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The ethics of space, design and color in an oncology ward

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Palliative and Supportive Care (2013), 11, 215– 221.
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doi:10.1017/S1478951512000077

REVIEW ARTICLES

The ethics of space, design and color in an

oncology ward

ELISABETH ANDRITSCH,1 HERBERT STÖGER,1 THOMAS BAUERNHOFER,1

HANS ANDRITSCH,2 ANNE-KATRIN KASPAREK,1 RENATE SCHABERL-MOSER,1
FERDINAND PLONER,1 AND HELLMUT SAMONIGG1
1
Clinical Division of Oncology, Department of Internal Medicine, Medical University Graz, Graz, Austria
2
Division for Child and Adolescent Psychiatry, Landesnervenklinik Sigmund Freud Graz, Graz, Austria
(RECEIVED December 20, 2011; ACCEPTED February 26, 2012)

ABSTRACT
Change affects all areas of healthcare organizations and none more so than each aspect of the
oncology ward, beginning with the patient’s room. It is there that the issues faced by the major
players in healing environments – administrator, caregiver, family member, and, most
importantly, the patient – come sharply into focus. Hospitals are building new facilities or
renovating old ones in order to adapt to new environmental demands of patient care and
security. Driven by ethical and professional responsibility, the oncological team headed by
Professor Hellmut Samonigg of Graz Medical University Graz pursued a vision of designing a
model oncology ward unique in Europe. Friedensreich Hundertwasser, the world-famous artist,
was the creative force behind the design. The oncology ward became a place of healing,
permeated with a colorful sense of life and harmonious holistic care. The successful outcome was
confirmed by the extraordinarily positive feedback by patients, families, and healthcare staff.
KEYWORDS: Oncology ward, Design, Healing, Patient perceptions

THE BEGINNING. . . ing to open them again. Suddenly, light penetrated

Anna, a 38-year-old secretary, lived with her partner.
She had metastatic breast cancer, with liver and lung
involvement, which was first diagnosed in December
2007. Anna knew her prognosis when she was hospi-
talized.
. . .I didn’t want to come. . . I wanted to die before
being hospitalized in a closed room with white
walls. . .like the anticipatory jail for the dying. It
was just a nightmare!
Then, you suggested that I come just to see the
ward, and only reflect on what I feel inside. . .
I remember that I closed my eyes without want-
Address correspondence and reprint requests to: Elisabeth
Andritsch, Clinical Division of Oncology and the Palliative Care
Unit, Department of Internal Medicine, Medical University Graz,
Auenbruggerplatz 15, A-8036 Graz, Austria. E-mail: elisabeth.
andritsch@klinikum-graz.at
215
my face like a laser of life. . .colors, shapes, texture. . .
It was like being in Disneyland. . . My memories of
the ward were as a dark, overcrowded prison without
any possible escape. . .everything dark. . .
It isn’t that I want to be here. . .but now, I feel differ-
ently. . .to be here, in the room, in the halls. . . It is like
a game of cards. . .counting the variety of colors and
shapes. . . It is like a game that infuses life and hope
with the warm feeling of being cared for in every as-
pect of my living and dying. . .
[Translated with patient’s permission]
ONCOLOGY WARD DESIGN: UTOPIA OR A
REAL NEED?
Change affects all areas of healthcare organizations
and none more so than in a hospital oncology ward
where the issues faced by the major players in the
healing environment – administrator, caregiver,
216
family member, and, most importantly, the patient –
come into sharp focus. It is there that the delivery of
care is undergoing more change than at any other point
in history (Miller, 2010). Moreover, new technologies
are altering the landscape of the hospital and many
procedures that once required hospitalization can be
done on an outpatient basis. The recent program of
hospital building in the United Kingdom has been ac-
companied by a vigorous debate over what constitutes
good hospital design, with four significant ideas emer-
ging: hospitals should be clinically efficient, be integra-
ted within the community, be accessible to consumers
and the public, and should encourage patient and staff
well-being (Gesler et al., 2006).
In an interview with .550 architects, designers,
and hospital staff members, respondents said advan-
cing technology, cancer environment, patient and
family experience with the ward, and efficiency in
design were their top areas of concern (Miller, 2010).
With the changing nature of cancer care, oncology
wards will serve patients who are sicker and need
acute cancer care. Hospitals are building or renovat-
ing existing facilities so that they can accommodate
new technologies, patient demands, an aging popu-
lation, and new patterns of environmental care (Kur-
tis et al., 2008; Larsen, 2008).
The University of Medicine & Dentistry of New
Jersey designed a 200,000 square foot state-of-the-
art comprehensive cancer center and research lab-
oratory in Newark, which includes research, clinical,
administrative, and support spaces with an ultra-
modern design (University of Medicine of New Jersey
Cancer Center, 2011).
A study analyzed 17 interviews with patients, sig-
nificant others, and staff at an oncology center in Swe-
den. The physical environment was found to influence
experiences of care in four ways: 1) as a symbol itself
that expressed messages of death, dying, danger,
shame, stigma, and lower social value; 2) it contained
symbols that expressed messages of caring and uncar-
ing, life and death; 3) it influenced interaction and the
balance between being involved and finding privacy;
and 4) it contained objects that could shift the focus
away from the self and find the light in the midst of
darkness. The comprehensive understanding from
the study illuminates that the physical environment
is not merely a place for caring but is also part of nur-
sing care (Edvardsson et al., 2005, 2006).
Memorial Sloan-Kettering Cancer Center (MSKCC)
recently opened an innovative, 7745 square-foot outpa-
tient chemotherapy facility called the Brooklyn Infu-
sion Center. The hospital was designed to fulfill the
specific needs of outpatient chemotherapy, for both
patients and family (Wittes, 2011).
A recent survey conducted by the Georgia Tech
College of Architecture and Center for Health Design
Andritsch et al.
(Taylor, 2009) studied healthcare architects, design-
ers, consultants, and those in related professions.
Most professionals used design research to make de-
cisions in connection with cancer centers. The fea-
tures most frequently incorporated in patient rooms
included single bed setup, highly visible sinks for
hand washing, and designated zones for patients, fa-
milies, and clinicians (Taylor, 2009).
Analysis of patient satisfaction data made avail-
able by Press Ganey, Inc. (Press Ganey, 2003) shows
that patients in single-bed rooms, compared with
those with several roommates, are consistently
much more satisfied regarding “concern for privacy.”
The satisfaction data were obtained from 2,122,439
patients who received care during 2003 in 1462
healthcare facilities. Fifty-six percent of the patients
were in single rooms; 44% had roommates. Greater
satisfaction with privacy in single rooms was evident
across all major patient categories and types of medi-
cal units and across different age and gender groups.
Satisfaction with privacy was 4.5% higher on average
nationally in single rooms than in doubles; a substan-
tial difference considering that it can be difficult for
hospitals to increase satisfaction scores by even 1–2%.
Although the patient needs a safe environment in
order to heal, there are a number of factors beyond
safety and wise architectural designs that contribute
to healing. Access to daylight and bright colors
reduces pain, depression, and length of stay as well
as improves patient and staff satisfaction. Natural
landscapes have been linked to reduced pain,
reduced stress, and improved rehabilitation (Georgia
Tech College of Architecture and Center for Health
Design, 2008).
Patients who have a sense of control recover more
quickly. One of the most difficult things about being a
patient is that you do not have control over what is
happening in your surroundings. Giving a patient
some measure of control, even just in the patient’s
personal environment, goes a long way toward im-
proving a patient’s experience with illness and care
(Yundt, 2009).
FAMILY ROLE IN THE WARD
The role of family members has changed in recent
years from that of concerned bystanders to members
of the care team. Family members are now expected
to be fully involved in the healing process. With these
responsibilities has come the need for additional ac-
cess. Family members regularly stay in the patient’s
room around the clock. This is good for the patient’s
recovery but has implications for the staff and the
facility (Meyers, 2009).
Studies show that family involvement in caring for
the patient results in better and faster healing.
Ethics of space, design and color in an oncology ward
Family zones in the patient room result in fewer
patient falls, reduced patient stress and depression,
improved patient privacy and confidentiality, im-
proved communication with patient and family mem-
bers, improved social support, and increased patient
satisfaction (Cardon, 2009).
COLOR ENVIRONMENT
Healing and care are internal processes that can be
influenced by objects in the environment that shape
the exterior space. Space and structure are defined
by the visual elements. Brick, color, corridor, door,
window, trim, and carpet are only a few of these
visual elements; all of them combining to allow us to
experience a space. Structure in this case determines
function.
Some oncology wards are created to encourage so-
cial interaction, whereas others are designed to en-
courage silence and reflection. A properly designed
healing environment can create an integrative and
harmonious balance accessible to the eyes of patients
and families during the long journey of curing and
caring (Whitehouse et al., 2001).
Even if the perfect oncology ward environment of
care cannot be defined in universal terms, it can be
approximated by observing the subjective needs of
patients and their families. A gentle, unobstructed,
calming atmosphere enhances the healing process,
with all the vitality that emerges from the lifelike col-
ors, shapes, and artistic designs (Sanders, 2005).
Colors emphasize particular moods and particular
behavioral reactions to health and illness. All colors
have associative qualities, with physiological effects
upon the organs and metabolism (Table 1). Blue
suggests coolness; red can bring warmth, stimulation,
passion, and aggression; yellow brings light to a sun-
less room and vitality and cheerfulness; whereas
green is calming and refreshing, and is the color of
surgical gowns. The conjunction of all these colors
can be used to create magical walls in oncology wards.
The proportions of structures determine whether
places are at rest or whether there is a directional dy-
namic with an associated feeling. Awe, expectation,
or soothing can be produced with upward, forward,
or an all-round horizontal emphasis. Proportions
that are in “balance” reflect “balance” in the human
body and in the soul. The environmental design of
our oncology ward was created to achieve this pro-
portion and to emanate caring.
GRAZ: THE ONCOLOGY WARD BECOMES
A REALITY
In 1992, Professor Hellmut Samonigg and the pro-
fessional team of the Clinical Division of Oncology
217
Table 1. Colors and their psychological effects
(Johnson, 2005)
Color Psychological effects
Black Color of power and authority. Absorbs light
and dims a space, usually making the
space less desirable to occupy.
White Reflects light and makes a space brighter
and, usually, more pleasurable to be in.
Red Most emotionally intense color. Tends to
cause a faster heartbeat and breathing.
However, pink causes the team to lose
energy (Morton, 2005).
Blue Opposite of red, it causes body to produce
relaxing chemicals.
Green Most popular color in decorating, because it
is most calming and refreshing and can
even improve eye health.
Yellow Although a cheerful color, it is common for
people to lose their temper and babies
tend to cry more in yellow rooms. It tends
to increase metabolism.
Purple The color of royalty, purple connotes luxury,
wealth, and sophistication. It is also
feminine and romantic. However, because
it is rare in nature, purple can appear
artificial.
Brown Brown is the color of nature. It symbolizes
strength and genuineness. Men are more
likely to say that brown is their favorite
color.
at the Medical University, Graz, Austria assumed
responsibility for the oncology ward. They strongly
believed that an essential requirement for effec-
tively caring for patients and staff was to renovate
the inadequately designed, colorless, and sterile
ward, with its cracked and dingy walls, dimly lit cor-
ridors, and rooms furnished with tubular steel beds
and nightstands. Financial considerations meant
that the renovation of the ward would have to wait
12 years as a part of a comprehensive building res-
toration. The professional oncology team found
this decision unacceptable, both morally and ethi-
cally. Their values of patient care were based on a
holistic approach to providing the best medical
treatment in a pleasant, caring, protective, and op-
timistic environment.
An innovative idea was urgently needed, so as
not to postpone the renovations. Friedensreich
Hundertwasser, the world-famous artist, was invi-
ted to participate in the unique project. He was so
fascinated by the idea that he offered to work for
free to realize its implementation and completion.
Additional creative activities by the interdisciplin-
ary team were initiated, following the establish-
ment of a nonprofit organization called “Verein für
Krebskranke”.
218
THE ARTIST: FRIEDENSREICH
HUNDERTWASSER
Friedensreich Regentag Dunkelbunt Hundertwasser
was an artist who was widely accepted and appreci-
ated, despite controversies in the art world. He at-
tempted to integrate both nature and fantasy into
his work. His philosophy was to sharpen a person’s
senses and to demonstrate, through his lifestyle and
art, that everyone can have paradise on earth. One
has only to understand it (Hundertwasser, 1996).
Hundertwasser was born in 1928 in Vienna. By the
end of the twentieth century, he had become one of the
best-known contemporary Austrian artists. His archi-
tectural work was compared with the work of Antoni
Gaudı́ (1852–1926) by integrating biomorphic forms
and the use of tiles. Hundertwasser believed that
rational, sterile, monotonous architecture breeds
unhappy people, and he rejected the conventional,
functional, and straight architecture. His art was
influenced by the Vienna Secession and in particular
the Austrian painters Egon Schiele (1890–1918) and
Gustav Klimt (1862–1918). An outstanding charac-
teristic of his work was the spiral, a form that fascina-
ted Hundertwasser because he considered straight
lines “the devil’s tools.” His theory of art was based
on Surrealist automatism and is defined as “transau-
tomatism” (Schmied, 2000; Fürst, 2002).
The main attributes that the oncology team con-
sidered in selecting the artist for the project were
that his or her art should have an overall positive
effect on patient well-being and should bring vivid-
ness, hope, and motivation into the eye of the obser-
Fig. 1. Corridor.
Andritsch et al.
ver. Hundertwasser’s colorful, constructive, and
inspiring paintings, buildings, and sculptures met
the stringent selection criteria. With his participation
in the project, an atmosphere of pain, suffering, and
death was replaced with a friendly, supportive, and
spirited ambience (Hundertwasser, 1996).
FINAL DESIGN OF THE WARD
Approximately 2000 adult cancer patients are admit-
ted each year to the oncology ward for invasive and
adjuvant therapies, palliative or curative treatment,
and supportive care. The renovated oncology ward,
which opened its doors in 1994, is designed for 30
beds in 14 rooms (Fig. 1). There are five rooms for
physicians, seven rooms for the nursing staff, and
three rooms for psychologists. In addition, a winter
garden, rooftop terrace, and benches in the corridor
provide a variety of comfortable and private meeting
areas for patients and visitors.
The artist’s aim was to create an atmosphere of se-
curity by utilizing bright, warm, and vivid colors, a
large amount of light and many plants, with many
conspicuous details. As a result, the redesigned
ward includes skylights to brighten the corridors,
variously shaped incandescent lamps to replace the
old neon lamps, walls consisting of curiously shaped
and multicolored tiles, and black marmoleum floors
(Fig. 2). The black color for the floor in the corridor
was chosen to accentuate the colors on the doors,
walls, and columns. The doors and floors of each
room were painted in different colors (red, blue,
Ethics of space, design and color in an oncology ward
Fig. 2. Entrance.
yellow, and green) and shapes, with a blob of paint
trailing from each room into the corridor. The beds,
nightstands, and wardrobes were all varnished in
these various colors and shades. The individual
washing facilities were restyled by Hundertwasser
himself with his typical rough-surfaced, spiral tiles.
One of his ideas was to make each patient room dis-
tinct in order to facilitate identity. Even the bed
linens are colorful, giving the patient a more intimate
and individual perception and a sense of “being
home.” A room is set up in the middle of the ward
for family members to be with the patient during
the curative or terminal phase of the illness.
Another innovative space is the winter garden
available for eating, relaxing, conversing, and special
family or staff events (Fig. 3). Breakfast is served
around the aquarium, and patients are able to
make their own selections from a variety of foods
and drinks. Colored carpets, relaxing chairs, and
plants create a home-like ambience, with a panora-
mic view of the city. The rooftop terrace is designed
like a little garden with a variety of plants, a foun-
tain, beach chairs and an awning; inviting both
219
Fig. 3. Winter garden.
patients and staff to leave the burdens of the daily
clinical routine at the doorstep (Fig. 4).
The innovative design of the ward has generated
admiration from colleagues worldwide and very posi-
tive feedback from most of the patients, family mem-
bers, friends, and staff. It reinforces and confirms the
viability of incorporating unconventional designs of
hospital oncology wards to help patients and their
families reduce anxiety and isolation, and support
them through the long trajectory of the illness.
CONCLUSION
Martin, 71 years old, was a teacher in a small town,
married with four children and grandchildren. He
was diagnosed with pancreatic cancer in March 2009
and after a month in hospital died in December 2009.
. . .My children want to bring the grandchildren to
visit me here. . .I sent them pictures and told
them about the multiple figures, unique designs
like the sink for washing, and the abstract shapes
of each colored wall tile. . .I close my eyes and sense
220
Fig. 4. Rooftop terrace.
every color that I touch with my fingers. . .It is like
being in another dimension. . .I am not alone in my
dying. . .I return to the land of children’s games or
searching for hidden treasure through a forest cov-
ered by the light of the leaves. . .
. . .Dying has been transformed to a different di-
mension for me here. . .reminiscent of what it was
before. . .
. . .The colors and shapes do not leave me alone
with my pain and sorrow. . .
. . .You built a “temple” for reflection and care. . .a
place where I can smile in the face of death. . .the
nights are filled with a magical melody of hope
and prayer. . .
[Translated with patient’s permission]
Despite the final implementation of the project, it is
relevant to point out its limitations. Advanced-stage
cancer patients and their families, in particular, were
not active partners in the decision concerning the
ward design. Similarly, concrete ideas presented by
a number of invited architects and artists could not
be considered because of budgetary constraints.
The suggestion to invite Hundertwasser came as a
unique and unprecedented opportunity because of
his total commitment to the project and his refusal
to accept any financial remuneration.
There is a clear need for additional studies that
examine privacy and confidentiality breaches associ-
ated with the physical environment in single versus
double rooms, multibed spaces in oncology wards
and other types of units, and in spaces such as
Andritsch et al.
waiting rooms and nurses’ stations. Furthermore,
priority should be given to generating more research
that investigates how the quality of communication
and information from patients to physicians and nur-
ses is affected by the architecture. The therapeutic
value of hospitals is related to their physical, social,
and symbolic design, and requires expert knowledge
to develop the environment that promotes patient re-
covery and healing (Gesler et al., 2006).
ACKNOWLEDGMENT
The project was supported by the “Verein für Krebskranke
der Klinischen Abteilung für Onkologie Graz” [Society for
Cancer Patients of the Clinical Division of Oncology
Graz]. The publication of this article is not contingent on
the sponsor’s approval or censorship of the manuscript.
There are no direct or indirect financial relationships be-
tween the authors and the sponsor.
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