Healing Architecture: For a long time, we have supposed that good design will improve patient well-being. Now we have figures to prove it. Bryan Lawson reports on how patient treatment and behaviour improved with new architecture. (Theory).

Most hospital patients may get the personal attention of a doctor for only a few minutes a day and slightly longer periods of personal care from nurses and therapists. However they often remain in bed, or if they are more fortunate sit, for many hours with little to do. This may well make them even more susceptible to the environment and more sensitive to it. It is reasonable therefore to assume that environment maybe a contribatory factor to their snese of well-being and actual recovery. Over a century ago Florence Nightingale noted the effect of their sort founding on her patients. (1)

Our research set out to test the proposition by measuring effects on patients of hospital architecture. Many in the field poured scorn on our work. Suggesting that patients in hospital have other things on their mmd than the quality of architecture. In fact, we found patients extraordinarily responsive to and articulate about their surroundings. We also found that not only can them time on hospital be substantially improved through good architecture but also that the treatment they receive appears to be enhanced. (1)

One general medical and one mental health hospital were upgrading their accommodation using what is currently considered best practice in hospital design. In each case the hospitals were providing new wards bus using the same patients of patient referral and same treatment regimes in the new buildings as they had in the old ones. In many cases medical and clinical staff were the same. This enabled us, as far as in practically possible, to see clearly any effects resulting from changes to patients environment. (1)

Poole Hospital Trust was returbishing a series of existing 1960s general wards. In the original wards there were six four-bed bays and six one bed bays with lavatories at each end of the ward. In the refurbished unit there are 16 single bedrooms and there four-bed bays. The new bedrooms have a clean simple interior using matural timber and have ensuite bathrooms.

At South Downs Health NHS Trust in Brighten the original accommodation for the mentally ill comprised 15-bed wards in typical Victorian brick institutional buildings with characteristically high ceilings. These were replaced with a new medium secure mental healthcare building designed by Powell and Moya using only single rooms and now known as Mill View Hospital Hove.

Higher satisfaction

In both the newly designed wards, patients showed very significantly higher levels of satisfaction with their surroundings. Ratings given by patients in the newer hospitals were significantly higher for appearance, overall design and spatial organization. Patients in the two new sets of wards were particularly pleased with their own private area, whether it was a room of their own or a bay in a multiple bed ward. (5)

Significantly more of the patients in the newer wards told us that the environment had helped them to feel better. We went on to ask them about the treatment they had received and the staff who bad cared for them. Remarkably, patients in the newly designed environments gave significantly better ratings to their actual treatment. Indeed they also thought more highly of the staff treating them. In most cases these were actually the same people. Some of these differences were not statistically significant but he overall picture is remarkably clear. In the newer environments, patients were more content, though they had received better treatment and their doctors, nurses and therapists were more helpful and attentive.

So far, although this is empirical evidence to support our argument about the effect of architecture on patients, it still remains largely subjective. Two questions remain. First, do the patients actually benefit from this in real health outcomes? Second, what are the major contributory architectural factors responsible?

The two health trusts involved monitored the patients and provided us with a mass of data about their progress while in hospital. Measuring patient progress is not as simple a matter as it might seem since there are many potential indicators with perhaps the most obvious being length of treatment.

In fact many patients in both our physical hospital and mental hospital samples were released significantly more quickly from the new wards than from the old ones. Non-operative acute patients showed a significant reduction of some 21 per cent in treatment times and mental health patients a reduction of 14 per cent.

However, there are interesting indicators that further contribute to the picture. In our physical hospital, analgesic medication is largely taken on demand within prescribed limits. There was a dramatic reduction in the amount of analgesic medication taken by the patients on the new wards. (1) Effectively here we see patients requesting less pain-killing medication in the new hospital ward environments than in the old.

In a mental health hospital it is normal to record many items of patient behaviour including all instances of verbal abuse, physical violence towards others and physical self harm. These records were studied and the results quite remarkable. While the number of incidents of verbal and physical abuse remained largely the same, their severity dropped quite significantly in the new wards. The number of instances of patients injuring themselves was dramatically reduced by two thirds. Patients who become particularly distressed and are considered a danger to themselves are normally put for a period into seclusion in a safe room with intense supervisory care. The amount of time this was necessary was reduced by a remarkable 70 per cent in the new unit with an average reduction of nine days, from 13 to four in a typical stay.

A clear and consistent picture emerges from a very complex set of data. Patients in the new buildings seem to spend less time in hospital and appear to feel less physical pain or to be psychologically calmer. In addition to making life better for patients, this must in turn make life easier for the staff, certainly in the mental hospital. Finally of course this may well result in significant savings in the cost of treatment, but we have yet to show this and to quantify it.

What should architects do?

Next we set about trying to ascertain exactly which features and aspects of the environment were responsible for causing these effects. What is it that architects should concentrate on to stand the best chance of promoting this healing architecture?

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 such studies of the psychology of place. (2) The first and most obvious concern the direct relationship between people and their environment. Such factors might 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. Such factors might include matters of privacy or how spaces enable people to establish community or maintain personal place.

It is often falsely assumed that the value of good design ties largely in the first category. While this may be true for designers with heightened visual sensibility in fact it is more often the second group that matters more to ordinary people. This study is no exception. The most commonly raised issue among 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 he either private or not as they wished seems to be of the greatest importance in them and them sense of well-being.

Following from privacy came the matter of view - or more often the lack of it. Nurses and other clinical staff also mentioned this problem, not just for themselves but on behalf of their patients too. There had already been some other evidence that patient treatment times can be reduced when they have a view. 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 ordinary life that seem in demand. Views in which something happens seem desirable, and views that enable conversation between patients of the events unfolding perhaps children leaving school or the postman on his rounds.

Next came the two obvious issues of appearance and noise. Appearance is inevitably a highly personal matter, although many patients agreed on the desirability of high and airy spaces. Whatever peoples taste they also appreciate an environment that appears loved and cared for. The acoustic environment secured almost as important as the visual one. While many complained about noise, not all patients want an entirely silent ward. What matters most here seems to be to have some degree of control. Both patients and the staff mentioned this about such things as heating, the lighting, windows and blinds as well as noise. In fact the newer wards generally continued to offer relatively low levels of patient control of these matters. In a separate study done of what healthcare professionals think important. It became apparent that such issues seldom appear in the brief for architects. 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 of single rooms we decided to investigate this matter in much detail. In fact just over half of the patients in our sample expressed a preference for multiple bed space accommodation rather than a private room. Two reasons were commonly given for preferring multiple bed spaces: the wish for company and others to chat to and a feeling that they were more likely to be given attention by nurses there was a fear that they might be forgotten if isolated in their own room. So the debate is a classical one for architects between the two great forces of community and privacy. Which you prefer is clearly a matter both of personal preference and circumstance.

Appreciating architecture

Our data show 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. They regard their treatment as better, rate the staff more highly and consider the overall design of the hospital to be superior. Such patients however did not express any higher levels of appreciation of the appearance of hospital.

These data confirm two interesting conclusions. First, being able to decide what levels of privacy and community you want is extremely important to people. Second, being able to control the environment is also very high on the agenda. 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. While it would clearly be foolish to advocate neglecting the appearance of the environment, these data unequivocally demonstrate that matters of privacy versus community and personal control over the environment are fundamental and of great significance to most of us.

These results offer some interesting lessons for architects and their clients. We have shown the architectural factors that appear to be responsible for increased patient well-being to be generally universal rather than specific. They could be seen to apply to many environment rather than being particular to the hospital. As well as visual appearance, they concern such general matters as privacy and community, view, environmental comfort and control of the environment.

Such factors taken together could surely be thought of as a mater of good place-making. Sadly in the highly technical world of contemporary medicine, place-making, often seems to come low down if at all on the list of considerations. Perhaps its frequent neglect in recent hospital design is as much a result of the tyranny of the functionalist view of architecture as it is of overly technical briefs. An yet our results show that not only is place-making very important to the well-being of patients but that good architecture may turn out to extremely good value for money compared with the highly expensive treatment that are administered in our hospitals.

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(1.) Nightingale, I (1860), Notes on Nursing, London, Harrison and Sons.

(2.) The project funded by NHS states at the University of Sheffield was directed by Bryan Lawson, an architect and psychologist, chaired by John-Wells Thorpe, both an architect and an NHS Trust chairman. South Downs Health NHS Trust and Poole Hospital NHS Trust collaborated.

(3.) For more details of the research methods used see Lawson B.R. and M. Phiri (2000). 'Room for improvement', Health Service Journal 110(5688 20:1:2000):24-27.

(4.) Samples sizes were approximately 40 in Poole General Hospital where patients typically stayed for nine or 10 days, and about 75 in the Brighton Mental Health units where patients typically stayed rather longer for about 35-40 days.

(5.) At Poole Hospital 72 percent of the patients in the new unit gave the highest rating they could for overall appearance compared with only 37 percent of the patients in the old unit. At South Down, these figures were both lower with 41 percent giving the highest rating in the new unit compared with only 20 percent in the old. Generally lower satisfaction figures in the case of mental health patients is expected.

(6.) On the newer wards the average number of days on which Class A pain-killing drugs were administered was reduced by 22 percent and the number of doses applied on these days of Class B drugs taken on the newer wards.

(7.) For a fuller discussion of this see Lawson,B.( 2001). The language of Space, Oxford, Architectural Press.

(8.) Ulrich R.S. (1984). 'View through a window may influence recovery from surgery', Science 224:420-421.

(9.) A further study was done at Poole Hospital involving a sample of 473 patients on this particular question.

(10.) Sadly, some 22 percent of our patients were moved during their stay not for their own good but as a result of need to accommodate others. Such moves were frequently at very short notice and often at night.

(11.) In a separate study for NHS Estates we showed that although senior health service managers and patients agreed about the importance of this issues, those responsible for briefing architects did not share this view but rather laid emphasis on more technnical matters.