I also hope to evaluate patient percep-tions of the patient information through asample group of acute leukaemia patientsand through a representative sample inthe inpatient and outpatient setting.

ConclusionThe standardization of neutropenicinpatient management and the avail-ability of neurtropenic patientinformation should optimize practice inthe use of a peer reviewed evidence-basedframework. This will serve to give thesepatients the most effective care that willconsider the physical and psychologicalimplications of their condition. Patientsshould feel more confident knowing thattheir care is standardized throughout thetrust. It will also enable staff to counseland educate patients about neutropeniawith confidence, knowing that the infor-mation they have is current and promotesbest practice.

This secondment has been a valuablepersonal learning experience. It hasenabled me to network with other profes-sionals within my field of practice andgiven me the time and resources to

improve and update my own professionalknowledge base.

Regarding the benefit to my directorateI feel that this has allowed a concern to beexplored in detail. It has provided guide-lines and patient information that willpromote optimal nursing care forneutropenic patients. It has demonstratedto staff such as myself that there is a needto support the directorate with projects ofthis kind. Improved communication hasbeen established between units throughrepresentatives being part of a practicedevelopment group, this has served toaddress the core issue and other issuesthat were related to the main topic.

Working within the clinical gover-nance and risk department has given methe confidence to try to pull ideastogether and demonstrated that a multi-disciplinary approach is required todisseminate ideas and best practice.

Susan Leach

Address correspondence to: Susan Leach,Royal Victoria Infirmary, Queen VictoriaRoad, Newcastle upon Tyne, NE1 4LP

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Impact ofthe builtenvironment

The key drivers influencing the design ofthe physical environment in health care formany years have been functional efficiencyand cost. More recently there has been agrowing interest in the concept that theenvironment can make a contribution tothe well-being of the patient. In the

predominant culture of seeking evidence tosupport theory it is difficult to measure thiscontribution precisely. There are somescientific studies that provide quantitativemeasures and some social studies thatprovide qualitative measures, but designquality itself is much harder to measure.

The concept of creating a healingenvironment in health care buildings hascome into focus in recent years but weshould remember that FlorenceNightingale in her book, Notes onHospitals (1863), said that the first

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requirement of the hospital is that itshould do the sick no harm. She includedguidance on issues such as sanitary condi-tions, principles of construction and theimpact of the building on patient care.Nightingale placed great emphasis on thecontrol of infection by providing anindividual space for each patient in a well-ventilated environment with plenty of airmovement. She proposed a number ofsophisticated ventilation systems usingventilation shafts in the walls to supportair movement created by fireplaces. Anumber of other ideas that we recognize asimportant today were introduced byNightingale. For example, she pointed outthe value of looking at life cycle costingwhen she proposed that double glazedwindows and increased funds for more fuelfor fireplaces would allow patients torecover more quickly and so reduce thelength of stay. She emphasized the value ofa view and the value of sunlight, subjectsof further research today.

There is a growing recognition that thedesign of the physical environment canmake an impact on health care in terms ofpatient outcomes. Roger Ulrich’s classicstudy (1984) showed that patients recov-ering from surgery had better outcomeswhen nursed in rooms overlooking a smallstand of trees rather than a brick wall;requiring fewer analgesic drugs andneeding shorter lengths of stay. Furtherstudies showed that patients in anintensive care unit in Sweden faired betterwhen exposed to pictures of nature.

During a trial of light therapy in the careof depressed patients in Edmonton,Canada, Beauchemin and Hayes (1998)observed that the stay of patients in roomson the sunny side of the building was anaverage of 15% shorter than the stay of

patients in rooms on the non-sunny side. Asimilar study was made over four years in acardiac intensive care unit of eight beds,with four beds facing north and four facingsouth. In a patient sample of direct admis-sions with a similar diagnosis, it was foundthat those in bright rooms stayed anaverage of 2.3 days, while those in darkrooms stayed an average of 2.6 days.

Ulrich (1990) has developed a theory ofthe need to create a psychologicallysupportive environment for patients. Inacknowledging that stress can debilitatethe immune system, the role of gooddesign is to alleviate any stress caused bythe physical environment such as facil-ities that are noisy, confusing in terms ofway finding, invade privacy and provideno personal control of lighting andtemperature. He suggests that buildingsshould be designed to support patients incoping with stress, by fostering a sense ofcontrol of the physical and socialsurroundings and providing both access tosocial support and positive distractions inthe physical surroundings. The expectedbenefits are an enhancement of thera-peutic outcomes, increased staffperformance and satisfaction, and supportfor visitor and family participation.

Similar ideas have been developed in thePlanetree Approach in the USA. Thisbegan as a response from a single patientwho aimed to personalize, humanize anddemystify the health care experience forfuture patients and their families. The keyconcept is that care should be patientcentred, focusing on the patient’sperspective and empowering patients andtheir families through information andeducation. The intention is to create ahealing partnership with care givers,through a holistic approach to mental,

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emotional, spiritual and social aspects, aswell as the physical environment. ThePlanetree movement encourages designfactors that create home-like, barrier-freeenvironments which support patientdignity and encourage family participationin care. For example, making pre-operativewaiting areas more homely, withcomfortable chairs, soft music and afountain and, in a post-operative nursingarea, facing patient’s feet to the wall sothat patients can look at a picture ratherthan out into the room.

The Picker Institute (1998) (both USAand European based) takes these ideasfurther, focusing on the patient’s actualexperience. An initial study investigatedconsumer perceptions of the health careenvironment through focus groups inthree settings: ambulatory, acute, andlong-term care. Consumers defined thebuilding environment to include aspectssuch as parking, lifts, accessibility andbarriers to mobility, e.g. thresholds.Studies found that first impressions arethe most important, followed by theability to find your way. Patients wantedenvironments that promoted confiden-tiality and privacy, were considerate ofimpairments and were close to nature andthe outside world.

In ambulatory care patients wanted theconvenience of proximity of parking toclinic location and then proximity ofancillary services, e.g. laboratory, imagingand pharmacy. The connection to staffand reception in waiting areas, howpatients are called and the lack of confi-dentiality and privacy through being ableto hear through the walls, were allimportant. In acute care the ability to seestaff and what is going on and morecontrol over the local environment to

ensure comfort, were important. Noisewas considered a problem. Caring for thefamily is important to patients who wantmore space for family members andamenities such as access to telephones,bathrooms, food, coffee and space inpatients’ rooms to accommodate family,e.g. sleeping chairs. All patient groupswanted to be closer to nature. Inambulatory care they wanted windows tothe outside, and indoor nature. In acutecare they wanted windows in patientrooms with outside views and access tooutside areas such as balconies, outsidesitting areas or walking paths.

There are a number of studies nowsupporting such ideas. Lawson and Phiri(2000) have undertaken a study in theUK, comparing old and new environ-ments for two groups of patients:psychiatric and orthopaedic. They foundthat both patient groups treated in newor upgraded units rated their treatmentsignificantly higher than those treated inold facilities. Patient outcomes werechanged as fewer analgesics were requiredthan on the old orthopaedic wards andpsychiatric patients had earlier discharge.Patient groups felt that the environmentcontributed to their recovery and thatcolour and decoration influenced theirwell-being. Noise control was found to bea common problem which received littleattention and irritated patients, as didthe lack of patient control of theenvironment, particularly ventilationand lighting. Having a view to natureoutside was seen by patients as animportant factor.

The value of access to outdoor space isexplored in the Cooper Marcus andBarnes study for the Centre for HealthDesign (1995). This showed that patients,

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visitors and staff all felt they benefitedfrom access to outdoor space, whichprovided contrast to indoor space and asense of getting away. Different types ofoutdoor spaces are reviewed from thefront porch, to the courtyard and the roofgarden. A key aspect is that such externalspaces should be visible or signposted forease of patient access. In the designrecommendations, the study points outthat physically ill people are verysensitive to physical comfort andattention must be paid to both the microclimate of the outside space and theactual mobility of patients.

Other studies now under way are lookingat different aspects of the healingenvironment such as the contribution ofart projects to staff satisfaction andretention. The underlying intention of allthis body of work is to improve thepatient’s experience in health carebuildings and provide evidence of theeffectiveness of the design quality onimproving patients’ well-being.

ReferencesBeauchemin K, Hayes P. Seeing ward design in a new light.

Hospital Development 1998; 29(9).Cooper Marcus C, Barnes M. Gardens in Healthcare

Facilities: Uses, Therapeutic Benefits, and DesignRecommendations. Center for Health Design, 1995.

Lawson B, Phiri M. Room for improvement. HealthService Journal 2000; 20 January.

Nightingale F. Notes on hospitals, 1863. Reprinted in LWilliamson (ed.) Florence Nightingale and the Birthof Professional Nursing (vol 3). Bristol: ThoemmesPress, 1999.

Planetree. Patient Centred Health Care. http//www.planetree.org

Picker Institute. Working paper: Consumer Perceptions ofthe Healthcare Environment. Picker Institute, 1998.

Ulrich R. View through a window may influence recoveryfrom surgery. Science 1984; April: 224.

Ulrich R. Effects of healthcare interior design on wellness:Theory and recent scientific research. In SOMarberry (ed.) Innovations in Healthcare Design.Van Norstrand Reinhold, 1990; pp88–104.

Rosemary Glanville

Address correspondence to: RosemaryGlanville, Medical Architecture ResearchUnit, London South Bank University, 103Borough Road, London SE1 0AA

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