Home > RNJ > 2006 > November/December > Editorial: Is Your Healthcare Environment Therapeutic?

Editorial: Is Your Healthcare Environment Therapeutic?
Elaine Tilka Miller, DNS RN CRRN FAHA FAAN: Rehabilitation Nursing Editor

There is mounting evidence that physical environments correlate with patient outcomes. For instance, we now know that natural light, paintings or pictures, music, colorful fabrics, family space, a non-institutional feel, and other such environmental items have a strong effect on a patient’s well-being and are associated with health improvement.

As patients enter the healthcare setting, there is an element of uncertainty regarding their health status, what to expect, safety concerns, and a sense of isolation from familiar support systems. In recent years, more attention is being given to the value of a “therapeutic environment.” Its importance emerges from the basic premise that physical environment has an overall positive effect upon patient outcomes. This idea is not based purely on theory, but on well-respected empirical studies. Healthcare architects, interior designers, and researchers have collectively identified evidenced-based factors that, if applied to diverse healthcare environments, improve patient outcomes by reducing or eliminating undesirable stressors, providing positive distractions, permitting social support, and giving patients a greater sense of control.

Environmental Stressors

When dealing with Alzheimer’s patients in 15 special care units, environmental characteristics significantly correlated with behavioral outcomes even when individual patient characteristics (e.g., age, sex, length of stay) and nonenviromental facility characteristics (e.g., number of patients, size of facility) were taken into account (Zeisel et al., 2003). Behaviors such as verbal aggression (cursing), physical aggression (hitting, kicking, biting), wandering, restlessness, attention seeking, and noncompliance were reduced with privacy and personalization of space, use of common spaces to facilitate interaction with others, and a use of a more homelike, less institutional environment.

In another study, Roberts (2000) found that lighting serves as a major stressor that can alter mood, increase stress, disrupt daily rhythms, and modulate hormone production. Because lighting supports natural circadian rhythms, natural daylighting or bright white lights (400–600 nm) should only be used in the daytime, while only red lights (650–700 nm) should be present for nighttime movement. Other factors frequently identified as major contributors are the maintenance of good air quality, acoustical separation of staff work areas from patient rooms, appropriate use of color, and comfortable furnishings and room layouts.

Amazingly, many of these key attributes were identified long ago by Florence Nightingale as factors promoting positive patient outcomes. Aesthetic aspects of an environment excite, delight, and stimulate warm, homelike comforting feelings. Yet, despite the tendency to take our environment and patient responses for granted, we must remain vigilant regarding how individual patients interpret and react to the environmental stressors and the potential impact these responses have on their behaviors as well as neuroendocrine and immune systems.

Positive Distractions and Social Support

Connections to nature and interactions with family play a key role in the healing process. New healthcare facilities more regularly provide additional space in rooms for families, resource rooms to educate patients and family regarding their illnesses, and more ambient features such as music, artwork depicting nature, water features (e.g., ponds, water fountains), healing gardens, and opportunities for pet therapy. Additional research supports the premise that blood pressure and anxiety in patients, families, and health professionals can be significantly decreased with more therapeutically oriented physical environments (Schweitzer, Gilpin, & Frampton, 2004; Shannon & French, 2005).

Providing a Sense of Control

For many patients, entry into the healthcare system results in a loss of control over their time, decision making, comfort level, sense of security, and familiarity with their personal environments. Providing privacy, some degree of control over their environments, even if appearing minor (i.e., reading light, pictures of loved ones), can be incredibly important to patients and families. Although the illness or reason for hospitalization may vary, the need for some degree of control is a commonality among most patients (even those confused and disoriented) that can affect overall well-being.

Even though most of us take our work and home environments for granted, much can be done to create and advocate for a therapeutic environment for our patients, their families, and healthcare professionals. Exploring the evidence that supports positive outcomes in practice settings is an essential responsibility that all of us must assume.

What does this mounting evidence mean to rehabilitation nursing? First, we must have a greater awareness of the effect that different caregiving environments have on our patients and understand that this awareness is backed by empirical evidence. Second, we need to advocate for our patients and their families so that others in our system understand the impact of environment on healthcare outcomes. Third, we should play a larger role in room and common area redesigns, and make suggestions to the architects and planners on the importance of environment to our patients and make specific recommendations that will benefit both patients and families. As nurses, we understand the importance of environment. The key is in getting others to have this same understanding and to be thinking of new and inventive ways to make our caring environments healthier for our patients, families, and caregiving professionals.


Roberts, J. E. (2000). Light and immunomodulation. Annals of the New York Academy of Sciences, 917, 435–445.

Schweitzer, M., Gilpin, L. & Frampton, S. (2004). Healing spaces: Elements of environmental design that make an impact on health. Journal Alternative Complementary Medicine, 10(1), S71-83.

Shannon, V., & French, S. (2005). The impact of the re-engineered world of health-care in Canada on nursing and patient outcomes. Nursing Inquiry, 12(3), 231–239.

Zeisel, J., Silverstein, N M., Hyde, J., Levkoff, S., Lawton, M P. & Holmes, W. (2003). Environmental correlates to behavioral health outcomes in Alzheimer’s Special Care Units. The Gerontologist, 43(5), 697–711.