The Journal of Continuing Education in Nursing

Original Article 

Designing Health Care Environments: Part I. Basic Concepts, Principles, and Issues Related to Evidence-Based Design

Sandra K. Cesario, PhD, RNC, FAAN


A 2001 Institute of Medicine report captured the nation’s attention regarding the dangers that can result from the health care environment. This report, fueled by the need for new facilities to be constructed, led to an explosion of research that now links the physical structure and design of health care facilities to the health and well-being of patients, nurses, other health care workers, and visitors. Continuing nursing education that highlights the importance of evidence-based design has been associated with measurable improvement in health care facilities’ clinical outcomes, economic performance, employee productivity, customer satisfaction, and cultural congruency. Three major categories of outcomes can be impacted by evidence-based design: stress reduction, safety, and overall health care quality and ecology. In this article, Part I of a two-part series, the basic concepts, principles, and issues related to evidence-based design are introduced. Part II will describe continuing education programs available for nurses.


A 2001 Institute of Medicine report captured the nation’s attention regarding the dangers that can result from the health care environment. This report, fueled by the need for new facilities to be constructed, led to an explosion of research that now links the physical structure and design of health care facilities to the health and well-being of patients, nurses, other health care workers, and visitors. Continuing nursing education that highlights the importance of evidence-based design has been associated with measurable improvement in health care facilities’ clinical outcomes, economic performance, employee productivity, customer satisfaction, and cultural congruency. Three major categories of outcomes can be impacted by evidence-based design: stress reduction, safety, and overall health care quality and ecology. In this article, Part I of a two-part series, the basic concepts, principles, and issues related to evidence-based design are introduced. Part II will describe continuing education programs available for nurses.

Dr. Cesario is Doctoral Program Coordinator and Associate Professor, College of Nursing, Texas Woman’s University, Houston, Texas.

Presented in part at the 39th Biennial Convention of the Sigma Theta Tau International Honor Society of Nursing, Baltimore, Maryland, November 2007.

Address correspondence to Sandra K. Cesario, PhD, RNC, FAAN, 6700 Fannin Street, Houston, TX 77030.

In 2001, the Institute of Medicine (IOM) published Crossing the Quality Chasm, which identified U.S. hospitals as dangerous places (IOM, 2001). Medical errors and hospital-acquired infections are among the leading causes of death in America, contributing to more deaths than AIDS, breast cancer, and car crashes (Ulrich, Quan, Zimring, Anjali, & Choudhary, 2004). However, the problems related to the health care environment are not limited to patient outcomes. The structure and design of health care facilities also impact the health and well-being of patients, nurses, other health care workers, and visitors.

Health care is changing rapidly in the United States, raising many questions about the best way to serve patients and health care providers (Barker & DeBord, 2005). Care must be financially and geographically accessible and free of stigma. The needs of increasingly diverse and acute patient populations must be considered when designing new facilities. The larger size of patients must also be considered. All major renovations and new construction must comply with the requirements set forth by the Americans with Disabilities Act. The expanded use of technology is necessary for the provision of up-to-date health care. Patient expectations regarding access to wireless computer services, medical records, and test results promote technological advances (Carpenter, 2006).

The physical environment of health care facilities may also play an important role in recruiting and retaining the nursing work force. Health care facilities are interested in modifying their environments not only to attract the technologically savvy younger generation, but also to meet the needs of the current aging nursing work force.

With existing structures being renovated and new facilities being built, health care construction costs are nearing $20 billion per year in the United States (Berry et al., 2004). The structures being built today are designed to last 30 to 50 years. Therefore, nurses must join multi-professional design teams to create facilities that will improve the delivery of health care, benefiting patients, their families, nurses, and all members of the health care team (Bradley, 2003). Knowledge of design issues and familiarity with the technical terms associated with architecture will enable nurses to become articulate and confident members of such teams from the outset of projects. The lived experience of nurses in providing bedside care is an essential component of the process (Reed, 2005). Nurse educators play a key role in preparing nurses to fully participate on design teams.

This article, the first of a two-part series, discusses evidence-based concepts related to health care facility design and construction.

Literature Review

A rapidly growing body of literature links characteristics of the health care environment to patient, visitor, and staff outcomes. In an extensive review of the literature, Ulrich et al. (2004) noted that during the 30-year period between 1968 and 1998, only 84 well-constructed studies addressed environmental design. During the next 5 years (1999 to 2004), there were more than 600 reports of research in this area and the evidence is increasing each year.

Stress Reduction for Patients and Employees

Stress is intricately intertwined with environmental factors. Noise, spatial disorientation, excessive light, and isolation experienced by patients and employees are associated with less than optimal outcomes. Reducing patient stress has been found to decrease the perception of pain, improve sleep, lower blood pressure, increase satisfaction with care, and decrease length of stay. Nurses experiencing stress are more likely to complain of fatigue, use sick time, make medication errors, and leave nursing (IOM, 2004).

Noise is often cited by both patients and nurses as a major stressor. Poorly designed acoustical environments may compromise patient confidentiality, disrupt sleep, and cause fear or disorientation. An environment that has poor acoustics may interfere with communication between patients and nurses or between members of the health care team. Impaired communication related to prolonged reverberation times and speech intelligibility due to background noise has been linked to errors (Blomkvist, Eriksen, Theorell, Ulrich, & Rasmanis, 2005).

Reduction of sound levels can be accomplished by using single-patient rooms, installing high-performance sound-absorbing ceiling or wall tiles, using hands-free communication devices to eliminate overhead paging, silencing alarms in patient rooms, and providing areas for staff interaction away from patient care areas. Additional evidence supports the use of music to reduce stress and anxiety among patients in a wide variety of health care settings (Joseph & Ulrich, 2007).

Spatial disorientation is a major source of stress for patients and their visitors. Patient transfer from one room to another or between units may result in confusion or fear, falls, gaps in health care, and delayed healing. Visitors are often frustrated and confused as they attempt to navigate large or complex health care facilities. Episodes of spatial disorientation have led to an area of study known as “wayfinding.” Wayfinding refers to the way individuals orient themselves to their physical environment and move from place to place. Proper signage can meet visitors’ navigational needs and alleviate health care workers’ spending time giving directions. Easy-to-read signs and room numbers, clear and consistent verbal or written directions, information desks, and accessible electronic information are key to effective wayfinding within facilities (Haq & Zimring, 2003). Outside of facilities, highly visible signs, parking information, sufficient lighting, and accessible entrances reduce visitor frustration and stress.

The relationship between bright light, both natural and artificial, and improved health care outcomes is well documented. Depression, agitation, and disrupted circadian sleep-wake cycles are improved by appropriate use of light (Wallace-Guy et al., 2002). It has been demonstrated that increased amounts of sunlight in patients’ rooms improve psychosocial health and decrease analgesia use, medication cost, and length of stay (Walch et al., 2005). Exposure to morning sunlight can be optimized through the use of sky-lights and rooms facing east (Ulrich et al., 2004).

Adequate lighting improves nurses’ performance by facilitating accurate completion of visual tasks, positively affecting mood and perception, normalizing circadian rhythm, and improving adjustment to night-shift work. Windows in the workplace and access to daylight have been linked to increased satisfaction with the work environment (Joseph, 2006a). Health care facility designs that promote natural or full-spectrum lighting can improve staff productivity at little or no cost and are widely preferred.

Both health care providers and patients prefer windows with a view of a natural setting. A view of green grass, water, trees, flowers, gardens, or wildlife has been shown to have a calming effect and to promote more rapid healing when compared to no outside view or views of other buildings (Sternberg, 2009). Patients who have undergone painful procedures have reported decreased levels of discomfort when provided with ceiling-mounted nature scenes or a wall-mounted television displaying views of nature (Diette, Lechtzin, Haponik, Devrotes, & Rubin, 2003; Ulrich, Simons, & Miles, 2003). A similar decrease in pain and anxiety scores was reported when patients viewed a nature videotape with no audio (Tse, Ng, Chung, & Wong, 2002) or took a “virtual reality nature walk” through the forest while confined to bed (Schneider, Prince-Paul, Allen, Silverman, & Talaba, 2004). Employees with a window view of nature report less stress, better health status, and higher job satisfaction (Schweitzer, Gilpin, & Frampton, 2004).

Artwork displayed in a facility can also assist with the healing process. Most studies have found that patients prefer nature paintings and prints. Chaotic, ambiguous, surreal, or abstract art forms are perceived negatively by the majority of patients and do not effectively alleviate stress or anxiety (Ulrich & Gilpin, 2003).

Color scheme is an important aspect of corporate branding and product recognition and also plays a role in providing a stress-reducing atmosphere. However, the meaning of color varies between individuals and between cultures. Madden, Hewett, and Roth (2000) investigated the preference for and meaning of different colors and color combinations in eight countries. The findings suggested that colors that may elicit energy, sadness, relaxation, and other emotions among Americans may not be perceived the same way by individuals from other countries. Therefore, the décor of a health care facility should be culturally appropriate for the patient population it is intended to serve.

Appropriate positive distraction techniques can also reduce stress, anxiety, pain, and boredom. Such distractions can include music, pet therapy, sources of laughter or comedy, art or art therapy, and nature. More controversial is the use of television, computers, and video games as positive sources of distraction. Additional research is needed to identify conditions under which these media are stress reducing or inducing in the health care environment.

Family presence, access to information, and professional caregiver support all contribute to a reduction in anxiety and the promotion of healing. An environment that accommodates family at the bedside maximizes emotional support, positive distraction, family understanding of the patient’s illness and care, and shared decision making (Henriksen, Isaacson, Sadler, & Zimring, 2007). The “family zone” should be on the side of the bed away from the doorway so the nurse will not be impeded from reaching the bedside in the event of an emergency. The family zone should be furnished with a couch or chair that opens into a bed, storage space separate from the patient’s belongings, and a desk or table. Comfortable furnishings that indicate the family is welcome encourage family support and participation in the care of the patient. Carpeted floors and movable furniture that can be arranged in small, flexible groupings are ideal for patient rooms and nearby waiting areas.

An advantage of the single-bed patient room is the space and privacy afforded to the family and the patient. Chaudhury, Mahmood, and Valente (2005) observed that nurses found it easier and more efficient to provide care to patients in private rooms. Patients’ satisfaction and open communication with health care providers are increased when they are assigned to a single-bed room. Patient confidentiality and compliance with the Health Insurance Portability and Accountability Act regulations are more easily achieved in this setting (Rashid, 2007). Other design features such as Internet access from the patient room and decentralized nursing units are perceived to be supportive to patients and their families (Rashid, 2006).

Patient and Nurse Safety

The most common safety issues facing health care workers and patients are infection and unintended injury. Hospital-acquired infections, sometimes referred to as nosocomial infections, are a leading cause of death in the United States. It is estimated that hospital-acquired infections cause the deaths of 90,000 to 100,000 Americans each year, with patients whose immune systems are compromised being the most likely victims (Nash, 2006). Hospital-acquired infections are transmitted via three environmental routes—air, surface contact, and water.

Airborne infections are spread when pathogens are released into the air through contamination or malfunction of the health care facility’s ventilation system. Using high-efficiency particulate air filters and decreasing indoor pollutants are important in maintaining good air quality (Banholzer, 2005).

Surface contamination usually results from poor handwashing and inadequate cleaning of shared patient equipment. Strategically placed handwashing stations and single-bed rooms are the two most important design features for decreasing the spread of microorganisms (Joseph & Ulrich, 2006). Alcohol-based hand sanitizer dispensers placed at the doorways of patient care areas and bedsides and handwashing sinks in the path of providers can increase compliance with handwashing and reduce surface contamination (Dettenkofer et al., 2004; Vernon, Trick, Welbel, Peterson, & Weinstein, 2003).

Medication errors in health care settings increased from 5% in 1992 to almost 25% in 2007, seriously compromising the culture of safety in many facilities (IOM, 2007). These errors occur an estimated 1.5 million times per year in the United States at a cost of $3.5 billion. The elderly are the largest consumers of medication and therefore are most commonly affected by these potentially deadly errors (Matsen-Picone et al., 2008).

Reasons most commonly cited for errors include illegible handwriting, distraction when preparing or administering medication, and patient transfer. All of these circumstances can be improved by appropriately designed and technologically supported environments. Single-bed acuity-adaptable designs eliminate errors associated with patient transfer (Hendrich, Fay, & Sorrells, 2004). Electronic medical record systems facilitate accuracy and speed of medication delivery if appropriate interfaces are in place between systems.

Patient falls pose another safety issue for health care facilities. In addition to potential physical injury, falls can result in adverse psychological effects and an increased length of stay (Vassallo, Azeem, Pirwani, Sharma, & Allen, 2000). The overall cost of falls among the elderly is skyrocketing and is expected to reach more that $30 billion by 2020 (Chang et al., 2004). Falls occur most often between the bed and the bathroom and when patients are not assisted or not observed when attempting to get out of bed. Design flaws contributing to falls in patient rooms include slippery floors, narrow doorways, poor placement of grab bars, and incorrect toilet and furniture heights. Design features such as night lights, glow-in-the-dark grab bars, and lighted paths to bathrooms are being investigated for reducing falls (Sheperd & Foureur, 2001).

Health care facilities are not immune to “sick building syndrome” (i.e., situations in which workers in the same work area experience acute or chronic health effects seemingly associated with time spent in the area and where no other illness or cause can be identified). Sick buildings can elicit a variety of nose or throat irritations, fatigue, nausea, and skin disorders. Employee health departments should monitor clusters of symptoms as outlined by the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee (Sehulster & Chinn, 2003).

Back, neck, and leg strain or injury described by nurses may be related to poor ergonomic design of work areas. Evidence suggests that unit design (e.g., radial, single corridor, or double corridor) determines the number of steps taken by nurses and contributes to fatigue and back pain (Shepley & Davies, 2003). Decentralized nursing stations have been found to reduce the amount of walking required by staff and increase time for patient care, especially when linens, medications, and disposable supplies are stored near patient rooms (Hendrich & Lee, 2005; IOM, 2004). However, decentralization has been noted to create physical distance between bedside care providers, leading to a sense of isolation and a lack of teamwork among nursing staff (Flynn, 2005).

Ergonomic design of health care facilities, when combined with considerations regarding air quality, noise level, and light, can positively affect the health and productivity of nurses. Caring for caregivers sends a positive message to the community that maintaining the health and safety of all individuals is the mission of the organization.

Overall Health Care Quality and Ecology

The single-bed patient room is the most important design feature in promoting overall quality of care and patient satisfaction. The extremely large and varied body of research reviewed leaves little doubt that single-bed rooms have numerous advantages over multi-occupant rooms or open bay designs (Sattler & Hall, 2007). These advantages include decreased rates of hospital-acquired infection, which lead to reduced length of stay; fewer patient transfers and fewer associated medication or communication errors; decreased sound levels; improved sleep; enhanced confidentiality and privacy; and family accommodation (Ulrich et al., 2004).

Increased patient satisfaction results in an overall perception of quality hospital care. When satisfaction scores of patients in traditional, two-bed hospital rooms were compared with those of patients in private, therapeutically decorated, home-like hospital rooms, the latter rated the health care staff, housekeeping services, dietary staff, food, and hospital higher (Swan, Richardson, & Hutton, 2003).

Ecological components are becoming increasingly important when designing health care facilities, as many building materials and disposable products are depleting the world’s resources. There is increased interest in incorporating eco-friendly concepts with “sustainable” design features that conserve energy and water and use natural materials to reduce potentially dangerous emissions (Landro, 2006).

External design features such as terra cotta blocks, aluminum panels, and other natural materials reduce waste because they can be recycled at the end of a building’s usefulness. Natural air flow rather than air conditioning may be suitable in some situations and conserves energy. Greenery that beautifies a facility can also house ventilation units that draw air from the outside, filter it, and circulate freshened air to appropriate places throughout the facility (Eaton, 2006).

U.S. hospitals can be transformed into environmentally healthy and safe places through the education of nurses and key administrators, strict adherence to environmentally preferable purchasing policies, conscientious waste management strategies, and leadership in environmental stewardship (Sattler & Hall, 2007).

What is Evidence-Based Design?

Evidence-based environmental design refers to choices that are informed by rigorous research. The best available research to make building decisions requires a merger of evidence from health care with environmental science, interior design, architecture, engineering, and other disciplines. The goal of the multi-professional design team is to create an environment that promotes healing, supports family involvement, facilitates efficient staff performance, and reduces stress in all users of the facility (Brown & Gallant, 2006). At the same time, the design should result in measurable improvement in the facility’s clinical outcomes, economic performance, employee productivity, customer satisfaction, and cultural congruency (Hamilton, 2003).

The multi-year research initiative of The Center for Health Design’s Pebble Project ( has been instrumental in developing a body of evidence that incorporates concepts of healing environments into plans for new construction or renovation. Data from these projects are documented and analyzed to determine the impact of the environmental changes on the quality of patient care outcomes, recruitment and retention of nurses, and operational efficiency and productivity (Levin, 2007).

Key Concepts of Evidence-Based Design

It is crucial that the nurse understand and effectively communicate with other members of the design team. Possessing the vocabulary necessary to communicate nursing needs to the multi-professional design team enhances the effectiveness of the design process.

Universality of rooms or units refers to a design that can be easily renovated as care needs change over time. Strategic placement of building supports, plumbing, wiring, and ventilation systems allows reallocation of space without moving these aspects of the structure. The size or configuration of patient rooms can be changed at a much lower cost if these permanent features do not have to be altered (Rawlings & White, 2006).

Acuity adaptable refers to a room that is designed to allow the patient to stay in the room regardless of level of acuity. The environment is designed to house monitoring systems, gases, and other high-tech equipment when the patient requires acute care, but to conceal these features in a decorative head wall if they are not needed, giving the room a homey appearance. As the patient recovers and the acuity level decreases, the patient remains in the room and the level of nursing care is adapted to meet the patient’s needs.

Patient flow refers to the process and timing by which patients are transferred from one nursing unit to another. Patient transfer is usually dependent on level of acuity, level of nursing care required, and the need for specialized equipment or procedures. Historically, nursing unit and bed assignment were based on type of diagnosis and level of acuity. Multiple patient transfers are associated with an increased risk of medication errors, patient falls, family dissatisfaction, and miscommunication between health care providers (Reiling, 2007). An acuity-adaptable room design has the potential to reduce these risks.

Work flow refers to the movement and efficiency of the health care provider, usually the nurse. It is the systematic examination of the amount of time spent and the types of human motions used to perform a specific procedure or activity. Studying the environment in which nursing tasks are performed may yield important information about productivity and safety improvements. The goal is to eliminate unnecessary motions and to identify the most efficient sequence of motions to prevent fatigue and injury to nurses (Hendrich et al., 2004).

Patient safety, an issue that is at the forefront of the strategic plans of most health care facilities, is integrally related to the design of the environment. Ensuring patient safety includes the development of a system of operations that minimizes the likelihood of patients finding themselves in unsafe situations. Rooms specifically designed to prevent or minimize the effect of falls, electronic monitoring technologies, a clearly defined medication administration protocol with a series of checks, and an adequately lit area that is free from distractions where nurses can prepare medications all contribute to a safe environment (Joseph, 2006b). Other safety features include air filtration systems, distinction of “clean” and “dirty” areas on nursing units, sound panels on ceilings and walls, patient transfer policies, standardization and consistency of the floor plan of patient rooms, and glare-free lighting. Three characteristics of facility design that enhance patient safety are readily available hand hygiene stations, single-occupancy patient rooms, and acuity-adaptable patient rooms (Berry et al., 2004).

Ergonomics is an area of applied science that designs equipment to maximize worker productivity by reducing fatigue and discomfort and promoting safety. Ceiling-mounted patient transfer devices and self-propelled patient beds are examples of ergonomic innovations designed to decrease nurse discomfort and injury.

Facilities that employ the concept of increasing efficiency in the use of energy, water, recyclables, and other materials while minimizing the impact on human health and the natural environment are often referred to as “green buildings.” These ecological buildings, operating under the most optimal conditions, have the potential to decrease operating expenses through efficient use of water and energy; to promote public and employee wellness through improved indoor air quality; to reduce damage to the natural outdoor environment; and to provide an aesthetically pleasing environment that creates harmony between a structure and its surrounding natural and built environment.

The term “sustainable development” or “sustainability” is closely related to green buildings, but is a different concept. Sustainability refers to the indefinite productivity of a system. Vital human ecological support systems related to the longevity of natural ecosystems and the planet’s reserves of clean air, water, forests, agriculture, and fossil fuels are taken into consideration when constructing green buildings (Dubow & Lykidis, 2006).

Acoustics is a branch of mechanics and engineering concerned with the study of sound. Noise levels have increased considerably in health care settings during the past 50 years and have been associated with negative effects on patient outcomes and nurse performance. Frequent or prolonged exposure to high noise levels has been associated with stress, hearing impairment, slower healing rate, hypertension, lapses in short-term memory, irritability, patient sleep disruption, family dissatisfaction, and nurse burnout (World Health Organization, 2005). Exceptionally high noise levels are noted during shift changes, during orthopedic surgery, in the laundry area, and on the heliport. Sound waves that carry patient information to someone other than the intended recipient may violate patient privacy standards as outlined by the Health Insurance Portability and Accountability Act. A variety of interventions may be effective in reducing the noise levels in hospitals and improving the acoustical environment. Key interventions include silencing alarms, using hands-free communication devices to eliminate or reduce overhead paging, installing high-performance sound-absorbing ceiling tiles, and providing ear protection for nurses and patients exposed to prolonged noise (Joseph & Ulrich, 2007).

The evidence base in health care is expanding so rapidly that it can no longer be managed by traditional paper-based data systems. Accompanying advances in computer and communication technologies is the growing specialty of health care informatics. Informatics combines science and technology to facilitate interactions between natural and artificial systems to manage the storage, retrieval, and optimal use of information and data. Communication between health care professionals and hospital departments has changed significantly in the past decade as the result of informatics. E-ICUs (i.e., electronic intensive care units) are one example of a design feature incorporating informatics.

Aesthetics is associated with pleasurable feelings that humans experience as a result of certain environmental stimuli or conditions. Aesthetics addresses philosophical questions about the nature of beauty and psychological issues related to the effects of beauty on individuals. The perception of what is beautiful or culturally appropriate varies widely from one person to another. Color schemes, furniture, floor coverings, artwork, and the view from a hospital room have been found to impact patient well-being, healing, and outcomes (Car-roll, 2005). In addition, well-designed facilities that are aesthetically pleasing contribute to nurse recruitment and retention.

An antimicrobial agent is a chemical substance that inhibits or destroys bacteria, viruses, fungi, yeasts, or molds. Impregnating resins and acrylic polymers to create antimicrobial surfaces for flooring, counter tops, sinks, and dinnerware has been attempted. However, there is concern that these surfaces may contribute to drug-resistant forms of bacteria. Therefore, they are not currently in widespread use.

Contributions Nurses Make to Design Teams

The lived experience of patient care that nurses can bring to the planning stages of health care facility renovation or construction is unparalleled by any other profession (Reed, 2005). Nurses are knowledgeable about the most efficient methods for delivering patient care.

Nurses are more in-tune with the demographics of the populations their facilities serve than are administrators, hired consultants, or other members of the design team. Meeting the cultural needs of the community and respecting the values of the patient groups the facility will ultimately serve are essential to holistic health care.

Management skills and creative problem-solving abilities are additional assets that nurses bring to design teams. Nurses are increasingly accountable for patient outcomes, so their input is crucial to optimal functioning in the professional role. As rooms and units are being designed, full-scale mock-ups can be constructed so nursing care situations can be simulated. Continuing nursing education is essential at each stage of the process so nurses can maximize their contributions to the team.

However, there are barriers to nurses’ participating in design teams. Often, nurses are not consulted during the early stages because they are not recognized as having environmental design knowledge. This could possibly be due to an inability to effectively communicate with architects, engineers, and other members of the design team. Numerous conferences, online tutorials, and university programs offer education in this area. Nurses should explore these opportunities and take an active role in developing this expertise (Stichler & Cesario, 2007). Presenting one’s self as a confident professional facilitates participation as an equal and valuable member of the design team. The Table provides some web-based resources nurses can use to develop their knowledge and understanding and overcome barriers.

Web-Based Resources

Table: Web-Based Resources

There is also a lack of nursing-specific research in the area of health care facility design to guide nursing actions and initiatives. More research conducted by nurses addressing nursing issues impacted by the environment is needed. The results of such studies must be shared with nurses at the bedside.


The following evidence-based design features improve patient outcomes and promote the health and well-being of nurses (Ulrich et al., 2004):

  • Acuity-adaptable, single-bed patient rooms.
  • Universality of new and renovated structures.
  • Therapeutic use of lighting, sound, color, and artwork.
  • Improved ventilation systems and acoustics.
  • Views of nature and other positive distractions.
  • Well-planned and coordinated wayfinding systems.
  • Unit design that reduces nurse fatigue and increases efficiency of patient care.
  • Hands-free electronic communication devices.
  • Electronic medical record systems.

Designing health care environments that promote the well-being of nurses and improve the outcomes of patients requires a strong, collaborative team approach and an organizational structure that supports necessary environmental changes (Arquilla & Cram, 2005). Adequate preparation of nurses for participation on design teams is the first step in addressing the problems unique to the health care environment.


  • Arquilla, L. & Cram, N. (2005, April/June). The relationship between clinical engineers and nurses in the hospital. Journal of Clinical Engineering, 81, 100–103.
  • Banholzer, M. (2005). A vital link: Interior features can contribute to better infection control. Health Facilities Management, 18(11), 23–26.
  • Barker, B. & DeBord, D. (2005). Innovative hospital designs make a difference. Trustee, 58(10), 34–36.
  • Berry, L., Parker, D., Coile, R., Hamilton, D., O’Neill, D. & Sadler, B. (2004). The business case for better buildings. Frontiers of Health Services Management, 21(1), 3–24.
  • Blomkvist, V., Eriksen, C., Theorell, T., Ulrich, R. & Rasmanis, G. (2005). Acoustics and psychosocial environment in intensive coronary care. Occupational and Environmental Medicine, 62(3), e1. doi:10.1136/oem.2004.017632 [CrossRef]
  • Bradley, C. (2003). Blueprint for care: Facilities should seek design input from the bedrock of care. NurseWeek California, 16(9), 4.
  • Brown, K. & Gallant, D. (2006). Impacting patient outcomes through design. Critical Care Nursing, 29(4), 326–341.
  • Carpenter, D. (2006). The boom goes on: Technology and consumer demands keep driving construction and renovation. Trustee, 59(3), 6–10.
  • Carroll, R. (2005). Applying design and color to healing. Nursing Homes: Long Term Care Management, 54(2), 48–52.
  • Chang, J. T., Morton, S. C., Rubenstein, L. Z., Mojica, W. A., Maglione, M. & Suttorp, M. J. et al. (2004). Interventions for the prevention of falls in older adults: Systematic review and meta-analysis of randomised clinical trials. British Medical Journal, 328(7441), 680–680. doi:10.1136/bmj.328.7441.680 [CrossRef]
  • Chaudhury, H., Mahmood, A. & Valente, M. (2005). Advantages and disadvantages of single-versus multiple-occupancy rooms in acute care environments. Environment and Behavior, 37(6), 760–786. doi:10.1177/0013916504272658 [CrossRef]
  • Dettenkofer, M., Seegers, S., Antes, G., Motschall, E., Schumacher, M. & Daschner, F. (2004). Does the architecture of hospital facilities influence nosocomial infection rates? A systematic review. Infection Control and Hospital Epidemiology, 25(1), 21–25. doi:10.1086/502286 [CrossRef]
  • Diette, G. B., Lechtzin, N., Haponik, E., Devrotes, A. & Rubin, H. R. (2003). Distraction therapy with nature sights and sounds reduces pain during flexible bronchoscopy: A complementary approach to routine analgesia. Chest, 123(3), 941–948. doi:10.1378/chest.123.3.941 [CrossRef]
  • Dubow, M. & Lykidis, P. (2006). Ten steps to enhance long-term sustainability. Health Care Strategy Management, 24(1), 1, 11–15.
  • Eaton, L. (2006). Green buildings. British Medical Journal, 332(7554), 1389–1390. doi:10.1136/bmj.332.7554.1389 [CrossRef]
  • Flynn, L. (2005, February). Healthcare boom: Nursing stations for the 21st century. Retrieved May 4, 2009, from
  • Hamilton, K. (2003). The four levels of evidence-based practice. Healthcare Design, 3, 18–26.
  • Haq, S. & Zimring, C. (2003). Just down the road a piece: The development of topological knowledge of building layouts. Environment & Behavior, 35(1), 132–160. doi:10.1177/0013916502238868 [CrossRef]
  • Hendrich, A., Fay, J. & Sorrells, A. (2004). Effects of acuity-adaptable rooms on flow of patients and delivery of care. American Journal of Critical Care, 13(1), 35–45.
  • Hendrich, A. & Lee, N. (2005). Intra-unit patient transports: Time, motion, and cost impact on hospital efficiency. Nursing Economic$, 23(4), 157–164.
  • Henriksen, K., Isaacson, S., Sadler, B. & Zimring, C. (2007). The role of the physical environment in crossing the quality chasm. The Joint Commission Journal on Quality and Patient Safety, 33(11), 68–80.
  • Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.
  • Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academies Press.
  • Institute of Medicine. (2007). Preventing medication errors. Washington, DC: National Academies Press.
  • Joseph, A. (2006a). Issue paper 2: The impact of light on outcomes in healthcare settings. Retrieved May 4, 3009, from
  • Joseph, A. (2006b). Issue paper 3: The role of the physical and social environment in promoting health, safety, and effectiveness in the healthcare workplace. Retrieved May 4, 2009, from
  • Joseph, A. & Ulrich, R. (2006). Issue paper 1: The impact of the environment on infections in healthcare facilities. Retrieved May 4, 2009, from
  • Joseph, A. & Ulrich, R. (2007). Issue paper 4: Sound control for improved outcomes in healthcare settings. Retrieved May 4, 2009, from
  • Landro, L. (2006). Hospitals go ‘green’ to cut toxins, improve patient environment. Retrieved May 4, 2009, from
  • Levin, D. (2007). CHD president highlights Pebble Project successes and plans for 2007. Retrieved May 4, 2009, from
  • Madden, T., Hewett, K. & Roth, M. (2000). Managing images in different cultures: A cross-national study of color meanings and preferences. Journal of International Marketing, 8(4), 90–107. doi:10.1509/jimk. [CrossRef]
  • Matsen-Picone, D., Titler, M., Dochterman, J., Shever, L., Kim, T. & Abramowitz, P. et al. (2008). Predictors of medication errors among elderly hospitalized patients. American Journal of Medical Quality, 23(2), 115–127. doi:10.1177/1062860607313143 [CrossRef]
  • Nash, D. (2006). Hospital-acquired infections: Raising the anchoring heuristic. American Journal of Medical Quality, 21(6 Suppl.), 5S–6S. doi:10.1177/1062860606294600 [CrossRef]
  • Rashid, M. (2006). A decade of adult intensive care unit design: A study of the physical design features of the best-practice examples. Critical Care Nursing, 29(4), 282–311.
  • Rashid, M. (2007). Developing scales to evaluate staff perception of the effects of the physical environment on patient comfort, patient safety, patient privacy, family integration with patient care, and staff working conditions in adult intensive care units: A pilot study. Critical Care Nursing, 30(3), 271–283.
  • Rawlings, S. & White, D. (2006). Beyond the universal patient room. Retrieved September 2, 2006, from
  • Reed, R. (2005). How to build your role in healthcare construction projects. Biomedical Instrumentation and Technology, 39(5), 347–352. doi:10.2345/0899-8205(2005)39[347:HTBYRI]2.0.CO;2 [CrossRef]
  • Reiling, J. (2007). Safe by design: Designing safety in health care facilities, processes, and culture. Oakbrook Terrace, IL: Joint Commission Resources.
  • Sattler, B. & Hall, K. (2007). Healthy choices: Transforming our hospitals into environmentally healthy and safe places. OJIN: The Online Journal of Issues in Nursing, 12(2),
  • Schneider, S., Prince-Paul, M., Allen, M., Silverman, P. & Talaba, D. (2004). Virtual reality as a distraction intervention for women receiving chemotherapy. Oncology Nursing Forum, 31(1), 81–88. doi:10.1188/04.ONF.81-88 [CrossRef]
  • Schweitzer, M., Gilpin, L. & Frampton, S. (2004). Healing spaces: Elements of environmental design that make an impact on health. Journal of Alternative and Complementary Medicine, 10(Suppl. 1), S71–S83. doi:10.1089/1075553042245953 [CrossRef]
  • Sehulster, L. & Chinn, R. Y. (2003). Guidelines for environmental infection control in healthcare facilities: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Morbidity and Mortality Weekly Report, Recommendations and Reports, 52(RR-10), 1–42.
  • Sheperd, L. & Foureur, M. (2001). Introduction of night-lights to reduce falls on an assessment, treatment and rehabilitation unit. Journal of the Australasian Rehabilitation Nurses Association, 4(4), 11–13.
  • Shepley, M. M. & Davies, K. (2003). Nursing unit configuration and its relationship to noise and nurse walking behavior: An AIDS/HIV unit case study. Retrieved January 20, 2008, from
  • Sternberg, E. (2009). Healing spaces: The science of place and well-being. Cambridge, MA: Harvard University Press.
  • Stichler, J. & Cesario, S. (2007). Preparing nurses for a leadership role in designing health care facilities. Journal of Nursing Administration, 37(6), 257–260. doi:10.1097/01.NNA.0000277726.84821.9b [CrossRef]
  • Swan, J., Richardson, L. & Hutton, J. (2003). Do appealing hospital rooms increase patient evaluations of physicians, nurses, and hospital services?Health Care Management Review, 28(3), 254.
  • Tse, M. M. Y., Ng, J. K. F., Chung, J. W. Y. & Wong, T. K. S. (2002). The effect of visual stimuli on pain threshold and tolerance. Journal of Clinical Nursing, 11(4), 462–469. doi:10.1046/j.1365-2702.2002.00608.x [CrossRef]
  • Ulrich, R., Quan, X., Zimring, C., Anjali, J. & Choudhary, R. (2004). The role of the physical environment in the hospital of the 21st century: A once-in-a-lifetime opportunity. Concord, CA: The Center for Health Design.
  • Ulrich, R., Simons, R. & Miles, M. (2003). Effects of environmental simulations and television on blood donor stress. Journal of Architectural & Planning Research, 20(1), 38–47.
  • Ulrich, R. S. & Gilpin, L. (2003). Healing arts: Nutrition for the soul. In Frampton, S. B., Gilpin, L. & Charmel, P. (Eds.), Putting patients first: Designing and practicing patient-centered care (pp. 117–146). San Francisco: Jossey-Bass.
  • Vassallo, M., Azeem, T., Pirwani, M. F., Sharma, J. C. & Allen, S. C. (2000). An epidemiological study of falls on integrated general medical wards. International Journal of Clinical Practice, 54(10), 654–657.
  • Vernon, M. O., Trick, W. E., Welbel, S. F., Peterson, B. J. & Weinstein, R. A. (2003). Adherence with hand hygiene: Does number of sinks matter?Infection Control and Hospital Epidemiology, 24(3), 224–225. doi:10.1086/502193 [CrossRef]
  • Walch, J., Rabin, B., Day, R., Williams, J., Choi, K. & Kang, J. (2005). The effect of sunlight on postoperative analgesic medication use: A prospective study of patients undergoing spinal surgery. Psychosomatic Medicine, 67, 156–163. doi:10.1097/01.psy.0000149258.42508.70 [CrossRef]
  • Wallace-Guy, G., Kripke, D., Jean-Louis, G., Langer, R., Elliott, J. & Tuunainen, A. (2002). Evening light exposure: Implications for sleep and depression. Journal of the American Geriatrics Society, 50(4), 738–739. doi:10.1046/j.1532-5415.2002.50171.x [CrossRef]
  • World Health Organization. (2005). WHO experts consultation on methods of quantifying burden of disease related to environmental noise. Retrieved May 4, 2009, from

Web-Based Resources

The Center for Health Design (CHD) ( research, education, advocacy, and technical assistance, CHD supports health care and design professionals all over the world in their quest to improve the quality of health care through evidence-based building design. Its mission is to transform health care settings, including hospitals, clinics, physician offices, and nursing homes, into healing environments that contribute to health and improve outcomes through the creative use of evidence-based design.
Whole Building Design Guide (WBDG) ( are the most complex of building types. The diversity of services and functions is reflected in the breadth and specificity of regulations, codes, and oversight that govern hospital construction and operations. The wide-ranging and constantly evolving functions of a hospital may have competing needs and priorities. Actual functional needs such as work flow and patient characteristics must be balanced with the financial status of the organization.
Ergonomic Injury Prevention in Healthcare Services ( to free web-based educational tools and resources that address the growing problem of ergonomic injury in health care settings is provided. The highlighted resources provide important information to guide health care employers and workers through the recognition, management, and prevention of work-related ergonomic injuries.
The American Institute of Architects—Guidelines for Design and Construction (Can be purchased at (The 2010 edition will be available in fall 2009.)These guidelines are the standard referenced by architects, engineers, and health care professionals throughout the United States and in other countries when renovating or planning health care facilities.
The Environmental Design Research Association (EDRA) ( international, interdisciplinary organization, founded in 1968, was created to advance and disseminate environmental design research. Its goal is to increase understanding of the interrelationships between individuals and their built and natural surroundings and to help create environments responsive to human needs.
Parson’s Healthcare Design and Construction Checklist ( is a comprehensive list of action items and decision points that are typical in the planning, design, and construction of a new health care facility or the renovation of an existing facility.

Evidence-Based Design

Cesario, S. K. (2009). Designing Health Care Environments: Part I. Basic Concepts, Principles, and Issues Related to Evidence-Based Design. The Journal of Continuing Education in Nursing, 40(6), 280–288.

  1. The architectural design of health care facilities plays a key role in the safety and satisfaction of patients and individuals who care for them.

  2. Understanding basic concepts and principles of environmental design prepares bedside nurses to participate as essential members of the design team.

  3. The single-bed patient room is the most important design feature associated with improved patient outcomes and satisfaction.


Dr. Cesario is Doctoral Program Coordinator and Associate Professor, College of Nursing, Texas Woman’s University, Houston, Texas.

Presented in part at the 39th Biennial Convention of the Sigma Theta Tau International Honor Society of Nursing, Baltimore, Maryland, November 2007.

Address correspondence to Sandra K. Cesario, PhD, RNC, FAAN, 6700 Fannin Street, Houston, TX 77030.


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