Regardless of how con-ducive a specific settingis for patient treatment,achieving optimum

patient care is nursing’s mainobjective. Although tried and truesettings generally produce satisfac-tory patient outcomes, it’s impor-tant to stay on top of new environ-mental developments that betterpatient care and advocate for incor-porating them into nursing’s dailypractice.

Holistic environments engagepatients in the conscious process ofself-healing and spiritual growth.Passive ways to promote a holisticatmosphere include providing awindow in a patient’s room thatallows views of nature and naturaldaylight, or painting a wall a softcolor. Conversely, you can activelyincorporate alternative modalities,such as music or art therapy. Suchsuggestions actually originatedwith Florence Nightingale, whoonce observed that the variety ofform and brilliancy of color inobjects presented to patients aidedtheir recovery.1

The Planetree movementThe introduction of holistic environ-ments in this country is traced tothe Planetree movement, whichbegan in 1978. Planetree’s founder,Angelica Thieriot, realized duringher personal experiences as apatient that highly technical med-ical care with no attention to spiri-tual, social, or emotional needscomprised her dysfunctionaldichotomy. Convinced that medi-cine had lost its holistic, patient-centered focus, Thieriot sought toreturn the healthcare perspective tothe patient with the advent of thePlanetree facility.

The name Planetree was takenfrom the planetree, or sycamoretree, which was the legendary siteof the ancient Greek physician Hip-pocrates when lecturing his stu-dents. In 1985, supported by fund-ing from The Henry J. Kaiser Fam-ily Foundation and The San Fran-cisco Foundation, a 13-bed Plane-tree model unit was opened atPacific Presbyterian Medical Centerin San Francisco. Planetree pio-neered many patient-centered care

concepts, including access to infor-mation by providing open nursingstations, encouraging patientreviews and written comments oncharts, having patients and familymembers directly communicatewith physicians and staff on theirindividualized care plan, and hav-ing access to research and infor-mation through onsite medicallibraries.1

A different perspectiveArchitecturally, a typical inpatientunit includes a central core of pri-vate staff rooms and nursing sta-tions separated by a corridor toaccess standard patient rooms onthe outside of the floor. In contrast,Planetree units offer more patientspaces to address the spiritual,social, and emotional needs ofpatients and their families. Typicalwalls “guarding” the nursing sta-tion are removed, allowing patientaccess into the station.

In addition to structural ameni-ties, nurses encourage patients toleave their rooms and visit thelounge, or make a snack in the

www.nursingmanagement.com July 2006 Nursing Management 31

By Linda Porter Bishop, ASID, IIDA, AAHID, and Charles Griffin, AIA, ACHA

2.0CONTACT HOURS

CE

Natural, patient-centeredenvironments bring quality healthcare

full circle by addressing patients’ spiritual,social, and emotional needs.

The authors have disclosed that they have no significant relationship with or financial interestin any commercial companies that pertain to this educational activity.

33

pediatric unit was 60 dB and nevervaried whether day or night.8

Unfortunately, hospital personnelactually produce the majority ofwhat’s considered noise. Whether it’sat the patient’s bedside or the nurs-ing station in the form of conversa-tions, noise affects the daily activitiesinherent in modern hospitals.5

To create a holistic or healingenvironment on a nursing unit, youmust first consider noise control.This can range from fixing asqueaking or fast-closing door,installing carpet in a nursing stationand patient corridors, or addingacoustical panels or tiles in nursingstations or corridor walls.

Noise from televisions is apatient distraction that’s sometimesoverlooked. If it’s necessary to offer

television in a room that’s one largespace, provide headphones.

The family perspectiveTo care for the family as a compo-nent of caring for the patient, sup-port and involve the family in car-ing. Achieving holism and familycenteredness depends on yourresponse to family care and willing-ness to find a fit for the family in theICU environment.9,10 In a study of165 staff members in a hospital inFinland, 66% considered nurse/family interactions vital to the provi-sion of holistic patient care and animportant determinant of familyhealth and successful post-hospitalpatient care. Unfortunately, the samestudy showed that less experiencednurses placed less emphasis on

nurse/family interactions.10

In 1997, a study detailing familymembers’ experiences of their role ina hospital reported that 68% of thefamilies of patients spent 1 to 3 hourson each visit to their loved ones, with18% spending more than 3 hours.Eighty percent of the respondentsreported that the hospitalization oftheir kin had changed family life,with young adults (89%; 29 to 39years) feeling the effects mostacutely. Most of the visits (49%) tookplace in the patient’s room, with 22%occurring in the hospital cafeteriaand 20% in the patient lounge on thesame floor. Eighty-seven percentreported they visited privately. Sur-prisingly, when asked for the form of support, 90% responded theywanted staff support for information.

kitchenette with a family member.Family members can stay withpatients, visiting hours are open,children are welcomed, and over-night stays are accommodated. Thisrequires a larger patient room to pro-vide a comfortable bed for the familymember. Each room promotes indi-vidualization via different paint col-ors and shelving for patients’ per-sonal belongings and family photos.

To encourage post-Planetree qual-ity of life, qualified patients learn aself-medicating program with a pri-mary goal of patient responsibility.Patients receive a fact sheet of op-tional medicines with their potentialside effects, and patients make deci-sions with the assistance of a phar-macist. Family members act as carepartners and learn early care prac-tices for the patient’s home recovery.Since philosophically, the body,mind, and spirit must be addressedand healed, spaces for relaxation ormassage therapy are included, andareas are identified to accommodatethe visual arts. Music therapy isaccommodated, with space providedin the family and patient lounges forpianos. Moreover, a medical librarywith books and research tools is pro-vided to allow patients easier accessto information.1

Over time, holistic medicine prac-tices have shown considerable ben-efits for participating Planetree pa-tients. Today, the Planetree Alliancehas more than 95 healthcare facili-ties throughout the United States,Canada, and Europe, ranging fromsmall community hospitals to largeurban campuses. The success of thisorganization is a testament to howthe architectural and environmentalfacets of healthcare positively affecta patient’s healing.

Evidence-based design Today, many healthcare providersclaim to offer holistic, healing, orpatient-focused care, yet confusion

remains. There’s the “hospitel”movement, in which hospitals re-semble hotels with budget to bou-tique-type amenities. Also, the“hospital as spa” movement boastsrestful environments similar tohigh-cost, pampering experiences.

The nonprofit Center for HealthDesign supports and promotes thisgrowing holistic environmentmovement. Based on rigorousresearch, the movement has beenidentified as evidence-based design(EBD). EBD occurs when an evi-dence-based designer makes criticaldecisions together with an informedclient on the basis of the best avail-able information from credibleresearch and the evaluation of com-pleted projects.2 This movementchanges the design process fromarchitects believing it’s better todesign a unit or facility differentlyto having evidence-based data thatshows improved patient outcomesbased on a different unit or facilitydesign.

Triangle of focusThe Planetree model is based onrigorous research and evidence. Atriangle that comprises addressingthe needs of patients, their familymembers, and the staff caring forboth defines this model. Crucial tothis model is an understanding ofthe stressors that diminish the heal-ing process and a deliberate designto minimize those stressors.

By incorporating the triangle’sprinciples, nurses can improvepatient healing and minimize thelength of stay, and thus improvepatient satisfaction. Additionally,when patient satisfaction improves,staff satisfaction improves.

Environmental psychologistsdeliberate on the theories of restora-tive environments and the experi-ence of place. The experience of nat-ural environments contributes tostress reduction and promotes posi-

tive moods and feelings.3 Suchrestorative natural environmentsfacilitate recovery from illness.4

Furthermore, research indicates thatemphasizing the recovering aspectsof places allows patients to relaxand distance themselves from ordi-nary aspects of life. In doing so,their minds are free to be at peace,unlike when in noisy, invasive envi-ronments typically found in health-care facilities.

Disturbing the peaceNoise refers to any unwantedsound that disrupts performance, isannoying, and is physiologicallyand psychologically stressful.5 Thephysiological effects of exposure toaudible noise include cardiovascu-lar stimulation, increased gastricsecretion, pituitary and adrenalgland stimulation, and suppressionof the immune response to infec-tion. Noise also causes staff“burnout” in critical care nurses,postoperative delirium in patients,and affects female reproduction andfertility. In a 15-item questionnairedeveloped to assess nursing staffknowledge on the physiologicaleffects of noise exposure, only 5% ofnurses were able to correctlyanswer the questions.5

While nurses commonly acceptthat sleep is important for ill pa-tients, understanding sleep doesn’tget the prominence it deserves innursing education and practice. Of454 patients studied, 155 reportedsleep disruption caused by noise.6

Results of a similar study report themost common disruption of sleeppatterns in an intensive care unit(ICU) is attributed to noise.7

Patients reported ICU noise levelsranging from 50 to 75 decibels (dB)with peaks to 85 dB (factory noise iscomparable to 80 dB; a busy officeis 70 dB). In a study done at JohnsHopkins Medical Center, engineersfound the average noise level on a

www.nursingmanagement.com32 Nursing Management July 2006

H O L I S T I C H E A L I N G

ties, and sufficient room for familymembers are important for thepatient’s care. Family supportincludes accommodations in thepatient room as well as familyspaces on the care unit. Don’t mini-mize staff support spaces. Designateareas for stress reduction in appro-priate environments, as well as per-sonal amenities and educational andpersonal development programsnecessary for staff appreciation,recruitment, and retention. Overall,remember to consider noise reduc-tion, as research clearly identifiesphysiological and psychologicalissues when noise isn’t addressed.By considering and implementingas many of these concepts as possi-ble, you’ll ensure a win-win designfor patients, family members, staff,and your facility. NM

REFERENCES1. Frampton S, Gilpin L, Charmel P, eds.

Putting Patients First: Designing andPracticing Patient-Centered Care. Hobo-ken, NJ: Jossey-Bass; 2003.

2. Hamilton K. Hospital architecture: evi-dence-based design and the art of heal-ing. Powerpoint presentation for Architec-ture of Hospitals conference, Groningen,Norway. April 13-15, 2005.

3. Scopelliti M, Giuliani M. Choosing restora-tive environments across the lifespan: amatter of place experience. J EnvironPsychol. 2004;24(4):423-437.

4. Ulrich RS. View through a window mayinfluence recovery from surgery. Science.1984;224(4647):420-421.

5. Christensen M. What knowledge do ICUnurses have with regard to the effects ofnoise exposure in the intensive care unit?Intensive Crit Care Nurs. 2005;21(4):199-207.

6. Southwell M, Wistow G. Sleep in hospitalsat night: are patients’ needs being met? J Adv Nurs. 1995;21(6):1101-1109.

7. Parthasarathy S, Tobin M. Sleep in theintensive care unit. Intensive Care Med.2004;30(2):197-206.

8. Boyce N. Hospital seeks quieter stays forpatients. National Public Radio. Morningedition, December 29, 2005.

9. Pryzby B. Effects of nurse caring behav-

iours on family stress responses in criti-cal care. Intensive Crit Care Nurs.2005;21(1):16-23.

10. Astedt-Kurki P, Apaunonen M, Lehti K.Family members’ experiences of theirrole in a hospital: a pilot study. J AdvNurs. 1997;25(5):908-914.

11. The American Institute of Architects. Theacademy update. February 10, 2006.Available at: http://www.aia.org/nwsltr_aah.cfm?pagename=aah_gd_hospcons.Accessed June 15, 2006.

12. Simmons J. Health organizations look to‘higher ground’ to reduce turnover,achieve quality care. Qual Lett HealthcLead. 2002;14(5):2-9.

13. Parsons R, Hartig T. Environmental psy-chophysiology. In: Cacioppo J, TassinaryL, Berntson G, eds. Handbook of Psy-chophysiology. 2nd ed. New York, NY:Cambridge University Press; 2000.

ABOUT THE AUTHORSLinda Porter Bishop is senior interiordesigner and Charles Griffin is senior princi-pal and senior project manager at WHRArchitects, Houston and Dallas, Tex. WHRArchitects specializes in evidence-baseddesign for healthcare, science, and researchfacilities.

www.nursingmanagement.com July 2006 Nursing Management 35

That is, family members viewedinformation about their loved one asthe most important form of support.This finding contrasts strongly tostudies done in the 1980s indicatingfamilies wanted emotional supportfrom staff.

Because of these statistics, hospi-tals nationwide are initiating pro-grams to identify when and how toinvolve families in patient care. Thepolicies include allowing families inthe operating room during emer-gency procedures, code events, andresuscitation attempts. Nurses haveurged the increase in family in-volvement with the support of theAmerican Association of Critical-Care Nurses and the EmergencyNurses Association.

In addition to an increase in fam-ily participation, revisions in thebuilt environment need to occur toproperly accommodate the family.Foremost and concurring with theJune 2006 American Institute ofArchitects’ healthcare guidelines,private patient rooms seem obvi-ous.11 Accommodating overnightfamily stays, in a standard twin-sized mattress instead of a chair,seems equally justified. Other itemsto consider include providing fam-ily lounges for brief respites from acritically ill loved one with freshand healthy refreshments, currentmagazines and newspapers, andaccess to technology; opportunitiesfor cooking family meals, baking acelebratory birthday cake, or shar-ing a snack; and medical librarieswith access to technology.

The staff perspective As learned from Planetree, recog-nizing and integrating staff needsare vital to any holistic environ-ment. The Higher Ground Leader-ship Program, introduced by MountCarmel Health System, helps stafffind meaning, fulfillment, andinspiration in the workplace. The

main reason staff members resign istheir relationship with their super-visors, and the second reason istheir relationships with theircoworkers. The program seeks toreinforce harmony in all facets ofeach staff member’s work life.12

As recently as 10 years ago, thehealthcare design industry showedsharp differentiation betweenpatient or public spaces and back-of-house or staff spaces. Fundsweren’t allocated to create comfort-able staff areas. Often, staff loungesreceived minimal design featuresthat included vinyl tile and paintedwalls with a refrigerator, micro-wave, and wall-mounted televi-sions. Today, efforts bring the sameamenities offered to patients tostaff, such as views to nature andnatural light, comfortable lounge-type seating, and access to technol-ogy for the majority that don’t havean office or “touch down” spaceduring the day. Some hospitalshave enhanced their appeal withsuch amenities as 24/7 deliveryservice from the in-house cafeteriaor outside vendors, reduced rates atlocal gyms and fitness centers, drycleaning, valet and car service, childcare, and reduced tuition packagesat local colleges.

As with patients, awareness ofthe effect of noise on job perfor-mance is central to the staff per-spective. Various studies concludedthat noise can have definite effectson performance and that tasksrequiring concentration and sus-tained attention likely suffer fromnoise.13 Thus, make efforts to havequiet meditation areas as well asquiet patient charting spaces. Addi-tional studies indicate that exposureto noise can elicit negative changesin mood when noise interferes withongoing activities.13 If noise can’t becontrolled or eliminated, ensuring aquiet and convenient staff lounge isimportant.

A worthwhile endeavorImplementing these ideas in ahealthcare facility is challenging,but worthwhile. First, understandthe benefits of a holistic designapproach. Next, gain senior man-agement’s support and commit-ment, and champion the idea toother stakeholders in the organiza-tion. Talk about holistic designapproaches to various groups,involve staff in design decisions,and continually articulate the pro-ject’s goals and objectives in othercommunication formats, such asnewsletters, posters, e-mail, andWeb sites.

As the project goes through anumber of phases, from design toconstruction, everything will comeunder budget scrutiny. It’s impor-tant to prioritize and make difficultdecisions as to what’s affordable.Senior management will need tostand behind the holistic designideas with a much longer-termvalue. For example, providinglarger windows in patient roomsallows for greater access to the out-doors and natural light, whichreduces the length of stay andamount of required pain medica-tion.4 Although larger windowscost more upfront, there is a long-term value.

A win-win situationEvidence-based design in holistic orhealing environments addresses notjust the patient’s needs, but also theneeds of the family and staff whileintegrating all three areas success-fully. The Planetree Alliance, origi-nated in 1985, forms the foundationfor holistic environments to providethe necessary blueprint for self-heal-ing and spiritual growth. The Cen-ter for Health Design’s work linkedresearch to these concepts. Views tonature and natural light, appropri-ate art, space for personal belong-ings, alternative medicine modali-

www.nursingmanagement.com34 Nursing Management July 2006

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Holistic healing methods positively advance patient careTEST INSTRUCTIONS• To take the test online, go to our secure Web site at http://www.nursingcenter.com/ce/nm.• On the print form, record your answers in the test answer section of theCE enrollment form on page 36. Each question has only one correctanswer. You may make copies of these forms.• Complete the registration information and course evaluation. Mail thecompleted form and registration fee of $16.95 to: Lippincott Williams& Wilkins, CE Group, 2710 Yorktowne Blvd., Brick, NJ 08723. We willmail your certificate in 4 to 6 weeks. For faster service, include a fax num-ber and we will fax your certificate within 2 business days of receiving yourenrollment form. • You will receive your CE certificate of earned contact hours and ananswer key to review your results. There is no minimum passing grade.• Registration deadline is July 31, 2008.

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Earn CE credit online: Go to http://www.nursingcenter.com/CE/NM andreceive a certificate within minutes.

Holistic healing methods positively advance patient careGENERAL PURPOSE: To provide the registered professional nurse with an overview of holistic healing environment concepts for improving patient outcomes.LEARNING OBJECTIVES: After reading this article and taking this test, you should be able to: 1. Review the concepts and identify the organizations which areengaged with promotion of holistic healing environments. 2. Discuss aspects of healthcare that have been shown to affect the healing environment.

1. Holistic environments are designed to a. enable self-care in patients’ home environment.b. encourage self-care in a highly technological

environment.c. facilitate care provided by family and lessen care

required from staff.d. engage patients in self-healing and spiritual

growth.

2. The Planetree movement of holistic environ-mentsa. began in l988.b. was founded by Angelica Thieriot.c. was established by Florence Nightingale.d. addresses only the medical needs of patients in a

hospital setting.

3. Planetree patient-centered concepts incorpo-ratea. closed, confined, and comfortable nursing sta-

tions.b. restricted patient access to medical records to

reduce stress.c. access to research and information via onsite

medical libraries.d. communication only between nurses and physi-

cians about patient care plans.

4. New architectural concepts incorporating thePlanetree concepts include which of the follow-ing?a. private, enclosed nursing stationsb. a small patient room without windowsc. a comfortable lounge area for patients and fami-

liesd. limited shelving and closet space

5. How many Planetree Alliance healthcare fa-cilities are in the United States, Canada, andEurope?a. less than 25 c. about 75b. about 50 d. over 95

6. The patient-focused holistic environment ofthe Planetree model focuses ona. building a spa-type facility.

b. architectural and environmental facets of health-care.

c. providing high-cost pampering.d. inclusion of boutique-type amenities.

7. Evidence-based design promotes environ-ments for healthcare bya. making decisions with the client based on patient

outcome research.b. making decisions based on the clients’ prefer-

ences.c. basing an architectural plan on “hospitel” con-

cepts.d. focusing on cost containment.

8. The Planetree “triangle principles” include allof the following excepta. addressing the needs of patient, family, and

healthcare staff.b. understanding stressors that diminish the healing

process.c. delaying discharge until achievement of mind-

body-spirit balance.d. developing a deliberate design to minimize stres-

sors.

9. Restorative natural environments are thoughtto do all of the following excepta. promote positive feelings.b. improve cognitive function.c. distance oneself from ordinary aspects of life.d. free one’s mind to be at peace.

10. Exposure to audible noise can causea. decreased gastric secretions.b. a stimulated cardiovascular system.c. decreased pituitary gland function.d. stimulated immune response against infection.

11. Which is true about the noise researchreported in this article? a. Fifty percent of patients reported sleep disruption

caused by noise.b. Fifty percent of nurses knew about the physiologi-

cal effects of noise.c. Intensive care unit noise levels were consistently

lower than either a busy office or factory.d. Average noise levels on a pediatric unit were con-

sistent throughout the day and night.

12. Which finding was supported by the 1990sresearch studies cited in the article?a. More experienced nurses placed less emphasis on

nurse/family interactions.b. Less experienced nurses placed more emphasis

on nurse/family interaction.c. Less experienced nurses placed less emphasis on

nurse/family interaction.d. Families wanted more emotional support than

informational support from staff.

13. The Higher Ground Leadership Program intro-duced by the Mount Carmel Health System isdesigned toa. help staff find meaning, fulfillment, and inspiration

in the workplace.b. find solutions to reduce noise levels to promote a

healing environment.c. address the needs of family members to promote

a holistic environment.d. address the needs of the patient to promote spiri-

tual growth.

14. Suggestions for implementing holistic heal-ing approaches in healthcare facilities include allof the following excepta. maximizing natural light.b. providing quiet, comfortable staff lounges.c. providing large chairs for family to sleep in patient

rooms overnight.d. arranging for reduced membership rates for staff

at fitness clubs.

15. How does noise affect staff in the healthcaresetting?a. It has no adverse effect on staff, only on patients.b. It interferes with concentration, but not perfor-

mance.c. It interferes with performance, but not concentra-

tion.d. It has adverse effects on both performance and

concentration.

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