A Place to Heal: Environmental Sources of
Satisfaction Among Hospital Patients'
PAULB. HARRIS^
Univrrsiry ofArizonu
CHETRoss
University ofAri:ona
GLENMCBR~DE
Intermountain Health Care, Inc.
Salt Luke City, Utah
LINNEACURTIS
Intermountain Heulth Cure, Inc.
Salt Luke City,Utah
Telephone interviews with 380 discharged inpatients were conducted to identify environmental sources of satisfaction with the hospital, to determine the relative contribution of
environmental satisfaction to overall satisfaction with the hospital experience, and to
explore differences in satisfaction across 4 departments (medical, obstetrics, orthopedics,
and surgical) and 6 hospitals. Analyses indicate that interior design, architecture, housekeeping, privacy, and the ambient environment were all perceived as sources of satisfaction. Environmcntal satisfaction was a significant predictor of overall satisfaction, ranking
below perceived quality of nursing and clinical care. There were no significant differences
between hospitals or departments in the level or sources of environmental satisfaction.
Results suggest potential directions for architects, designers, and health care providers.
Although the hospital might not be a highly familiar setting in most people's
lives, clearly it is an important setting. Visits to the hospital might be infrequent
and short in duration, but they are often punctuated by strong emotion. What role
does the environment play in the hospital experience? In the present study, we
identify sources of environmental satisfaction and dissatisfaction among hospital
inpatients, and examine the relative contribution of environmental satisfaction to
the overall hospital experience. Because patient evaluations may be tied to specific locations and type of care received (Shumaker & Pequegnat, 1989; Sitzia &
Wood 1997; Ware, Davies, & Rubin, 19871, we compare responses for patients'
hospital rooms and public areas outside of the room for four different types of
departments (medical, obstetrics, orthopedics, and surgical) and for six different
hospitals (from 101 beds to 520 beds).
'We thank Irwin Altman, Barbara Brown, Dennis Doxtater, Robert Rice, and Carol Werner for
their comments on an earlier draft of this paper. We also thank Eric Conrad and Dennis Deak for their
help during the content analysis phase of the project.
ZCorrespondence concerning this article should be addressed to Paul B. Harris, who is now at
Department of Psychology, Kollins College, 1000 Holt Avenue -2760, Winter Park, FL 32789-4499.
E-mail: pharris@rollins.edu
Journal of Applied Social Psychology, 2002, 32,6, pp. 1276-1299.
Copyright 0 2002 by V. H. Winston & Son, Inc. All rights reserved.
A PLACE TO HEAL
1277
Patient Satisfaction
The idea that the physical environment can play an important role in the
health care experience is not a new one. In her Notes on Nursing, originally published in 1859, Florence Nightingale (1969) commented on a number of environmental issues, including ventilation, temperature, noise, windows, light, plants,
music, cleanliness, drainage, wall finishes, furnishings, and even color. Despite
Nightingale’s efforts, the design of hospitals reflected more of an institutional
than a humanistic aesthetic until fairly recently. During the 19th and early 20th
centuries, hospital designs were guided by changing views of disease and treatment, by the functional needs of medical staff, and by ever-changing requirements to accommodate new medical technologies (Horsburgh, 1995; Shumaker
& Pequegnat, 1989). While these factors still play an important role in hospital
design, during the past two decades there has been an increase in attention to consumer needs (i.e., patients and visitors).
The inclusion of patients’ needs in the design process reflects a growing concern within health care over the issues of service quality and patient satisfaction.
Service quality has joined clinical quality as a guiding principle in health care
delivery, and patient satisfaction measures have become a means to monitor service quality (Sitzia & Wood, 1997). These measures reflect a variety of perspectives, with patient satisfaction defined variously by patient beliefs, attitudes,
evaluations, expectations, needs, and goals (Linder-Pelz, 1982; Sitzia & Wood,
1997; Ware et al., 1987). We adopt Ware, Snyder, Wright, and Davies’ (1983)
definition ofpatient satisfaction as “a personal evaluation of health care services
and providers” (p. 247).
Along with a variety of definitions, there has been a variety of classification
systems detailing the components that determine patient satisfaction (Sitzia &
Wood, 1997; Ware et al., 1987). Our classification system is based on research
conducted at Intermountain Health Care, Inc. (IHC), a nonprofit health care organization based in Salt Lake City, Utah, that operates 24 hospitals in Utah, Idaho,
and Wyoming. Over the past 10 years, IHC has mounted a research program to
develop and refine a set of measurement systems to monitor patient satisfaction
at their facilities (Harris, McBride, & Curtis, 1994, 1996). Based on patient interviews, focus groups, and quantitative examination of multi-item scales, eight
major aspects of inpatient satisfaction have been indentified: (a) clinical quality
(e.g., tests, treatments, outcome, pain management); (b) nursing care (e.g., caring
and concern, information provided, professional skills); (c) physician care (e.g.,
caring and concern, information provided, clinical skills); (d) admitting procedures (e.g., ease of paperwork, friendliness of staff); (e) discharge procedures
(e.g., ease of paperwork, information on home care); (Q financial services (e.g.,
billing policies and procedures); (8) food services (e.g., delivery, food quality);
and (h) facilities (e.g., cleanliness, quality of linen, overall satisfaction).
1278 HARRIS ET AL.
Sources of Environmental Satisfaction
Although patient satisfaction classification systems differ, most include some
aspect of the physical environment (Fottler, Ford, Roberts, & Ford, 2000; Sitzia &
Wood, 1997; Ware et al., 1983, 1987). For example, Ware et al. (1983) described
this environmental component as “features of setting in which care is delivered
(e.g., orderly facilities and equipment, pleasantness of atmosphere, clarity of
signs and directions)” (p. 248). Despite the inclusion of the environment in these
systems, much of the empirical research on hospital settings has focused on stress
rather than satisfaction (Carpman & Grant, 1993; Shumaker & Pequegnat, 1989;
Shumaker & Reizenstein, 1982; Zimring, Carpman, & Michelson, 1987). However, minimizing stress should provide more satisfying hospital experiences.
Shumaker and Reizenstein (1982; see also Carpman & Grant, 1993; Shumaker
& Pequegnat, 1989; Zimring et al., 1987) described four factors that are important
in hospital design: (a) wayfinding or features that aid users in finding their way
around the hospital; (b) physical comfort or features ( e g , ambient, architectural,
interior design) that relate to the comfort of hospital users; (c) privacy and territoriality, or features that affect the ability to control social contact; and (d) symbolic
meaning or environmental messages about the value of the facility and its users
(e.g., image, atmosphere). In the present paper, we divide the rather broad physical
comfort category into four more specific categories: ambient features, architectural features, interior design features, and maintenanceihousekeeping.
Ambient Environment
Ambient features that might be sources of satisfaction or dissatisfaction for
patients include lighting, noise levels, air quality and odors, and temperature
(Fottler et al., 2000; Shumaker & Reizenstein, 1982; Zimring et al., 1987).
Extreme environmental conditions can result in stress, especially if they are
unpredictable or uncontrollable (Evans, 1982; Evans & Cohen, 1987). Design
features that minimize these sources of stress or allow patients more control over
the ambient environment (e.g., individual thermostats, dimmer switches) might
enhance satisfaction for the hospital environment.
Architectural Features
We define architectural features as relatively permanent aspects of the hospital environment, such as the plan or layout of the hospital, the size and shape of
rooms, and the placement of windows. The plan or layout of the hospital might
impact on the ease of wayfinding and speed of travel to the various locations that
patients visit during their hospital stays (Carpman & Grant, 1993). For example,
patient satisfaction could be influenced by the ease or difficulty of getting from
admitting to patient rooms, and from patient rooms to such places as the bathroom, x-ray, and so on.
A PLACE TO HEAL
1279
Although the size and shape of hospital rooms has received little attention in
the literature, it is reasonable to expect that cramped rooms will be less appreciated than will spacious rooms. Smaller rooms might make it difficult to accommodate staff and visitors, and increase perceptions of crowding (see Baum &
Paulus, 1987, for a review). With regard to size in the hospital as a whole,
Horsburgh (1995) suggested that patients might have problems with public areas
that are too small to accommodate traffic, abrupt transitions from large public
areas to smaller private areas, and long confusing institutional hallways connecting areas in the hospital.
Windows also might be an important feature of hospital rooms. Research suggests that windows might be related to place attachment in hospitals (Baird &
Bell, 1995) and that patients prefer rooms with windows, but only if they have an
interesting view, preferably a view of nature (Verderber, 1986). Research by
Urlich (1984) suggested that rooms with views of nature might reduce patients’
psychological distress, recovery time, and need for pain medication. These findings are consistent with laboratory research (Urlich, 1981) indicating that views
of nature produce higher levels of relaxation (electroencephalogram, or EEG,
alpha waves) when compared with urban scenes.
Znterior Design Features
We define interior design features as less permanent aspects of the hospital
environment, such as furnishings, nonmedical equipment (e.g., televisions, telephones), colors, finishes, artwork, and the layout of furnishings in hospital
rooms. There has been very little research focusing on the interior design features
of hospitals. In their description of the physical comfort dimension of hospital
environments, Shumaker and Reizenstein (1982; see also Carpman & Grant,
1993; Fottler et al., 2000; Zimring et al., 1987) suggested that both type and layout of furniture and equipment can influence patient experiences. Furnishings
might be comfortable or uncomfortable, and their layout can facilitate or interfere
with comfortable body positions. For example, arranging furnishings so that
patients must turn their bodies to watch the television can cause patients considerable discomfort.
Despite the lack of research, many design and health care professionals
believe that aesthetically pleasing decor and artwork can enhance the patient
experience (Behrman, 1997; Fottler et al., 2000; Friedrich, 1999). Although not
directly related to interior design, research on perception of natural environments
might provide some support for this belief. Research in this area indicates that
people prefer views of nature (Kaplan & Kaplan, 1989); and that exposure to
nature might help combat mental fatigue (Kaplan, 1995; Kaplan & Kaplan,
1989), reduce stress (Ulrich, 1981), and aid in healing (Ulrich, 1984). The bulk of
research in this area has been conducted using photographs and slides rather than
1280 HARRIS ET AL.
on-site exposure to nature (Kaplan & Kaplan, 1989; Pitt & Zube, 1987). If photographs and slides of nature are viewed positively and reduce stress, it is not too
much of a stretch to propose that artwork and decor that mirror nature might also
have this effect. In fact, Verderber (1986) found that rooms with "nature surrogates," such as artwork and plants, were preferred to rooms without windows and
to rooms with windows but no view.
Muintenance/Housekeeping
Even with the best architecture and design, poorly maintained environments
are likely to evoke negative judgments. Although most patient satisfaction surveys contain some measure of satisfaction with housekeeping services, it is difficult to find any published research on this topic. Patients who might equate dirt
with disease might be particularly sensitive to the cleanliness of their environments. Maintenance also might be important because furniture and finishes that
look worn or that have fallen into disrepair might be perceived as dirty even if
they are not.
Social Feutures
A number of authors have described privacy as being an important issue in
hospital design (Carpman & Grant, 1993; Shumaker & Pequegnat, 1989;
Shumaker & Reizenstein, 1982; Zimring et al., 1987). Altman (1975) defines
privacy as selective control over access to the self or one's group. In residential
settings, there is some evidence that control over privacy might increase environmental satisfaction and place attachment (Harris, Brown, & Werner, 1996; Harris, Werner, & Brown, 1996). Privacy might be especially important for inpatients
who feel an overall lack of control because of their unfamiliar surroundings and
routine. However, the needs of medical staff to monitor and to have access to
patients might sometimes work against patient efforts to control privacy. For
example, Shumaker and Reizenstein point out that while radial ward designs that
allow easy access to patients are preferred by nurses (Trites, Galbrith, Sturdavant,
& Leckwart, 1970), patients complain about the lack of privacy with these floor
plans (Jaco, 1979). In addition to interruptions from staff, patients might experience privacy violations from other patients when they share a room. Although
there is not a great deal of research on multiple-occupancy rooms in hospitals,
there is some evidence that dementia patients respond more positively to singleoccupancy rooms (Morgan & Stewart, 1998).
According to Altman (1975), privacy also involves attempts to increase contact when we want to be with others. The social support provided by family and
friends might be important to both the physical and psychological well-being of
the patient (Uchino, Cacioppo, & Kiecolt-Glaser, 1996). Hospital design that
A PLACE TO HEAL
1281
accommodates family and friends (e.g., well-designed waiting areas, patient
rooms large enough for visitors) might be appreciated by both visitors and
patients (Carpman & Grant, 1993; Shumaker & Reizenstein, 1982; Zimring
et al., 1987).
Wayfinding. In larger hospitals, it can be difficult to navigate between any two
locations (Brown, Wright, & Brown, 1997; Carpman & Grant, 1993; Shumaker
& Pequegnat, 1989; Shumaker & Reizenstein, 1982; Zimring et al., 1987). Problems with wayfinding might occur because of complicated hospital plans, lack of
signage, confusing signage, or confusing cues (e.g., dim lights, narrow entrances
to major destinations; Brown et al., 1997). Although these problems might affect
patients, they might be more troublesome for visitors who must navigate between
the patient’s room and other locations (e.g., parking, waiting areas, the cafeteria,
and the gift shop).
Symbolic meaning. Symbolic meaning refers to the set of messages that an
environment communicates to its users (Shumaker & Reizenstein, 1982). This
feature is, to a large extent, a product of all of the other features discussed. Architecture, design, maintenance, and social factors combine to communicate to
patients that the hospital views them either as objects to be worked on or as individuals about whom the hospital genuinely cares. Symbolic meaning might be
the most difficult of all of the features to study, primarily because the concept is
so general and holistic. Despite the lack of research, heath care and design communities have been moving hospitals away from the sterile institutional designs
of the past toward friendlier, more intimate designs for patient areas and grander,
more welcoming designs for public areas (Hair, 1998; Horsburgh, 1995; Voelker,
1994).
The Present Study
There are three major goals in the present study. The first is to explore the relative contribution of environmental satisfaction to overall satisfaction with the
hospital experience. Compared to such factors as interactions with medical staff
and perceived quality of care, how important is the physical environment in predicting overall satisfaction with the hospital stay?
The second goal is to explore sources of environmental satisfaction in the
hospital setting. Although we have spent most of the introduction listing a number of environmental features that might be important to patient satisfaction, we
do not specifically ask patients about any of these features in our study. Rather,
we let the patients tell us what is important. This is accomplished by asking
patients, in general, to describe the features of their rooms and of the hospital
environment outside of their rooms that they find satisfying and dissatisfying.
The resulting qualitative data are then analyzed to catalogue these features.
Although we recognize that there might be aspects of the environment that
1282 HARRIS ET AL.
patients are less aware of that might, nonetheless, influence satisfaction, we also
feel that creating a taxonomy of patient perceptions is critical in defining the
salient sources of environmental satisfaction in hospital settings.
The third and final goal of the present study is to examine differences in the
level and sources of satisfaction across six different hospitals and four different
types of departments (medical, obstetrics, orthopedics, and surgical). We are
interested in determining which features are context specific and which generalize across settings.
Method
Sample und Procedures
The sample was randomly drawn from inpatients who had received treatment
at six different hospitals owned by IHC. These hospitals included two smaller
facilities (101 beds and 106 beds), two mid-sized facilities (148 beds and 277
beds), and two larger facilities (409 beds and 520 beds).
Telephone interviews were conducted with 380 inpatients (241 female, 139
male). Participants were hospitalized for an average of 3 days ( M = 3.03, SD =
2.53, range = I to 24) and were interviewed 2 to 54 days ( M = 22.30, SD = 9.94)
after discharge. Patients ranged in age from less than 1 year to 90 years (A4 =
47.14, SD = 2 1.29). Interviews were conducted with the parents of 17 patients
younger than 18 years of age.
Interviews were conducted during the winter of 1997- 1998. Questions of
interest were piggybacked onto an existing interview schedule, the Patient Perceptions of Quality Interview-Inpatient Form (PPQ-I; IHC, Inc., 1993), which is
used year round to monitor patient satisfaction at IHC hospitals. Once a participant agreed to be interviewed, he or she was randomly assigned to either the standard PPQ-I or to one of the modified interview schedules used in this study.
Because participants had agreed already to be interviewed before being selected
for our study, the response rate was 100%; this simply means that no one terminated an interview already in progress. A more meaningful figure can be calculated for the PPQ-I sample as a whole during the time that our interviews took
place. For the overall sample, the response rate was 65%. Out of an initial sample
of 6,620 patients, 4,273 completed an interview.3
3lHC does not collect refusal rates on a continuous basis, so we do not have refusal data for this
study. However, nonreponse as a result of refusal and termination typically ranges between 7% and
10%. Other common reasons for nonresponsc include no answer, reaching an answering machine,
reaching a disconnected number, or having the wrong number listed in a patient’s file. Although there
is always a potential for nonresponse bias, with a response rate over 60% and a refusal rate of less
than lo%, we are fairly confident in our results.
A PLACE TO HEAL
1283
In order to keep the length of the interview reasonable, two modified interview schedules were used for the study, Schedule A and Schedule B (Measures
section), with half of the participants completing each schedule ( n = 190 for each
schedule). In order to make comparisons between hospitals and types of hospital
units, a quota sample was used to obtain 20 participants (10 Schedule A, 10
Schedule B) from four different types of hospital units at six different facilities4
Measures
Open-ended questions. As mentioned in the previous section, two modified
forms of the PPQ-I (Schedule A and Schedule B) were used to interview participants. Both schedules include additional open-ended and closed-ended questions
about satisfaction with the physical environment. The open-ended questions for
Schedule A relate to satisfaction with the hospital room, while the open-ended
questions for Schedule B relate to satisfaction with the hospital environment outside of the room.
Questions for Schedule A asked participants “Can you tell me something
about your room that you liked or that left you with a positive impression?” and
“Can you tell me something about your room that you disliked or that you felt
needed improvement?” After each of these questions, there were two follow-up
probes asking participants if there was anything else that they liked or disliked
about their rooms.
Questions for Schedule B asked participants “Considering areas of the
hospital other than your room, can you tell me something about the hospital environment that you liked or that left you with a positive impression?” and “Considering areas of the hospital other than your room, can you tell me something about
the hospital environment that you disliked or that you felt needed improvement?”
As with the other interview, each of these questions was followed by two probes
asking participants if there was anything else that they liked or disliked about the
hospital environment.
Closed-ended questions. The closed-ended questions were identical for both
Schedule A and Schedule B. For both forms, two questions about environmental
satisfaction were added to the PPQ-I interview. The first question asked participants to rate their hospital room, and the second asked them to rate physical environment of the hospital outside of the their room. Both of these questions
employed a 5-point rating scale ranging from 1 (poor) to 5 (excellent).
PPQ-I interview. The PPQ-I includes 15 closed-ended questions asking
participants to rate the overall quality of care and services received (1 question),
4This design was not hlly crossed since only two of the hospitals contained all four types of
units: Three hospitals contained three types of units, and one hospital contained two types of units.
Overall, patients from five medical units, five obstetrics units, three orthopedic units, and six surgical
units were samplcd. For this reason, it was not possible to conduct any Hospital x Unit analyses.
1284 HARRIS ET AL.
six separate aspects of service quality (10 questions), and perceived quality of
clinical care (4 question^).^ With the exception of clinical quality, all of these
questions employ 5-point rating scales ranging from 1 (poor) to 5 (excellent). The
six aspects of service quality include three questions about nursing care; three
questions about physician care; and one question each about admitting procedures, discharge procedures, food services, and housekeeping services (i.e., the
cleanliness of the patient’s room).6 Nursing and physician questions asked
respondents to rate the caring and concern, information provided, and professional skills of nurses and physicians. The housekeeping question in the modified
schedules of the interview was asked after the open-ended environmental satisfaction questions so as not to bias participants to include cleanliness in their
open-ended responses.
The clinical quality questions employ a 5-point Likert-type scale ranging
from 1 (do not agree) to 5 (completely agree). These four questions ask participants to rate their agreement with statements that the tests and treatment they
received were appropriate, the staff made an effort to alleviate their pain, the staff
made an effort to help improve their condition, and that their condition actually
did improve as a result of the hospital visit. The two questions about improvement of the patient’s condition are not asked of labor and delivery patients, since
pregnancy is not considered a medical condition in need of improvement.
Scale construction. Since the modified interview schedules contained multiple indicators of nursing care, physician care, clinical quality, and environmental
quality, data from these closed-ended questions were analyzed to determine the
feasibility of combining them into scales. A factor analysis using principal components extraction and varimax rotation yielded four factors with eigenvalues
greater than 1. As shown in Table 1, these factors corresponded to our conceptual
categories. Based on this analysis, items were combined using a simple mean to
form nursing, physician, clinical quality, and facilities scales, The internal consistency of these scales was indexed through Cronbach’s alpha scores, also shown in
Table 1.
Results
Analytic Strategy
The first set of analyses examined group differences (e.g., hospitals, types of
units) in reported levels of environmental satisfaction. The second set of analyses
sFor more information about the development and content of the PPQ-1, contact Glen McBride,
Research and Planning, Intermountain Health Care, Inc., 36 South State Street, Salt Lake City, UT
8411 1-1486.
60ne aspect of the inpatient experience that is conspicuously absent from the PPQ-I is billing. This
is because many patients were contacted prior to receiving their final accounting from the hospital.
IHC uses a separate set of measures to monitor patient perceptions of billing policies and procedures.
A PLACE TO HEAL
1285
Table I
Rotated Factor Loadings for Scale Questions
Factor
Questions
Nursing scale questions (a = .87)
1. Information provided
2. Caring and concern
3. Professional skill
Physician scale questions (a= 32)
1. Information provided
2. Caring and concern
3. Professional skill
Clinical scale questions ( a = .74)
1. Condition improved
2. Staff tried to improve condition
3. Tests and treatment appropriate
4. Staff tried to alleviate pain
Facilities scale questions (a = .72)
1. Overall quality of room
2. Environment outside of room
3. Cleanliness of the room
1
2
3
4
.80
.78
.78
.29
.22
.25
.15
.27
.14
.16
.13
.2 1
.28
.30
.06
.82
.79
.78
.12
.07
.11
.I0
.08
.16
-.14
.33
.2 1
.46
.3 1
.0 1
.14
-.12
.76
.72
.68
.62
.04
.15
.08
.05
.03
.16
.20
.02
.17
.12
.05
.09
.10
.86
.73
.72
utilized multiple regression to determine the relative contribution of environmental satisfaction to overall satisfaction with the hospital stay. The final set of analyses explored sources of environmental satisfaction and dissatisfaction through a
content analysis of the open-ended responses. An alpha level of .05 was used for
all statistical tests.
Groups Differences in Environmental Satisfaction
A number of statistical tests were conducted using the combined data of both
interview schedules to determine if various groups reported different levels of
satisfaction with the hospital environment. All of these analyses used the facilities scale as the dependent variable. None of the analyses yielded statistically significant results.
More specifically, Pearson correlation coefficients did not find a relationship
between environmental satisfaction and age ( r = -.08, p > .lo), length of hospital
stay ( r = -.03, p > .50), nor days elapsed between discharge and interview ( r =
-.02, p > .60). There was no difference in environmental satisfaction between
1286 HARRIS ET AL.
male ( M = 4.03,SD = 0.70)and female (A4= 3.94,SD = 0.77)participants when
tested using an independent groups t test, t(376) = 1.23,p > .20.A one-way
ANOVA did not find differences between the six hospitals ( M i
= 3.98,SD,=
0.71;M2 = 4.06,SD2 = 0.74;M3 = 4.06,SD3 = 0.71; M4 = 3.95,SD4 = 0.70;M.j =
3.91,SD, = 0.86;M6 = 3.86,SD, = 0.78),F(5, 372) = 0 . 7 7 , ~ S O . A second
one-way ANOVA did not find differences between medical ( M = 3.98,S D =
0.72),OBiGYN ( M = 4.01,SD = 0.70),orthopedics ( M = 3.98,SD = 0.82),and
surgical ( M = 3.94,SD = 0.76)departments, F(3,374) = 0.17,p > .90.In summary, the results do not indicate any group differences in the level of environmental satisfaction for different departments, hospitals, or patient types.
Relating Environmental Satisfaction to Overall Satisfaction
A second set of analyses, again using the combined data from both interview
schedules, explored the relationship between environmental satisfaction and
overall satisfaction with the hospital experience. A multiple regression using
simultaneous entry regressed the seven quality measures (i.e., nursing, physician,
clinical, admitting, discharge, facilities, and food) onto participant ratings of the
overall quality of care and services that they received at the hospital. The results
of this regression indicate that the seven measures of hospital satisfaction
accounted for 48% (adjusted R2) of the variance in participant ratings of overall
quality, F(7, 372) = 5 1.42,p < .01.As illustrated in Table 2,nursing care was by
far the strongest predictor of overall satisfaction, followed by perceived quality of
clinical care, environmental satisfaction, and satisfaction with admitting procedures. Satisfaction with discharge procedures, food services, and physician care
was not a significant predictor of overall satisfaction with the hospital. Although
it might seem surprising that physician care ranked last in this group of variables,
keep in mind that, in most cases, the patient’s personal physician does not work
for the hospital and thus his or her performance might not be associated directly
with overall ratings of the hospital. In summary, participant satisfaction with the
environment was a significant predictor of overall satisfaction, although not as
strong a predictor as nursing care and clinical quality.
Perceived Sources of Environmental Satisfaction
Responses to the open-ended questions on interview Schedules A and B were
reviewed to identify emerging categories that could be used to classify environmental sources of satisfaction and dissatisfaction. These categories were then
used in a content analysis, quantifying the number of participants mentioning
each environmental feature in their responses. Two raters read and coded all of
the responses to obtain reliability measures. One rater’s assessments were used
for the remaining analyses.
1287
A PLACE TO HEAL
Table 2
Summary of Simultaneous Regression Analysis for Variables Predicting Ratings
of Overall Quality of Care and Services
Predictor variable
r
B
SE B
P
Nursing scale
Clinical scale
Facilities scale
Admitting procedures
Discharge procedures
Quality of food
Physician scale
.64**
0.39
0.25
0.12
0.09
0.05
0.04
0.03
0.05
0.06
0.04
0.04
0.04
0.03
0.05
.41**
SO**
.40**
.36**
.43**
.29**
.40**
.19**
.12**
.lo*
.06
.05
.03
*p<.05.**p<.Ol.
Sources of satisfaction in the hospital room. As Table 3 shows, the analysis of
the open-ended responses for Schedule A identified five major sources of satisfaction and dissatisfaction with the hospital room: interior design features, architectural features, social features, maintenanceihousekeeping, and the ambient
environment. Interrater reliabilities for these scales ranged from .77 to .96, with
an average reliability of .87. Responses relating to interior design features
included references to equipment (usually the television), furniture (usually the
bed), finishes (usually wall finishes), color and decor (usually comments on artwork), and the plan or layout of the room (often relating to accessibility).
Respondents who were satisfied could be Characterized as liking the color of the
walls and the artwork in the room, having a comfortable bed, having a television
and telephone that worked properly, and having a room where everything was
easily accessible. Architectural features referenced included the presence of a
window, the size of the room, the bathroom, and the location of the room.
Respondents who were satisfied could be characterized as having a window with
a nice view; having a larger room (although a minority of the participants liked a
smaller room); having an accessible bathroom, preferably in the room; and having a room located away from noisier areas of the unit. References to housekeeping and maintenance related primarily to the cleanliness of the room. Participants
who were satisfied with the social features of the room could be characterized as
having a private room or having their privacy protected through environmental
means (e.g., a shut door). These participants also appreciated accommodations
for family and other visitors, such as seating, a bed or cot, and space for visitors
in the room. Finally, references to the ambient environment related to having adequate lighting, quiet surroundings, and a comfortable temperature.
1288
HARRIS ET AL.
Categories Used to Analyze Participants’ Responses Concerning Their Hospital
Rooms
Examples of responses
Category
Interior design features
Equipment
Furniture
Finishes, color, and
decor
Plardlayout
Architectural features
Size of room
Windowlview
Bathroom
Location of room
Maintenance1
housekeeping
Social features
Privacy
Visitor
accommodations
Ambient environment
Lighting
Noise
Temperature
Satisfied
Dissatisfied
Having a TV to occupy
time.
The bed was very
comfortable.
Painting and the pictures
made it warm.
The arrangement and
accessibility of things.
My TV remote didn’t
work.
The chair was not very
comfortable.
It needs some color. It was
drab.
Everything I needed was
out of reach.
1 liked how much room
there was.
Window made me feel I
wasn’t closed in.
There was a bathroom in
there.
It was far enough away
from the desk.
It was very clean and well
taken care of.
It was kind of small and
crowded.
I didn’t have a very good
view.
Too small of a bathroom.
Very noisy across from the
nurses’ station.
My room was never
cleaned.
I enjoyed not having other There were two of us, and I
people.
didn’t like it.
There was enough room They need
for visitors.
accommodations for the
spouse.
It was nice and light.
It was quiet-it wasn’t
noisy.
The heat was also nice.
No light-gloomy.
It was a little noisy, but I
lived with that.
It was cold at night.
A PLACE TO HEAL
1289
Table 4
Participants’ Mention of Sources of Satisfaction and Dissatisfaction With Their
Rooms
Percentage citing categories (subcategories)
Categories and subcategories
Satisfied
Dissatisfied
Total
Interior design features
Equipment
Furniture
Finishes, color, and decor
Planllayout
Architectural features
Size of room
Windowiview
Bathroom
Location of room
Maintenancehousekeeping
Social features
Privacy
Visitor accommodations
Ambient environment
Lighting
Noise
Temperature
Other comments
Note. n = 190.
In addition to these five major categories, an “other” category was used to
classify environmental features that did not fit into any other category. As shown
in Table 4, most of the responses coded as “other” were positive impressions of
the hospital room. Almost all of these response were general positives, such as
“kind of homey” and “the atmosphere-they were nice rooms.”
Table 4 also shows that about half of the participants mentioned interior
design or architectural features; about one third mentioned maintenance/
housekeeping; and about one fourth mentioned social features, the ambient environment, or made comments that had to be coded in the “other” category (since
respondents could mention more than one category, the percentages do not total
100%). Overall, participants were more positive than negative about their
1290 HARRIS ET AL.
Table 5
Summary ojsimultuneous Regression Analysis for Variables Predicting Room
Satisjaction Ratings
Predictor variable
Negative maintenancelhousekeeping
Positive social features
Negative architectural features
Positive maintenancelhousekeeping
Negative design features
Negative social features
Positive ambient environment
Positive architectural features
Positive design features
Negative ambient environment
r
B
SE B
-.23**
.22**
-.28**
.21**
-0.87
0.51
-0.45
0.39
-0.38
-0.49
0.22
0.07
0.05
0.02
0.26
0.17
0.19
0.16
0.17
0.30
0.19
0.15
0.14
0.28
-.16*
-.20**
.09
.09
.07
-.03
P
-.23**
.2 1 **
-.17*
.16*
-.15*
-.I2
.08
-.03
.03
.oo
* p < .05.**p < .01.
hospital rooms. With regard to the number of coded responses, participants
tended to make more positive comments ( M = 1.58, SD = I . 12) than negative
comments (A4= 0.64, SD = 0.80), t( 189) = 8.64, p < .O 1.
Do the sources of satisfaction cited by participants relate to room satisfaction? A set of analyses was conducted using the 5-point scale (poor to excellent)
question asking patients to rate the quality of their hospital rooms. A set of Pearson’s correlation coefficients indicated that participants who cited a greater number of sources of satisfaction also rated their rooms more positively ( r = .3 1, p <
.Ol). Conversely, participants who cited a greater number of sources of dissatisfaction rated their rooms more negatively (r = -.38, p < .Ol).
A multiple regression using simultaneous entry was conducted to determine
how coding on the content analysis categories related to room satisfaction ratings. The results of this regression, shown in Table 5, indicate that the 10 predictor variables accounted for 20% (adjusted R2) of the variance in participants’
ratings of room quality, F(10, 178) = 5.56, p < .01. Although both positive and
negative mentions of maintenance relate to room satisfaction, only positive mention of social features and negative mention of design and architectural features
were significantly related. Neither positive nor negative mention of the ambient
environment was significantly related to satisfaction.
It is possible that sources of satisfaction and dissatisfaction might differ for
different hospitals or for different department types. A series of chi-square analyses testing for these differences did not yield any significant results.
A PLACE TO HEAL
1291
In summary, participants mentioned a number of sources of environmental
satisfaction and dissatisfaction, including interior design, architectural and social
features, maintenance/housekeeping, and the ambient environment. For the most
part, comments were positive and were unrelated to type of department or hospital. Significant predictors of room satisfaction included positive and negative
mention of maintenancehousekeeping, positive mention of social features, negative mention of architectural features, and negative mention of interior design
features.
Sources of satisfaction in the hospital outside of the room. Table 6 shows the
categories derived from open-ended responses to Schedule B, which focused on
physical environment outside of the hospital room. Analysis of the data identified
six major sources of satisfaction and dissatisfaction with the hospital: maintenancelhousekeeping, interior design features, architectural features, ambient
environment, remodelinglconstruction, and parking. Interrater reliabilities for
these scales ranged from .70 to 1.00, with an average reliability of .83. These categories were similar to those found for Schedule A, with several exceptions. A
new subcategory (signslwayfinding) was included as part of interior design category.7 Along with this addition, the pladlayout subcategory was moved to architectural features since with Schedule B it now relates to the layout of rooms in the
hospital plan, not to hrnishings in an individual room. The subcategory air quality was added to ambient environment since several respondents mentioned that
the hospital had a pleasant odor. Finally, a remodelinglconstruction category was
added to accommodate comments about projects in progress while the participant
was a patient, and a parking category was added to accommodate comments
about the ease of parking at the hospital.
In addition to these six major categories, an “other” category was used to
classify environmental features that did not fit into any other category, As shown
in Table 7, most of the responses coded as “other” were positive impressions. As
was the case with Schedule A, almost all of these responses were general positives, such as “Everything in general was fine” and “It looked nice.”
Table 7 also shows that about one fourth of the participants mentioned maintenancelhousekeeping and the “other” category, 20% mentioned interior design,
about 10% mentioned architectural features and the ambient environment, and
about 5% mentioned remodelinglconstruction and parking. Participants again
made more positive comments ( M = 0.79, SD = 0.87) than negative comments
( M = 0.23, SD = 0.5 l), t( 189) = 8.17, p < .01. Because of the relative small number of codable responses, statistical comparison of positive and negative comments for individual categories could not be conducted.
7It could be argued that wayfinding i s also an architectural issue, influenced by the overall layout
of the hospital. However, it was included in the interior design category since comments in this study
related most often to signage.
1292 HARRIS ET AL.
Table 6
Categories Used to Analyze Participants’ Responses Concerning the Hospital
Outside of Their Rooms
Categories and
subcategories
Examples of responses
Satisfied
Dissatisfied
~
Maintenancehousekeeping
~
~
The cleanliness of it was The floor was not clean.
very impressive.
Interior design features
Finishes, color, and
decor
The colors and decor were It would be nice if they had
really nice.
more pictures.
Signsiwayfinding
Good signs on where to
go.
Instructions . . . it was
confusing.
Furniture and
equipment
New seats in lobby.
They just need more chairs
in the ER.
Architectural features
Size of spaces
The halls were nice and
big.
__
Planllayout
The layout of the things
worked well.
-
Windowlview
The big windows at the
end of the hall.
-
Location of facility
Liked the way it’s situated
on the hill.
-
Ambient environment
Noise
It was clam and quiet.
Air quality
Lighting
It smelled good.
Cheerful lighting as you
enter.
Temperature
It was warm, not cold.
The noise level needs to be
lowered.
-
The X-ray room was really
cold.
Remodelingiconstruction Remodeling . . . working The construction is
to improve it.
annoying.
Parking
Valet parking.
It is also hard to park.
A PLACE TO HEAL
1293
Table 7
Participants’ Mention of Sources of Satisfaction and Dissatisfaction With the
Hospital Outside of Their Rooms
Percentage citing categories (subcategories)
Categories and subcategories
Maintenancelhousekeeping
Interior design features
Finishes, color, and decor
Signslwayfinding
Furniture and equipment
Architectural features
Size of spaces
Planllayout
Windowlview
Location
Ambient environment
Noise
Air quality
Lighting
Temperature
Remodelinglconstruction
Parking
Other comments
Note. n
=
Satisfied
Dissatisfied
Total
23
18
3
4
25
20
(15)
(2)
(2)
11
(1)
(2)
(1)
(16)
(4)
(3)
11
-
-
2
2
18
4
2
6
5
4
23
190.
In fact, participants who were asked to comment about the hospital environment outside of their rooms had a much more difficult time answering when
compared to participants who were asked about their hospital rooms. While 96%
of Schedule A participants provided at least one codable response, only 60% of
Schedule B participants could provide such a response, x2(1, N = 380) = 71.91,
p < .01. Since patients often spend little time outside of their rooms, they might
not be the best group to provide information about more public areas in the hospital. In fact, at least 8 respondents made statements to the effect that this line of
questioning “does not apply. I was just in my room and then discharged.” Many
more respondents simply stated that they did not know how to answer the
question.
1294
HARRIS ET AL.
Because of the low frequencies, most of the comparisons between departments and hospitals conducted with the Schedule A data were not possible with
the Schedule B data. Low frequencies also prevented regression analyses on these
data, although a set of simple correlations did suggest relationships between
open-ended responses and ratings on the 5-point scale question about satisfaction
with the hospital environment outside of the patient’s room. Pearson’s correlation
coefficients indicated that participants who cited a greater number of sources of
satisfaction also rated the hospital environment more positively ( r = .23, p < .O 1).
Conversely, participants who cited a greater number of sources of dissatisfaction
rated the hospital environment more negatively (r = -. 17, p < .05). Correlations
between the scale question and the four most frequently cited positive categories
indicated a significant relationship with maintenance/housekeeping (r = .27, p <
. O l ) , but not with interior design ( r = .06,p < .30), architecture (r = .02,p > .70),
or the ambient environment ( r = -.04, p > .50).
In summary, participants made fewer comments about the hospital environment outside of their rooms than about the room itself. For those who did
respond the most frequent comments were positive references to maintenance/
housekeeping, interior design features, architectural features, and the ambient
environment. Of these top four, only maintenance/housekeeping was related to
satisfaction ratings. However, the number of positive comments and negative
comments was related to satisfaction ratings.
Discussion
Although it is not the most important factor for inpatients, the physical environment plays a significant role in their hospital experience. The literature reveals
a number of valid methods for exploring that role. We have taken the direct
approach and simply asked patients what is important to them. Both practitioners
and scientists can find valuable suggestions in patients’ responses to this question.
Our participants said that interior designers should provide rooms with functional equipment (e.g., televisions, telephones) and comfortable furnishings, and
arrange these items in such a way that they are accessible, especially from the
bed. With regard to decor, forget that patients are in an institution and think of
them as being at home: The use of color, artwork, wallpaper, carpeting, or other
homelike decor is noticed and appreciated. Aesthetically pleasing decor is appreciated outside of the room in other areas of the hospital as well. Our participants
said that architects should provide a private room that has a window with a view,
enough space to accommodate visitors, and its own bathroom. They said that
hospital maintenance staff should provide a clean and well-maintained environment in rooms and throughout the hospital. To architects, designers, and hospital
staff, our participants said that patients need the ability to control social contact.
Architects, designers, and hospital staff should help protect patients’ privacy and
A PLACE TO HEAL
1295
provide accommodations for visitors. Finally, our participants said that they
needed a comfortable environment-one that is well lit, quiet, not too hot or cold,
and free of unpleasant odors.
These results also suggest the utility of communication and coordination
between the various groups who manage, work in, and design health care environments. Shumaker and Pequegnat (1989) pointed out that there are a number of
constituents who influence hospital design who might work with or against each
other. Our data indicate that environmental satisfaction involves contributions
from a variety of these constituents. For example, patient privacy might be influenced by architects (e.g., private room), interior designers (e.g., sound-reducing
materials and finishes), and hospital staff (e.g., closing doors, knocking before
entering). The cleanliness of the hospital is contingent on the interface between
housekeeping services in the hospital and architects and designers specifying
materials that might be high or low maintenance. Hospital environments are far
too complex to design without carefd programming, teamwork, and input from a
variety of sources.
To scientists, our results indicate the continuing need to study hospital environments. Although the literature contains some excellent efforts, certain areas
revealed in this study as important to patients are virtually devoid of research. For
example, although there are very few empirical studies of hospital interior design
features, these were the most common room features and the second most common hospital features mentioned by participants in this study. With the growing
popularity of more homelike designs for patient care units (Hair, 1998; Voelker,
1994), hospital interior design deserves greater attention by researchers.
A second area that deserves greater attention is maintenance/housekeeping,
which was mentioned by nearly one fourth of the patients from both the room
sample and the hospital sample. It is surprising that there is so little research on a
topic that is so familiar in our everyday lives. Most of us clean house, we notice
the level of cleanliness in both the private and public spaces we visit, we might
even form attributions about others based on the cleanliness of their homes or
places of business. Yet it is difficult to find any studies on this topic. In her book
on housework, Horsfield (1 998) writes, “Anyone curious about household cleanliness will probably find that this is a peculiarly awkward subject to research. Not
only is material scattered and diffuse, it is also unkempt and unconsidered, the
subject being so rarely granted serious attention” (p. 262). Given that so many
patient satisfaction surveys ask for judgments about housekeeping, it is important
to know more about the processes involved in making these judgments.
While suggesting new areas of research, the present study also added support
for ideas previously expressed in the literature. The importance of windows and
views to patients (Baird & Bell, 1995; Urlich, 1984; Verderber, 1986) and the
importance of physical comfort and privacy (Carpman & Grant, 1993; Shumaker
& Pequegnat, 1989; Shumaker & Reizenstein, 1982; Zimring et al., 1987) are
1296 HARRIS ET AL.
consistent with our results. Although our results did not suggest that wayfinding
was an issue, this might be the result of interviewing inpatients. Wayfinding
might be more of a critical issue for hospital visitors than for inpatients (Carpman
& Grant, 1993; Zimring et al., 1987), especially those patients who spend the
bulk of their time in or near their rooms.
Previous research has also indicated the importance of the ambient environment as a potential source of stress (see Evans & Cohen, 1987, for a review).
Although we did not find a relationship between the ambient environment and
satisfaction for the hospital room, we cannot dismiss these variables as unimportant. If the ambient environment is not salient or problematic, patients might
ignore these features. Were extremes in temperature, lighting, noise, or odor to
exist in the facilities sampled in this study, the ambient environment might have
played a more significant role in predicting satisfaction.
A final set of findings that are worthy of note is the lack of differences when
comparing hospitals and types of departments. It is probable that there are differences in perceptions of the physical environment for outpatients versus inpatients,
and for short-term care versus long-term care patients, but we failed to find any
significant differences between inpatients in medical, obstetrics, orthopedics, and
surgical departments at six different hospitals ranging in size from 101 to 520
beds. Although we are unwilling to make any firm conclusions based on null findings, the similarity of patient perceptions across these locations is intriguing. We
would not suggest that environmental professionals take this similarity as support
for applying a standard design template to all inpatient units: Each setting needs to
be programmed individually to determine its individual needs. However, the general categories presented here might serve as a framework to structure the search
for more detailed information. For example, it might be a given that patients
appreciate comfortable furnishings, but decisions about appropriate materials,
quantity, type, and style of furnishings are likely to vary from setting to setting.
Spending time as a hospital patient can be a highly meaningful event punctuated by strong emotions and sometimes intense boredom. Clinical quality, often
measured by such factors as infection rates and medical outcomes, has long been
a concern among health care providers. More recently, service quality, measured
by obtaining feedback from patients, has joined clinical quality as a goal in the
care of patients. We have provided further support that satisfaction with the hospital environment is an important part of service quality. The physical environment is not backdrop for the delivery of health care-it is an integral part of the
hospital experience.
References
Altman, I. (1975). The environment and social behavior: Privucy, personal
space, territoriality, crowding. Monterey, CA: BrooksICole.
A PLACE TO HEAL
1297
Baird, C. L., & Bell, P. A. (1995). Place attachment, isolation, and the power of a
window in a hospital environment: A case study. Psychological Reports, 76,
847-850.
Baum, A., & Paulus, I? B. (1987). Crowding. In D. Stokols & I. Altman (Eds.),
Handbook of environmental psychology @p. 533-570). New York, N Y John
Wiley & Sons.
Behrman, l? (1997). Art in hospitals: Why is it there and what is it for? The
Lancet, 350, 584-585.
Brown, B., Wright, H., & Brown, C. (1997). A post-occupancy evaluation of
wayfinding in a pediatric hospital: Research findings and implications for
instruction. Journal ofArchitectura1 Planning Research, 14, 35-5 1.
Carpman, R. J., & Grant, M. A. (1993). Design that cares: Planning healthfacilities
for patients and visitors (2nd ed.). Chicago, IL: American Hospital Publishing.
Evans, G. W. (Ed.). (1982). Environmental stress. New York, NY: Cambridge
University Press.
Evans, G. W., & Cohen, S. (1987). Environmental stress. In D. Stokols & I.
Altman (Eds.), Handbook of environmental psychology (pp. 57 1-610). New
York, N Y John Wiley & Sons.
Fottler, M. D., Ford, R. C., Roberts, I?,& Ford, E. W. (2000). Creating a healing
environment: The importance of the service setting in the new consumeroriented healthcare system. Journal of Healthcare Management, 45, 9 1-106.
Friedrich, M. J. (1999). The arts of healing: How the arts can affect the health of
patients. Journal of the American Medical Association, 281, 1779-1781.
Hair, L. I? (1998). Satisfaction by design. Marketing Health Services, 18, 5-8.
Harris, P. B., Brown, B. B., & Werner, C. M. (1996). Privacy regulation and place
attachment: Predicting attachments to a student family housing facility. Journal of Environmental Psychology, 16,287-301.
Harris, I? B., McBride, G., & Curtis, L. (1994). Patient perceptions of quality
(inpatient form): A qualitative analysis of open-ended interviews. Unpublished report, Intermountain Heath Care, Inc., Salt Lake City, UT.
Harris, P. B., McBride, G., & Curtis, L. (1996). Analyses of ZHC Inpatient PPQ
survey results. Unpublished report, Intermountain Heath Care, Inc., Salt Lake
City, UT.
Harris, F? B., Werner, C. M., & Brown, B. B. (1996). Relocation and privacy regulation: A cross-cultural analysis. Journal of Environmental Psychology, 16,
287-30 1.
Horsburgh, R. C., Jr. (1 995). Healing by design: Architecture of hospitals. New
England Journal of Medicine, 333, 735-741.
Horsfield, M. (1998). Biting the dust: Thejoys of housework. New York, NY: St.
Martins Press.
IHC, Inc. (1993). Patient Perceptions of Quality Interview-Inpatient Form.
Unpublished questionnaire, Intermountain Heath Care, Inc., Salt Lake City, UT.
1298 HARRIS ET AL.
Jaco, E. G. (1 979). Ecological aspects of hospital patient care: An experimental
study. In E. G. Jaco (Ed.), Patients, physicians, and illness: A sourcebook in
behavioral science and health (3rd ed.). New York, N Y Free Press.
Kaplan, R., & Kaplan, S. (1989). The experience qf nature: A psychologicalperspective. New York, N Y Cambridge University Press.
Kaplan, S. (1 995). The restorative benefits of nature: Toward an integrative
framework. Journal of Environmental Psychology, 15, 169-182.
Linder-Pelz, S. (1982). Towards a theory of patient satisfaction. Social Science
and Medicine, 16, 577-582.
Morgan, D. G., & Stewart, N. J. (1998). Multiple occupancy versus private rooms
on dementia care units. Environment and Behavior, 30,487-503.
Nightingale, F. ( 1969). Notes on nursing: What it is, and what it is not. New York,
NY: Dover.
Pitt, D. G., & Zube, E. H. (1987). Management of natural environments. In D.
Stokols & I. Altman (Eds.), Handbook of environmental psychology
(pp. 1009- 1042). New York, NY: John Wiley & Sons.
Shumaker, S., & Pequegnat, W. (1989). Hospital design, health providers, and the
delivery of effective health care. In E. Zube & G . Moore (Eds.), Advance5 in
environment, behavior and design (Vol. 2, pp. 161-199). New York, N Y
Plenum.
Shumaker, S. A., & Reizenstein, J. E. (1982). Environmental factors affecting
inpatient stress in acute care hospitals. In G. W. Evans (Ed.), Environmental
stress (pp. 179-223). New York, NY: Cambridge University Press.
Sitzia, J., & Wood, N. (1997). Patient satisfaction: A review of issues and concepts. Social Science and Medicine, 45, 1829- 1843.
Trites, D. K., Galbrith, F. D., Sturdavant, M., & Leckwart, J. E (1970). Influence
of nursing unit design on the activities and subjective feelings of nursing personnel. Environment and Behavior, 2,303-334.
Uchino, B. N., Cacioppo, J. T., & Kiecolt-Glaser, J. K. (1996). The relationship
between social support and physiological processes: A review with emphasis
on underlying mechanisms and implications for health. Psychological Bulletin, 119,488-53 1.
Urlich, R. (198 1). Natural versus urban scenes: Some psychophysiological
effects. Environment and Behavior, 13, 523-556.
Urlich, R. (1984). View from a window may influence recovery from surgery.
Science, 223,420-444.
Verderber, S . (1 986). Dimensions of person-window transactions in the hospital
environment. Environment and Behavior, 18,450-466.
Voelker, R. (1994). New trends aimed at healing by design. Journal of the American Medical Association, 272, 1885-1886.
Ware, J. E., Davies, A. R., & Rubin, H. R. (1987). The suitability ojconsumers’
assessments of physician and hospital performance as indicators of the
A PLACE TO HEAL
1299
quality of care. Washington, DC: Health Program, Office of Technology
Assessment, U.S. Congress.
Ware, J. E., Snyder, M. K., Wright, W. R., & Davies, A. R. (1983). Defining and
measuring patient satisfaction with medical care, Evaluation and Program
Planning, 6, 247-263.
Zimring, C., Carpman, R. J., & Michelson, W. (1987). Design for special populations: Mentally retarded persons, children, hospital visitors, In D. Stokols & I.
Altman (Eds.), Handbook of environmental psychology (pp. 9 19-949). New
York, N Y John Wiley & Sons.