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PLANNING AND DESIGN

Designing Humanistic Critical

Care Environments

The critical care environment can be designed to become more humanistic. Consideration of the environmental
challenges of noise, lights, color, views, temperature, and comfort is essential. This article identifies the issues and
concerns in the design of more humanistic healing in critical care units. Strategies to improve the environment
include improving the physical and emotional tone of the unit through creative design, family and pet visitation,
sleep promotion, and aromatherapy among others. In a life-threatening illness, attention paid to these concerns
may significantly improve quality of life for patients and family. Key words: architecture, critical care, design,
humanistic care

Dorrie K. Fontaine, RN, DNSc, FAAN

Associate Dean
Georgetown University School of Nursing
I N ONE CORNER of a busy surgical
critical care unit, the health care team
is valiantly opening the chest of a young
& Health Studies trauma patient to more effectively provide
Washington, DC CPR. At the same moment in the next bed, a
daughter sits beside her elderly father, who
Linda Prinkey Briggs, RN, MS, ACNP is on a ventilator; she is speaking softly and
Clinical Assistant Professor holding his hand so he will not pull on any
Acute Care Nurse Practitioner Program tubes and lines. Since the inception of crit-
Georgetown University School of Nursing ical care units in the 1950s, designs for pa-
& Health Studies tient survival were considered primary. To-
Washington, DC day we ask: Is there an optimal environment
where calm healing can occur side by side
Briggit Pope-Smith, RN, MS, CRNA with life-saving technology? Is there evi-
Instructor, Nurse Anesthesia Program dence that suggests critical care units have
Georgetown University School of Nursing adapted to the needs of patients and that more
& Health Studies attention is paid to aesthetics? Patients con-
Washington, DC tinue to get better despite aversive units, but
serious complications that occur secondary
to the environment are often unexplored.
Many clinicians and managers believe we
can redesign units to provide more humanis-
tic care for patients and families. This article
will review the aversive environment of crit-
ical care and make recommendations for a

Crit Care Nurs Q 2001;24(3):21–34

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c 2001 Aspen Publishers, Inc.

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22 CRITICAL CARE NURSING QUARTERLY/NOVEMBER 2001
more humanistic and aesthetically pleasing
“fourth generation” environment that pro-
motes patient healing and family integrity.
When accepting the challenge of design-
ing a new critical care unit, it is easy to
get caught up in the enormity of techni-
cal details. By definition, an intensive care
unit (ICU) is an area with one of the high-
est concentrations of sophisticated biomed-
ical equipment in the entire hospital. Cer-
tainly, planning for the appropriate types and
amounts of equipment, space, and electrical
wiring is important.1 However, the delivery
of optimal care requires more than the lat-
est in monitoring devices and computerized
bedside charting. It is more than sliding glass
doors and recessed areas for code carts. Op-
timal care means addressing and satisfying
as many patient needs as is humanly possi-
ble. This means taking a step back from the
stark, unfeeling lines of the blueprints and
envisioning a place that patients and fami-
lies find more comfortable, more calming,
and more healing than the ICUs of the past.
This approach reflects the philosophy and vi-
sion of the American Association of Critical-
Care Nurses (AACN), which seeks to create
a health care system based on the needs of
patients and families.2
THE PARADOX OF CRITICAL CARE
The critical care unit is a life-sustaining,
healing environment that paradoxically con-
tains the noxious stimuli of noise, bright
lights, and frequent interruptions. Patients
and families are bombarded with stimuli that
assault the senses of even the most seasoned
visitor to critical care. The environment of
critical care has contributed to the survival of
many, while at the same time initiating seri-
ous complications and distress in others. For
example, the constant presence of light and
loss of normal day-night pattern contributes
to delirium in patients in the ICU. Health care
providers have the power to make this aver-
sive environment more palatable by recog-
nizing its effects on patients and by manip-
ulating and controlling many key features.
An opportunity to design a unit from the
ground up requires a reflective analysis of
typical complaints and stressors. Improving
the ICU experience for patients and families
may begin with a basic redesign of critical
care units.3
NIGHTINGALE AND THE
ENVIRONMENT: A LEGACY
OF HEALING
Nursing has a long tradition of identi-
fying and intervening with physiological,
psychological, and social stressors. Contem-
porary critical care nursing leaders such as
Guzzetta and Dossey have written exten-
sively regarding therapeutic techniques that
address the individual as a holistic being.4,5
Despite this, the physiologic mechanisms of
some interventions have remained a mys-
tery, and skeptics persist among the health
care community. Guided imagery, relaxation
techniques, massage, and therapeutic touch
are just a few holistic techniques under in-
vestigation by the National Center for Com-
plementary and Alternative Medicine estab-
lished in 1998.5 There is a growing body
of evidence from the field of psychoneu-
roimmunology supporting the ancient con-
cept of the body-mind-spirit connection. Re-
cent investigation indicates that stress of any
kind can lead to measurable decreases in
immune function. These effects are medi-
ated by the hypothalamic-pituitary-adrenal
axis.6 Therefore, efforts to reduce stress
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can protect immune function and foster
recovery.
Florence Nightingale effected many im-
portant changes in patient care that influ-
enced the well-being and survival of patients
in her own time; she was a true visionary.
Much of what she advised in the mid-to late
1800s still holds true today. Most often re-
membered for her pioneering work in im-
proving hospital sanitation, Nightingale was
one of the first to address topics such as
lighting, noise, and sensory stimulation in
hospitals.7 A central tenet woven through-
out her many works is the idea that only na-
ture cures, and that nursing’s role is to put
the patient in the best situation for nature to
act.7,8 Extending this philosophy to the 21st
century, we need to make every effort to opti-
mize the patient’s environment, by reducing
noxious stimuli and enhancing factors that
promote a sense of well-being, relaxation,
and sleep. Achieving this goal, at times, is
as daunting a task now as it was in Nightin-
gale’s era, especially with the advent of ad-
vanced technology, a predominant feature of
modern critical care units. Critical care en-
vironments are often designed to facilitate
the use of technology rather than to address
patient need from a holistic perspective.9
EARLIER GENERATION ICUs
The first ICUs were built in the early to
mid-1950s (see Table 1).10 They were often
open rooms with four to six beds clustered
around a central nurses’ station. Second gen-
eration ICUs were designed specifically for
the care of the critically ill with architec-
tural plans that included “clocks and calen-
dars to help patients remain oriented to time,
windows to facilitate day-night sleep sched-
ules, equipment located at central nursing
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Designing Humanistic Environments 23
stations rather than at the bedside to reduce
noise, and beds placed within individual par-
titions or cubicles to provide some degree
of privacy.”11(p. 14) These units continue to
pose a threat to patients’ well-being. Archi-
tects recommend that attention to auditory,
visual, and sensory environments is key in
designing critical care units.1 Noise control,
lighting, color, window views, control over
persistent disagreeable odors, and a tactile
environment where temperature and comfort
are considered essential in design.1
Despite the evolution of second and even
third generation critical care units, research
on patient perceptions of the critical care en-
vironment is replete with examples of detri-
mental effects.12–14 In a systematic review
of 26 studies of patients’ responses to the
environment, positive and negative experi-
ences were noted in critical care settings.14
Positive experiences resulted from patients’
feeling the safety and security of having
nurses close by, while the negative experi-
ences ranged from anxiety, cognitive distur-
bances, and pain to sleeplessness. The most
powerful examples of environmental effects
come from former patients,15 who often felt
powerless and at the mercy of not only envi-
ronmental stimuli but also their caregivers.
The health care team is a major feature of
the environment and affects the physical and,
especially, the emotional tone of any given
unit. Noise, bright lights, and frequent in-
terruptions, including the 4 am bed bath are
considered noxious stimuli by patients and
families.16
NEEDS OF PATIENTS AND FAMILIES
Perhaps the most common and overrid-
ing need of patients and families is the re-
duction of stress. Disease or injury creates

Table 1. ICU Designs
1st generation 1950s
Characteristics Open unit/ward. No
partitions except
curtains or screens.
Nurses’ station/desk in
center or at the foot of
beds. Unit lighting
control often on one
switch.
Advantages Increased nurses’
proximity to patients
Disadvantages Lack of privacy. Inability to
control noise or light.
Infection control issues.
2nd generation 1970s
Individual rooms or walled
cubicles. Rooms often
on either side of a hall
containing an open
nursing station or
surrounding an open
nursing station on 3–4
sides (square
configuration). Central
monitoring. Some units
without external patient
room windows
(increased incidence of
delirium). Patient room
lighting with separate
switch(es) from nursing
station. Calendars and
clock in patient rooms.
Increased patient privacy.
Better control of lighting,
noise, and infection.
Less direct patient
access/observation. Less
than optimal control of
noise and lighting.
3rd generation
1980s---present 4th generation---future
Individual rooms. Folding Individual rooms. Folding
or sliding glass doors.
Rooms often arranged
on a semicircle or circle
with the nursing station
in the center. Some units
configured with
decentralized nursing
stations. Patient room
windows with external
views/lighting. Increased
control of patient room
lighting levels.
Increased nursing access Nursing access and
during high-intensity
activities.
Glass doors reduce patient
privacy.
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with privacy
curtains/blinds.
Circular/pod shaped
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floor plan. Increased
noise reduction
designing. Patient
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windows with a view of
outdoors (natural or
contrived).
Patient-controlled
lighting—artificial and
natural. Planned areas
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for family within patient
rooms. Increased use of
CRITICAL CARE NURSING QUARTERLY/NOVEMBER 2001
color and texture in
wall, floor, and ceiling
coverings.
availability of high-tech
care in a more
home-like environment.
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significant physiological stress on the body.
However, there are many other stressors in
the ICU environment: fear and uncertainty
about the impact of the current illness, unfa-
miliar surroundings, separation from loved
ones, pain, noise, and bright lights. Struc-
tural features of the unit such as the tex-
ture and color of walls and ceilings can be-
come stressors due to the lack of sensory
input or sensory overload. Many of these
have an impact on the patient’s and the fam-
ily’s response to the crisis of a critical illness.
Ultimately, the intensity, number, and vari-
ety of stressors may combine to affect the
patient’s outcome. Something as simple as
considering that supine patients are visually
isolated—they can see almost nothing but
the ceiling above—15 has specific humanis-
tic implications for redesigning critical care
environments.
NOXIOUS STIMULI
Light and noise are two of the most com-
monly viewed noxious stimuli in critical
care settings. Patients identified noise as the
most important irritant after surgery in one
study.17 Bright light, especially during night
hours, can be very distressing to patients.
The first phase in creating a more pleasant
environment is an awareness of the stimuli,
positive and negative, that are present.
Light
Natural light
Light is a form of electromagnetic en-
ergy that can have both positive and nega-
tive effects on living organisms. One positive
effect of sunlight is the conversion of
7-dehydrocholesterol to vitamin D3 in the
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Designing Humanistic Environments 25
skin.18 A negative effect of direct sunlight
is potential retinal injury in preterm infants
who experience prolonged exposure when
placed near the window in intensive care
nurseries.19 The effects of light relate not
only to the intensity and duration of expo-
sure but also to the pattern. For example, the
ratio of hours of light versus hours of dark-
ness influences circadian rhythms of animals
and humans.20 Seasonal affective disorder is
a syndrome of depression linked with sea-
sonal decreases in the duration of daylight.21
Interruptions in normal light-dark patterns
can disrupt normal physiological processes.
For example, Vinall found that artificial light
exposure for as little as 20 minutes during a
normal sleep cycle caused a drop in mela-
tonin levels.20 He also discovered that con-
stant lighting led to a complete disruption of
the normal melatonin concentration rhythm.
Further, high-intensity light can lead to a to-
tal cessation in melatonin production.22 This
has important implications in the critical care
setting because melatonin facilitates sleep
and modulates corticosteroid and thyroid
hormone levels.23 Continuous lighting and
the absence of natural light have also been
implicated in the development of cognitive
disturbances in ICU.24 In fact, in a window-
less critical care unit built in Great Britain
in 1975, the percentage of patients experi-
encing delirium was twice the level noted in
units with windows.25 Further, a systematic
review of patients’ ICU experiences noted
that impaired cognition occurred in 50% of
the population in windowless units and in
41% of individuals in units with windows.14
Artificial light
Artificial light in the hospital setting is
provided predominantly by fluorescent bulbs
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26 CRITICAL CARE NURSING QUARTERLY/NOVEMBER 2001
and tubes. This type of lighting tends to be
rather harsh and, if unshielded, can lead to vi-
sual fatigue and headaches.26 Another prob-
lem that occurs with both artificial and natu-
ral light is glare. Glare occurs when light is
reflected off environmental surfaces. Glass,
shiny metal, mirrors, and enameled or pol-
ished finishes can all contribute to the pro-
duction of glare. This is especially trouble-
some to the elderly.27 Finally, lack of control
over artificial lighting is a source of frustra-
tion to critical care patients.28 Lighting in
critical care settings is often bright with lit-
tle day-night rhythm.29 Bright lights were
found to be left on for many hours in a pedi-
atric ICU, even when no direct patient care
was being performed.30
Enhancing the environment: strategies for
lighting
While the merits of natural lighting in
maintaining circadian rhythms have already
been discussed, the quality of natural light-
ing can be enhanced to optimize the patient
environment. When windows are placed in
patients’ rooms, they should be within the
patient’s line of vision and positioned to
allow a view of the outside world.25 Flo-
rence Nightingale advised that the patient
should be able to see out the window with-
out changing position in the bed.7 When-
ever possible, the view should be of the
natural environment rather than the walls
of another building. This idea may sound
intuitive, but it also has scientific support.
In a retrospective review of patients who
underwent cholecystectomy, those who had
rooms that provided views of nature required
less pain medication and had shorter lengths
of stay.31 Moving and reorienting the bed,
carts, and equipment as well as using screens
can improve the patient’s view while still
accommodating necessary but distracting
technology.3
Natural lighting is desirable but should not
be so intense that it is uncomfortable to pa-
tients. The use of slightly tinted or reflective
glass can effectively reduce glare and heat
production from natural sunlight.32 Vertical
blinds and other window treatments can en-
able the nurse to adjust light intensity as de-
sired by the patient.
Interventions to eliminate the negative ef-
fects related to disruptions in natural light
include the incorporation of windows or sky-
lights in patient rooms or their proximate
vicinity.25,32 Nurses should also attempt to
maintain normal light-dark patterns by keep-
ing lights off during the patient’s anticipated
sleep cycle. Lighting mimicking the 24-hour
day is a trigger for normal sleep patterns,
so bright lights should be avoided at night.
The environment should be titrated to pa-
tient preference with acceptable light, sound,
temperature, and interruptions for care. Fur-
ther, the Society of Critical Care Medicine
recommends that the maximum intensity of
light used at night be 6.5 foot-candles for
continuous lighting and 19 foot-candles for
lighting used for short periods.32 The use of
eye masks may also be helpful, but care must
be taken not to create unintended periods of
sensory deprivation.
Interventions to eliminate the noxious ef-
fects of artificial lighting include the use of
indirect light, selection of less harsh spec-
trum bulbs, mounting of light fixtures behind
the head of the patient’s bed, and avoiding
the use of overhead procedure lights except
when necessary.27 Light intensity generally
should not exceed 30 foot-candles except
for procedures, when 150 foot-candles is
recommended.32 Glare can be reduced by
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the careful selection of matte finishes for
furniture, fixtures, and equipment. Patient
control of lighting can be increased by in-
corporating switches in bed control panels
or nursing call systems. For patients unable
to manage these controls, nurses need to
ask patients about their lighting preferences
throughout their interactions.
Color as an adjunct to light
Color has been important to healing
throughout the ages. The ancient Egyptians
ascribed healing powers to color. Arche-
ologists have discovered that the orienta-
tion and light openings in some temples
were arranged so that a prism effect would
occur, sending different colors of light to
the various chambers used for treating the
sick.33 In the Indian culture, seven of the
twelve chakras are energy centers of the body
that have assigned colors and meanings.33,34
Florence Nightingale also used color as a
therapeutic tool, primarily through flowers.7
There is even a discipline called chromother-
apy, in which individuals are exposed to cer-
tain colors as treatment for disorders. The
premise of this therapy is that color, a form
of light and, therefore, electromagnetic en-
ergy, has the power to effect changes in the
body.34 While there is little scientific proof
to support this theory, more is being learned
every day regarding the effects of electro-
magnetic energy on the body.
Whether or not color has healing power,
the fact remains that color has meaning to
most individuals, even if one is only choos-
ing a favorite color. Lack of color can be a
source of distress. In the book Bed Number
Ten, Baier remembers the lack of color in
her room during her 41/2 month ICU stay for
Guillain-Barré syndrome.28
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Designing Humanistic Environments 27
The Society of Critical Care Medicine rec-
ognizes the importance of color in its guide-
lines for ICU design. The society recom-
mends that room colors should be calming
and promote rest but does not indicate which
colors might achieve this goal.32 Blue, green,
and violet have calming and restful effects,
while pastels provide a more cheerful qual-
ity than do deeper shades.35 Cannava rec-
ommends soft and mixed tones that do not
have sharp contrasts to promote rest.35 Duffy
and Florell recommend softer colors in pa-
tient areas and brighter colors as accents in
drapes, upholstery, and artwork.25
Artwork can be another method of bring-
ing together light, color, and nature for pa-
tients. Ulrich studied the effects of artwork
on cardiac surgical patients.36 In an experi-
ment, he randomly assigned patients to have
a nature scene, abstract art, or nothing at
the foot of their beds. He found that those
who were shown the nature scene required
less pain medication and sedation, had lower
blood pressures, and had decreased lengths
of stay.
A modern example of these concepts is
exemplified by a noncritical care unit in
Minnesota.37 “Designed with the guidance
of a healing arts consultant, the unit is
painted in muted colors of beige, blue, and
green. Although bright lights are available
when needed, muted lighting is the norm,
the art on the walls, which comes from
many different cultures, depicts the splen-
dor and peacefulness of nature. The rooms
are quiet, private, and each has a window
with a view.”37(p. 92)
Noise
Noise in critical care settings is an en-
vironmental hazard that creates discomfort
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and may disrupt sleep,29,38–40 impair wound
healing,41 and activate the sympathetic ner-
vous system. Noise annoyance varies among
patients.42 Statements from patients regard-
ing noise include “clanging, big bangs, un-
expected noises, bubbling of chest tubes,
alarms going off all the time, and open-
ing and shutting of door” and others.42(p. 188)
Sources of noise include equipment, alarms,
telephones, ventilators, and staff conversa-
tions. Noise is measured in decibels using
a logarithmic scale,41 and an increase of
10 dB makes a sound perceived as twice as
loud. Noise levels above 80 decibels are re-
lated to arousals from sleep,38 as sleep oc-
curs best below 35 decibels.43 Patients and
staff may be at risk for noise-induced hear-
ing deficits.44 In patients the combination of
noise and aminoglycosides is a risk factor.44
Kahn et al. measured noise in two intensive
care units using a sound meter placed at the
head of an ICU patient’s bed.45 Over 50% of
the noise in the environment was attributed to
human behavior, with a mean sound level in
the medical ICU of 84 decibels.45 Television
and talking were some of the most frequent
disruptive sounds for patients. Freedman
queried 203 patients using a questionnaire
upon discharge from ICU and found that
noise from talking and alarms was the most
disruptive to sleep.39
Noise control
Nurses enhance person-environment com-
patibility by acting as “environmental acti-
vists.”46 In this capacity, controlling noise
and seeking solutions to the problem of noise
in ICUs are essential. Investigators were able
to reduce sound peaks in a Rhode Island
Hospital’s critical care units by instituting
a behavioral modification program for all
unit personnel, health care providers, and
others.45 In a study at the University of
Virginia, staff education was not effective
in changing noise levels, however, closing
patient doors resulted in decreasing noise
by 6 decibels.47 In a surgical ICU set-
ting in Switzerland, the mean intensity of
noise and light was diminished using a ded-
icated program of behavior change based
on guidelines.48 While results seem mixed,
there is evidence to suggest that paying atten-
tion to the behaviors of health care providers
is one aspect of the key to noise control.
Headsets for patients, increased staff
awareness of noise, periodic assessment of
ICU noise through noise level monitors, and
selection of sound-absorbent surface cover-
ings in the ICU are also recommended.44 Ini-
tiating a performance improvement project
utilizing environmental noise detectors dis-
tributed throughout the unit may be useful in
reducing decibel levels.49 Nurses should also
be encouraged to collaborate with architects
to redesign stressful patient environments
and, at the least, to directly reduce any exist-
ing unnecessary environmental stressors by
turning off unused equipment.46
Music therapy
While noise is a noxious stimuli, other
forms of sound, such as music, may be
comforting or beneficial. Music therapy re-
laxes anxious patients and decreases pain.
A music intervention with cardiac surgery
patients during the first postoperative day
decreased noise annoyance, heart rate, and
systolic blood pressure.42 In mechanically
ventilated patients, music therapy decreased
anxiety and promoted relaxation.50 Music
therapy is a proven intervention for anxious
patients in several critical care settings.50–52
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Music can decrease heart rate, respiratory
rate, myocardial oxygen demand, and anxi-
ety scores,53 and improve sleep.54 The group
most studied with music therapy is patients
with acute myocardial infarction;4,53,54 how-
ever, a growing body of knowledge suggests
a wider success from music therapy.55 This
intervention is easy to initiate on a unit and,
when based on patient preference, may en-
hance the environment for healing for pa-
tients.
SLEEP DISRUPTION
The basic human need for sleep is in
conflict with the ICU environment. Sleep
is believed to be important for recovery
from illness, as sleep deprivation may af-
fect tissue repair and overall cellular immune
function.56 Factors contributing to sleep dis-
turbance from a patient’s perspective include
ICU activity, inability to find a comfortable
position, to talk, or to distinguish day from
night.14 In the critical care unit, sleep is
characterized by few complete sleep cycles,
numerous awakenings, and infrequent rapid-
eye-movement (REM) sleep.57–59 Sleepless-
ness induces additional stress in critical care
patients.14,60
SLEEP PROMOTION
Nonpharmacologic interventions to pro-
mote sleep include modifying the environ-
ment, relaxation, back massage, and music
therapy. Controlling noise and promoting
sleep may be as important to the patient
as monitoring fluid intake.61 Earplugs effec-
tively decreased noise and increased REM
sleep in a study of simulated intensive care
unit noise in healthy volunteers.62 Back
massage is an alternative or adjunct to
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Designing Humanistic Environments 29
pharmacologic therapy in critically ill pa-
tients. According to Felver, one group of
nursing interventions to optimize patient-
environment interactions is focused on
protecting patients’ customary sleep-wake
schedules.63 Protection from environmental
stimuli is challenging. Turning down alarms,
dimming the lights, rescheduling of routine
care, and being vigilant about blocking mul-
tidisciplinary care between midnight and 5
am are recommended.64
Back massage is an alternative or adjunct
to pharmacologic therapy in critically ill pa-
tients. Approximately 5 to 10 minutes of
massage initiates the relaxation response and
improves sleep.65 Critical care patients re-
ceiving a 6-minute back massage versus rou-
tine nursing care experienced one additional
hour of sleep per night in a study of car-
diovascular ICU patients.66 Traditional “pm
care” that nurses were taught, which in-
cluded a back rub, is not a standard of prac-
tice in busy ICUs, and the evidence suggests
this intervention needs to reappear. The nurs-
ing shortage will make it increasingly diffi-
cult for nurses to make these humanistic and
proven interventions a priority.
AROMATHERAPY
For centuries herbal remedies have been
used to treat a variety of ailments. Though
the exact chemical compounds were not al-
ways known, the healing properties of plants
are well documented. In the ICU technology
and modern pharmacology are the mainstays
of patient care. As the population at large in-
creasingly utilizes aromatherapy, this form
of alternative treatment is making its way
into critical care units. The appeal of alter-
native therapies such as aromatherapy lies in
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30 CRITICAL CARE NURSING QUARTERLY/NOVEMBER 2001
the ability to relax the patient and increase
self-awareness.67 Aromatherapy uses the
sense of smell to evoke feelings of well-
being. Found especially useful for mood
elevation and pain control,68 these proper-
ties are sorely needed in the acutely ill pa-
tient. Studies have demonstrated that jas-
mine and rosemary increase beta waves,
thus increasing alertness. Likewise, laven-
der increases alpha waves, thereby promot-
ing relaxation.67 The overstimulation of in-
tensive care patients is well documented as
is the lethargy caused by commonly used
sedatives. In consideration of these two con-
ditions it is obvious that acutely ill patients
could benefit from aromatherapy. Dunn et al.
demonstrated that aromatherapy improved
mood and decreased anxiety in a group
of ICU patients.69 At a midwest hospi-
tal in a special postoperative holistic care
unit, nurses use 15-minute holistic interven-
tions such as essential oils, peppermint and
lavender, as part of their standard nursing
practice.37
Other oils commonly used in aromather-
apy include chamomile, eucalyptus, lemon,
peppermint, thyme, and geranium. These
oils are purported to produce results rang-
ing from relaxation to immune enhance-
ment. Concerns that arise in using aromatic
therapy are many. Primary is the poor in-
dustry control, which leads to impure sub-
stances in the marketplace with improper la-
beling. These substances may cause effects
contradictory to those desired and in some
cases have no effect at all.68 Standardization
of the industry may alleviate this problem.
Another concern is the level of training of
the practitioner. Weekend courses are avail-
able, and graduates of these courses may
represent a danger in practice without fur-
ther education.68 There is also a concern for
the allergic potential of these oils. Careful
patient history should precede any attempt at
aromatherapy.
FAMILY VISITATION
When considering enhancing the environ-
ment one cannot minimize the importance
of family visitation. Historically, nurses and
hospitals have severely limited family vis-
its to the intensive care units. The stated
rationale for limiting visitors includes al-
terations in patient physiologic status re-
lated to these visits.70 Studies have not sup-
ported this line of reasoning and, in fact,
according to Tullman and Dracup, a scien-
tific basis for restricting visitors in critical
care does not exist.49 Schulte et al. con-
cluded that there is no significant change in
heart rate or cardiac ectopy associated with
family visitation.71 Lazure et al. concluded
that patient control of visitation resulted in
less vital sign fluctuation than visits con-
trolled by staff.72 With an increasing body of
knowledge amassing in favor of unrestricted
and patient-controlled visitation, more and
more ICUs are relinquishing their hold on
patient visitation.73 The concept of patient-
controlled visiting involves the respecting
the patient’s wishes for timing and number
of visitors. This differs from open visiting in
that the needs of the patient are considered
paramount.
Over the years the importance of the fam-
ily as a support system for the patient and
an integral part of the health care team
has emerged.74 Research into the holis-
tic care of seniors has further emphasized
the importance of family support dur-
ing hospitalization.49 Negative physiologi-
cal and psychological outcomes may be as-
sociated with interference of social support
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systems in the elderly. Byers addresses the
need of chronically ill patients in a holis-
tic care unit.75 Patients and families are
evaluated and interventions are implemented
with the goal of lowering anxiety, decreasing
pain, and elevating the patient’s ability to
cope. Multiple holistic therapies are utilized
and accessible to the entire family. The move
toward increased family involvement in the
care of their loved ones is long overdue.
Holistic care of the patient as a part of the
larger family unit must be a tenet in achiev-
ing wellness.
Institutional policies regarding visitation
are changing.76,77 Furthermore, most nurses
do not restrict visiting even when restric-
tive policies are in place, according to sur-
vey data of 201 nurses.77 Roland et al. de-
scribed an interesting approach to process
improvement for family visitation in one unit
using surveys to measure the effects of a less-
restricted policy.78 In the future, connecting
family members with patients and caregivers
may include the use of e-mail, Internet con-
nectivity, and even videocameras.
PET THERAPY AND PET
VISITATION
Medical literature dating back to the 17th
century advocates the use of horseback rid-
ing as an intervention for low morale. In the
18th century animals were used at the York
Retreat of London to assist in the treatment
of the mentally disturbed. In 1859 Florence
Nightingale advocated the use of small pets
for the sick.79 Not surprisingly pet therapy
has emerged as a useful tool in the care of
the critically ill. Pet therapy as defined by
Connor et al. is a scheduled intervention to
improve a patient’s cognitive and or physi-
cal functioning.80 This therapeutic modality
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Designing Humanistic Environments 31
uses certified animals and a skilled practi-
tioner and is usually conducted one-on-one.
Pet therapy is contrasted to pet visita-
tion, which is simply the short-term pres-
ence of an animal used to enhance mood
and decrease loneliness. Visitations may oc-
cur as a group or individually and may
be a volunteer with a single or multiple
animals.80 There are many reported bene-
fits of pet therapy. With such therapy, Hueb-
scher reports more diminished feelings of
loneliness among pet owners than nonpet
owners in crisis health situations.81 Simi-
larly improved physical and psychological
well-being were associated with pet owner-
ship. Benefits of pet therapy include reduced
loneliness, improved communications, re-
duced need for medication, enhanced qual-
ity of life, improved physical functioning,
decreased stress and anxiety, improved vi-
tal signs, and increased motivation.80 Fur-
ther benefits of pet therapy include the pro-
vision of physical and psychological benefit
not only to the patients but to caregivers as
well.79
Nurses are in a position to know the needs
of patients, and it is nursing’s responsibility
to incorporate strategies that assist healing.
Pet therapy, with its many positive proper-
ties, has great potential in the critical care
setting. Pets may be an increasing part of the
environment in critical care. Animal-assisted
therapy using an aquarium has been found to
minimize patient stress levels in those await-
ing a heart transplant in a pilot study.82
A program of pet visitation at Baystate
Medical Center in the critical care unit has
been in place for several years.83 This time-
consuming intervention is well received by
patients and families and is a strong ther-
apeutic option at an increasing number of
clinical agencies.
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32 CRITICAL CARE NURSING QUARTERLY/NOVEMBER 2001
CONCLUSION
Awareness of all aspects of the environ-
ment and the potential for healing is a key
to designing a humanistic critical care set-
ting. The concept of titrating environmental
stimuli just like we titrate drug therapy is
useful in considering the nurse’s major role
REFERENCES
1. Hamilton DK. Design for flexibility in critical care.
New Horiz. 1999;7:205–217.
2. American Association of Critical Care Nurses. Key
statements, belief, and philosophies behind the Amer-
ican Association of Critical Care Nurses. http:
//www.aacn.org/AACN/membership.ns. Accessed May
2001.
3. Jastremski CA, Harvey M. Making changes to improve
the intensive care unit experience for patients and their
families. New Horiz. 1998;6:99–109.
4. Guzzetta CE. Effects of relaxation and music therapy on
patients in a coronary care unit with presumptive my-
ocardial infarction. Heart Lung. 1989;18:609–616.
5. Dossey BM, Keegan L, Guzzetta CE. Holistic Nursing:
A Handbook for Practice. Gaithersburg, MD: Aspen;
2000.
6. Black PH. Psychoneuroimmunology: Brain and immu-
nity. Sci Am Science & Medicine. 1995;2(6):16–25.
7. Nightingale F. Notes on Nursing: What It Is and What It
Is Not. Boston: William Carter; 1860.
8. Dossey BM. Florence Nightingale: Mystic, Visionary,
Healer. Springhouse, PA: Springhouse; 2000.
9. Benner P, Hooper-Kyriakidis P, Stannard D. Clinical
Wisdom and Interventions in Critical Care. Philadelphia:
W.B. Saunders; 1999.
10. Fairman J, Lynaugh J. Critical Care Nursing: A History.
Philadelphia: University of Pennsylvania Press; 1998.
11. Dracup K. Are critical care units hazardous to health?
Appl Nurs Res. 1988;1:14–21.
12. Novaes M, Aronovich A, Ferraz MB, et al. Stres-
sors in ICU: patients’ evaluation. Intensive Care Med.
1997;23:1282–1285.
13. Russell S. An exploratory study of patients’ percep-
tions, memories and experiences of an intensive care unit.
J Adv Nurs. 1999;29:783–791.
14. Stein-Parbury J, McKinley S. Patients’ experiences of
being in an intensive care unit: A select literature review.
Am J Crit Care. 2000;9:20–27.
as an “environmental activist.” Paying atten-
tion to sound, light, color, and other stimuli
is no small feat when life-threatening illness
keeps the health care provider busy, but per-
haps increased attention to the physical and
emotional tone of the ICU would yield better
results in terms of patient and family quality
of life.
15. Hayden WR. Life and near-death in the intensive care
unit. Crit Care Clin. 1994;10:651–657.
16. Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL.
Through the Patient’s Eyes: Understanding and Promot-
ing Patient-Centered Care. San Francisco: Jossey-Bass;
1993.
17. Moore MM, Nguyen D, Nolan SP, et al. Interventions
to reduce decibel levels on patient care units. Am Surg.
1998;64:894–899.
18. Guyton AC, Hall JE. Textbook of Medical Physiology.
10th ed. Philadelphia: W.B. Saunders; 2000.
19. Graven SN. Clinical research data illuminating the re-
lationship between the physical environment and pa-
tient medical outcomes. J Health Care Interior Design.
1997;9:15–19.
20. Vinall PE. Design technology: What you need to know
about circadian rhythms in healthcare design. J Health
Care Interior Design. 1997;9:141–144.
21. Hellekson C. Phenomenology of seasonal affective dis-
order: An Alaskan perspective. In: Rosenthal NE, Blehar
M, eds. Seasonal Affective Disorders and Phototherapy.
New York: Guilford Press; 1989.
22. Kohen E, Santus R, Hirschberg JG. Photobiology. San
Diego: Academic Press; 1995.
23. Holtzclaw BJ. Thermal balance. In: Kinney MR, Dunbar
SB, Brooks-Brunn JA, et al., eds. AACN Clinical Refer-
ence for Critical Care Nursing. 4th ed. St. Louis: Mosby;
1998.
24. Urban N. Patient and family responses to the critical care
environment. In: Kinney MR, Dunbar SB, Brooks-Brunn
JA, Molter N, Vitello-Cicciu JM, eds. AACN Clinical
Reference for Critical Care Nursing. 4th ed. St. Louis:
Mosby; 1998.
25. Duffy TM, Florell JM. Intensive care units. J Health Care
Interior Design. 1990;2:167–179.
26. National Institute for Occupational Safety and Health.
Guidelines for Protecting the Safety and Health of the
Healthcare Worker. Washington, DC: National Institute
P1: GKW/UKS P2: GKW/UKS QC: GKW
Aspen Pub./CCNQ AS097A-02 September 27, 2001 8:25
for Occupational Safety and Health; 1988. Pub #88–
119.
27. Williams MA. Physical environment of the intensive
care unit and elderly patients. Crit Care Nurs Q. 1989;
12(1):52–60.
28. Baier S, Zimmeth M. Bed Number Ten. New York: Holt,
Rinehart, and Winston; 1986.
29. Meyer TJ, Eveloff SE, Bauer MS, et al. Adverse envi-
ronmental conditions in the respiratory and medical ICU
settings. Chest. 1994;105:1211–1216.
30. Cureton-Lane RA, Fontaine DK. Sleep in the pedi-
atric ICU: an empirical investigation. Am J Crit Care.
1997;6:56–63.
31. Ulrich RS. View through a window may influence recov-
ery from surgery. Science. 1984;224:420–421.
32. Guidelines/Practice Parameters Committee of the
American College of Critical Care Medicine, Society
of Critical Care Medicine. Guidelines for intensive care
unit design. Crit Care Med. 1995;23:582–588.
33. Zagon L. Design technology: Selecting appropriate col-
ors for healthcare. J Health Care Interior Design.
1993;5:136–141.
34. Roeder C. Environmental design technology: Using
color and light as medicine. J Health Care Interior
Design. 1996;8:133–136.
35. Cannava E. “Gerodesign”: Safe and comfortable living
spaces for older adults. Geriatrics. 1994;49(11):45–49.
36. Ulrich RS, Linden O, Etinge JL. Effects of exposure
to nature and abstract pictures on patients recovering
from open heart surgery. Psychophysiology. 1993;30:
37–43.
37. Horrigan B. Region’s hospital opens holistic nursing
unit. Alt Ther. 2000;6(4):92–93.
38. Aaron JN, Carlisle CC, Carskadon MA, Meyer TJ, Hill
NS, Millman RP. Environmental noise as a cause of sleep
disruption in an intermediate respiratory care unit. Sleep.
1996;19:707–710.
39. Freedman NS, Kotzer N, Schwab RJ. Patient perception
of sleep quality and etiology of sleep disruption in the in-
tensive care unit. Am J Respir Crit Care Med. 1999;159(4
Pt 1):1155–1162.
40. Tsiou C, Eftymiatos D, Theodossopoulou E, Notis P,
Kiriakou K. Noise sources and levels in the Evgeni-
dion Hospital intensive care unit. Intensive Care Med.
1998;24:845–847.
41. McCarthy DO, Ouimet ME, Daun JM. Shades of Flo-
rence Nightingale: Potential impact of noise stress on
wound healing. Holis Nurs Prac. 1991;5(4):39–48.
42. Byers JF, Smyth KA. Effect of a music intervention
on noise annoyance, heart rate, and blood pressure
in cardiac surgery patients. Am J Crit Care. 1997;6:
183–191.
43. Environmental Health Criteria. 12: Noise. Geneva,
Switzerland, World Health Organization, 1980.
Char Count= 0
Designing Humanistic Environments 33
44. Halpern NA, Pastores SM, Price JB, Alicea M. Hearing
loss in critical care: An unappreciated phenomenon. Crit
Care Med. 1999;27:211–219.
45. Kahn DM, Cook TE, Carlisle CC, Nelson DL, Kramer
NR, Millman RP: Identification and modification of envi-
ronmental noise in an ICU setting. Chest. 1998;114:535–
540.
46. Topf M, Bookman M, Arand D. Effects of critical care
unit noise on the subjective quality of sleep. J Adv Nurs.
1996;24:545–551.
47. Moore MM, Nguyen D, Nolan SP, et al. Interventions
to reduce decibel levels on patient care units. Am Surg.
1998;64:894–899.
48. Walder B, Francioli D, Meyer JJ, Lancon M, Romand
JA. Effects of guidelines implementation in a surgical
intensive care unit to control nighttime light and noise
levels. Crit Care Med. 2000;28:2242–2247.
49. Tullman D, Dracup K. Creating a healing environment
for elders. AACN Clinical Issues. 2000;11(1):34–50.
50. Chlan LL. Effectiveness of a music therapy intervention
on relaxation and anxiety for patients receiving ventila-
tory assistance. Heart Lung. 2000;27:169–176.
51. Updike P. Music therapy results for ICU patients. DCCN.
1990;9:39–45.
52. Bolwerk CA. Effects of relaxing music on state anxi-
ety in myocardial infarction patients. Crit Care Nurs Q.
1990;13:63–72.
53. White JM. Effects of relaxing music on cardiac auto-
nomic balance and anxiety after acute myocardial in-
farction. Am J Crit Care. 1999;8:220–230.
54. Zimmerman L, Nieveen J, Barnason S, Schmaderer M.
The effects of music interventions on postoperative pain
and sleep in coronary artery bypass graft (CABG) pa-
tients. Sch Inq Nurs Pract. 1996;10(2):153–170.
55. White JM. State of the science of music interventions.
Crit Care Clin. 2000;12:219–225.
56. Krachman SL, D’Alonzo GE, Criner GJ. Sleep in the
intensive care unit. Chest. 1995;107:1713–1720.
57. Cooper AB, Thornley KS, Young GB, Slutsky AS, Stew-
art TE, Hanly PJ. Sleep in critically ill patients requiring
mechanical ventilation. Chest. 2000;117:809–818.
58. Fontaine DK. Measurement of nocturnal sleep patterns
in trauma patients. Heart Lung. 1989;18:402–410.
59. Richards KC, Bairnsfather L. A description of night sleep
patterns in the critical care unit. Heart Lung. 1988;17:35–
41.
60. Redeker NS. Sleep in acute care settings: An integrative
review. J Nurs Schol. 2000;32:31–38.
61. Jastremski CA. ICU bedside environment: A nursing per-
spective. Crit Care Clin. 2000;16:723–734.
62. Wallace CJ, Robins J, Alvord LS, Walker JM. The ef-
fect of earplugs on sleep measures during exposure to
simulated intensive care unit noise. Am J Crit Care.
1999;8:210–219.
P1: GKW/UKS P2: GKW/UKS QC: GKW
Aspen Pub./CCNQ AS097A-02 September 27, 2001 8:25 Char Count= 0
34 CRITICAL CARE NURSING QUARTERLY/NOVEMBER 2001
63. Felver L. Patient-environment interactions in critical
care. Crit Care Nurs Clin. 1995;7:327–335.
64. Edwards GB, Schuring LM. Sleep protocol: A research-
based practice change. Crit Care Nurse. 1993;13(2):84–
88.
65. Labyak SE, Metzger BL. The effects of effleurage back-
rub on the physiological components of relaxation: A
meta-analysis. Nurs Res. 1997;46:59–62.
66. Richards KC. Effect of a back massage and relaxation
intervention on sleep in critically ill patients. Am J Crit
Care. 1998;7:288–299.
67. Muirhead G. CAM strategies to promote wellness . . .
complementary and alternative medicine. Patient Care.
1999;33(18):143–145, 149–150, 155–158.
68. Downer K. Safety is of the essence. Nursing Times.
1999;95(7):14–15.
69. Dunn C, Sleep J, Collet D. Sensing an improvement: An
experimental study to evaluate the use of aroma therapy,
massage, and periods of rest in intensive care units. J Adv
Nurs. 1995;21:34–40.
70. Kirchhoff KT, Pugh E, Calame RM, Reynolds N. Nurses’
beliefs and attitudes toward visiting in adult critical care
settings. Am J Crit Care. 1993;2:238–245.
71. Schulte D, et. al. Pilot study of the relationship between
heart rate and ectopy and unrestricted versus restricted
visiting hours in the coronary care unit. Am J Crit Care.
1993;2:134–136.
72. Lazure L, Baun M. Increasing patient control of fam-
ily visiting in the coronary care unit. Am J Crit Care.
1995;4:157–164.
73. Simpson T, Lee ER, Cameron C. Relationships among
sleep dimensions and factors that impair sleep after car-
diac surgery. Res Nurs Health. 1996;19:213–223.
74. Moseley M, Jones A. Contracting for visitation with fam-
ilies. DCCN. 1991;10(6):364–371.
75. Byers J. Holistic acute care units: partnerships to meet
the needs of the chronically ill and their families. AACN
Clinical Issues. 1997;8(2):271–279.
76. Carlson B, Riegel B, Thompson T. Visitation: Policy ver-
sus practice. DCCN. 1998;17(1):40–47.
77. Simon SK, Phillips K, Badalamenti S, Ohlert J, Krum-
berger J. Current practices regarding visitation poli-
cies in critical care units. Am J Crit Care. 1997;6:
210–217.
78. Roland P, Russell J, Richards KC, Sullivan SC. Visita-
tion in critical care: Processes and outcomes of a perfor-
mance improvement initiative. J Nurs Qual. 2001;15(2):
18–26.
79. Willis D. Animal therapy. Rehabilitation Nursing.
1997;22(2):78–81.
80. Connor K, Miller J. Help from our animal friends. Nurs-
ing Management. 2000;31(7):42,44–46.
81. Huebscher R. Pets and animal-assisted therapy. Nurse
Practitioner Forum. 2000;11(1):1–4.
82. Cole KM, Gawlinski A. Animal-assisted therapy:
The human-animal bond. AACN Clinical Issues.
2000;11(1):139–149.
83. Giuliano KK, Bloniasz E, Bell J. Implementation of a
pet visitation program in critical care. Crit Care Nurse.
1999;19(3):43–50.