A Systematic Literature Review of Healing Environments in the Inpatient Healthcare Setting

Abstract

Background: Health care settings are generally regarded as stress inducing environments. Stress can alter the immune response, impair wound healing and create a greater risk for asthma, diabetes, gastrointestinal disorder and myocardial infarction. Beginning in the 1980s and 1990s, there has been increasing interest in healing environments and evidence-based design concepts. Yet, there has been little progress developing healing environments and using evidence-based design for psychiatric inpatient units, a uniquely stressful environment. Psychiatric units today continue to use designs such as caged in outdoor patio areas that resemble facilities that incarcerate rather than facilities which reduce stress and facilitate healing. The purpose of this systematic literature review was to identify design features that are evidence-based which can be used to create an optimal inpatient psychiatric patient room by: (1) analyzing the research literature for evidence of architectural and design elements that could be used in the inpatient psychiatric care setting to reduce stress and improve the well-being; (2) identifying design elements that are consistent with accreditation and licensing standards for inpatient psychiatric units; and (3) designing a psychiatric inpatient room that has evidence-based elements to reduce stress and improve well-being. Methods: A systematic literature review was conducted to identify factors in the inpatient healthcare environment that support an optimal healing environment. The PICO question for this review was what design factors in the inpatient healthcare environment support an optimal healing environment? A search of five databases and a hand search of reference lists were conducted. The search included studies from 1980 to the present, original research conducted on inpatient units with adult patients that investigated an intervention with an outcome that promotes a healing environment. Experimental, quasi-experimental, non-experimental, systematic literature reviews and expert opinions were sought and evaluated using a scale to analyze scientific rigor and research quality. Results: A total of 6,874 articles were identified in the search. Seventy-six articles were eligible for full text screening. After review of the full text, 38 articles were determined to be eligible for evidence analysis. After removing 11 inadmissible articles due to poor quality, 27 articles were included in the final synthesis. The search found research on eight hospital design features which may support optimal healing environments: artwork (n = 7), building configuration (n = 2), finish materials (n = 7), interior details (n = 6), lighting (n = 11), nature and view (n = 8), noise (n = 10), room configuration (n = 6). More than 50% of the research on optimal healing environments used quasi-experimental and non-experimental designs with rare use of experimental research designs. Overall, the quality of the research on optimal healing environments is not high, but results were reasonably consistent across studies. Conclusions: Evidence suggests seven design features for healing inpatient psychiatric environments, including: (a) single rooms, (b) calm, naturalistic and domestic artwork or photographs, (c) east facing windows, (d) plants, (e) acoustic ceiling tiles, (f) patient rooms removed from noise producing unit areas and (g) a window view of nature. These seven recommendations were examined for consistency with existing Arizona statutes and industry standards for behavioral health care environments. Recommendations found to be inconsistent with these statutes and standards were modified to reach congruency with the statutes and guidelines, and then an evidence-based design of a psychiatric inpatient room design was formulated and is illustrated. Future research on interventions to create healing environments at the greatest scientific rigor is needed along with measurement techniques to quantify stress responses to the environment.