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The therapeutic impacts of environmental design interventions on wellness

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 Complementary Therapies in Clinical Practice 24 (2016) 174e188

Contents lists available at ScienceDirect

Complementary Therapies in Clinical Practice

journal homepage: www.elsevier.com/locate/ctcp

The therapeutic impacts of environmental design interventions on

wellness in clinical settings: A narrative review
Timothy Onosahwo Iyendo a, *, Patrick Chukwuemeke Uwajeh a, Ezennia Stephen Ikenna b
a
usa, North Cyprus, Via Mersin 10, Turkey
Department of Architecture, Eastern Mediterranean University, Gazimag
b
Department of Architecture, Nnamdi Azikwe University Awka, Anambra State, PMB, 5025, Awka, Nigeria

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: The aim of this review is to document the role of physical environmental factors in clinical
Received 26 May 2016 environments and their impact on patients and staff wellness with a particular focus on physical and
Accepted 24 June 2016 mental healthcare.
Methods: Data sources comprised relevant English language articles and the results of literature search of
Keywords: ISI Web of Knowledge, PubMed, Scopus, ProQuest Central, MEDLINE, and Google.
Clinical settings
Results: Incorporating physical environmental factors into hospital design can facilitate better user
Design factors
satisfaction, efficiency and organisational outcomes. Many of the design interventions convey positive
Healing environment
Physical environment
distractions for patients and staff, in terms of views of pleasant outside vistas, soothing sound, artwork
Therapeutic sound and music.
Wellness Conclusions: Well-designed physical settings play an important role in the healing process of patients in
health care facilities. The challenge then is to fully understand that role in the ecological context of health
care. Other contributors are possible and should be explored in further research.
© 2016 Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
1.1. Understanding a therapeutic environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
3. Results and discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
3.1. Artwork and healing process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
3.2. Optimising environmental light and views in hospital rooms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
3.3. Hospital auditory environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
3.4. Incorporating musical sound for therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
3.5. Landscape and therapeutic gardens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
3.6. Colour and its impact in hospital environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
3.7. Personal control and access to privacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
3.8. Access to social support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
3.9. Cleanliness and ease of maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
3.10. Architectural design impact on hospital occupants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
4. Suggestions for clinical interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
Authors' contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185

* Corresponding author.
E-mail address: tidosmart2012@gmail.com (T.O. Iyendo).

http://dx.doi.org/10.1016/j.ctcp.2016.06.008
1744-3881/© 2016 Elsevier Ltd. All rights reserved.
 T.O. Iyendo et al. / Complementary Therapies in Clinical Practice 24 (2016) 174e188
1. Introduction
The ideology behind healing is the psychological and spiritual
concept of wellness. In recent decades, research on healthcare
design and planning has highlighted substantial relationships be-
tween physical environmental factors and wellness [118]. The
physical environment in which a patient receives care plays a sig-
nificant role in their outcomes and should reduce pain, anxiety and
stress for patients' comfort and safety [46,97].
Ulrich [170] advocated that healthcare physical and social en-
vironments promote wellness if they are designed to foster the
reduction of environmental stressors such as the sense of control
over physical-social surroundings, access to social support,
connection to nature, and access to positive distractions. The
healing environments approach in hospitals is, however, not a
novel concept as such. Previously, there has been research interest
in healing environments for promoting the patient's wellness and
wellbeing [27], although it was mainly employing diverse meth-
odologies such as holistic and spiritual [75]. However, in the 1970s,
hospital designs began to transform when healthcare users started
choosing hospitals based on aesthetic appeal, such as beautiful
objects, artwork, sculptures, and fascinating colours. Consequently,
the appearance of the hospital environment became a significant
marketing strategy [2].
Similarly, earlier research has advocated that hospital design
should do the sick patients no harm [122]. Research has linked poor
design to psychological and physiological discomfort [175] but
these negative effects can be tackled through good design
[134,175]. Indeed, patients would recover more quickly from ill-
nesses if they were cared for in an environment that had natural
light, ventilation, cleanliness, and basic sanitation including
reduced sound levels [122]. Similar research remarks that patients
who viewed trees had shorter post-operative stays, took fewer pain
relief drugs, and had a favourable response about their outcomes in
medical notes when compared to those exposed to view a brick
wall [2,169].
As such, hospital environments promote wellness if they are
designed to foster social, psychological, physical, spiritual, and
behavioural components of healthcare support and stimulate the
body's innate capacity to heal itself [6]. Indeed, patients experience
a positive satisfaction and better recovery in an environment that
incorporates various aspects of the physical environmental factors,
including art gallery, natural light, inciting natural elements,
blended colours and decor, soothing music, pleasant sound and
views, access to gardens and easy access to staff [61,141]. It is
important to take into consideration these attributes and study
their impact on patient and staff outcomes [43].
1.1. Understanding a therapeutic environment
Designers are faced with the increasing task of integrating cul-
tural diversity, psychological and socio-spatial considerations by
the application of Evidence-based design (EBD) in both the interior
and exterior context of buildings. Evidence-based design strategies
can improve stress-free environments in healthcare, by empha-
sizing strategic opportunities to influence the design of health care
facilities. Evidence-based design (EBD) as a tool for healthcare
planning is a method that began with the general purpose of
providing evidence based medicine [76]. EBD has now become the
theoretical concept of what are called healing environments. The
healing environment in hospital settings begins with the healing
presence of the healthcare providers. Healthcare providers create a
healing environment by incorporating an atmosphere of safety,
trust, and openness that allows for compassion, clarity, and truth.
To achieve this, hospital providers must maintain a non-
175
judgmental relationship to invite those same qualities to flow
from others. Donna [44] argued that therapeutic environments
create a shared environment that strengthens the self-healing ca-
pacity of both patients and hospital providers. In other words, the
healing environment should reflect the values, beliefs, and philos-
ophies of the patients served.
There is a growing body of evidence on the positive impacts of
the patient's physical environment (e.g.
Refs. [6,7,42,45,82,112,116,144,158,174,179] and this ideology was
first initiated by Florence Nightingale [122]. There is good evidence,
largely from existing studies, that specific design approaches in the
hospital environment have the potential to reduce stress, pain, and
anxiety. This includes good quality natural lighting, captivating
healing colours, therapeutic sound (such as music, bird songs,
water sounds etc.), privacy, and speech intelligibility. In addition, it
has also been postulated that physical factors contributing to
healing in the healthcare environment include a view of natural
landscape, mitigating the degree of noise levels, interactive arts,
good air quality, adequate signage, maintaining and effecting
environmental changes to enhance patient safety that may
heighten medical error and increase infection rates [43,169,196].
Similarly, Malkin [108] argued that the physical setting has the
potential to be therapeutic if it achieves attributes set out in (Fig. 1).
A healthy work environment that integrates physical environ-
mental factors helps in the development of a healing environment
that improves hospital staff efficiency and reduces the patient's
hospital length of stay that promotes less stressful conditions [175].
2. Methods
This narrative review documents the role of physical environ-
mental factors in clinical environments and its impacts on patients
and staff wellness with a particular focus on physical and mental
healthcare. In addition, this paper also elucidates the design trends
towards the creation of a proper healing environment for hospital
occupants.
A review of the literature was considered the appropriate
method to answer the research question under investigation. Tak-
ing this approach, a review was undertaken between June 2015 and
May 2016, which involved searching several electronic databases.
Data sources comprised results of a literature search of Google,
PubMed, Scopus, ProQuest Central, MEDLINE and Web of Knowl-
edge using terms such as therapeutic sound, noise, artwork, light,
colour, healing environment, architecture, therapy, landscape, natural
view, stress reduction, social support, positive distraction, access to
nature, music, wellbeing, wellness, hospital, clinical settings, design
factors, physical environment and relevant additional terms derived
from the papers retrieved. In addition, the references of retrieved
articles were scanned for additional relevant material and earlier
studies, significant in shaping the field under investigation. Priority
was given to the reporting of empirical studies from peer-reviewed
journals. There was no restriction to article publication dates.
Article selection was generally founded on the title and the ab-
stract. In case of uncertainty, the researchers read the entire text of
an article. In addition, book reviews, non-empirical articles, news
items, monographs, duplicates, encyclopaedia articles, non-English
publication and editorials were in most cases excluded from the
materials used in this narrative review. It was not possible to rely
only on simple electronic searches of databases; therefore, the
reference lists of relevant sources (e.g., books/book chapters and
proceedings) were searched by hand to identify other studies of
related interest.
The review grouped the literature and issues in the field into
themes concerning the physical environment factors in healthcare
settings; artwork and healing process; environmental light and
176 T.O. Iyendo et al. / Complementary Therapies in Clinical Practice 24 (2016) 174e188
Fig. 1. A model for understanding a therapeutic environment (adapted from Refs. [108,174e176].
views from hospital rooms; hospital auditory environment; incor-
porating musical sound for therapy; landscape and therapeutic
gardens; architectural design impact on hospital occupants; colour
and its impact in the hospital environment; personal control and
access to privacy; access to social support; cleanliness and ease of
maintenance and suggestions for ways of conceptualising clinical
interventions for improving wellness in health care facilities
(Fig. 2).
3. Results and discussion
The literature search was purposely wide ranging and multi-
disciplinary. This included aspects of architecture, ecology, medi-
cine, music, nursing, occupational therapy and rehabilitation,
physical therapy as well as a collective concern with the healthcare
environment. Using the title of this narrative review, the initial
search identified 1393 references, which on closer examination
relative to the research question was reduced and in total 195 ref-
erences were included. The main inclusion criterion was that the
references contained significant content concerning physical
environmental factors that enhances wellness in a clinical context.
This results of this review demonstrated that the well-designed
physical environment has the potential to impact upon patients
and staff outcomes in several distinct ways, which include reducing
staff stress and fatigue, increasing effectiveness in delivering care,
reducing stress and other possible negative outcomes, and
improving patient safety and overall health care quality.
3.1. Artwork and healing process
More than a millennium ago, palaces, castles, town halls, and
cathedrals in Europe were primarily constructed for achieving
worldly glory and posthumous remembrance [10]. The advent of
artwork in European hospitals became visible in the 14th century.
As of that time, religious buildings were used as a healing envi-
ronment for the care of the sick and needy, and art was portrayed in
a very specific way. In the 18th century, a transition influenced the
hospital environment's appearance, and hospitals with a more
business-minded approach began to advance. For example, William
Hogarth painted two canvases in 1734, for St Bartholomew's Hos-
pital in London. These paintings emphasised the virtues of charity
and compassion. Hogarth's works at that time were not really
designed with the patients in mind, but rather to evoke the emo-
tions of visiting royalty and grandees who were stimulated to drop
a donation to the hospital managers for the support of arts projects
[12,107]. Patients and the arts have been associated together for
more than a thousand years now, at first with the intention of
healing and more recently to beautify the hospitals. Today, the vi-
sual environments of several hospitals, both old and new, are
enhanced by works of art displayed for the delight of patients, staff,
and visitors. They may also possess certain functions such as having
therapeutic value that gives comfort to patients and medical staff
 T.O. Iyendo et al. / Complementary Therapies in Clinical Practice 24 (2016) 174e188 177

Fig. 2. The selected physical environment factors that enhances wellness in clinical environment.

[10]. an alteration in their mode of thinking and consequently move

According to Behrman [12]; the artworks at Chelsea and West- forwards [71]. The investigator found that art therapy portrays the
minster hospital transformed the atmosphere, which results in a following attributes set out in (Fig. 3). A study which included a
positive impact on the patients' wellbeing that reduces the feeling sophisticated psychological analysis demonstrated that the images
of being isolated from the outside world, and brings the community are proverbial, deeply associated with our emotions and uncon-
into the hospital. Consistent with this argument, Macnaughton scious mind. In line with this emotional cogitating, whenever a
[107] advocated that art also built upon existing close community painting, a photograph, a piece of music, or the smell of a flower
links with the hospital, by increasing public interest and support for moves an individual in a way that cannot be expressed, then it can
the Arts Project. It is important to note that several researchers be concluded that such an individual has been evoked by the power
have investigated people's emotional reactions towards environ- of images [201].
mental aesthetics through different methodologies, and demon-
strated a direct effect and correlation with human physiological
3.2. Optimising environmental light and views in hospital rooms
reactions. An investigation on visitors' experiences of the art gallery
at a teaching hospital disclosed that human beings change their
Hospitals are complex buildings with a variety of functions. The
emotions according to environmental stimulation such as colour,
quality of the visual environment has a positive effect on the oc-
sound, and objects [53]. A study conducted to evaluate the effects of
cupant's feeling of well-being in healthcare buildings, and this can
pictorial intervention in a paediatric hospital environment
affect staff performance and patient recovery. Although natural
concluded that children respond differently to stressful events
lighting has no benefits over artificial lighting for the performance
depending on their level of cognitive, social, and personality
of visual tasks, most users prefer daylighting in hospital buildings,
maturity [118].
since it offers a dynamic interior space and views from the hospital
Significant evidence exists that scenes of naturalistic artwork
room window [69]. Research has evidently suggested that sufficient
could provide a positive distraction, producing positive feelings,
daylight in rooms is of paramount importance to both the recovery
promoting sustained attention and interest, and reducing worri-
and rehabilitation of patients, as well as the health and wellbeing of
some thoughts and postoperative anxiety [174]. The growing
hospital care-providers [172]. Similarly, Joseph [81] ascertained
acceptance of the distraction theory approach has been supported
that office occupants opted for daylight over electric lighting for
in a review of evidence-based healthcare, which argued that
several distinct motives, including psychological comfort, office
viewing naturalistic scenery might have a positive influence on the
appearance and pleasantness, general health, visual health, colour
experience of pain, distracting patients through a pleasant stimulus
appearance of people and furnishings, work performance, and jobs
that can divert attention, and enhance pain reduction [177].
requiring fine observation. Another study concluded that the eye
Evolutionary theory suggests that nature will best promote resto-
needs sufficient lighting in the indoor spaces to see well [113].
ration across diverse groups of people if it contains calm or slowly
Lighting design is of vital importance in the creation of a pleasant
moving water, verdant foliage, flowers, foreground spatial open-
and ambient environment. Specifically, daylighting has been asso-
ness, park-like or Savannah-like properties, and birds or other
ciated with improved attention and mood, reduced strain,
nonthreatening wildlife [176].
anxiousness, tiredness, and eyestrain, as well as controls the pro-
Research evidence has supported that art therapy offers a reli-
duction of the hormone melatonin, which affects sleep, puberty
able means to express, or release feelings, which would otherwise
onset, tumour development and body temperature when it is
remain hidden. Moreover, whatever the state of the situation, most
absorbed by the eye [47].
people who were referred to art therapy could think about creating
Natural lighting maximises user comfort, and provides more
178 T.O. Iyendo et al. / Complementary Therapies in Clinical Practice 24 (2016) 174e188
Fig. 3. Benefit of art therapy as summarised by Ref. [71].
enjoyable and fascinating indoor environments with higher per-
formance and productivity. It saves energy use and its associated
environmental emissions. In terms of visual comfort and energy-
efficient building design, daylighting is very beneficial [5,98,101].
A considerable amount of research has shown that daylight in
hospitals can maximise occupant comfort, as well as providing a
more pleasant and attractive indoor environment with higher
performance and productivity [77]. Lighting varies in intensity,
duration of exposure, and pattern. Artificial light can cause visual
fatigue and headaches. Softening the hospital environment with
natural lighting can generate a healing environment [2,113].
Researchers have also shown that ultraviolet light enhances
healing by increasing protein metabolism, decreasing fatigue,
stimulating white blood cell production, increasing the release of
endorphins, decreasing blood pressure, and generally promoting
emotional well-being [19,126]. Investigators studying daylighting
impacts in the hospital environment have identified that good day
lighting has a positive influence on health, wellbeing, alertness, and
even sleep quality [24,32,98,156,180] Natural lighting also helps
with the implementation of day/night cycling in humans and ani-
mals. Cognitive disturbances can occur if there is a lack of natural
light for patients and staff. Some research evidence has shown that
bright light can improve nursing performance, leading to a
decrease in errors. Natural light offers both patients and caregivers
with substantial health benefit (physical and mental) that coincides
with a general economic benefit to the facility [55]. Natural lighting
is also beneficial to patients who have long hospital stays by aiding
their ability to look out of the windows to see the time of day and
observe the weather and surrounding landscape in natural light.
One study at the University of Texas at Austin, has demonstrated
that comforting colours and views of nature aid the healing process
of patients [197,113]. Research evidence has explored the effect of
space occupancy on indoor daylight quality in hospitals and
explicitly states that the overall, daylighting in a hospital environ-
ment has a positive influence on both patients' physiological and
psychological health [5]. Several other studies have demonstrated
that natural daylight or view out reduces depression among pa-
tients with seasonal affective disorder and bipolar depression,
which in turn decreases the length of stay in hospitals [13,198]. In
an extension of this line of research Lewy et al. [100] examined
morning and evening light treatments on patients who were
experiencing winter depression and established that morning light
was at least twice as effective as evening light in the treatment of
seasonal affective disorder.
Other evident studies have defined the benefit of natural
lighting from a different perspective, such as improving sleep,
lessening agitation, and the ability to treat hyperbilirubinemia
among infants [81,174,183]. Lighting can have an impact on peoples'
 T.O. Iyendo et al. / Complementary Therapies in Clinical Practice 24 (2016) 174e188
perceptions and responses to the environment and can affect pa-
tient recovery rates, improving the quality and overall experience
of patients, staff, and visitors. When hospital lighting is carefully
designed, it transforms the appearance of the space, making it
attractive, welcoming and either restful or stimulating. It also en-
hances the architectural appearance of the hospital atmosphere.
Indeed, appropriate daylighting is also a powerful tool for coding,
navigation, and wayfinding, as well as for promoting a sense of
well-being and independence [33].
The visual environment, including the quality of daylight and
electric light, is a vital element influencing hospital staff morale and
productivity. An enhanced visual environment has produced faster
recovery rates by as much as 10% [33]. Indeed, these improvements
have been ascribed to particular elements of the visual environ-
ment, including the use of appropriate colour in interior design, the
display of certain types of artwork and the provision of sunlight and
attractive views out [33,104,169]. Research findings have strongly
indicated that a view out from the hospital environment can reduce
feelings of isolation and claustrophobia, provide contact with the
outside world, add interest to the healthcare environment, and
enhance visitor's navigation or wayfinding within the hospital
premises [33]. These findings are consistent with the notion that a
view through the hospital window accelerates patient's recovery
from surgical operations, as well as shortening the length of hos-
pital stay for patients who could sight natural landscape through
their windows, as compared to those with the view of a brick wall.
Moreover, patients with the arboreal view took fewer doses of
moderate and strong analgesics and recorded slightly lower scores
for minor post-surgical complications [169].
3.3. Hospital auditory environment
The sound environment is a vital part of the overall environ-
mental ecosystem, and undesirable sound (usually referred to as
noise) is one of the most significant environmental stressors
currently found in the clinical environment [192]. The impact of
sensory stimuli such as sound and light is a critical issue in creating
a healing environment in hospital settings for occupants. A growing
body of evidence has shown that undesirable sound is a significant
barrier to sleep for hospital patients, and sleep has been shown to
be therapeutic for health, including healing and recovery
[58,73,117,185,192]. Research studies demonstrate that unpleasant
sound in the clinical environment has deleterious effects on health
and the healing process. These effects include altered memory,
increased agitation, aggressive behaviour, depression, anxiety,
psychiatric disorders and deciphering speech difficulties [142,150].
In several cases documented research has revealed that un-
welcome sound could have negative psychological and physiolog-
ical effects on patients. Noise has been associated with annoyance,
sleep disruption and awakening, decreased oxygen saturation,
elevated blood pressure, increased heart and respiration rate
among neonatal intensive-care patients, induce higher incidence of
re-hospitalization, increased perceived work pressure, emotional
exhaustion and burnout [51,70,82]. There have been claims in an-
imal experimentations that loud noises and other associated
stressors such as cold and heat can delay the rate of wounds healing
in rats [28,132,191], although this has not been attested by hospi-
talised patients. Researchers have reported that noise can affect
pharmaceutical name recognition, and suggested that areas where
drugs are prescribed and administered should be as quiet as
possible, well-illuminated, and free from distractions that include
background music and ringing phones [91e94,136]. According to
Frumkin and Louv [57] it could be argued that people are closely
attached to the natural world, which suggests that contact with
nature is beneficial to health and wellbeing. Indeed, sound may also
179
be included in the environment as a positive distraction [149],
which have been shown to have a significant influence on patients'
clinical and behavioural outcomes [128]. For example, an investi-
gation has shown that patients listening to ocean sounds during the
night on postoperative coronary artery bypass graft surgery after
transfer from an ICU, statistically scored significantly higher on a
scale measuring self-reported sleep [190]. Additionally, a survey
conducted to investigate stress recovery during exposure to natural
sounds and noisy urban environments indicated that the applica-
tion of pleasant natural sounds of fountains and tweeting birds
reduced psychological stress and facilitated fast physiological re-
covery of the sympathetic nervous system when matched with
disagreeable city noises of road traffic [3]. Similarly, an investiga-
tion has demonstrated that participants who either listened to river
sounds or saw a nature movie with river sounds during a post-task
restoration period reported having more vigour and better moti-
vation after the restoration period when matched with participants
that only listened to office noise or silence. Furthermore, this same
study also suggests that the combination of viewing a nature movie
and listening to river sounds during the restoration period had a
more positive effect than only listening to the river sounds alone
[78]. A similar study conducted by Diette et al. [40] in a Baltimore
teaching hospital observed that positive distraction therapy with
sounds of nature significantly reduced stressful pain in patients
undergoing flexible bronchoscopy when matched with patients
who did not receive any sound therapy. However, the same study
concluded that in order to improve the understanding of how the
sounds of nature affect individual's healing, further research should
be considered. Although music is highly subjective Harikumar and
Kumar [65] advocated that the combination of nature sounds with
music may be more acceptable as it spans across languages, social
and cultural roadblocks.
3.4. Incorporating musical sound for therapy
Sound is one of the oldest forms of healing known to man and
can influence patients and hospital caregivers in many distinct
ways. In other words, sound healing is the therapeutic application
of sound frequencies to the human body or mind with the intention
of bringing them into the state of harmonious health, through
listening to another person's voice or a number of voices or music
or sound musical instruments [68]. There has been an increasing
amount of research evidence on the therapeutic effect of sound
healing through music (Fig. 4). This evidence has demonstrated
that music therapy has the ability to mitigate the physiological and
psychological stressors experienced by patients undergoing medi-
cal procedures [148,167].
Relaxing music provides great benefits to both patient and
clinician, and its application in clinical settings have the potential of
significantly decreasing anxiety and stress [39], heart rate [160],
blood pressure [199], and pain thresholds in patients [87,110].
Music also has effects on patients recovering from cancer surgery
[74,123,138,139,155]. Studies have found listening to motivational
music to be effective in terms of mitigating the physical state of
patients with disabilities, including stroke, Parkinson's disease,
Tourette syndrome, dementia and psychiatric disorders
[64,84,129,153], as well as eliciting more positive affective response
in patients with cystic fibrosis [21]. Music therapy has proven to be
effective in treating anxiety and depression in patients with Alz-
heimer's disease, as well as easing the emotional and physical
burden experienced by hospital care providers [62]. A randomised
clinical trial demonstrated that there is evidence of strong positive
effects on the quality of life of hospitalised patients who received
30e40 min' therapeutic harp sound treatment along with 24 h'
standard care. The study argued that fatigue, anxiety, sadness,
180 T.O. Iyendo et al. / Complementary Therapies in Clinical Practice 24 (2016) 174e188
Fig. 4. Selected positive effects of music on stress outcomes.
relaxation, and pain significantly improved among hospitalised
patients, and approximately 30%e50% of patients showed a sub-
stantial increase in the quality of life measures after harp sound
treatment [145].
There are study findings that noisy environments invoke
negative emotions, whereas therapeutic intervention through
music and a comfortable environment, promote more relaxed mind
and well-being for patients recovering from illness and surgery
[53,56]. To recapitulate the effect of music therapies, accumulated
studies have found music to be a substantial therapy to relieve pain
in conjunction with anaesthesia or pain medication [52,63,127,1].
Music therapy is effective in calming stress reactions associated
with apprehension or fear in patients undergoing cerebral angi-
ography [200], inducing sleep [184], reducing muscle tension for
the purpose of relaxation, depression, anxiety and length of hos-
pital stay in female breast cancer patients after radical mastectomy
[194].
3.5. Landscape and therapeutic gardens
Hospitals can be exceedingly stressful places. However, the
ability to draw upon the therapeutic qualities inherent in nature
can extend one's capacity to cope with uncertainty, and this in turn
can potentially improve health outcomes [182]. The landscape and
its relationship with health have been observed for decades and in
various periods and diverse cultures and societies [163]. There has
been accumulated research on the therapeutic effects of landscape
on hospital occupants, and this is believed to have effects on human
beings in several ways, including aesthetic appreciation, health and
well-being [181]. It is certain that poor design can lead to psycho-
logical and physiological discomfort, whereas good design hinders
negative effects [170,176]. The healing effects of nature to amelio-
rate patients' recovery was first deliberated upon, written, and
published by Florence Nightingale in Notes on Nursing, 1860. She
believes that visual connections to nature, such as natural scenes
through the window and bedside flowers, contribute to the re-
covery of patients [122].
A study by Diette et al. [40] ascertained that adults undergoing
bronchoscopies reported less pain if randomly assigned to view a
ceiling-mounted nature scene versus a blank ceiling. Similarly,
research has shown that viewing natural vegetation, water, and
other natural elements can improve stress and patients wellbeing
in healthcare environments [42,181]. Ulrich [176] supported the
view that gardens will likely calm stress efficaciously if the garden
integrates verdant foliage, flowers, water, congruent natural sounds
such as the one found in birds, breezes, or water, and visible
wildlife. Studies have also demonstrated that natural scenes when
incorporated with trees, green vegetation and cultivated fields to
 T.O. Iyendo et al. / Complementary Therapies in Clinical Practice 24 (2016) 174e188
improve well-being, reduced anxiety, and increased positive out-
comes. In addition, natural scene, including trees is associated with
lower scores for minor post-surgical complications [168,169].
Activities that take place in the hospital therapeutic garden can
range from sitting outside, to dozing, napping, or being engaged in
meditation, prayer, exercise, walking to a preferred spot, eating,
reading, working outside, viewing children playing in the garden,
self-involved in raised bed gardening, and light sports activities
[31,182]. Previous research has designated that hospital garden-
users reported significant positive mood change resulting from
garden use, and that time spent in observing nature establishes a
restorative experience [187]. Research indicates that incorporating
gardens in hospital settings can improve quality of life for patients,
and affords an opportunity for them to exercise without becoming
agitated, and lighten the burden of care for nurses [66].
The links between landscape and environmental noise pollution
and its adverse effects on human wellbeing has been well docu-
mented. These adverse effects can reduce productivity, decrease
performance in learning, lead to absenteeism in the workplace and
increase drug use and accident rates in the hospital environment
[14]. From an urban context, several studies have suggested that
landscapes can mitigate a large amount of the environmental im-
pacts of urban growth, which in turn improves urban hydrology
and air quality, reduces noise pollution and the energy re-
quirements of the city [86]. In a different study related to the effects
of interior plants on acoustics in spaces, results demonstrated that
plants can reflect, diffract, or absorb sounds of varied frequencies.
The same survey presents that, plants worked best at reducing high
frequency sounds in rooms with hard surfaces and was argued to be
as effective as adding carpet [105].
3.6. Colour and its impact in hospital environment
The patient, staff and family members or friends (visitors) must
be considered when applying colours in a healthcare facility. When
colour is strategically used, it can create a supportive environment.
Colour is an inherent property of materials and an inseparable
component of the design. Research has shown that colour evokes
emotional and physiological responses that produce feelings of
serenity or agitations that can aggravate or alleviate stress [34].
Colour can also affect individuals' emotional state, as well as
cheerfulness, and calmness [83,109]. Pile [130] advocates that
colour design can play a part in the healing process and add to a
sense of well-being. An earlier study by Ref. [125] demonstrated
that colours have an impact on the nervous system, respiration,
blood pressure, muscle tension, eye blinks, cortical activity, and
other body functions.
Studies have identified that colour can have a systematic impact
on the mood, feelings, and behaviour of people
[48,49,88,115,124,193]. An early work on the long-term effects of
colours in a health care environment, argued that modifying the
colour scheme of the ward modulates perception of both staff and
families as less institutionalised and more cheerful [29]. In the
healthcare environments, designers use colours, images, and signage
to orient better wayfinding within the hospital spaces [133,140].
3.7. Personal control and access to privacy
Personal control is associated with the ability of an individual to
have influence over a particular situation or environment. In-
vestigators have explored the impact of the hospital environment
on patients' perceptions of personal control, and found that opti-
mising personal control contributes to emotional comfort, facili-
tating the therapeutic process of hospitalised patients [188,189].
Greater sense of control cannot be achieved when patients are not
181
offered access to privacy, bedside dimmers that enable control over
lighting, headphones that support patients to select their choice of
music, control over televisions, architectural design that supports
active waiting areas and accessibilities for handicapped (e.g.
wheelchair) patients [174e176].
It has been demonstrated that patients in hospital felt greater
personal control and emotional comfort when they felt secure,
informed, and valued. Moreover, the patients felt insecure and
experienced emotional discomfort when assistance was not
rendered [95]. One early study supported that unavoidable and
painful medical routines, lack of information and uncertainty, long
waiting times, and loss of control over eating and sleeping times
can debilitate feelings of control [161]. Another study proponent
claims that unsupportively designed environments can lead to
privacy deprivation, noisy environments, isolated patients' rooms
that do not permit a view out of the windows, staring at glaring
ceiling lights by patients, and inappropriate and confusing way-
finding [176].
3.8. Access to social support
An extensive amount of research has shown that support from
family and close friends can help in healing. For example, an
investigation has demonstrated that having social support accel-
erates recovery in heart patients and improves the emotional well-
being as well as quality of life in the late-stage of cancer patients
[166]. Social support from family and friends improves the health
outcome of patients. One survey has described that both healthy
and non-healthy people with a high level of social support have less
stress and exhibit higher levels of wellness compared to people
with lower support [159]. Hospitals can promote social support by
providing waiting rooms and lounges with comfortable furniture,
designing patient rooms that accommodate visitors, and providing
amenities that make it easier for family members to stay overnight.
Furthermore, the design of social, supportive areas are paramount
to provide areas of privacy. Ulrich et al. [196] indicated that an
environment that abdicates privacy could be very stressful for pa-
tients. A design that promotes social support for patients can
mitigate stress and improve other associated outcomes [170,171].
3.9. Cleanliness and ease of maintenance
Researchers have clearly shown a relationship between envi-
ronmental cleaning and infection control, and have argued that
these infections can be controlled through proper hygiene, and
facility cleaning and maintenance (e.g., [20,35,37,85,114,174].
Research has foregrounded that adequate cleaning of hospitals
promotes a better healing environment for patients and facility
managers' performance, laying emphasis on the impacts of the
cleaning/infection control related policy and guidelines issued
through the Department of Health [111]. Another important survey
found that among other factors (including air quality, noise floor,
etc.), cleanliness and ease of maintenance were ranked as the most
important physical environmental design factors in hospitals [120].
A broad range of microorganisms can cause infections, and are
often located on a large number of surfaces in the healthcare
environment [38]. A research study has suggested that mitigating
problems that could hinder cleanliness and ease of maintenance in
the hospital environment requires setting priorities, teamwork, a
rigorous daily regime of cleaning, and a willingness to make im-
provements as opportunities become available [157]. Accumulated
studies have shown that enhanced cleaning significantly decreases
environmental contamination through a range of (Healthcare-
Associated Infections) HAI pathogens, emphasizing the important
role that the environment plays in infection transmission and
182 T.O. Iyendo et al. / Complementary Therapies in Clinical Practice 24 (2016) 174e188

Table 1
Summary of the literature review and suggestion for clinical practice.

Design factor(s) and references Findings Recommendation for clinical practice

Artwork
[12,54,53,71,174,177,151].
Lighting and views
[69,81,172,33,81,98,101,174,183].
Noise
[58,73,82,91,94,117,142,150,185,192].
Music and sound
([167,39,148,160,87,74,110,155,84,
3,21,40,56,62,78,103,128,129,149,
153,190,194,199].
Reduce the feeling of being isolated from the outside
world.
Enhance positive emotions and physiological responses.
Art incorporating nature evokes positive response, positive
distraction producing positive feelings that promote
sustained attention and interest and reduced worrisome
thoughts and anxiety.
Enhance pain reduction, patient coping and promote
restoration. Improved nurse-patient communication and
attitude toward hospitalization.
Helps in maintaining a sense of identity and well-being.
Whilst abstract or inappropriate art evokes a negative
response, including increased stress and exacerbate other
related outcomes. Much art is emotionally challenging or
provocative.
Daylighting offers a dynamic interior and views from the
hospital room window.
Sufficient daylight in rooms are very important for both
recovery and rehabilitation of patients, as well as the health
and wellbeing of hospital care-providers.
High preference to daylight over electric lighting and
improved energy efficiency.
Natural lighting improves sleep, lessens agitation, and can
be used to treat hyperbilirubinemia in infants.
Daylighting is a powerful tool for coding, navigation, and
wayfinding, as well as promotes a sense of well-being.
Noise altered memory, increase agitation, aggressive
behaviour, depression, anxiety, and promote speech
difficulties.
Noise is a major barrier to sleep for patients.
Deleterious effects on health and recovery.
Noise can have significant effects on annoyance and stress.
Noise increase perceived work pressure, emotional
exhaustion and burnout among staff.
Noise affects pharmaceutical name recognition.
Music therapy mitigates the physiological and
psychological stressors experienced by patients undergoing
medical procedure.
Relaxing music decreased depression, heart rate, blood
pressure, pain, anxiety and stress.
Music elicits positive affective response in patients with
disabilities, including cancer, dementia, Parkinson disease,
Alzheimer disease, and stroke.
Music therapy promotes a more relaxed mind, well-being
and reduced hospitalization for patient's recovery from
surgery.
Sound may be included as a positive distraction in health
care.
Ocean sounds improve postoperative patient sleep.
The sound of nature reduces stressful pain conditions in
patients.
The sound of birds and fountains reduces psychological
stress and improves physiological stress recovery.
Incorporate natural stimulating nature and art to support less
stressful hospital premises for patients and staff.
Artwork in the clinical environment should provide a calming
atmosphere.
As art varies enormously in subject matter and style, when
choosing it for hospitals, designers should pay close attention to
individual's preferences because culture, religion, and
geographical area of users may vary. However, it may be
unthinkable to expect all kind of art to be appropriate for stress
reduction in healthcare spaces.
Art therapy intervention should be used to distract and
promotes comfort level, reduce pain, and other ambient
environmental stressors that could impede patients and staff
health outcomes.
In rooms that do not have the benefit of an outside window,
smart curtains with natural sight or attractive views of nature
art that would add an appealing and memorable figure to
patients' rooms should be considered.
Hospitals should take on technological systems which
incorporate artwork that the patient and family can effortlessly
change at will as easily as changing channels on a TV.
Improve lighting, especially access to natural lighting and full-
spectrum lighting.
Develop lighting, which supports wayfinding systems that
allow users, and particularly patients and visitors to find their
way efficiently and with little stress.
Providing single-bed suites, installing high-performance
sound-absorbing ceilings, and eliminating noise sources, for
instance, using noiseless paging.
Storage areas, staff lounges and utility rooms should be located
away from patient rooms and family spaces to avoid intrusive
sound.
Healthcare designers should locate service corridors between
storage and utility rooms permitting clinical and support staff to
conduct needed tasks without disturbing patients and families.
Hospitals should provide noiseless paging systems and
encourage single-bed rooms rather than shared rooms or bays.
Locating beds away from the corridor minimises noise which
can have a detrimental effect on health.
Music should be used in hospital environments to subdue
noise and improve the quality of hospital environment for
occupants.
Educating hospital care providers and implementing
educational programs and health care provider behaviours that
contribute to noise.
Provision of earplugs or earmuffs to patients to decrease peak
ICU noise levels as well as to reduce arousals from sleep.
Implementing a therapeutic music in the hospital background
to evoke the minds and enhance healing among hospital
occupants.
Music should be played in hospital environments to mask
other irritating sound.
Sounds of nature supplemented by soft classical music can be
used in healthcare waiting areas to calm anxious family
members or visitors.
Music therapy should be considered as an initiatory step to
alleviate stress management, including psychological and
physiological associated stress responses, as well as patients
recovering from surgical pain.
Health care practitioners should purposefully introduce
sounds such as those from birds, background music, ocean
waves, rain showers in the health care environment to reduce
stress correlated outcomes.
Not all type of music can produce a desired calming effect, due
to life experience, different musical tastes, and preferences. As
such, it is essential to give patients and staff a sense of control
over their music preferences.

Table 1 (continued )
Design factor(s) and references
Nature views, landscape and gardens
([42,169,181,181,176,105,86].
Colours [34,83,109,125,133].
Sense of personal control and
privacy [188,176,189].
Social support ([166];
Ulrich et al., 2008).
Cleanliness and maintenance
([111,26,178,25,119,131].
T.O. Iyendo et al. / Complementary Therapies in Clinical Practice 24 (2016) 174e188
Findings
Environments that incorporate elements from the natural
world have a positive impact on people and productivity.
Exposure to nature promotes positive feelings such as
increased pleasantness, calmness, and reduced anxiety,
anger, or other negative emotions.
Nature scenes function as pleasant distractions that may
block worrisome and stressful thoughts.
Effects of landscape on hospital occupants, including
aesthetic appreciation, health and well-being.
Shorter post-operative stays in hospitals, reduced pain
relief drugs administered, and favourable responses on
patient's outcomes by those who viewed trees, compared to
those exposed to views of a brick wall.
Garden integrated with greenery, water, congruent natural
sounds such as birds, breezes, or water and visible wildlife
have calming effect on stress.
 Landscapes can mitigate the environmental impacts of
urban growth, improve urban hydrology and air quality,
reduce noise pollution and the energy requirements of the
city.
 Indoor plants can reflect, diffract, or absorb sound of
varied frequencies.
Plants reduce high frequency sounds in rooms with hard
surfaces and is argued to be as effective as adding carpet.
Colour evokes emotional and physiological responses that
produce feelings of serenity or agitation alleviate or
aggravate stress.
Colour affects individuals' emotional state, such as
cheerfulness, and calmness.
Colours have an impact on the nervous system, respiration,
blood pressure, muscle tension, eye blinks, cortical activity,
and other body functions.
Colours are used for signage and wayfinding within the
hospital spaces.
Having a sense of personal control with respect to a
potential stressor helps to reduce the negative effects of the
stressor.
Contributes to emotional comfort, facilitating the
therapeutic process of hospitalised patients.
Unsupportively designed environments support privacy
deprivation and noisy environments.
Unsupportively designed environments support privacy
deprivation, noisy environments, isolated patients' rooms
that does not permit a view out from the windows, staring
at glaring ceiling lights by patients, inappropriate and
confusing way-finding.
Social support from family members and close friends
accelerates recovery and improve emotional wellbeing as
well as quality of life of patients.
 Poorly designed environments abnegates privacy and
could be very stressful for patients.
Lack of social support increases stress and negative
outcomes in patients.
Social support can improve patients' outcome if they are
provided with waiting rooms and lounges incorporating
comfortable furniture that can be adjusted at will.
Patients-staff communication help reduce patients and
family anxiety and promote better care and outcomes.
Promotes a better healing environment for patients and
facility managers' performance.
 Single-bed or private patients' rooms, en-suite hand
washing stations and toilets, reduces infection rates, such as
nosocomial infection.
183
Recommendation for clinical practice
Provide patients stress reducing views of nature and other
positive distractions.
Healing gardens should be a priority and should be
incorporated in the hospital environment for sick patients to
encourage healing, particularly for the old and children. If
possible, patients ward or spaces need to be close to gardens
with plants, water, and other natural objects.
Incorporating natural green or landscape qualities in the
healthcare spaces can have a range of health benefits for
patients, visitors and clinicians.
Integrating interactive, appealing healing colours in the
hospital premises, especially in the patient rooms and large
corridors would mitigate isolation, as well as enhanced better
wayfinding within hospital spaces.
Personalised environments for patients and family members
should be employed to increase the sense of control and
intimacy.
Flexible seating arrangements should be adopted to reduce
frustration among families.
Patients and family members will experience less stress and
satisfaction if they can have control over the temperature in
their rooms and the volume and type of music.
Greater sense of control can be achieved when patients are
offered access to privacy, bedside dimmers that enable control
over lighting, headphones that support patients to select their
choice of music, control over televisions, architectural design
that supports active waiting areas and accessibilities for
handicap (e.g. wheelchair) patients.
Single bedroom configurations afford easier patient
examination, increased sense of privacy and history taking.
Design health care layout and wayfinding to reduce
disorientation that help patients and staff feel in control of their
surroundings.
Increase patient care time, and support staff activities such as
medication supply, communication, charting, and respite from
stress.
Providing social spaces such as lounge, day rooms, and waiting
rooms for patients creates opportunities for connecting with
their family members and friends, and is a significant source of
reducing stress and promoting well-being.
Spaces without specific or prescribed functions that enable
spontaneous, impromptu activities; homeliness e a sense of
safety and familiarity; pleasantness e clean and peaceful, or
bustling and lively; specialness e unique qualities, aesthetics, or
subjective memories reduce the rate of recovery for patients.
Design patients' rooms to accommodate family members and
close friends to stay overnight. This incorporates movable or
flexible furniture to inhibit social interaction and improve
patients and family members' satisfaction.
Installing portable high efficiency HEPA filters.
Installing barriers between patient care and construction areas,
negative air pressure in construction or renovation areas
relative to patient-care spaces, and sealing patient windows.
Reducing infections by increasing hand washing. This can be
(continued on next page)
184 T.O. Iyendo et al. / Complementary Therapies in Clinical Practice 24 (2016) 174e188

Table 1 (continued )

Design factor(s) and references Findings Recommendation for clinical practice

Architectural design
impact [15,121,195,8,16,76,137].
Private patient rooms reduce the risk of hospital-acquired
infections, allows for greater flexibility in operation and
management, and has positive therapeutic impacts on
patients.
No differences in the occurrence of hospital-acquired
infections or colonisations observed for medical patients
admitted in single-bed versus multi-bed wings or units.
Infection control and patient satisfaction, stress reduction
and increased health outcomes in a comparison between
single and semiprivate rooms.
Increased contamination rate of interior features (e.g., Tap
handle, door fixtures, lavatories) when in contact with
patients in semiprivate rooms.
Well-planned environment that considers climate
conditions and sunlight impacts reduces length of stay for
hospitalised patients.
Poorly designed ward layout and nurses station increases
walking and fatigue for staff and diminishes patients care
time.
Properly designed hospital space support staff activities
such as medication supply, communication and reduced
stress among staff and patients.
achieved by continued education and training programs for
clinicians and other healthcare personnel.
Employing appropriate ventilation systems and air change
rates.
Use single-bed rooms rather than multi-bed rooms to increase
isolation capacity and diminish transmission from infected
patients.
Design ward layouts and nurses' stations to reduce staff
walking and fatigue.
Improve ventilation through the use of improved filters,
attention to appropriate pressurization, and special vigilance
during construction.
Implementation of single-bed rooms, installing high-
performance sound-absorbing ceilings, and eliminating noise
sources.
Using materials that limit allergies or potential toxins for
hospital space construction.
Patients wards in particular should have effective blackout
options to support good sleep patterns, for example, in the form
of thermal shutters (for cold periods) and/or adjustable louvres
(for secure night time ventilation in warm conditions).

prevention (e.g., [17,23,30,38,60,67].
Investigators of risk factors for Health-acquired infection (HAI)
have supported the case for single-bed or private patients' rooms,
hand washing stations and a toilet for every patient for the
reduction of infection rates, such as nosocomial infection (e.g.,
[26,119,178]. It is obvious that private patient rooms reduce the risk
of hospital-acquired infections, allow for greater flexibility in
operation and management, and have positive therapeutic impacts
on patients [25]. Similarly, one study has indicated that intensive
care units (ICUs) with private rooms may lead to better infection
control practices, thus reducing the transmission of infectious or-
ganisms. The authors strongly agreed that the conversion to single
rooms could significantly reduce the rate at which patients obtain
infectious organisms while in the ICU [162]. In contrast, two studies
have found that there are no differences in the occurrence of
hospital-acquired infections or colonisations observed for medical
patients admitted in single-bed versus multi-bed wings or units
[50,131]. Extensive literature has demonstrated the benefits and
limitations that exist between methods of environmental cleaning
and is useful in assessing adherence to cleaning protocols as well as
to predict and manage potential clinical risks [22,89,99,106].
3.10. Architectural design impact on hospital occupants
Design features that enhance healthcare users' health and well-
being should consist of an appropriate use of furniture [41,143],
ergonomics and safety measures [59]. There have been positive
reports of studies on healthcare facilities regarding the psycho-
logical and physiological effect of a well-designed spatial organi-
sation of patient and staff workstations [147]. Earlier studies dated
back to 1970s revealed that the efficacy of a hospital room were
characterized by its design and not the size [164]. Subsequent
research further revealed the positive architectural design factors
needed in intensive care units (ICUs) which includes: single-bed
rooms for improved patient care, comfort, privacy and safety, bed
locations that afford proximity to wash hand basins, waste bins, and
use of natural lighting in the patient rooms. The negative factors
included among others, health and safety hazards caused by con-
struction defects in renovated rooms, workspace layouts devoid of
design solutions to accommodate families and care givers, and
mixed used units for staff, with a lack of proximity to patients'
rooms [135,137].
Furthermore, studies have shown that properly designed pa-
tient rooms can diminish the infection spread due to contact. These
studies compare single and semiprivate rooms in hospital wards
and conclude that single rooms improve both infection control and
patient satisfaction [15,121,195,137], which lead to stress reduction
and increased health outcomes. Similarly, the type and quality of
material used in hospitals play a key role in its overall cleanliness.
Interior fixtures and fittings (e.g., Tap handle, door fixtures, lava-
tories) and surfaces can be easily contaminated when in contact
with patients [8,16,76].
4. Suggestions for clinical interventions
There is a need for implementing therapeutic music in hospitals
to calm the mind and enhance healing. Healing gardens should be a
priority and should be incorporated into the hospital environment
to encourage healing, particularly for the old and children. The
hospital environment should provide periods of low light to allow
patients to sleep, and rooms should be configured to allow patients
to enjoy views of nature and natural daylight.
Hospitals should incorporate stimulating nature and art to
support a less stressful hospital environment for patients and staff.
Integrating appealing and healing colours in hospital premises,
especially in patient rooms and long corridors would mitigate
isolation, and lead to better wayfinding. Art therapy should be used
to promote higher levels of comfort, thereby easing pain, and other
ambient environmental stressors that could impede patients and
staff health outcomes. Attractive curtains with good sight lines
towards views of nature would add appeal to patients' rooms.
Healthcare professionals and their collaborators should work
towards incorporating therapies such as art, music, the sound of
birds, waterfalls and other positive distractions in the routine care
of patients with pain and psychological infirmities as this would
reduce stressful outcome and strengthens coping strategies. Table 1
presents the literature review findings and related clinical recom-
mendations for improving the hospital environment for its users.
5. Conclusion
In summary, the intention of this paper was to shed light on
factors in the physical environment that could enhance health and
wellbeing as well as increase organisational productivity and
 T.O. Iyendo et al. / Complementary Therapies in Clinical Practice 24 (2016) 174e188
profitability. It was deduced from the review that a calming elegant
hospital interior with natural surfaces, natural lighting and views,
serene landscaped gardens, fascinating colours, whimsical sculp-
tures and dramatic art collections reduces stressful conditions and
creates a better healing environment for patients and staff. This is
consistent with the findings documented by Ulrich et al. [177]
which indicate that well-designed physical settings plays an
important role in the healing process of patients and family
members in healthcare facilities. Access to personal control and
privacy as well as social support and positive distraction (e.g., art,
music, television) have the potential to reduce the stress patients
feel in hospital environments. Designing a healing environment
through thoughtful design can alleviate stress and even promote
eccentricity and imaginative thinking.
In addition, the Department of Health in 2007, laid an emphasis
on the positive impacts of music in relation to medical treatments,
which include calming and relaxing agitated psychiatric patients,
reaching autistic children, handling depression, reducing pain and
blood pressure, heart and breathing rates, but it also cautions that
some individuals might perceive music as unwanted sound [18].
Therefore, sound should be viewed from a social aspect as a positive
addition to clinical settings to promote health in the mental care
environment, rather than just noise. However, it should be
remembered that when it comes to music what is soothing for
some may be stressful to others.
Winston Churchill once said that “We shape our buildings and
afterwards our buildings shape us” [154], by which he meant that
the buildings we design have a significant impact on our social,
physical and mental behaviour. There is a need for more empirical
studies that investigate and verify the healthcare physical envi-
ronment and identify a range of factors that serve as a supportive
design which in turn enhance wellness. Specifically, creating a
therapeutic space is closely dependent on and intertwined with so
many other aspects of an optimal healing environment, which in-
dicates that whether it is fostering healing relationships or a
healing culture, each one cannot thrive without the others [6].
Although, this review has elucidated several environmental factors
for achieving improved wellness in the clinical settings, more
should be explored in further research.
Authors' contributions
TOI was responsible for the study conception and design. TOI,
and PCU performed the data collection. TOI, PCUand ESI were
responsible for drafting and editing the manuscript. TOI, PCUand
ESI reviewed, edited and approved the final manuscript.
Acknowledgements
The authors would like to thank Asst. Prof. Dr. Münevver
€
Ozersay for her kind assistance during the preparation of this
manuscript as part of a PhD course taken under her. The authors
would like to sincerely thank Hugh Clarke for the proofreading
and insightful comments that contributed significantly to the
article.
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Timothy Onosahwo Iyendo received his master's degrees
in the discipline of Architecture (Architectural Acoustic)
from Eastern Mediterranean University, North Cyprus,
Turkey in August 2011. He is currently pursuing his Ph.D.
degree in Architecture at the aforementioned University.
His Ph.D. investigation explores the healthcare environment
design with a focus on sound perception and occupants
experience in hospital ecosystem. His current research in-
terest besides the impacts of sound perception in the built
environment, include music psychology/medicine and use
in a health care context, visual articulation of space as it
relates to artwork and lighting in design, as well as climate
adaptive building in Cypriot settlements with a particular
interest in contemporary and vernacular architecture.
Patrick Chukwuemeke Uwajeh received his master's
degrees in the field of Architecture from Eastern Medi-
terranean University, North Cyprus, Turkey in March 2015.
He is currently pursuing Ph.D. in the aforementioned
University. His PhD research explores evidence based
design theories and healing environment in architecture
with a focus on therapeutic use of landscape in health care
facilities. My research interest besides the therapeutic use
of landscape in the health care context includes, thera-
peutic use of art in healthcare.
Ezine Ikenna Stephen received his master's degrees in the
field of Architecture in 2011 and second a master's degree
in the field of Construction Management from Nnamdi
Azikiwe University, Awka, Nigeria in 2014. He is a lecturer
in the Department of Architecture at Nnamdi Azikiwe
University, Awka, Nigeria, and currently pursuing his
doctor of philosophy (Ph.D.) education in Eastern Medi-
terranean University.