Healing environments and the limits of empirical evidence.
The impact of the environment on health has been a concern to healthcare providers at least since the time of Hippocrates. (1) Healthcare providers and researchers interested in exploring the relationship of healing and the hospital environment are confronted with the predominant focus of acute care: the efficiency of treatment to stabilize and/or cure physiologic disorders. This focus is particularly evident in critical care units, where the technology, work flow, and unit design emphasize standard interventions aimed at the eradication of disease, often at the expense of more individualized in·di·vid·u·al·ize
tr.v. in·di·vid·u·al·ized, in·di·vid·u·al·iz·ing, in·di·vid·u·al·iz·es
1. To give individuality to.
2. To consider or treat individually; particularize.
3. and holistic healing practices. Rather than take this atmosphere for granted as the best approach to life-threatening illness, some healthcare providers would like to remake re·make
tr.v. re·made , re·mak·ing, re·makes
To make again or anew.
1. The act of remaking.
2. Something in remade form, especially a new version of an earlier movie or song. critical care units into humane places of healing that support the physical, emotional, social, and spiritual needs of each patient and family. (2,3)
Given the history and present state of critical care and of the institutions in which it resides, however, I wonder if efforts to transform hospital critical care units into healing environments Healing environment, for healthcare buildings describes a physical setting and organizational culture that supports patients and families through the stresses imposed by illness, hospitalization, medical visits, the process of healing, and sometimes, bereavement. are realistic. Are such efforts even necessary? Would it be better to design a critical care unit that emphasizes efficiency and standardization in pursuit of measurable, disease-based outcomes that does not attend to the individual needs of whole persons within the context of their particular families and communities?
Such questions point to a tension in critical care practice: whereas staff and patients may be aware of the importance of creating healing environments, they nevertheless find themselves in a culture in which an empirical approach to disease--one that focuses primarily on measurable, predetermined pre·de·ter·mine
v. pre·de·ter·mined, pre·de·ter·min·ing, pre·de·ter·mines
1. To determine, decide, or establish in advance: outcomes--is the standard. The tension produced by these circumstances can contribute to moral distress in healthcare providers, patients, and families. Using the environment of the critical care unit as an example, I want to discuss some of the shortcomings A shortcoming is a character flaw.
Shortcomings may also be:
Efficiency, Standardization, and the Empirical Model
Physicians and nurses who practice in the critical care unit in some way participate in a Western scientific understanding of disease. Western science is based on a reductionist re·duc·tion·ism
An attempt or tendency to explain a complex set of facts, entities, phenomena, or structures by another, simpler set: "For the last 400 years science has advanced by reductionism ... empirical account of knowledge in which we know with certainty only those things for which we have a particular kind of evidence. Scientific empiricism scientific empiricism: see logical positivism. seeks inductive inductive
1. eliciting a reaction within an organism.
a form of radiofrequency hyperthermia that selectively heats muscle, blood and proteinaceous tissue, sparing fat and air-containing tissues. confirmation of a theory by reducing problems to the smallest elements that can be experimentally manipulated. Experimental research of this sort seeks what Taylor (4) calls the completely objective "brute fact Brute facts are opposed to institutional facts, in that they do not require the context of an institution to occur. The term was coined by G. E. M. Anscombe and then popularized by John Searle. " that experimental evidence supports and that cannot be disputed.
In this view, disease resides in cells (and, perhaps ultimately, in genes); we know this because cellular dysfunction can be demonstrated experimentally. Within this model, disease can best be controlled by attending to cellular function and dysfunction and by intervening to manipulate the cell using techniques that have empirically demonstrated effectiveness. This understanding of disease rests on the foundation of natural science and is ultimately explained in terms of physical laws.
The overarching o·ver·arch·ing
1. Forming an arch overhead or above: overarching branches.
2. Extending over or throughout: "I am not sure whether the missing ingredient . . . purpose of the critical care unit is to cure disease and/or restore stable physiologic function in patients who are severely ill. In a strict interpretation of scientifically based medicine, medical and other healthcare practice in the Western scientific model should consist of the implementation of standardized practices that are based on the best empirical evidence. The "gold standard" of evidence in this model is the randomized controlled trial A randomized controlled trial (RCT) is a scientific procedure most commonly used in testing medicines or medical procedures. RCTs are considered the most reliable form of scientific evidence because it eliminates all forms of spurious causality. . An intervention is most acceptable when it has been shown in a randomized controlled trial to be better able to accomplish a predetermined outcome than is some other intervention or no intervention at all (placebo). The most familiar example of this experimental design is the clinical drug trial, in which one pharmaceutical compound is tested against a placebo to determine whether it is effective in achieving a specifically defined outcome.
It's clear that the randomized controlled trial is a powerful tool for determining the usefulness of a discrete intervention such as a medication. It's also clear that pharmaceutical interventions are powerful tools in achieving the discretely defined goals of critical care medicine. But how does something less discrete like the environment of the unit contribute to the goals of critical care? As in the case of clinical drug trials, it is possible to describe the impact of the environment in terms of discretely defined variables that are connected to the larger goals of critical care.
One often-sited retrospective study retrospective study,
a study in which a search is made for a relationship between one phenomenon or condition and another that occurred in the past (e.g. has suggested that surgical patients who had a view of nature from the window of their hospital room spent less time in the hospital and required less analgesic analgesic (ăn'əljē`zĭk), any of a diverse group of drugs used to relieve pain. Analgesic drugs include the nonsteroidal anti-inflammatory drugs (NSAIDs) such as the salicylates, narcotic drugs such as morphine, and synthetic drugs medication than did similar patients whose room had a view of another building. (6) To build evidence to support the theory that a hospital window affording a view of nature is an effective intervention to provide comfort and to decrease surgical patients' length of stay in the hospital, we would design a prospective randomized controlled trial using the same variables. This is the kind of evidence that empirically based practice demands in support of a chosen intervention; the intervention is specific and reproducible, and the outcomes are discrete and measurable.
Human Science, Humanity, and Healing
The power of empirically based science is its ability to explain the events of nature in terms of physical laws. To the extent that human physiology Human physiology is the science of the mechanical, physical, and biochemical functions of humans in good health, their organs, and the cells of which they are composed. The principal level of focus of physiology is at the level of organs and systems. is bound by physical laws, empirical methods Empirical method is generally taken to mean the collection of data on which to base a theory or derive a conclusion in science. It is part of the scientific method, but is often mistakenly assumed to be synonymous with the experimental method. can further our understanding. But reproducibility and exact measurement of variables are difficult standards to uphold even in the notoriously controlled world of laboratory science, much less in clinical settings that feature real, whole, human animals. If we look at health as more than simply the absence of disease, and we concern ourselves with the background understandings and processes of human relationships involved in healing as much as with outcomes such as time spent in the hospital, the story becomes richer and can no longer be described or understood by means of empirical evidence. The restoration of health and well-being is not strictly a matter of natural science.
In addition to empirically derived explanations of physiology and disease, healthcare providers must have an appreciation for human meaning derived from philosophy, history, and other branches of the humanities to begin to grasp what lies behind human understandings and experiences of health, disease, and illness. An appreciation for the importance of human experiences and of how a person's understanding affects the process of disease and recovery requires that the healthcare provider expand his or her inquiry and include more than measurable physiologic parameters and other indicators of specific and predetermined outcomes. The meanings that disease and illness hold for patients and their families and the experience of hospitalization hospitalization /hos·pi·tal·iza·tion/ (hos?pi-t'l-i-za´shun)
1. the placing of a patient in a hospital for treatment.
2. the term of confinement in a hospital. and critical illness are important elements that do not lend themselves to empirical evidence-gathering procedures.
In the current healthcare culture, attempts to create a more humane environment are subjected to the same evaluative criteria as interventions directed toward efficiently and safely curing disease. In light of this fact, the needs of hospital staff and administrators for a particular environmental design often take priority over the perhaps less specific and more difficult to justify needs of patients and families. For example, noise has been identified as a problem in the critical care unit, but to best effect a cure, staff members must be able to communicate freely with one another and must have unimpeded unimpeded
not stopped or disrupted by anything
Adj. 1. unimpeded - not slowed or prevented; "a time of unimpeded growth"; "an unimpeded sweep of meadows and hills afforded a peaceful setting" access to technological support and monitoring devices. In the interest of safety, the alarms on these devices must be set at a high enough volume level to be heard over other noises.
Lack of family access can contribute to patients' sense of isolation from their community, and it poses yet another challenge in the critical care unit. However, to meet the demands for critical care services, patients' rooms cannot be large enough to accommodate needed equipment, staff, and family members all at the same time. In the interest of providing the most efficient care, patients and their families are asked to endure a noisy and isolating environment for the time they spend in the critical care unit.
These are small examples of how the desire to create a healing environment healing environment,
n any circumstances that promote recovery from people in the direction of wholeness and healing. is easily subjugated sub·ju·gate
tr.v. sub·ju·gat·ed, sub·ju·gat·ing, sub·ju·gates
1. To bring under control; conquer. See Synonyms at defeat.
2. To make subservient; enslave. to the priority of curing disease and stabilizing physiologic systems. In the fast-paced critical care unit, the demand for efficiency makes prioritizing medical treatment in the interest of cure seem like the only reasonable approach; individualized healing practices often are seen as less important. Concerns such as the meaning illness has for a family or efforts to acknowledge the patient's personhood--for example, bringing a patient's world back by creating a particular environment with music, light, and scent--can seem irrelevant when the problem ultimately resides in the cells and outcomes that are sought are presented in terms of measurable physiologic criteria such as the number of days until the patient is discharged from the hospital.
Room for Process As Well As Outcome
Environmental concerns like the sights, smells, and sounds in the critical care unit may or may not contribute directly to measurable outcomes. The retrospective study of surgical patients previously mentioned concludes that designing patients' rooms such that windows look out onto a garden can positively impact medication use and hospital length of stay. These are undeniably good outcomes, but restricting the inquiry to these discrete variables Discrete variable
Variable like 1, 2, 3. Bond ratings are examples of discrete classifications. may result in insufficient empirical evidence to support hospital redesign. If they are to gain any credibility in a world where evidence-based practice is understood primarily in empirical terms, healing practices such as music therapy, aromatherapy aromatherapy
Therapy using essential oils and water-based colloids extracted from plant materials to promote physical, emotional, and spiritual health and balance. Single or combined extracts may be diffused into inhaled air, used in massage oil, or added to bathwater. , and imagery must fit into the model of a controlled clinical trial controlled clinical trial,
n a research strategy that calls for two samples: an experimental sample of patients receiving a pharmaceutical, and a second sample of control patients receiving a placebo. and demonstrate positive effects as defined by a narrow idea of outcomes.
It is questionable whether such practices can be reduced to any kind of measurement. In fact, it may be a waste of time to try to measure them. I seriously doubt that attention to the environment and the contributions it makes to the recognition of a patient's personhood per·son·hood
The state or condition of being a person, especially having those qualities that confer distinct individuality: "finding her own personhood as a campus activist" and spiritual needs can be reflected in measures such as pain scores, mixed-venous oxygen saturation oxygen saturation sO2 The O2 concentration of blood expressed as a ratio of its total O2-carrying capacity; the OS is a measure of the utilization of O2 transport capacity; sO2 , or hospital length of stay. In the study of surgical patients, the researchers were asking the wrong question. Maintaining a connection to the natural world even in the midst Adv. 1. in the midst - the middle or central part or point; "in the midst of the forest"; "could he walk out in the midst of his piece?"
midmost of illness or injury is an intrinsic good--an unquestionable good in the process of healing that need not be connected to specific outcomes. The more important question is this: Why is the patient's and family's view from the hospital room ever not a concern?
An overriding commitment to empirical science is evident in the culture of critical care; the controlled trial controlled trial Clinical research A clinical study in which one group of participants receives an experimental drug while the other receives either a placebo or an approved–'gold standard' therapy. See Blinding, Double-blinded. is gaining ground, fast becoming the standard for research that provides the most important evidence for critical care practice. The power given to empirical methods at the expense of other ways of knowing contributes to the moral distress healthcare providers experience when space is not given to important healing practices that cannot be demonstrated to contribute to quantifiable outcomes specified by empirically designed research. Benner (7) makes a strong case for the healing potential of relational ethics involving practices such as touch and presence. Like actions to enhance the healing aspects of the critical care environment, these practices are contextual and responsive to the particular; as such, they cannot be supported by evidence gathered using empirical scientific methods. Whereas empirical methods are obviously powerful in the pursuit of natural science explanations, the complexity of situations and relationships involving human understanding demand an approach that reductionist methods such as controlled clinical trials cannot support on their own.
The best healthcare practice therefore demands attention to natural and human science as well as the humanities and values. Critical care professionals must begin to see the possibilities of another world in which healing practices consist of more than bad food (or no food at all), noisy monitors, and drugs derived from randomized controlled trials. We must let ourselves commit to the importance of seeing through the hospital window to the garden or the forest beyond, being touched by a caring nurse or doctor, smelling something other than urine disguised by antiseptic antiseptic, agent that kills or inhibits the growth of microorganisms on the external surfaces of the body. Antiseptics should generally be distinguished from drugs such as antibiotics that destroy microorganisms internally, and from disinfectants, which destroy spray, and listening to the sounds of a hushed unit.
I would never presume to challenge standardized, evidence-based practice at its own game, but I can say with some certainty that it is absurd to use randomized controlled trials to define everything important in critical care. The more thoughtful proponents of evidence-based practice point to the importance of balancing clinical expertise and patient/family values with the evidence provided by empirical research Noun 1. empirical research - an empirical search for knowledge
inquiry, research, enquiry - a search for knowledge; "their pottery deserves more research than it has received" . (8) I encourage us all to commit to exploring alternative ways of looking at practice, healing, disease, and prevention. It is important that healthcare providers work toward making our practice and the environment that supports it reflect our values and our intent to heal regardless of the specific measurable outcomes these acts can generate.
ACKNOWLEDGMENT acknowledgment, in law, formal declaration or admission by a person who executed an instrument (e.g., a will or a deed) that the instrument is his. The acknowledgment is made before a court, a notary public, or any other authorized person.
Thanks to Molly Sutphen, PhD. Research Scholar, Carnegie Foundation
The Carnegie Foundation ("Carnegie Stichting" in Dutch) is an organization based in The Hague, The Netherlands. for the Advancement of Teaching, for her insightful help in articulating the ideas contained in this column.
Lisa Day. RN, CNS See Continuous net settlement.
See continuous net settlement (CNS). , PhD. From the University of California, San Francisco , School of Nursing, Department of Physiological Nursing.
Corresponding author: Lisa Day, RN, PhD. Assistant Clinical Professor, Department of Physiological Nursing, University of California--San Francisco, Campus Box 0610, San Francisco San Francisco (săn frănsĭs`kō), city (1990 pop. 723,959), coextensive with San Francisco co., W Calif., on the tip of a peninsula between the Pacific Ocean and San Francisco Bay, which are connected by the strait known as the Golden , CA 94143 (e-mail: email@example.com).
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