LEADERSHIP IN ACTION
Abstract
Health care leaders are continually
seeking ways to optimize their care
services, become financially viable,
and retain quality caregivers. Such
goals seem impossible in today’s
intensely competitive environment. The
incorporation of a healing
environment into the health care
setting not only optimizes clinical care
and outcomes, it also optimizes staff
satisfaction, morale, retention, and
fosters repeat business. It has been
shown that views of nature, natural
light, soothing colors, therapeutic
sounds, and the interaction of family
members can enhance healing. These
elements must be balanced with staff
needs when designing critical care
environments.
© 2004 Elsevier Inc. All rights
reserved.
From the Good Samaritan and Bethesda North
Hospital TriHealth, Cincinnati, OH.
Address reprint requests to Leslie B. Altmier,
RN, MSN, Good Samaritan and Bethesda North
Hospital TriHealth, Cincinnati, OH 45220.
© 2004 Elsevier Inc. All rights reserved.
1527-3369/04/0402-0000$30.00/0
doi:10.1053/j.nainr.2004.03.001
Healing
Environments:
For Patients and
Providers
By Leslie B. Altimier, MSN, RN
H
ealing environments are the focus of any current hospital design and/or
renovation process to promote patient, family, and staff comfort.
Facilities must be functionally planned as well as attractively designed
with an esthetic appeal to create a therapeutic and/or healing environment.
Special attention to the use of natural light, relaxing colors, therapeutic sounds,
and pleasant views, especially in the intensive care unit setting have become
vital considerations for hospital planning and design teams. A therapeutic
environment not only promotes quality patient outcomes, it enhances nursing
care, which can minimize human errors.1 Creating an environment that attracts
and retains bright, diverse, and talented individuals is an important component
of clinical leadership and strategic thinking.
With today’s health care environment focusing on sentinel events and human
errors coupled with the use of increasingly high technology, it is possible that
the incorporation of a healing environment in the critical care area may add
another dimension to quality care by significantly reducing human errors
through a less stressful environment.
The concept of healing environments is not new. Over 200 years ago,
Florence Nightingale suggested patients would recover more quickly from
illnesses if they were cared for in an environment that had natural light,
ventilation, cleanliness, and basic sanitation.2 Historically, patients were cared
for in a big, single room (ward) because of limited caregivers. This ward design
had the advantage of visibility so that care providers could see all the patients.
Hospital designs began to change in the 1970s when consumers of health
care began choosing hospitals based on esthetic appeal. The appearance of the
hospital environment became an important marketing strategy.
The concept of healing environments suggests that the hospital environment
can make a difference in how quickly a patient recovers. Research has shown
that patients do experience a positive outcome in an environment that incor-
porates natural light, elements of nature, soothing colors, meaningful and
varying stimuli, peaceful sounds, pleasant views, and a sense of beauty.3 These
studies indicate that patients have a shorter length of stay, take less pain
medication, and have fewer negative comments documented in the nursing
notes than those patients placed in a traditional hospital environment.
Although healing environments are typically focused on the needs of pa-
tients and families rather than staff, the needs of staff, families, and infants need
to be balanced. Healing environments do not simply exist. They must be
created. Some specific design elements that must be considered when designing
a healing environment are: light, color, sound, and privacy.4
Newborn and Infant Nursing Reviews, Vol 4, No 2 (June), 2004: pp 89 –92 89
90 Leslie B. Altimier
Light
L ighting varies with intensity, duration of exposure,
and pattern. Artificial light can cause visual fatigue
and headaches. Healing environments stimulate positive
awareness and connection with nature, culture, and peo-
ple (staff and families). Softening the “tech” side of
care can create a healing environment. Because of the
increased stress experienced when caring for intensive
care patients, professional staff also benefit from soft-
ening of this environment! Ultraviolet light has been
shown to enhance healing by increasing protein metab-
olism, decreasing fatigue, stimulating white blood cell
production, increasing the release of endorphins, de-
creasing blood pressure, and generally promoting emo-
tional well being.5 Natural lighting also helps with the
implementation of day/night cycling for humans and
animals. Cognitive disturbances can occur if there is a
lack of natural light for patients and staff. There is some
evidence that bright light can improve nursing perfor-
mance, leading to a decrease in errors.6,7
Color
C olor has been used as an adjunct to light. Specific
colors in the spectrum are thought to affect emotion
and physiologic responses.8 Florence Nightingale used
color as a therapeutic tool, primarily through flowers.2 The
premise of this therapy is that color, a form of light and,
therefore, electromagnetic energy, has the power to effect
changes in the body.1 While there is little scientific proof
to support this theory, more is being discussed in literature
regarding the effects of electromagnetic energy on the
body.
Regardless of the opinion that color does or does not
have healing power, the fact remains that color does have
meaning to most individuals. The Society of Critical Care
Medicine recognizes the importance of color and recom-
mends that room colors should be calming and promote
rest. This concept is extremely important when designing
neonatal units. In pediatric settings, primary colors are
often chosen. Although the bright colors are pleasing to
toddlers, neonatal units must consider the needs of infants
and families.
Noise
N oise in the intensive care unit has been associated
with increased blood pressure, heart rate, anxiety,
and pain scores.9,10 Excessive noise levels in the NICU can
damage delicate auditory structures and can have adverse
physiologic effects such as hypoxia, increased intracranial
pressure, increased blood pressure, apnea, bradycardia,
and color changes.11 In developing a healing environment
for intensive care, every effort should be made to reduce
noise. The elimination of loud noises, as well as the
implementation of therapeutic sounds, will benefit the
staff, patients, and families. Many of us during our work-
ing hours have commented how stressed out we feel when
the noise levels rise. Some of us have been in neonatal care
long enough to remember radios and intercoms blaring
that disturbed us, our patients, and their families. Music
therapy is used in some units to calm and soothe the
environment. This therapy works for infants, families and
staff alike. However, the sound must be monitored for safe
and reasonable levels.
Sound levels in NICU’s have been documented to
range from 50 to 90 decibels (dB) with peaks to 120
decibels.9 Safety standards for sound exposure in adults
have long been established, yet this area is relatively new
for infants.10
Privacy
A ll families desire privacy, even in the intensive care
unit. The families’ need for privacy and the provid-
ers’ need for complete visualization of the patient are at
opposite ends of the privacy continuum. The promotion of
privacy lessens family anxiety, which increases their par-
ticipation, thus promoting true, family-centered care.
Creating a healing environment in the neonatal inten-
sive care unit is crucial in today’s health care market. The
specific design elements discussed can enhance healing in
the patient and their families. These same elements can
reduce staff stress levels, which promotes job satisfaction
and retention. Awareness of all aspects of the environment
is needed to promote healing in the patient and family. The
creation of a healing environment enhances patient clinical
outcomes and promotes staff satisfaction, both of which
benefit health care organizations financially.
Renovations at Good Samaritan Hospital in Cincinnati,
Ohio to create a new neonatal intensive care unit provided
upgraded services and much-needed additional space in a
homelike atmosphere. The NICU features high-grade ceil-
ing tiles and carpeting everywhere, with the exception of
the sheet vinyl flooring that was laid under the infants’
beds. Raised ceilings help give the area as a whole a more
spacious look, and lavender and teal tones brighten up the
space. Furthermore, an alarm lights up if the decibel level
exceeds 55 dB, the maximum noise level appropriate for
the unit. “You can really hear a pin drop in there,” stated
Peggy Eichel, RN, Staff Nurse.
The unit was decorated to appeal to the adult eye and
 Healing Environments: For Patients and Providers 91

Fig 3. Reports of severe ROP pre/post implementation NICU

design change and developmental care program. (Color version
of figure can be viewed online @www.sciencedirect.com).
Fig 1. Individual “Pod” Room. (Color version of figure can be
viewed online @www.sciencedirect.com).
grades 3 and 4, decreased as well, from 11% in 1998 to 3%
in 2000 (Fig 4), also as reported by the Vermont Oxford
did not use nursery themes. The NICU was an open floor
Network.13 During this time prophylactic indomethacin to
plan, yet a ceiling soffit enhanced the feeling of quiet and
prevent IVH was not implemented.
privacy by creating a sense of separation between corri-
The costs of health care have received considerable
dors and pods. Attention was focused on the bed layout,
attention over recent years. In a study by Petryshen and
lighting, sound control, and traffic patterns that would
coworkers13, infants receiving conventional care spent, on
support the developmental needs of sick infants and pro-
average, more days in the acute care NICU than infants in
vide soothing spaces for families and staff to interact
the developmental care group. These costs were $25,072
(Fig 1).
per infant compared with $18,919, respectively.14
Our unit design focused on providing family-friendly
Extremely tiny babies are very expensive and are consum-
care in a calm, sensitive, developmentally appropriate
ing more resources as the complexity of their care in-
environment. Decentralized nursery “pods” promote
creases.15,16
privacy for families as well as functionality for staff12
Costs related to length of stay (LOS) in a NICU are
(Fig 2).
great. The national daily average cost is $2,000. This
Creating a new design, as well as focusing on behav-
accounts for the room and nursing care only. Other
ioral changes of our staff, contributed significant improve-
charges such as physician fees, ventilator charges, phar-
ments in patient outcomes. The Vermont Oxford Network
macy charges, laboratory charges, as well as the charges of
(VON) reported rates of severe Retinopathy of Prematu-
disposables are quite costly. Costs related solely to the
rity (ROP) (stages 3 and 4).13 A 6% decrease was reported
LOS are demonstrated in Table 1. The LOS was catego-
in this two-year period (Fig 3). During this timeframe,
rized by gestational age. Cost analysis was determined by
there was no change in our approach to the target oxygen
multiplying the total days saved by the number of admis-
levels.
sions in the year 2000 in each gestational category by the
Rates of severe intraventricular hemorrhage (IVH),
average daily charge of $2,000. These numbers represent
charges, not collections.

Fig 4. Reports of severe IVH pre/post implementation NICU

Fig 2. Neonatal Intensive Care Nursery. (Color version of figure design change and developmental care program. (Color version
can be viewed online @www.sciencedirect.com). of figure can be viewed online @www.sciencedirect.com).
92 Leslie B. Altimier
Table 1. Costs Related to Decreased LOS National
Average ⴝ $2000/Day
Gestational Age Days Saved Cost Savings
24-27 weeks (n ⫽ 153) 21 $ 6,426,000
28-30 weeks (n ⫽ 132) 13 $ 3,432,000
31-34 weeks (n ⫽148) 11 $ 3,256,000
Total Yearly Cost Savings $13,114,000
In addition to these positive financial changes, fam-
ily-centered care was enhanced. Parents were encour-
aged to participate in medical rounds and were included
in shift changes. Parents were included as part of the
care team, which led to greater interaction by parents
with their babies. This increased involvement improved
their ability for caretaking on discharge and decreased
stress throughout their stay. This participation led to
improved family satisfaction scores as documented in
exit interviews.
These results show that a change in the physical NICU
environment, as well as a comprehensive educational pro-
gram, can be effective in improving the NICU environ-
ment, improving infant medical outcomes, decreasing
LOS, and decreasing hospital costs.
Certain design choices and strategies can work for or
against the well being of patients and staff. Health care
environments can lower stress and support wellness if they
are designed to foster calming physical–social surround-
ings and promote access to social supports. Creating an
environment sensitive to our NICU population is a chal-
lenge. As the age of viability keeps decreasing, the need to
protect the infant from extrauterine environmental (NICU)
stressors keeps increasing. High-tech and high-touch care
need to be combined to address developmental and healing
needs of our infants and their families.
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