Building healthier hospitals
Can the way hospitals are designed improve the experiences of staff and visitors, and even the recovery of patients? Lucy Maddox finds out.
“If one room can alter how we feel, if our happiness can hang on the colour of the walls or the shape of a door, what will happen to us in most of the places we are forced to look at and inhabit? What will we experience in a house with prison-like windows, stained carpet tiles and plastic curtains?” — Alain de Botton
This summer, Laura gave birth to twins. Five weeks early.
Laura’s girls were looked after in the Dyson Centre for Neonatal Care at the Royal United Hospital in Bath, England. Laura arrived there after a caesarean section, having lost more blood than expected and with a dangerously low temperature. Despite her condition, she remembers being wheeled through the double doors of the Centre for the first time: “It’s kind of a blur,” she says. “But I do remember the light just really hitting me.”
To reach the Dyson Centre you have to walk, or be wheeled, through the old corridors of the main hospital. It feels hot, that particularly uncomfortable hospital warmth that amplifies the medical smell. Your shoes click on the lino floors and the sound echoes off the plain walls.
As soon as you go through the doors to the Centre, things change. It is light, airy and spacious. Natural wood and soothing greens make it feel more like a Scandinavian spa than part of a hospital. You’re greeted by a wooden reception desk, and to the left, French windows open onto a Zen-like pebbled garden. It smells slightly of chlorine, like a posh swimming pool.
The Dyson Centre, finished in 2011 and funded in part by Sir James Dyson, of vacuum cleaner fame, is an example of a new and different type of healthcare design. Deliberately distancing itself from the traditional hospital look, feel and smell, this and other places like it are drawing on a growing body of research that shows that buildings themselves can speed the recovery of patients, as well as boosting the health and happiness of the staff who work in them.
The Dyson Centre is eight decibels quieter than the old Neonatal Intensive Care Unit that it replaced, and has both more natural and more controllable light. A central corridor loops round in a horseshoe shape with smaller rooms coming off it. The ceiling of the corridor is high, with skylights running its whole length, bright blue sky visible throughout. The upper walls are painted moss green. The floor below is a sandstone colour and the walls and the ceiling beams are whitewashed wood, not unlike a sauna.
The babies who need most care are in the high-dependency room. It’s dark as you enter, but the room still feels spacious, and the size of the tiny babies makes it seem even bigger. Born before they were quite ready, the babies are a disconcertingly dark red colour and lie in futuristic white cots with plastic bubbles protecting them. Further round the corridor the rooms progressively become lighter, with fewer machines, and bigger, healthier-looking babies.
The ward was designed to give parents a sense of progress as their newborns move from the high-dependency room to regular neonatal rooms. Laura, mum of the twin girls, noticed this sense of flow: “It’s like a horseshoe really. You have to make your way around.”
Looking at the original sketches for the Centre, one of them stands out. The architect has drawn the building like a hug, its arms enveloping a baby. “The whole point… was to provide a secure base,” says clinical psychologist Dr Mike Osborn, who was part of the team consulted about the design. “Secure base” is a term from attachment theory. It explains how as infants we attach to our primary caregivers, using them as a secure base from which to explore the world, and returning to them when we are afraid, ill or in need of care and reassurance. “Essentially we want the building to be a great big nurse. A really good nurse,” he says.
The design principles in typical healthcare environments inadvertently make patients and staff more stressed, Osborn says. “Ceilings are low, the lights are glaring, the floors are noisy, the privacy is non-existent,” he says. “It all accumulates to push us towards hyperarousal… it’s not soothing at all.”
For a building to be therapeutic, it should have spaces that flex to allow both sociability and privacy. Social spaces with comfortable, movable furniture encourage people to speak to other patients. Places that encourage family and friends to visit, like single-bed rooms or private areas which can be screened off, increase visiting, reduce patient stress and speed up recovery.
The Centre has been designed to allow families to get a balance between socialising with other patients and privacy. For example, relatives are free to rearrange the chairs, which are different heights: tall ones for looking in the incubators and lower, more comfortable ones for holding the babies.
“It’s very different,” says Debbie Grant, nurse specialist at the Centre. “I can honestly say I fell in love with this building.”
James Dyson, who enjoys living in the Wiltshire countryside, believes that good hospital design can make people get better more quickly. “Well-considered design and the inventive use of technology at the Dyson Centre for Neonatal Care is improving the health of premature babies,” he says. “New research, comparing the old and the new building, has proved that the building is a treatment in itself.”
Clinicians from the Centre were involved in the research to measure the impact. Unable, for obvious reasons, to ask the babies themselves how they felt, the team devised new and ingenious ways of measuring the activity of babies, staff and parents.
Ten families using the old unit and ten families using the new Centre took part in the research, along with over 40 staff members. Staff movement was tracked using wifi and infrared receivers. The result? Staff in the new Centre spent nearly twice as much time in clinical rooms with the babies as the staff in the old unit did.
The tricky problem of how to measure the babies’ activity was solved by designing special baby accelerometers that fix on to their nappies. Usually used to measure the speed and movement of aircraft and sportspeople, the accelerometers were repurposed to monitor the breathing patterns of the sleeping babies, without any need for invasive tubing and tangled wires. “We had to colour-code them because initially people started throwing them away with the nappy,” says Professor Mark Tooley, a consultant clinical scientist who co-led the research.
The babies in the new Centre slept for 20 per cent longer than those in the old unit. Dr Bernie Marden, a consultant neonatologist who co-led the research, explains that this is crucial for premature babies, because sleep is “when all the brain development gets done”.
Parents visited the new Centre for an average of 30 minutes longer a day. Parents and staff reported feeling less cramped and less stressed than those in the old unit. Ninety per cent of babies observed in the new Centre were breastfed, compared with 64 per cent of those studied in the old unit.Now, Osborn and colleagues are hoping to employ the principles used in the Centre to create a new cancer centre. Dyson has agreed to fund part of it, and they are fundraising to cover the rest. Osborn explains that in a cancer centre the cure is also sometimes part of the stress. He thinks that the gruelling nature of chemotherapy and radiotherapy shouldn’t be underestimated: “It’s all relative because however nice the place is, it’s still the scene of the crime.”
Research into buildings that make us recover better goes back to the 1980s, and has gathered momentum in recent years. Roger Ulrich, Professor of Architecture at Chalmers University of Technology in Sweden, was one of the first to research how hospital buildings can affect patients.
In 1984, Ulrich took advantage of a natural experiment created by a long hospital corridor, in which half the patients had a view of a brick wall and half a view of trees. The patients facing the natural view got better more quickly and reported less pain than those facing the wall. They asked for fewer painkillers and reported fewer minor complications like headaches or sickness. “Reducing stress, and distracting patients from their internal focus or their obsession on their own pain, reduces the pain,” says Ulrich.
Other studies have shown similar results. In one experiment, bedridden heart-surgery patients were given colour pictures to look at after their operations. Patients looking at an open, well-lit and natural image of trees and water needed fewer painkillers than patients who had no picture or an abstract image. Another studyfound that healthy volunteers sat in a hospital had a higher pain threshold and better pain tolerance when they were watching a video of nature scenery than when they were watching a blank static screen.
Healthcare design has been improving in the USA, western Europe, Australia and parts of Asia, says Ulrich. The USA, in particular, is leading the way with design initiatives that aim to reduce the spread of infection, such as single-occupancy rooms. In one study, at McGill University in Canada, a move to only single bedrooms in an intensive care unit resulted in 10 per cent shorter stays than in another unit in a local hospital where not all the rooms were single.
Sleep is important. Poor quantity and quality of sleep can lead to increased stress, impaired immune function and difficulties with temperature regulation. Perhaps unsurprisingly, patients in quieter hospitals report that they sleep better. A quieter environment is also associated with fewer patients returning to hospital after discharge, perhaps because of the additional benefits that sleep brings.
The impact of noise on staff has been less widely researched, but this is changing. Studies show that working in quieter hospitals can buffer against stress at work, possibly also helping clinicians to sleep better when they go home. Less noise and better-lit environments also reduce clinician error.
Naturally lit rooms, which allow patients to see whether it’s day or night, have been linked to better sleep, less pain and less stress. In one study patients in naturally lit rooms took fewer painkillers than those in darker rooms, leading to a 21 per cent reduction in medication costs.
The Maggie’s Centre at Newcastle looks a bit like a Teletubby building as you view it across the car park, from the entrance of the main cancer ward. Surrounded by wild flowers and vibrant green grasses, it is topped off, mushroom-like, with a flattened solar panel. As you approach, the head of a tall statue becomes visible over the fence.
Inside, the building exudes a heavy feeling of calm, like a very expensive, modern house. The building faces south and light floods in through the windows. You can see flowers or grass from every room. Nature is reflected on the inside too, where most of the surfaces are wood. In the kitchen, there’s a long wooden table in front of the doors that lead out to the garden. Outside, people are sitting at another table, chatting and drinking tea out of nice mugs. There is nothing clinical about this space. It feels more like somewhere you’d spend a weekend away in the country.
Maggie’s centres are built in hospital grounds specifically for people affected by cancer. There are 15 centres around the UK and one in Hong Kong, with more in development. The centres were the idea of Maggie Keswick Jencks, a designer married to the architect and designer Charles Jencks. After being diagnosed with cancer, from which she died in 1995, Maggie worked to create a blueprint for a place for people affected by cancer that was different from the traditional hospital. Each Maggie’s centre is designed differently, following the blueprint of essentials which Maggie and her husband drew up.
The Newcastle Maggie’s was finished in 2013 and designed by architects from Cullinan Studio in London. One of them, Lucy Brittain, explains how the centres began: “Maggie got her diagnosis [of cancer]… in her 20-minute slot with her consultant, who then said ‘I’m really sorry, I know it’s terrible news, but I’ve got another patient to see.’ And she was in shock. She got put out into one of these stereotypical corridors with nowhere to sit, and all she wanted was to go and have a cry and take it all in.”
Maggie wanted to have a more human place to absorb what was happening, and thought about what patients and families need during cancer diagnosis and treatment. The brief she came up with is hard to categorise.
“Charles Jenks writes that [the Maggie’s Centres] are like a balance between all these typologies,” says Brittain. “So it’s a bit more than a house, but it’s not a house, and it’s into art, but it‘s not an art gallery, and it’s kind of spiritual, but it’s not a church, and it’s like a hospital, but it’s not medical.”
“I came to look around… walked in, and had this amazing feeling, like never before,” says Karen Verrill, Head of the Newcastle Maggie’s, remembering her first visit, made while she was deciding whether to accept the job.
People often arrive at the Maggie’s Centre when they’ve just been given a diagnosis. “A lot of it doesn’t register properly,” says Verrill. “It’s not unusual to see someone walk across the threshold for the first time and burst into tears. I think it’s that they’ve found somewhere safe to come to.”
Cancer treatment often requires a lot of sitting around and waiting. “When somebody’s very ill and they need to be rushed in, they don’t care where they’re going as long as it makes them feel less ill,” says Verrill. “But when you’re having routine treatment for a life-threatening illness like cancer, that’s when the environment makes more of a difference.”
Verrill thinks the building also makes it easier for the staff to cope with their sometimes difficult jobs. “Treating people every day, all day, can take its toll… [But here], if I’ve got a few people waiting for me, which I often do have, I don’t feel as stressed as I used to… For me it’s an amazing place to be, to work.”
JJ was a young Royal Navy submariner when he found out that he had cancer. He is still in his early 20s, but looks older. JJ hated to eat in the hospital so Verrill used to pick him up some tea to have on days when he was due for treatment. “I can’t really remember the first time I came. I wasn’t in the best place,” says JJ. “They thought I wasn’t going to survive.”
At Maggie’s, JJ likes to spend time in the kitchen, “in the centre of it all”. But he also appreciates the flexibility of the space. “There’s places you can disappear to as well. I used to go and have a little sleep. I don’t do much here, I like to soak it all in. I’ll sit and talk to people, sit in the garden and absorb the weather. It’s therapeutic.”
Simone, 46, speaks of her experience in hospitals: “Some of those corridors really give you the creeps. They’re those sort of beige magnolia colours, the sort of slightly sick vomity colour… and that feeling of being really claustrophobic. And the waiting rooms… you were all sitting almost like on a bus.”
When Simone had to decide whether to have chemotherapy, coming to Maggie’s really helped: “the light, the kitchen table, everything is so welcoming and so inclusive,” she says. “Somebody just made me a cup of tea and I waited for Karen… That sense of being really valued at a time when you are really struggling is very important…
“People can walk in here and come in anonymously… if you just want to sneak in and make a cup of tea you can do that. Usually somebody will smile at you but no one will force you to do anything.”
Most of us have been lost in a hospital. The corridors all look the same, the signs for the department you want are there one minute and then gone the next. Everybody seems too busy for you to bother them asking for directions.
Getting lost is not only a cause of stress to patients and their families, but, when staff have to give directions, it is also a waste of clinical time. One study in a 600-bed hospital estimated that poor wayfaring cost over $220,000 a year. Much of this was due to the 4,500 hours of clinical time a year — approximately two full-time positions — that was spent giving directions to lost patients and even staff.
Signs at every junction and clear demarcations of different areas with visual cues such as different-coloured floors or walls can help. Some of these principles have also been used for making wards dementia-friendly.
While clear wayfinding is crucial, the research suggests, weirdly, that we also do better in buildings that are not totally straightforward. Therapeutic spaces need to take into account not only the balance of sociability versus privacy, but also the tension between simplicity and complexity. Layouts need to be coherent enough for us to feel we that understand where we are and can interact easily and safely, but complex enough to give us a sense of exploration and mystery, a feeling that not all the space has been revealed at once.
The idea of mystery as a therapeutic element in hospital spaces seems counter-intuitive: why would we want to make environments more complex? The idea comes partly from evolutionary theories that suggest we will stay interested and alert if we have a sense that there are elements of our environment left to discover. But we also need to be able to feel that we have somewhere safe we can retreat to or hide if necessary.
There are many places in the Newcastle Maggie’s Centre where you could slip off and curl up in a corner if you wanted to, without bothering anyone, then wake up and continue with whatever was going on. There are no signs, and areas reveal themselves to you as you explore, like the mezzanine and roof garden that you see only when you walk up the stairs.
It feels like a building that holds a lot of emotion, one where it is possible to sit still and realise what you are feeling. The kitchen, garden and living room are shared spaces that promote sociability, but the smaller rooms provide easily accessible aloneness. Even the toilets contain a comfy chair, in case you want to sit and take a moment on your own.
Oslo’s landscape is a fairytale from above. Clouds give way to dark green forests, which are interrupted by smaller lakes, then larger lakes, then ragged-edged fjords joining the sea. Sandy-coloured roads wind through the trees and rock breaks through in rough textured patches on the hillsides. The pools scattered everywhere make established forests seem like they are growing up from temporary swampland. There is a sprinkling of houses, gathering mass nearer the airport.
The colours are all natural: the dark blue-greens of trees, the blue-black of the water, the misty blue-greys of the mountains receding into the far distance. White clouds hang still above, with purple, rain-bruised underbellies. This is a country where nature is all around you, even in the city, seeping up from the ground, on all sides and above. It is hardly surprising that nature is reflected in Norwegian building design.
Oslo’s Akershus Hospital, completed in 2008, won the coveted Better Building Healthcare Award for Best International Design in 2009 and is widely recognised as an excellent example of modern health-promoting architecture. In contrast to its backdrop of fir trees and hills, the hospital looks imposingly modern, all straight lines and white. As you follow the path round to the main doors, piano music pipes out of embedded speakers. A pregnant woman and her partner are on their way out, crying, and a sick-looking man in a dressing gown is having a cigarette. The entrance has two sets of revolving doors, one then another, in an effort to keep heat loss to a minimum.
Inside, the ceiling is high and pale wood is everywhere. To the left are some cosy lamps attached to wooden sofa-shaped benches. It is light, modern and noticeably quiet. If you walk a few metres further in, the ceiling suddenly opens up even more, stretching up several storeys and drawing the eye towards the sky, which is visible through the huge glass roof. Bridge-like open corridors traverse the atrium connecting one side of the hospital to the other.
Architect Anne Underhaug, from CF Møller, was involved in designing the hospital, along with other architects, doctors and nurses. For her, the wood and light are not particularly linked to the research on their value, but more to the experience of living in Scandinavia. “Daylight means a lot in Scandinavia because half the year you don’t have very much,” she says. “Regulations are very very strict on daylight. Unlike in the US where you don’t have any daylight regulations at all, where you can have an office with no windows… Here the operating theatres have windows in as well, everything, even the X-ray rooms and CT rooms, MRI rooms, all of them have daylight.”
As for the materials: “Have you seen the houses in Norway?” she laughs. “We build everything out of wood.”
One side of the hospital houses the wards, the other the treatment buildings. Through the middle runs the large glass-covered atrium, with shops, cafés and a hairdresser. The central ‘street’ is a principle copied from other Scandinavian hospitals and allows more normal social interaction in a central fluid space. Smaller, more private places come off the main street, and all areas are built with flexibility in mind. The different parts of the hospital are built so that wards are near other wards with similar functions.
The wards at Akershus have a cluster design, where equipment and nurses are shared between a certain number of patients. There are no closed nursing offices — instead the nurses sit at exposed desks in the middle of the ward corridors. This was a major change. One of the hospital’s nursing team leaders says: “It’s a good thing but also a challenge… You need to be very flexible.”
This wasn’t the only change that took adjustment. “The vision was to make a very technically advanced hospital,” says Underhaug. “It was actually too technically advanced. The people couldn’t use it when they moved over.” The electronic dosage system for prescribing and giving out medication had to be put on hold for a year so staff could get used to it. Clinicians at the hospital are now used to seeing the robots that deliver items gliding about, but for me they were a source of delight.
Within the building, hidden conduits transport waste and resources. Equipment is stored locally and can be ordered to clinical areas or dispatched to the sterilisation system via pneumatic delivery tubes. The containers used to carry equipment and clinical samples around the hospital are opened by another robot, Roberta. She lives in the basement and exists to stop the staff from getting wrist strain.
Akershus was built with the newest technologies at the forefront of its design. But has this made a difference? The majority of the hospital’s heating is provided renewably by heat-pump plants from specially drilled wells, 200 metres underground, on a neighbouring farmer’s land.
Looking at the length of time that patients stay there, it’s hard to draw comparisons as the new hospital serves more elderly patients than the one it replaced did. However, even with an older and more medically complex population, the average bed stay is now four days: approximately one day less than in the old hospital.
The impressive modernity of Akershus and the beauty of the building as you move around it seem to speak for the principles of evidence-based design. But Underhaug doesn’t agree. “I think evidence-based design came afterwards… People need to look out, they need the daylight. You don’t need a book on evidence-based design to know that.”
She thinks that the economic and social climate is more relevant than the research in Norway’s hospital design; that architectural judgement and human instinct play as much a part in good design as the research and textbooks. “Of course I would like to say that it’s our thinking that we like to be light and concerned about material,” she says. “I think it actually has more to do with the fact that hospital buildings in Norway go in cycles.”
While in neighbouring Denmark a large programme of hospital building was carried out at once, in Norway hospitals have been built in phases, each learning from the last. Akershus follows in the wake of Rikshospital, also in Oslo, and St Olav’s in Trondheim, and it uses similar principles of light, space and nature. Publicly funded, the hospital received about £700 million from the Norwegian government. “I think it was the right time,” said Underhaug. “Because also the economy was quite good and you could start to think about what you really wanted… and a kind of public discussion, what should a hospital be?”
Despite the available evidence, hospitals and clinics vary hugely in how much they take into account the design factors that we know are better for patient health. Many healthcare services are housed in buildings that do the exact opposite of what research suggests is helpful.
So, what should a hospital be? Are we treating patients and making staff work in places that are likely to make them feel worse? Shouldn’t the buildings where healthcare is given themselves have health-promoting properties?
The King’s Fund, an independent charity working to improve health and healthcare in England, has collated research on healthcare design. Sarah Waller, its Programme Director for Enhancing the Healing Environment, acknowledges the financial tensions that many services face. “It depends totally on what the service is going to provide and what’s affordable,” she says.
“There are still some big builds but more often it’s refurbishment… We have a better understanding than we did have, and there are some beautiful examples, for instance, some beautiful hospital gardens, but a lot of it still gets forgotten. And a lot of architects say they challenge their clients but the client says there’s not enough money.”
Roger Ulrich, the researcher who first compared natural and non-natural views in hospitals, firmly believes that good hospital design can save money. “It’s clear that hospital design can help reduce pain and stress,” he says. “By carefully selecting, in evidence-based ways, certain important design upgrades when creating a new hospital, the design upgrades will cost more, e.g., single rooms, measures to reduce noise, but they pay back rather quickly by shortening stays and reducing other costs.”
Ulrich also links better-designed buildings with staff who are happier and more effective, and who spend more time with patients while coping better with the demands of their jobs.
It’s not just cost that gets in the way of better buildings. “The timeline in designing, creating and building a hospital is at least five years, often ten,” says Ulrich. “So any hospital that opens its doors today is at a minimum five years out of date. The edge of knowledge moves on.”
An estimated 40,000 people are hospitalised every day in the UK alone, and even more work in healthcare services. As the world’s population continues to expand, and the proportion of those who are elderly grows, medical care — especially for the very young and very old — is more important than ever.
It might be expensive to invest in better design now, but the alternative means leaving patients and staff in buildings that make them feel sicker and more stressed. While the ferocious financial pressures on healthcare services make investment difficult, the research suggests that putting short-term costs ahead of the evidence on health-promoting buildings could cost us all dear.
In a related Mosaic story, Bryn Nelson explores how classroom design affects teachers and students.
Author: Lucy Maddox
Editor: Chrissie Giles
Copyeditor: Tom Freeman
Art director: Peta Bell
Fact checker: Francine Almash
Illustrator: Elena Boils
An overview of much of the literature (up to 2008) by Professor Ulrich, who originally did the experiment with different hospital views (abstract only).
Maggie Keswick Jencks’s personal perspective on healthcare architecture (PDF).
The original ‘room with a view’ study from 1984 by Roger Ulrich (PDF).