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ACUTE CARE OF THE ELDERLY COLUMN Establishing a Therapeutic Hospital Environment: The Patient Perspective Lorraine C. Mion, PhD, RN, FAAN ‘‘It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm.’’ —Florence Nightingale Hospitals can be dangerous places. According to the Institute of Medicine, more Americans die each year from medical errors and hospital- acquired infections than from AIDS, breast can- cer, or automobile accidents. 1,2 Up to 1 in 20 inpa- tients contract a hospital-acquired infection and patient fall injuries are estimated to exceed $30 billion by 2020. The Centers for Medicare and Medicaid Services (CMS) deems these as ‘‘never events’’ and will no longer cover the cost of hos- pital care for medical errors, hospital-acquired infections, or patient injuries. The hospital environment is an integral part of patient safety. It affects not only the patient, but also the family, staff, and organization. It is im- portant to note that no environment is neutral; rather, the effects can be positive or negative. Studies have shown that stressful environments can cause psychological distress resulting in anxiety, anger, sleeplessness, or depression and physiologic reactions such as increased blood pressure and cortisol levels. For the orga- nization, these effects can result in increased in- efficiencies and higher costs. When considering the context of older adult patients, we need to remember that this is a vulnerable group with an acute disease or condition superimposed on chronic conditions within the context of likely strained social support systems. Thus, the goals are to treat the acute condition, maintain or pro- mote function, and minimize adverse events. This article briefly reviews aspects of the thera- peutic environment as they pertain to the older adult patient. A future column will examine aspects of the environment as they pertain to the nurse. Therapeutic Environments Often times when we think of hospital environ- ments, we think of the physical plant and layout. But therapeutic environments encompass much more. The three major goals of therapeutic envi- ronments are 1) support clinical excellence in treatment of the physical body; 2) support the psychosocial and spiritual needs of the patient, family, and staff; and 3) produce measurable pos- itive patient outcomes and staff effectiveness. 3 Figure 1 depicts the components that comprise the therapeutic environment. The Physical Environment Since the time of Florence Nightingale, aspects of the physical environment of noise, light, and air and water quality have been cited to have an impact on patients’ recovery. Indeed, we have a growing number of studies that provide evi- dence for best practices when it comes to the physical plant. For instance, excessive noise has been well documented to have adverse effects on patient’s recovery. The World Health Organization has designated that background noise in hospital environments should not exceed 35 dB and that peaks should not exceed 40 dB. 4 Yet staff members’ voices and medical equipment have been recorded at 70 dB (equivalent to a busy restaurant) and alarms and equipment at over Elizabeth Capezuti Phd, RN, FAAN Sarah Hope Kagan Phd, RN, FAAN Mary Beth Happ Phd, RN, FAAN Lorraine C. Mion PhD, RN, FAAN 268 Geriatric Nursing, Volume 30, Number 4

Establishing a Therapeutic Hospital Environment: The Patient Perspective

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ACUTE CARE OF THE ELDERLY COLUMN

Elizabeth CapezutiPhd, RN, FAAN

Sarah Hope KaganPhd, RN, FAAN

Mary Beth HappPhd, RN, FAAN

Lorraine C. MionPhD, RN, FAAN

Establishing a Therapeutic Hospital Environment:

The Patient PerspectiveLorraine C. Mion, PhD, RN, FAAN

‘‘It may seem a strange principle to enunciate asthe very first requirement in a hospital that itshould do the sick no harm.’’

—Florence Nightingale

Hospitals can be dangerous places. Accordingto the Institute of Medicine, more Americansdie each year from medical errors and hospital-acquired infections than from AIDS, breast can-cer, or automobile accidents.1,2 Up to 1 in 20 inpa-tients contract a hospital-acquired infection andpatient fall injuries are estimated to exceed $30billion by 2020. The Centers for Medicare andMedicaid Services (CMS) deems these as ‘‘neverevents’’ and will no longer cover the cost of hos-pital care for medical errors, hospital-acquiredinfections, or patient injuries.

The hospital environment is an integral part ofpatient safety. It affects not only the patient, butalso the family, staff, and organization. It is im-portant to note that no environment is neutral;rather, the effects can be positive or negative.Studies have shown that stressful environmentscan cause psychological distress resulting inanxiety, anger, sleeplessness, or depressionand physiologic reactions such as increasedblood pressure and cortisol levels. For the orga-nization, these effects can result in increased in-efficiencies and higher costs. When consideringthe context of older adult patients, we need toremember that this is a vulnerable group withan acute disease or condition superimposed onchronic conditions within the context of likelystrained social support systems. Thus, the goalsare to treat the acute condition, maintain or pro-mote function, and minimize adverse events.This article briefly reviews aspects of the thera-

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peutic environment as they pertain to the olderadult patient. A future column will examineaspects of the environment as they pertain tothe nurse.

Therapeutic Environments

Often times when we think of hospital environ-ments, we think of the physical plant and layout.But therapeutic environments encompass muchmore. The three major goals of therapeutic envi-ronments are 1) support clinical excellence intreatment of the physical body; 2) support thepsychosocial and spiritual needs of the patient,family, and staff; and 3) produce measurable pos-itive patient outcomes and staff effectiveness.3

Figure 1 depicts the components that comprisethe therapeutic environment.

The Physical Environment

Since the time of Florence Nightingale, aspectsof the physical environment of noise, light, andair and water quality have been cited to have animpact on patients’ recovery. Indeed, we havea growing number of studies that provide evi-dence for best practices when it comes to thephysical plant. For instance, excessive noisehas been well documented to have adverseeffects on patient’s recovery. The World HealthOrganization has designated that backgroundnoise in hospital environments should not exceed35 dB and that peaks should not exceed 40 dB.4

Yet staff members’ voices and medical equipmenthave been recorded at 70 dB (equivalent to a busyrestaurant) and alarms and equipment at over

Geriatric Nursing, Volume 30, Number 4

Figure 1. Therapeutic hospital environment.

90 dB (equivalent to a motorcycle passing closeby). There are numerous sources of noise includ-ing staff and visitors, paging systems, alarms, icemachines, pneumatic tubes, and moving equip-ment. Environmental interventions include theuse of noise absorbing materials, such as carpet-ing on floor and ceiling tiles and use of singlepatient rooms versus multiple beds. There isalso a push for single patient rooms to helpstem the probability of acquiring a nosocomialinfection.5 Both technology and protocols canreduce staff-created noises, such as use of voice-less paging systems and minimizing transport ofequipment and supplies at night. Televisions arepresent in every room; the closed caption optionfor the hearing impaired can reduce noise anddisturbance.

Besides noise, we need to consider otheraspects of the physical environment that can pro-mote or maintain function for our elderlypatients. Lighting becomes a more critical issueas we age. The aging eye requires more light tosee, but it takes less light to produce glare. Thetype of flooring and artwork can affect the levelof glare. Positioning of lights is important toavoid direct eye exposure, yet illuminate theroom adequately without having spotty areas oflight and darkness. Seating furniture can bedesigned to promote transfers and sitting pos-tures. Chairs with nonpadded arms that extendto just past the seat facilitates patients’ abilityto grip the chair arms and use their upper extrem-ities in rising or sitting. A high back and firm cush-ion facilitate trunk support. In the bathrooms, anelevated toilet height not only facilitates patienttransfers but also protects staff members fromback strain.

Geriatric Nursing, Volume 30, Number 4

Take a close look at your hospital environmentand unit for orienting cues. Is the signage clear?And is it at a height easily seen by our olderpatients? One elderly gentleman on our commu-nity advisory board observed, ‘‘Why do you putyour signs up on the ceiling when most of usold folks have to look down and watch wherewe’re stepping?’’ Are the clocks in the patients’rooms easily seen and, importantly, in workingcondition? Most hospitals have communicationboards in each patients room, but it doesn’thelp the patients if they aren’t updated daily.Colors of walls, floors, and furniture furtherhelp clarify the environment.

The environment should be pleasant. Roomlayouts, color schemes, furniture design, plantsor gardens, and artwork have all been examinedfor their impact on individuals’ moods and phys-iologic states.5

Interdisciplinary Care Processes

The finest physical environment will have littleeffect on the patient’s recovery if we have poor in-terdisciplinary care processes. Perhaps one ofthe most deleterious care practices that impedesfunction is the use of physical restraints. Pro-cesses that can promote or maintain functioncan be simple to quite complex. For instance,simple processes such as time-limited orderscould facilitate function. Time-limited bed-restorders would promote activity out of bed. Time-limited orders for indwelling bladder cathetersnot only would promote urinary function butwould also decrease the potential for a nosoco-mial infection. Determining the maximum NPOtime for each radiology test would circumventunnecessary fasting for many of our patients.The process of administering medications canalso be used as a time to further instruct patientsand to avoid or minimize the chance of error. Forolder adults, many keep a particular routine fortaking medications. Once in the hospital, this rou-tine can be altered, and even their usual medica-tions may look different because of formularyequivalents. Opening the unit dose medicationpackages at the bedside when giving each medi-cation is an optimal time to explain variationsfrom the patient’s usual routine and hopefullyavoid errors.

Interdisciplinary care processes can also pro-mote a sense of control and enable social support,one of the goals of a therapeutic environment.

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Many hospitals are allowing relaxed visitinghours for families. More could be done to makefamilies feel welcome. For instance, we could es-tablish an area within the patient’s room for a fam-ily member to stay that is out of the way of staffbut facilitates his or her comfort. Is there anarea on the unit where patients can engage withtheir visitors and family?

Last, interdisciplinary processes can minimizeadverse events. The Joint Commission has estab-lished a number of safety goals that requireinterdisciplinary efforts.6 These include fall pre-vention programs, proper patient identificationprocesses, medication reconciliation processes,and discharge planning. The extent to whichnurses are able to collaborate with other depart-ments and professionals will determine thecost-effectiveness and efficiency that allow forfeasible and effective practices.

Knowledgeable and Competent Staff

Many health care professionals, includingnurses, received minimal geriatric content intheir basic curriculum, despite older adults asthe primary user of the health care system. Clini-cal education programs in hospitals are neededfor all hospital employees that come in contactwith older adults and their families. Thus, trans-porters, receptionists, environmental workers,and dietary personnel should all have basic sensi-tivity training. Appropriate geriatric training isnecessary for all health care professionals.Content includes differential presentation ofdisease processes, differential responses, vulner-ability for adverse events, management of delir-ium, fall prevention, pressure ulcer preventionand management, dehydration, and malnutrition.Moreover, content must emphasize the need toinclude family in patient education and carefuldischarge planning.

Community Care Partners and Linkages

The breakdown in transition of care across thehealth care continuum is well known and docu-mented. Establishing appropriate processes forthe safe transition of care is a national safetygoal of the Joint Commission and part of theIOM report.2,6 Hospitals, nursing facilities, com-munity agencies, pharmacies, and therapistsmust all communicate clearly on the patient’scurrent condition and plan of care. At the time

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of hospital discharge, we need to have a medica-tion review including the rationale for any newlyadded or removed medications. The patient’sability to manage his or her illness, condition,and treatments must be assessed and docu-mented. Any inability to perform these activitiesor activities of daily living should be included ina plan of care that addresses these gaps.

Summary

The United States is currently in a hospitalbuilding boom, replacing aging structures builtin the 1960s and 1970s, and it is estimated that$250 billion will be spent on new hospital con-struction within the next 10 years.5,7 Majordrivers for hospital construction include attract-ing clients, incorporating new technology, costefficiency, and meeting hospital guidelines andregulations. This is a unique opportunity fornurses to provide input into the hospital designthat can improve patient safety, as well as reducestaff stress and inefficiencies and improve healthcare quality. What we build now will be in usefor decades. More than the physical plantmust be addressed. The way we organize ourcare, the emphasis we place on the goals ofcare, the need to work interdisciplinarily, andensuring safe handoffs are as critical as the phys-ical plant.

References

1. Institute of Medicine. To err is human: building a safer

health system. Washington, DC: National Academy Press;

2000.

2. Institute of Medicine. Crossing the quality chasm: a new

health system for the 21st century. Washington, DC:

National Academy Press; 2001.

3. Smith R, Watkins N. Therapeutic environments forum. AIA

Academy of Architecture for Health. Whole Building Design

Guide. October 2008. Availableat www.wbdg.org/resources/

therapeutic.php?r5hospital. Cited May 14, 2009.

4. Berglund B, Lindwall T, Schwelaand DH, et al., editors.

Guidelines for community noise. Technical Report. World

Health Organization; 1999.

5. Ulrich R, Zimring C, Joseph A, et al. The role of the

physical environment in the hospital of the 21st century.

Center for Health Design. Available at www.rwjf.org/

research/featuredetail.jsp?featureID51230&type53

&gsa52. Cited February 8, 2006.

6. The Joint Commission. National Patient Safety Goals.

October 31, 2008. Available at: http://www.joint

commission.org. Cited July 7, 2009.

7. Nelson C, West T, Goodman C. The hospital built

environment: What role might funders of health services

Geriatric Nursing, Volume 30, Number 4

research play? (Prepared by The Lewin Group, Inc. under

Contract no. 290-04-0011). AHRQ Publication No. 06-0106-

EF. Rockville MD: Agency for Healthcare Research and

Quality; 2005.

LORRAINE C. MION, PhD, RN, FAAN, is the Independence

Foundation Professor of Nursing, Vanderbilt University

Geriatric Nursing, Volume 30, Number 4

School of Nursing, Nashville, TN, and a senior nurse

researcher, MetroHealth Medical Center, Cleveland OH.

0197-4572/09/$ - see front matter

� 2009 Mosby, Inc. All rights reserved.

doi:10.1016/j.gerinurse.2009.06.004

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