The Economic Case
for
Renewing Ireland’s
Healthcare Infrastructure
Professor Roger S. Ulrich
Dept of Architecture, Texas A & M University
Director Centre for Health Systems & Design
November 2008
2
Introduction
This briefing document has been prepared by Professor Roger Ulrich for the Hospice
Friendly Hospitals (HfH) Programme which is an initiative of the Irish Hospice
Foundation in partnership with the Health Service Executive. The HfH Programme,
which is supported by The Atlantic Philanthropies, The Health Services National
Partnership Forum and the Dormant Accounts Fund, has three key objectives:
 To develop standards for end-of-life care in hospitals
 To develop the capacity of hospitals to introduce and implement these
standards
 To change the culture of hospitals regarding end-of-life issues
The work of the programme is focused around four key themes: Integrated Care;
Communication; Design & Dignity; Patient Autonomy.
In May 2007, shortly after the launch of the HfH Programme, Tribal Consulting was
commissioned to undertake a review of the physical environment of hospitals
participating in the programme. The results of the review provided cause for
concern, most particularly with regard to: the lack of facilities for private
consultations and conversations in situations where confidentiality is paramount;
the extent to which already very limited single-room accommodation is denied to
the dying and their families because of the priority given to infection control and
isolation; the lack of facilities for families; the poor quality of mortuary facilities.
The issues raised in the report have been referred to in the Joint Statement on Endof-Life Care for Older People in Acute and Long-Stay Care Settings in Ireland from
the National Council on Ageing and Older People and the Irish Hospice Foundation
(June 2008). This statement indicated that ‘One of the significant barriers to good
quality end-of-life care is the physical and sensory environment in acute hospitals,
psychiatric hospitals and voluntary hospitals/homes’. It asserted that ‘hard questions
must be asked about how we plan the physical environment in facilities where
significant numbers of people are known to die’ and specifically asked:

Why do some facilities not provide the physical environment needed to allow
their residents to live and to die in dignity, for example with only thin curtains
separating the living from the dying, those eating from those using a
commode?

Why are so many older people allowed to die in busy wards against a
background of noise from other patients, televisions, etc? (Keegan et al.,
1999)

Why are appropriate facilities not provided for the dying and amenities for
those who accompany the dying in their last hours?
The review undertaken by Tribal Consulting for the HfH Programme, and the
associated literature review, was referred to in the Report of the Commission on
Patient Safety and Quality Assurance ‘Building a Culture of Patient Safety’ (July
2008). The Commission indicated that it was ‘..persuaded by such evidence as has
been made available to it and by submissions made on this issue that the
implementation of evidence-based design will result in safer and higher quality care
for patients, with resultant economic benefits for the health system’.
3
Conscious that Ireland has been described as having ‘one of the worst physical
health infrastructures of any country in the developed world’ and that, even in good
economic times, the problem of the physical environment of our hospitals has not
been seen as a priority by either government or opposition parties or indeed by
many health related advocacy groups, the HfH Programme has sought to develop a
positive agenda based on building an awareness of the importance of high quality
healthcare environments and the related clinical, social and economic benefits. The
HfH agenda includes: building the capacity of hospital and network-based work
groups to appreciate and engage with issues relating to the design, layout and
organisation of the physical environment; providing resources to assist hospital
staff engage in practical projects in specific areas as part of the process of
implementing improvements linked to standards development; supporting the
development of exemplar projects so that health care staff and planners can visit
and learn from examples of good practice; promoting a clear focus on design
related issues in the context of all new service plans and policy developments;
proposing a grants scheme to encourage small scale improvements in existing
hospitals. Most importantly the HfH Programme has, with the active involvement of
HSE Estates, health care professionals and hospital user representatives, developed
Design & Dignity Guidelines for Physical Environments of Hospitals Supporting Endof-Life Care (June 2008)
The HfH Programme believes that the unit of accommodation in hospitals should be
a room, rather than a bed, and that sharing a room with others at the end of life
should, in so far as is possible, be a matter of choice for all concerned. Our
concerns are shared, from differing perspectives, by many others. Consequently,
there is now an opportunity to link the agenda of the hospice movement with the
agendas of health care providers, quality and risk managers, infection control
experts, health economists, specific illness organisations, patient advocacy groups,
political parties and the social partners.
This briefing document, prepared by Professor Ulrich, makes the economic case for
renewing Ireland’s healthcare infrastructure and, in doing so, addresses one of the
commonest concerns which has been expressed in the course of discussions to date,
namely, that good healthcare infrastructure is not possible on the grounds of
financial cost.
4
HEALTHCARE OUTCOMES IMPROVED BY EVIDENCE-BASED DESIGN AND
BETTER BUILDINGS
Evidence-based design yields substantial annual savings
How can investment in new healthcare buildings be justified during a time of
economic uncertainty and limited funds? A peer-reviewed business analysis
concluded that building a new 300-bed U.S. hospital with comprehensive evidencebased design upgrades would add 5.3% to the initial construction costs (Berry et al.,
2004). However, conservative estimates of costs savings and gains in revenue
suggested that the one-time additional construction costs would be recaptured in
only one year. Furthermore, the savings stemming from the design improvements
would recur annually over many years of operation of the hospital.
In several countries, a rising tide of litigation and compensation linked to infection
outbreaks, falls, and medical errors has created another compelling fiscal
justification for building safer and better hospitals. A recent analysis suggests that
the economic case for building better hospitals has been further strengthened by
the adoption of pay-for-performance policies in countries such as the U.S. and
Britain (Sadler et al., 2008). If government payers or insurance entities withhold
payment to hospitals when preventable events occur such as falls and certain
infections, the business case for design measures that reduce such events (single
rooms, for example) is powerfully enhanced.
Given this business case, health authorities would be shortsighted and irrational to
forego rebuilding of healthcare infrastructure for fiscal reasons. Rather, authorities
should seize the opportunity to invest in evidence-based design and better buildings
as a means for improving the financial condition of the health system, and most
importantly the health and safety of patients and staff (Ulrich, 2006).
The sections below list several health and safety outcomes, and discuss specific
evidence-based building design measures that can improve each outcome and
thereby generate cost savings.
Reduce hospital-acquired infections
Hospital acquired infections are a major contributor to escalating care costs and one
of the leading causes of death. Aging or obsolete healthcare buildings facilities
hinder the prevention and control of infections. A large amount of scientific research
strongly supports the following design measures for reducing hospital acquired
infection:

Provide single-bed rooms with private toilets to enable separation or isolation
of patients on admission, so that those with unrecognized infections will not be
mixed in with uninfected patients in multibed rooms; to reduce airborne infection
transmission by increasing isolation capacity and facilitating good air quality
through measures such as ventilation, air flow direction and pressure, and
filtration; and to facilitate thorough cleaning after a patient leaves (Ulrich, 2004;
Ulrich and Wilson, 2006; Ulrich et al., 2008).
5

Design and maintain the water system at the proper temperature and
adequate pressure; and stagnation and back flow should be minimized.

To increase handwashing compliance install alcohol-based hand-rub dispensers
at the bedside and locate handwash basins close to staff movement paths in
visually prominent locations near work points (Ulrich and Wilson, 2006; Ulrich et al.,
2008).

Strong evidence indicates that air filtration in combination with single rooms
reduces the incidence of infection and mortality among immunocompromised and
other vulnerable patient groups, thereby lowering care costs.
Reduce falls
Falls are an increasing problem that produce physical injuries, longer stays in
hospitals, and substantially increase care costs. A study of 34,972 patients found
that 7.2 % experienced at least one fall during hospitalization, which increased
their length of stay by an average of 13.1 days (Schwendimann, 2006).

There is considerable evidence that bedrails are ineffective for reducing falls
and often increase the severity of injuries caused by falls from hospital beds.

Design to provide good visual access to patients. Most falls occur when
patients are not observed and/or unassisted. Visual access to patients in multibed
rooms is often blocked by drawn privacy curtains. Research indicates that designing
wards to provide very good visual access from nursing stations and corridors to
patients’ bed and rooms can effectively reduce falls, because nurses can quickly
identify needs of the patients and provide immediate assistance. One study
suggests that design to provide excellent visual access from hallway nurse stations
via windows may reduce falls by 25% (Vassallo et al., 2000).

Design to support family presence. Limited evidence has linked family
presence in patient rooms to fewer falls, because the presence of family appears to
reduce the risk that patients will get out of bed unassisted or unobserved. Providing
single rooms to support family presence, in combination with localized nurse
charting stations with direct visual access to beds (via hallway windows) can cut
falls by two-thirds (Hendrich et al., 2002, 2004) thereby markedly reducing injuries
and costs.
Reduce medical errors
A limited but growing amount of research shows that appropriate environmental
design can play an important role in reducing frequent, harmful, and costly medical
errors.

Increase lighting and reduce distractions. Medication dispensing and other
errors can be reduced significantly by providing relatively high levels of worksurface lighting, and designing work spaces to reduce distractions and interruptions.
6

Shorter distances to medication storage reduce errors.. A risk assessment
of several medication dispensing scenarios concluded that shorter distances from
patient rooms to medication storage reduces the risk that clinicians will bypass
procedures and access medications for multiple patients, thereby reducing errors
such as giving a patient a medication intended for another patient (Institute for
Healthcare Improvement, 2004). By comparison, centralized location of medications
increases nurse walking and can worsen patient safety by increasing medication
dispensing errors.
Provide single-bed rooms to improve several outcomes and lower longterm costs
The evidence-based design intervention that positively affects the largest number of
outcomes in hospitals, including care costs, is the provision of single-bed rooms
(Ulrich, 2006; Ulrich et al., 2008). Because of the many well-documented
advantages of single-bed rooms, the American Institute of Architects 2006
Guidelines for Design and Construction of Health Care Facilities recommends that in
new general hospitals “the number of beds per room shall be one” (American
Institute of Architects and Facilities Guidelines Institute, 2006, p. 40). Also, a
recent evidence-based report issued by the National Association of Children’s
Hospitals and Related Institutions (NACHRI, 2008) recommends that single rooms
should be provided for nearly all patients in pediatric facilities.
It was earlier emphasized that single rooms are important for reducing transmission
of hospital-acquired infection. Also, much research has shown that single-bed
rooms, compared to multibed accommodation, more positively impact other
outcomes as described below.

Single rooms substantially lessen noise, thereby reducing patient stress and
improving sleep (studies reviewed in Ulrich et al., 2008). Sleep deprivation hinders
the healing process and contributes to increased morbidity and costs by impaired
immune function, delirium, disrupted thermoregulation, and ventilatory compromise
(Wallace et al., 1999).

Single rooms reduce harmful and costly patient transfers. Multibed rooms
generate more transfers of patients between rooms because incompatibility among
patients is a frequent problem. Detrimental aspects of patients transports identified
by much research include adverse effects on patient stability and outcomes,
worsened rates of cross-infection, increased medication errors, manual lifting
injuries to staff, demand for staff time, high costs, and increased length of stay
(Ulrich and Zhu, 2007; Ulrich et al., 2008; Hendrich et al., 2004; Institute of
Medicine, 2004). Single rooms, by eliminating transfers related to roommate
incompatibility (such as when one patient becomes infected), improve safety and
several other outcomes and produce substantial cost savings (Berry et al., 2004;
Sadler et al., 2008).

Single rooms are far superior to multibed rooms for enhancing dignity and
privacy. The absence of roommates helps prevent privacy breaches during
discussions between patients and care staff (Ulrich et al., 2008). Patients in single
rooms are more willing to provide personal information to care providers, which
facilitates diagnosis, effective treatment, and improved outcomes (Barlas et al.,
7
2001; Mlinek and Pierce, 1997). Other research has found that nurses perceive
single rooms to be more appropriate than multibed rooms for patient examinations,
collection of medical histories, and protecting patient dignity (Chaudhury et al.,
2006). A high percentage of single rooms prevents the stressful and demeaning
problem of mixed-gender accommodation.

Single rooms are superior for supporting family presence. Compared with
multibed rooms, single rooms are more likely to provide space and furniture to
accommodate visiting relatives (Chaudhury et al., 2006) and to permit flexible
visiting hours. Single rooms also greatly increase privacy for patient-family
communication and social support. Nursing staff who have experience with both
single and multibed rooms judge singles to be better for accommodating family
(Chaudhury et al., 2006).

Single rooms enhance communication between clinical staff and patients.
Patients in single rooms report consistently higher satisfaction with communication
from physicians and nurses compared with patients in multibed rooms cared for by
the same staff (Press Ganey, 2003). Kaldenburg (1999) found that clinicians in
multibed rooms are reluctant to discuss patient issues or give information when
they are within earshot of a roommate, out of respect for patient privacy.

Single rooms increase patient satisfaction. A vast amount of sound data
provides unequivocal evidence that patients in single-bed rooms in American
hospitals, compared to patients with one or more roommates, are consistently and
substantially more satisfied with the overall quality of their care (e.g., Press Ganey,
2003). A study sponsored by NHS Estates at a large English hospital (Lawson and
Phiri, 2003) found that 93% of patients who had experience with both single and
multibed rooms preferred having a single room.

Single rooms compared to multibed rooms increase flexibility in managing
bed availability (Lawson and Phiri, 2003), and promote better patient flow and
efficiency per bed (Hendrich et al., 2004).
Reduce pain
Pain is a pervasive, serious, and costly problem that can be reduced by designing
healthcare buildings to provide:
 Exposure to daylight. Rigorous research suggests that patients experience less
pain and take significantly fewer costly analgesic medications, when the building
orientation and patient room design provide exceptional exposure to daylight. A
study by Walch et al. (2005) suggests that designing hospitals to increase daylight
exposure can reduce pain medication costs by 20% for patients undergoing surgery,
compared to the costs for comparable patients assigned to shaded rooms.
 Views of nature. Exposing patients to views of nature can produce substantial and
clinically important alleviation of pain (Malenbaum, Keefe, Williams, Ulrich, &
Somers, 2008). Design that provides patients with window views of nature, access
to gardens, and exposure to nature art and pictures, can alleviate pain and
emotional duress, and reduce care costs.
8
Alleviate depression and shorten stays by designing for daylight exposure

Higher room daylight exposure shortens stays of depressed patients. A
large body of rigorous evidence indicates that exposure to light -- daylight or bright,
full-spectrum artificial light -- is effective in reducing depression and improving
mood, even for persons hospitalized with severe depression (Golden et al., 2005).
Medical studies have reported that hospitalized patients with depression can have
more favorable recovery outcomes, including shorter and less costly stays, if they
are assigned to sunnier rooms rather than rooms that receive less daylight or are
always in shade. A study found that patients hospitalized for depression stayed an
average of 3.7 days less if they were assigned east-facing rooms exposed to
morning light, compared to patients in west-facing rooms with less sunlight
(Benedetti et al., 2001). Beauchemin and Hays (1996) found that adult patients
hospitalized for severe depression in a Canadian facility had shorter stays by an
average of 2.6 days if they were assigned to sunny rooms rather than rooms that
were always in shade.

Higher room daylight may shorten stays of female MI patients. Depression
is a serious problem not only for mental health patients, but also for several other
categories of patients, such as those with cardiovascular disease and cancer. An
investigation of myocardial infarction patients in an intensive care unit in a
Canadian hospital suggested that female patients had shorter stays (1.1 days
shorter) if their rooms were sited to provide higher versus lower daylight exposure
(Beauchemin and Hays, 1998). In the same study, mortality in both sexes was
lower in sunnier rooms than in north-facing rooms.
Reduce noise to improve several outcomes and lower care costs

Sound-absorbing ceilings reduce incidence of rehospitalization of cardiac
patients. Along with other proven acoustic performance enhancements (providing
single rooms and reducing noise sources) installation of high performance soundabsorbing ceiling tiles contributes to reduced noise and improved outcomes.
Published research suggests that the installation of high performance soundabsorbing ceiling tiles alone can produce substantial savings in caring for cardiac
patients by reducing the incidence of rehospitalization of myocardial infarction
patients by approximately 30% to 45% within three months after initial discharge
(Hagerman et al., 2005).

Reduce noise to improve outcomes in neonatal intensive care. Several
studies of infants in neonatal intensive care units (NICUs) have reported that higher
noise levels elevate blood pressure, heart and respiration rates, and decrease
oxygen saturation, thereby increasing need for oxygen support therapy (Slevin,
Farrington, Duffy, Daly, & Murphy, 2000). These negative effects on outcomes
foster longer, more costly hospital stays in newborn intensive care. Along with
eliminating and reducing noise sources such as medical equipment, installation of
high performance sound-absorbing ceiling tiles contributes to reduced noise and
promotes improved outcomes in NICUs (White et al., 2006).
9

Reduce noise to lessen intake of pain medication. There is limited evidence
that sound-absorbing ceilings may also contribute to lower costs by reducing intake
of pain medication by surgery patients.

Sound absorbing ceiling tiles and other noise reduction measures increase
patient satisfaction. When high performance ceiling tiles were installed in a
coronary critical care unit (CCU), noise levels declined and patients reported they
were significantly more satisfied with care quality -- compared to when low
performance ceiling tiles were in place (Hagerman et al., 2005)

Design that reduces noise diminishes staff work stress and perceived
demands. Nursing staff perceive higher sound levels on wards as stressful and
interfering with their work (Bayo et al., 1995; Norbeck, 1985). Topf and Dillon
(1988) reported that noise-induced stress was linked to emotional exhaustion or
burnout among critical care nurses. A rigorous, prospective study by Blomkvist et al.
(2005) in a Swedish hospital demonstrated that installing high performance soundabsorbing ceiling tiles (versus lower performance tiles) substantially reduced
perceived work demands, and lowered work pressure and stress.
Ceiling mounted patient hoists cut costly staff injuries

Several studies have shown that the pervasive and very costly problem of staff
lifting injuries can be substantially reduced by providing ceiling mounted patient
hoists. Research also has found that ceiling lifts, compared to portable hoists, are
more effective in reducing injuries and require less time and space to use (Hignett
and Evans, 2006; Keir and MacDonell, 2003).

Two studies of ceiling lifts installed in single patient rooms have reported that
the initial cost was paid back within 2.5 years or less by savings stemming from
fewer staff manual lifting injuries (Chhokar et al., 2005; Joseph and Fritz, 2006).
Design ward layouts to improve patient safety and outcomes, and reduce
costly attrition of nurses
Ward floor layouts in older hospitals generally provide long corridors organized
around a central nursing station, where medication and charts are located, and
central locations for supplies and medications. Considerable research has shown
that nurses therefore spend much of their time (more than 40% in older UK NHS
hospitals) walking up and down halls engaged in wasteful activity such as fetching
supplies, thereby increasing fatigue and stress, eroding job satisfaction, and sharply
cutting the time available for observing patients and delivering direct care
(Hendrich, 2003; Institute of Medicine, 2004; Ulrich, 2006). Studies in the U.S. and
Britain indicate that hospitals with obsolete floor layouts severely hamper nurse
work efficiency, and limit staff to providing only about 16-24 minutes of care time
per patient during an eight-hour work shift.

Wards designed according to modern evidence-based principles greatly
increase nurse time for observation and care of patients. Evidence-based ward floor
layouts provide single-bed rooms and decentralized nurse charting stations with
viewing windows to improve safety, outcomes, and reduce costs by fostering direct
10
observation of vulnerable patients. Research suggests that closer location of
supplies to patient rooms also is important because centralized supply location can
double staff walking and seriously reduce patient care time (Hendrich, 2003;
Institute of Medicine, 2004). Such properly designed wards substantially reduce
staff walking and fetching time, increase time for observation and care of patients,
and heighten nurse work satisfaction (Institute of Medicine, 2004; Hendrich et al.,
2004; Ulrich, 2006).

Importantly, there is good evidence that well-designed wards with single
rooms and decentralized nurse charting and observation do not require higher
nurse staffing levels than traditional multi-bed units, and can reduce costly nurse
attrition by up to 50% (Hendrich et al., 2004; Institute of Medicine, 2004).
Research References
American Institute of Architects and Facilities Guidelines Institute (2006).
Guidelines for Design and Construction of Health Care Facilities. Washington, DC:
American Institute of Architects.
Barlas, D., Sama, A. E., Ward, M. F., & Lesser, M. L. (2001). Comparison of the
auditory and visual privacy of emergency department treatment areas with curtains
versus those with solid walls. Annals of Emergency Medicine, 38(2), 135-139.
Bayo, M. V., Garcia, A. M., and Garcia, A. 1995. Noise levels in an urban hospital
and workers' subjective responses. Archives of Environmental Health 50(3):247251.
Beauchemin, K. M., and Hays, P. (1996). Sunny hospital rooms expedite recovery
from severe and refractory depressions. Journal of Affective Disorders, 40(1–2),
49–51.
Beauchemin, K. M., and Hays, P. (1998). Dying in the dark: Sunshine, gender and
outcomes in myocardial infarction. Journal of the Royal Society of Medicine, 91,
352–354.
Benedetti, F., Colombo, C., Barbini, B., Campori, E., and Smeraldi, E. (2001).
Morning sunlight reduces length of hospitalization in bipolar depression. Journal of
Affective Disorders, 62(3), 221-223.
Berry, L. L., Parker, D., Coile, R. C., Hamilton, D. K., O’Neill, D. D., and Sadler, B. L.
(2004). The business case for better buildings. Frontiers of Health Services
Management, 21, 3-24.
Blomkvist, V., Eriksen, C. A., Theorell, T. Ulrich, R. S. and Rasmanis, G. (2005).
Acoustics and psychosocial environment in intensive coronary care. Occupational
and Environmental Medicine, 62, 132-139.
Buchanan, T. L., Barker, K. N., Gibson, J. T., Jiang, B. C., and Pearson, R. E. (1991).
Illumination and errors in dispensing. American Journal of Hospital Pharmacy,
48(10), 2137–2145.
Chaudhury, H., Mahmood, A. and Valente, M. (2006). Advantages and
disadvantages of single versus multiple-occupancy rooms in acute care
environments. Environment and Behavior, 37(6), 995-999.
Chhokar, R., Engst, C., Miller, A., Robinson, D., Tate, R. S., and Yassi, A. (2005).
The three-year economic benefits of a ceiling lift intervention aimed to reduce
healthcare worker injuries. Applied Ergonomics, 36(2), 223-229.
Diette, G. B., Lechtzin, N., Haponik, E., Devrotes, A. and Rubin, H.R. (2003).
Distraction therapy with nature sights and sounds reduces pain during flexible
11
bronchoscopy: A complementary approach to routine analgesia. Chest 123(3), 941948.
Golden, R. N., Gaynes, B. N., Ekstrom, R. D., Hamer, R. M., Jacobsen, F. M.,
Suppes, et al. (2005). The efficacy of light therapy in the treatment of mood
disorders: A review and meta-analysis of the evidence. American Journal of
Psychiatry, 162(4), 656–662.
Hagerman, I., Rasmanis, G., Blomkvist, V., Ulrich, R., Eriksen, C. A., and Theorell,
T. (2005). Influence of intensive coronary care acoustics on the quality of care and
physiological state of patients. International Journal of Cardiology, 98(2), 267-270.
Hendrich, A., Fay, J., and Sorrells, A. (2002). Courage to heal: Comprehensive
cardiac critical care. Healthcare Design, 11–13.
Hendrich. A. (2003). Optimizing physical space for improved outcomes: Satisfaction
and the bottom line. Paper presented at the Impact Conference, Institute for
Healthcare Improvement and The Center for Health Design, Atlanta, GA.
Hendrich, A. L., Fay, J., and Sorrells, A. K. (2004). Effects of acuity-adaptable
rooms on flow of patients and delivery of care. American J. of Critical Care, 13(1),
35–45.
Hignett, S., and Evans, D. (2006). Spatial requirements in hospital shower and
toilet rooms. Nursing Standard (Royal College of Nursing, Great Britain), 21(3), 43–
48.
Institute for Health Improvement (2004). FMEA: Comparison of Five Medication
Dispensing
Scenarios.
Boston,
Massachusetts:
Institute
for
Healthcare
Improvement.
Institute of Medicine (2004). Keeping patients safe: Transforming the work
environment of nurses. Washington, DC: National Academies Press.
Joseph, A. and Fritz, L. (2006). Ceiling lifts reduce patient-handling injuries.
Healthcare Design, 6(1), 10-13.
Kaldenburg, D. O. (1999). The influence of having a roommate on patient
satisfaction.
Press
Ganey
Satisfaction
Monitor,
January/February
(www.pressganey.org).
Keir, P., and MacDonell, C. (2003). Muscle activity during patient transfers: A study
on the influence of lift assists and experience. Ergonomics, 47(3), 296–306.
Kozarek, R. A., Raltz, S. L., Neal, L., Wilber, P., Stewart, S., and Ragsdale, J.
(1997). Prospective trial using Virtual Vision® as distraction technique in patients
undergoing gastric laboratory procedures. Gastroenterology Nursing, 20 (1), 12-18.
Lawson, B. and Phiri, M. (with J. Wells-Thorpe) (2003). The Architectural Healthcare
Environment and its Effects on Patient Health Outcomes. Report sponsored by NHS
Estates. London: TSO.
Lewy, A. J., Bauer, V. K., Cutler, N. L., Sack, R. L., Ahmed, S., Thomas, K. H., et al.
(1998). Morning vs evening light treatment of patients with winter depression.
Archives of General Psychiatry, 55(10), 890–896.
Malenbaum, S., Keefe, F. J., Williams, A. C., Ulrich, R. S., and Somers, T. J. (2008).
Pain in its environmental context: Implications for designing environments to
enhance pain control. Pain, 134, 241-244.
Miller, A. C., Hickman, L. C., and Lemasters, G. K. (1992). A distraction technique
for control of burn pain. Journal of Burn Care and Rehabilitation, 13(5), 576-580.
Minckley, B. (1968). A study of noise and its relationship to patient discomfort in
the recovery room. Nursing Research, 17, 247-250.
Mlinek, E. J., & Pierce, J. (1997). Confidentiality and privacy breaches in a
university hospital emergency department. Academy of Emergency Medicine, 4(12),
1142-1146.
12
NACHRI (National Association of Children’s Hospitals and Related Institutions)
(2008). Evidence through innovation: Transforming children’s health through the
physical environment. Alexandria, VA: NACHRI.
Norbeck, J. S. (1985). Perceived job stress, job satisfaction, and psychological
symptoms in critical care nursing. Research in Nursing & Health, 8 (3), 253-259.
Press Ganey, Inc. (2003). U.S. national satisfaction data for 2003 comparing
patients with versus without a roommate. Press Ganey, Inc., South Bend, Indiana.
Sadler, B. L., DuBose, J., and Zimring, C. (2008). The business case for building
better hospitals through evidence-based design. Health Environments Research &
Design, 1(3), 22-39.
Schwendimann, R. (2006). Patient falls: a key issue in patient safety in hospitals.
Unpublished Doctoral Dissertation, University of Basel, Zurich, Switzerland.
Slevin, M., Farrington, N., Duffy, G., Daly, L., and Murphy, J. F. (2000). Altering the
NICU and measuring infants' responses. Acta Paediatrica, 89(5), 577-581.
Topf, M., and Dillon, E. (1988). Noise-induced stress as a predictor of burnout in
critical care nurses. Heart Lung 17(5):567-574.
Tse, M. M. Y., Ng, J. K. F., Chung, J. W. Y., and Wong, T. K. S. (2002). The effect of
visual stimuli on pain threshold and tolerance. Journal of Clinical Nursing 11(4),
462-469.
Ulrich, R. S. (2004). Evidenced-based design for patient safety. In: The
Environment for Care – Delivering the Best Environment for Care. NHS Estates
Report. London: TSO, pp. 14-18, 35-36.
Ulrich, R. S. (2006). Evidence-based healthcare architecture. Lancet, 368: S38-S39.
Ulrich, R. S. and Wilson, P. (2006). Evidence-based design for reducing infection.
Public Service Review: Health (UK), 8: 24-25.
Ulrich, R. S. and Gilpin, L. (2003). Healing arts. In S. B. Frampton, L. Gilpin and P.
Charmel (Eds.), Putting Patients First: Designing and Practicing Patient-Centered
Care. San Francisco: Jossey-Bass, 117-146.
Ulrich, R. S., Lundén, O. and Eltinge. J. L. (1993). Effects of exposure to nature and
abstract pictures on patients recovering from heart surgery. Psychophysiology, 30
(Supplement 1), 7.
Ulrich, R. S. and Zhu, X. (2007). Intra-hospital transport of patients and medical
complications: Implications for architectural design and research. Health
Environments Research & Design, 1(1), 31-43.
Ulrich, R. S., Zimring, C., Quan, X. and Joseph, A. (2006). The environment’s
impact on stress. In S. Marberry (Ed.), Improving Healthcare with Better Building
Design. Chicago: Health Administration Press, 37-61.
Ulrich, R. S., Zimring, C., Zhu, X., DuBose, J., Seo, H-B., Choi, Y-S., Quan, X., and
Joseph, A. (2008,). A review of the research literature on evidence-based
healthcare design. Heath Environments Research and Design, 1(3), 101-165.
Vassallo, M., Amersey, R. A., Sharma, J. C., and Allen, S. C. (2000). Falls on
integrated medical wards. Gerontology, 46(3), 158-162.
Walch, J. M., Rabin, B. S., Day, R., Williams, J. N., Choi, K., and Kang, J. D. (2005).
The effect of sunlight on post-operative analgesic medication usage: A prospective
study of patients undergoing spinal surgery. Psychosomatic Medicine, 67, 156–163.
Wallace, C. J., Robins, J., Alvord, L. S., and Walker, J. M. (1999). The effects of
earplugs on sleep during exposure to simulated intensive care unit noise. American
Journal of Critical Care, 8(4), 210-219.
White, R. D. (2006). Recommended standards for newborn intensive care unit
(NICU) design. Journal of Perinatology, 26, (3), S2-S18.