Studies show hospitals are noisy, stressful environments for patients, so researchers set out to change that. Three years after the publication of a white paper of recommendations to transform hospital environments, patients are seeing big improvements.

The Realization
In June 2004, Craig Zimring, PhD, of the Georgia Institute of Technology, Atlanta, and Roger Ulrich, PhD, of Texas A&M University, College Station, summarized an exhaustive review of more than 600 evidence-based approaches to hospital design at a conference sponsored by Robert Wood Johnson Foundation and The Center for Health Design.

"I'm here today because I believe hospitals are unnecessarily stressful and dangerous places," Dr. Zimring told participants at the summit of health care leaders, there to discuss the state of hospitals and establish a vision for the future. "The good news is we've discovered a large body of research that points to some remedies."

The researchers emphasized the importance of eliminating environmental stressors, such as noise, that negatively impact patient outcomes. They highlighted the need to reduce stress and promote healing by making hospitals more pleasant, comfortable, and supportive for both patients and staff. Many of their recommendations were aimed at promoting rest and sleep for hospitalized individuals.

After reviewing evidence-based practices, conference participants developed a white paper, "Designing the Hospital of the 21st Century."¹ Recommendations from that paper have been used to transform hospital environments through a holistic approach that addresses the mind, body, and spirit of those institutions.

Creating a Healing Environment
Drs. Zimring and Ulrich cited ample evidence that pleasant, comfortable, and informative environments relieve stress for patients and family, as well as staff. Their first recommendation was to provide all patients with private rooms.

Carol Chandler, MSN, BA, RN, service excellence and Planetree coordinator at Shady Grove Adventist Hospital in Rockville, Md., described a common scenario in new construction. "Our current med/surg units have both private and semi-private rooms, but in November we'll be moving into a new patient tower with spacious private rooms," she said. "That arrangement will allow patients more rest and privacy.

"We're a Planetree organization, which means we focus on providing patient-centered care in a healing environment," Chandler said. "The interaction between the patient and caregiver, as well as the environment, is very important within this model."

Bringing the Outside in
The white paper lauded design features that improve mood, and noted views of nature and gardens can effectively reduce stress and alleviate pain through pleasant distraction.

Ellen Guarnieri, MHSA, BSN, RN, CPHQ, FACHE, chief executive officer at Robert Wood Johnson University Hospital Hamilton, Hamilton, N.J., talked about how this recommendation was incorporated into their building plans. "The theme of our new building and subsequent renovation of our older space is to create a unique venue that treats the mind, body, and spirit of our patients," she said. "We wanted to create a healing environment using natural lighting and our beautiful campus. The building is positioned to face the lake and park, and we have a two-story glass atrium that overlooks our newest Grounds for Healing, a space with sculptures and a reflecting pool."

Anne Arundel Medical Center, Annapolis, Md., has a similar goal. "We have a healing garden with a small stream and plants right off the meditation center, a nondenominational space for quiet and peaceful contemplation," said Marti Harlan, RN, director of public relations and marketing.

At the Hospital of the University of Pennsylvania, Philadelphia, perioperative cardiac coordinator Rose McGrath, BSN, RN, knows how important the patient-caregiver interaction is. "Once we have a tissue match for a heart transplant, there's a waiting period while our surgeons travel to procure the organ and make sure it's the best one for the recipient," she explained. "During that wait, we do our best to help the patient rest and relax. We use special warming blankets, turn the lights low, and ask what kind of music the person might want to listen to. Besides all of these physical measures, we take the time to sit with patients."

Sound Control
Following the 2004 conference, Dr. Ulrich collaborated with Anjali Joseph, PhD, director of research for The Center for Health Design, on a report, "Sound Control for Improved Outcomes in Healthcare Settings."² The authors found high ambient and peak noise levels in hospitals significantly impact sleep loss; they recommended high-performance sound-absorbing acoustical building materials.

At Anne Arundel, they installed carpet in the hallways so patients wouldn't hear beds moving around, and then ordered motorized beds so nurses wouldn't get injured moving the beds.

At RWJ Hamilton, administrators chose materials for nurses' stations, hallways, and patient rooms to reduce noise, including ceiling tiles, carpets, and quieter wheels on carts.

Lisa Dugan-Kravchak, RN, director of the orthopedic unit at RWJ Hamilton, likes alcoves in the hallway that allow nurses access to the hospital information system. "That way, the nurses' station is quieter, and staff is closer to patients so they can answer call lights quickly and silence them," she explained.

Drs. Ulrich and Joseph also cited a large body of research showing music therapy is effective in reducing anxiety and distress among patients, and promotes rest and relaxation. "We have The C.A.R.E. Channel here at Anne Arundel, with soothing music and nature images," Harlan said. "In addition, our auxiliary staff supplies patients with reading materials to help them relax."

Reducing Loud Noise Sources
Drs. Ulrich and Joseph cited a wealth of research about methods to remove or reduce loud sounds on hospital units, and noted staff education about the impact of noise lowers ambient noise levels. Joy Rende, MSA, RN,C, CNA,BC, director of maternal child health at RWJ Hamilton, concurred, saying: "We did a trial using a noise meter and were constantly setting off the meter. We weren't aware of how our voices can escalate throughout the course of a shift."

In response to those findings, RWJ Hamilton leaders implemented an S-S-H program five years ago. "Employees' children came in and we dressed them as nurses or doctors," Dugan-Kravchak said. "We took pictures of them with their fingers over their mouths to say, 'Shh,' and featured them on wall posters with messages reminding us to be quiet. And each nursing unit has a Quiet Champion on the night shift to remind staff to lower their voices."

Rende mentioned other noise-reducing measures. "We have taught our staff to ask, 'Is there anything else I can do for you right now?' before leaving the patient," she said. "They've rehearsed shutting the door when they leave the room, since patients said hallway noise was bothering them. And we don't move equipment down the hall after 8 p.m."

At Anne Arundel, the new pavilion was designed with private patient rooms around the perimeter and a separate central core to serve as a staging area for ancillary services. "There are dedicated elevators for staff and supplies in that core, so patients don't have to hear everything being moved around," Harlan said.

For many hospitals, formal quiet times provide an oasis of peace, while informally educating staff. "We have implemented quiet time on med/surg units from 1 to 2 p.m. daily," Chandler said. "We try not to schedule interventions for the patient during that time. We limit traffic in the hallways and lower the lights on the unit."

"It's not just the amount of noise, it's the type of noise that's so stressful in the hospital," Chandler concluded. "We remind staff how the noise of our duties and interactions with colleagues can sometimes be a disturbance to the patients we are trying to help. Quiet time really has heightened the caregivers' awareness of how much noise we produce, and how foreign those sounds are to the patient. That awareness helps us manage our noise levels throughout the day, not just for one hour in the afternoon."

References
1. Robert Wood Johnson Foundation. Designing the 21st century hospital. Available from: URL: www.rwjf.org/files/publications/other/Design21CenturyHospital.pdf

2. Joseph A. Sound control for improved outcomes in healthcare settings. The Center for Health Design. Available from: URL: www.healthdesign.org/research/reports/sound.php

Sandy Keefe, MSN, RN, is a regular contributor to ADVANCE.