it was suggested
the two Trusts collaborate. At that stage it was clear that a leading research- orientated
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University needed to be involved as the third member of the team and, after a shortlist
had been drawn up, Sheffield University School of Architecture was appointed for this
task under the direction of Professor Bryan Lawson, an architect and psychologist. It was
significant that Poole and South Downs were represented by a consultant anaesthetist and
psychiatrist respectively alongside their managers to underline the importance clinicians
were giving to the possible outcome of this study.
We were keenly aware of the pressing need for hard evidence to prove what until then
had been only accepted anecdotally, namely that a well-designed environment could
enhance recovery rates and reduce dependence on analgesics. NHS Estates provided
active support and everyone was also encouraged that the relatively uncharted area of
mental health was being included in the study. At long last the opportunity had arisen to
examine what many distinguished figures outside healthcare had already said for so
many years, not least Sir Winston Churchill who had always asserted that “We shape our
buildings and afterwards our buildings shape us” (Churchill 1943) .
Background
While in hospital patients spend a great deal of time with perhaps rather less purpose than
in their normal lives. This may well make them even more susceptible to the
environment and more sensitive to it. A patient in hospital may get the personal attention
of a doctor for only a few minutes in a day and slightly longer periods of personal care
from nurses and therapists. However they lay in bed, sit, get pushed or walk around in
their environment for many hours. It is reasonable therefore to assume that this
environment may be a contributory factor to their sense of well-being and actual
recovery. Over a century ago Florence Nightingale had noted the importance of their
surroundings to her patients (Nightingale 1860). This work explores those ideas
empirically.
There is remarkably little research of this kind of a holistic nature, but a number of more
detailed studies. Roger Ulrich concluded that patients with a view were more likely to be
released from hospital more quickly than those without (Ulrich 1984). Another study
shows that sunny aspects have a better effect than dull ones (Beauchemin and Hays
1996). Others have looked at the organisation of space and the arrangement of furniture,
for example Baldwin’s work in mental health (Baldwin 1985). Other more anecdotal
work has looked at the effects of music and art in hospitals.
Methodology
Having identified two hospitals where construction was planned we set out to compare
patients’ opinions and health outcomes in the old and new buildings in each case
(Lawson and Phiri 2000). The Poole project involved the refurbishment of existing 1960s
general wards. In the original ward there were six four-bed bays and six one-bed bays.
There were lavatories at each end of the ward. In the refurbished unit there are 16 single
bedrooms and three four-bed bays. The new bedrooms have a clean simple interior using
natural timber and have ensuite bathrooms.
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The Brighton project involved the replacement of two 15-bed wards in the Freshfield
Mental Health Unit of Brighton General Hospital which were housed in Victorian brick
buildings with typically high ceilings with a new purpose built mental health unit. The
new Mill View Hospital that replaced these wards is a 32 bed unit with single rooms with
ensuite facilities.
Inevitably the samples of patients in the new buildings cannot have been perfectly
identical to those in the old, but we are confident that they were as similar as could
reasonably be hoped for in real practice. The patterns of referral, treatment regimes and
other factors were substantially the same and in many cases the staff were also the same.
Samples sizes were approximately 140 in Poole General Hospital where patients typically
stayed for 9 or 10 days, and about 75 in the Brighton Mental Health units where patients
typically stayed rather longer for about 35-40 days.
We first held focus groups with a series of people involved in the commissioning,
management, design and daily use of these kinds of buildings. We wanted to know what
the clients’ expectations were, what the design teams’ intentions were, and what
experienced users of such buildings thought important.
From these focus groups we were able to establish questionnaires that would be
administered to patients at the end of their stay in hospital. We asked them for their
reactions to the building, to the treatment they had received and for assessments of staff
who had been looking after them. We decided in conjunction with our clinical colleagues
that in the case of the mentally ill patients we would administer the questionnaires
through their carers. The patients on the general wards completed their own
questionnaires. At this point is worth noting that the patients were in general very happy
to take part in this study and remarkably forthcoming and articulate about their
environment.
The Patient Experience
The patients in the newer buildings expressed more satisfaction with the appearance,
layout and overall design of their wards. At Poole hospital 72% of the patients in the new
unit gave the highest rating they could for overall appearance compared with only 37% of
the patient in the old unit. At South Downs these figures were both lower with 41%
giving the highest rating in the new unit compared with only 20% in the old. (fig. 1) The
generally lower satisfaction figures in the case of mental health patients is not surprising.
What matters in this study however is not the difference between physical and mental
health patients but in each case the differences between the old and new buildings. A
series of other questions on the overall design and the extent to which the facilities met
the patients’ needs revealed similar responses. In all cases there was a highly statistically
significant difference in favour of the newer building.
Particular spaces in the newer buildings were also more highly praised. The most
significant differences were in the patients’ assessment of their own private area whether
in a multiple bed bay or a single room.
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We asked patients much more detailed questions about the physical environmental
conditions such as lighting, temperature, air quality and noise. Again in both sets of
samples the new building tended to fare better than the old. These differences were less
marked than those for the overall design and spatial organisation of the wards. Next we
asked what levels of control patients had over their environment and here we found
remarkably disappointing results. Patients generally reported low levels of control over
their environment whether in the old or new buildings.
Next we asked our patients quite explicitly if they thought the environment had helped
them to feel better. Both hospitals showed a significant increase in the patients’
assessments of this. We had also asked patients to assess the quality of their overall
treatment and to rate the staff who had cared for them during their stay. In all cases we
found an improvement in these ratings in the newer buildings although these differences
were not always statistically significant. There are so many of these figures that even
though there is a lack of strict statistical significance they seem to paint a remarkably
consistent picture. In the newer environments patients thought they had received better
treatment and that their doctors, nurses and therapists were more helpful and attentive.
We asked our respondents to tell us in their own words what features of their
environment were either particularly good or bad. There are two major groups of factors
that we commonly see in ‘architectural psychology’. The first and most obvious concern
the direct relationship between people and their environment. Such factors would include
the colours of surfaces or the temperature of rooms. However the second group of factors
concern the way the environment mediates the relationships between people (Lawson
2001). Such factors would include matters of privacy or how spaces enable people to
establish community or maintain ‘personal space’.
It is often falsely assumed that the value of good design lies largely in the first category.
Whilst this may be true for designers with heightened senses of aesthetics, in fact it is
more often the second which matters more to ordinary people. This study is no
exception! The most commonly raised issue amongst all four of our patient samples was
that of privacy. That is not to say that all our respondents were asking to be entirely
private; they were most definitely not. However the way the environment enabled them
to be either private or not as they wished seems to be of the greatest importance.
Following on from privacy came the matter of view. The most common complaint made
to us was the lack of view. Nurses and others working in hospitals also mentioned this
problem, not just for themselves but also on behalf of the patients. Again however this
factor should not be interpreted as a purely aesthetic matter. There was no evidence that
in general patients wanted classically beautiful views. If anything it is views of everyday
life that seem in demand here. Views in which something happens seem desirable, and
views that enable conversation between patients of the events unfolding; perhaps children
leaving school.
The next most frequent aspect of the environment to be mentioned was that of the
bathroom/shower/toilet areas available in hospital. Yet again the same message was
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repeated. Patients commonly raised this in connection with the two specific factors of
privacy and cleanliness. Of course patients were concerned about hygiene, or more
commonly the perceived lack of it when such places were dirty. However also important
seemed to be the symbolic value of a lack of cleanliness. What this seemed to be
signalling to patients was the lack of care, pride and concern that the authorities showed
for the environment. In turn of course this sends worrying signals to patients who find
themselves forced to stay in such a place!
Next come the two obvious issues of appearance and noise. Appearance is inevitably a
highly personal matter, but again whatever peoples’ taste they do appreciate an
environment that at least appears cared for. Again not all patients want an entirely silent
ward. What matters most here seems to be to have some degree of control. Our
respondents mentioned this about such things as heating, the lighting, windows and
blinds as well as noise. In fact the newer designed wards continued generally to offer
relatively low levels of patient control of these matters. There is a long way to go it
seems in convincing both clients and designers of their relative importance!
With privacy being such an important issue and our newer wards showing higher levels
of provision in single bed accommodation we decided to investigate this matter in much
more detail. We had already found that the levels of satisfaction with treatment were
higher for those patients in single bed accommodation. At first sight this might suggest
that this is therefore generally more desirable. However this data it turns out was
masking something more subtle and important. A further study was done at Poole
hospital involving a sample of 473 patients on this particular question.
In fact some 54% actually expressed a preference for multiple bed space accommodation.
43% voted for single beds and the rest expressed no preference. This majority in favour
of multiple accommodation may be slightly misleading. We found a majority of patients
expressed a wish to be in the same kind of accommodation as they were occupying at the
time. This may be partly due to patients getting their wish from the hospital and partly
due to them not being able to imagine the alternative. Two common reasons were given
for preferring multiple bed spaces. They were the wish for company and others to chat
to, and a feeling that they were more likely to be given attention by nurses and might be
forgotten about if isolated in their own room.
Now some 22% of patients were moved during their stay in hospital. Often this was
against their wish and to satisfy the needs of another patient. Such a move was not
infrequently made during the night in response to some emergency.
Our data shows very clearly that patients who are in the sort of accommodation they
prefer and are left there, express significantly higher levels of satisfaction than others.
(fig.2) They regard their treatment as better, rate the staff more highly and consider the
overall design of the hospital to be superior. They are also more satisfied with their level
of control over the environment, although this is most particularly true for patients in
single bed rooms. Such patients however did not express any higher levels of
appreciation of the appearance of hospital.
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This data confirms two interesting conclusions. Firstly being able to decide what levels
of privacy and community you want is extremely important to people. Secondly being
able to control the environment is also very high on the agenda. Finally not only does
meeting these needs of people in the design lead to higher levels of satisfaction it also
transfers significantly to their general feeling about their treatment. Whilst it would
clearly be foolish to advocate neglecting the appearance of he environment, this data
unequivocally demonstrates that matters of privacy versus community and personal
control over the environment are much more fundamental and of far greater significance.
Health Outcomes
Our study also looked at the actual health outcomes of the patients. These data were
recorded in the normal way by the clinical staff and extracted for us and associated with
the patient questionnaires. We looked at a number of measures that might indicate
improvements in health outcomes. The most obvious of these is length of stay.
In fact both our physical hospital and mental hospital patients were released significantly
more quickly from the new wards than the old ones. In the general medical wards at
Poole, patients who did not undergo operations were released on average one and a half
days earlier from the new wards. This represents a reduction of about 21% in the average
stay of just over a week. Patients who underwent operations showed no reductions in the
length of their stay post-operatively although there were differences in the pre-operative
stage. The reasons for this seemed unrelated to our study and are not reported here. In
mental health stays in hospital are normally longer with an average stay of over a month,
so the reductions in length of stay of 6 days seems even more dramatic but actually
represents a reduction of about 14%.
On our general medical wards at Poole there was also a dramatic reduction in the amount
of analgesic medication taken by the patients on the newer wards. On the newer wards
the average number of days on which Class A pain killing drugs were administered was
reduced by 22% and the number of doses applied on these days reduced by 47%. To
slightly offset this data there was a slight increase in the amount of Class B drugs taken
on the newer wards.
At Brighton in the new Mill View mental health unit patients were judged by staff as
significantly less aggressive, making fewer verbal outbursts and showing fewer instances
of threatening behaviour. The number of instances of patients injuring themselves was
reduced by two thirds. Most dramatically the amount of time patients needed to spend in
intensive supervisory care was reduced by 70% from 13.1 days to 3.9 days. Finally, staff
assessed some 79% of patients as making good progress with their condition compared
with only 60% in the old buildings. Taken together this paints a picture of a far calmer
and less hostile environment with patients making better progress and being released
earlier. (fig.3)
Conclusions so far
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It seems worth returning to the question of what aspects of the environment were most
correlated with satisfaction and improved health outcomes. We have shown them to be
largely universal rather than specific architectural factors. That is to say they could be
seen to apply to all environments rather than being specific to the hospital. They concern
such general matters as privacy and community, view, environmental comfort and control
of the environment. Whilst they also inevitably involve the appearance of buildings these
factors seem very much more a matter of personal preference. However where the
appearance communicates other more fundamental issues these factors again seemed
important and generic. Untidiness and a lack of cleanliness, when they occurred seemed
important to all our patient samples. These are taken by people to indicate a lack of care,
attention or even love of the place by those responsible for it. The communication of
such values, or lack of them, is clearly disturbing and upsetting to patients. Perhaps
patients are asking themselves; ‘if the place is not loved and cared for, what about the
inhabitants?’ What this work has shown is that design in the form of good place making
can benefit staff and patients and probably save the NHS money at the same time!
The last stage
The research programme now enters its final year and includes three important related
tasks. The first focuses on obtaining a clear idea of the relative costs involved to assist
our understanding of the value of environmental features, particularly in capital and
operating terms. The second task makes accessible the contents of the research via a
database for those commissioning and designing the estate, whilst the third task
concentrates on how best practice can be disseminated throughout the NHS community
and indeed, overseas where a great deal of interest in our work had already been shown,
particularly in Scandinavia and the United States.
We were confident that clinical corroboration of our work could release appropriate
funding to build-in the characteristics that seemed to be critical in any new building.
Similarly, cost effectiveness in outlay and maintenance would attract the serious attention
of estates and facilities managers who, with one or two distinguished exceptions, were
often ambivalent about the purpose and nature of the proposed research.
It has been pointed out by psychologists that social interaction in a hospital can be just as
important a determinant as environmental factors, but there is an obvious link where
spatial arrangements themselves can either facilitate or inhibit such interaction. The
other key factor frequently emphasized was how, in design terms, one must try and give
back to patients a measure of control they lost immediately over such aspects as heat,
light, ventilation and sound once they were put into a bed.
There emerged, of course, related considerations, which will inevitably support and
enhance the benefits of this research. The first is in giving serious priority to post-
occupancy appraisals; and the second is in encouraging better practice and fuller
understanding of the briefing process at the beginning of a project. To date, both of these
aspects have, by and large, been seriously neglected
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Applying the research at last
One of the ripple effects of the research already undertaken is that others working broadly
in the same area in U.K. and Scandinavian universities can now to build on what we have
done. Their interest in architectural psychology has helped to focus on the way that
certain design choices and configurations using colour, light, texture, space and view can
confer predictable therapeutic benefit. A key issue here is to understand more fully the
nature of ‘distraction’ and the part that it plays in the healing process for any sick person
and moreover, how it can be designed-in.
After nearly five years it is encouraging to see at last active support now being given by
political and clinical leaders, who openly support the concept of environmental
intervention as central to the patient’s recovery. At the recent Prince’s Foundation launch
of the new joint initiative between NHS Estates, the Commission for Architecture and the
Built Environment, and the Prince’s Foundation, Secretary of State Alan Milburn said:
“Hospital design has to pay attention to the impact the patient environment has on the
individual patient – their state of mind, their prospects of recovery, their sense of well-
being”. This political imperative is timely because it has already been echoed from the
clinical side by Sir Kenneth Calman and a whole array of distinguished consultants,
some of whom are involved with the new Centre for Medical Humanities at University
College London, which can provide yet another springboard for disseminating good
practice.
References
Baldwin, S. (1985). "Effects of furniture rearrangement on the atmosphere of wards in a
maximum-security hospital." Hospital & Community Psychiatry 36(5): 525-528.
Beauchemin, K. M. and P. Hays (1996). "Sunny hospital rooms expedite recovery from
severe and refractory depressions." Journal of Affective Disorders 40: 49-51.
Churchill, W. (1943). Parliamentary speech.
Lawson, B. (2001). The Language of Space. Oxford, Architectural Press.
Lawson, B. R. and M. Phiri (2000). "Room for improvement." Health Service Journal
110(5688 20:1:2000): 24-27.
Nightingale, F. (1860). Notes on Nursing. London, Harrison and Sons.
Ulrich, R. S. (1984). "View through a window may influence recovery from surgery."
Science 224: 420-421.
