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The aesthetic dimension in hospitals—An investigation into strategic plans
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International Journal of Nursing Studies 43 (2006) 851–859 www.elsevier.com/locate/ijnurstu
The aesthetic dimension in hospitals—An investigation into strategic plans Synnøve Casparia,, Katie Erikssonb, Dagfinn Na˚dena b
a Oslo University College, Faculty of Nursing, Oslo, Norway A˚bo Akademi University, Department of Caring Science, Wasa, Finland
Received 29 March 2006; accepted 8 April 2006
Abstract Background and rationale: The underlying assumption was that the aesthetics of the hospital surroundings are often neglected. Aims: This article is the first part of a larger study into the aesthetics of general hospitals. The aim of the study is to throw light on the influence of aesthetics on the health and well-being of patients and the professional personnel, and to examine how aesthetic considerations are dealt with. We present a survey of how the aesthetic dimension is planned and it is considered important in the strategic plans of Norwegian general hospitals. Methods: Data were sampled by analyzing the strategic plans of somatic hospitals. Sixty-four of 86 hospitals responded (74%). Concepts were categorized in a matrix of 11 main categories, each with subcategories. The method was quantitative, in that the analyzed material was amenable to counting. Results: Very few concrete guidelines or directions for the aesthetic dimension have been included in written documents. This indicates that the aesthetic area is a neglected field in the directions for the daily management of hospitals. Conclusions: The research available today on the contribution of environmental aesthetics to health, rehabilitation, and well-being suggests that it is important to have concrete guidelines recorded in strategic plans. This field concerns the maintenance of high quality in the caring professions. r 2006 Elsevier Ltd. All rights reserved. Keywords: Aesthetic environment; Aesthetic research; Hospital aesthetics; Patient environment; Survey
What is already known about the topic?
Aesthetics contributes to health and wellness. The aesthetic dimension is a need for the human being.
What this paper adds
There
are few concrete guidelines concerning aesthetics in somatic hospital strategy plans. High quality in nursing care includes the aesthetic dimension.
1. Introduction Corresponding author. Tel.: +47 22453844;
fax: +47 22453799. E-mail address: [email protected] (S. Caspari).
Our investigation started with an examination of the strategic plans of Norwegian general hospitals, to find
0020-7489/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2006.04.011
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whether and how aesthetics are considered important, and how the instructions that address aesthetic issues are formulated. Research has shown that aesthetically pleasing surroundings can have an important effect on patient health and well-being. This has been demonstrated by the reduced use of medications, fewer infections, better sleep, improved blood pressure, and shorter admissions (Ulrich, 2001). Aesthetic surroundings can also be stimulating for nurses and other healthcare professionals, resulting in a higher working capacity, greater job satisfaction, and fewer sick leaves (Fjeld, 1998b). 1.1. Literature review Aesthetics is, among other things, a philosophical discipline that concerns the fine arts and problems connected with artistic understanding in general, that is art philosophy. The term ‘‘aesthetic’’ is a Germanic form of the Greek term ‘‘aisthesis’’. The Latin term ‘‘aesthetica’’ can be translated as perception, sense, feeling, awareness, knowledge of the fine arts, and the standards used to understand them. In this study, the idea is used to describe the qualities of the surroundings that might influence the health and wellness of patients and of the professional health-care personnel. Analysis of the workplace and the work environment is often dominated by traditional scientific evaluations, logical rational analyses that ignore the aesthetic dimension (Strati, 1998). Aesthetics influence a person’s feelings, both physical and psychological. Both aesthetic and nonaesthetic surroundings create an impression and affect a person consciously or unconsciously (Ulrich, 1991; Beil-Hildebrand, 1992; Ku¨ller and Lindsten, 1992). Aesthetically pleasing surroundings will improve a person’s affective condition and contribute to a feeling of well-being (Ulrich, 2001; Fjeld, 1998a; Ulrich, 1991; Ku¨ller and Mikellides, 1993). Therefore, aesthetics has great importance, perhaps more than we imagine. There must be a congruence between the person and nature, between the person and his or her surroundings. Research has shown how important feelings are for an individual’s physical and mental health. A person’s feelings of well-being and happiness, of harmony and balance, directly influence his or her health and counteract destructive stress factors, among other things. Stress factors in the environment can have a negative effect on the immune system (Fjeld, 1998a; Dilani and Malkin, 1998; Watson, 1988). The aesthetic dimension covers a large range of concepts. It might include colors, art, insufficient daylight, blinding light, outlook to dull surroundings, limited choices, and restricted personal space, which can all create additional stress and increase the risk of illness. Research in psychology, the health-care sciences,
and medicine has provided insight into how a healing environment can be created and how it affects the body and soul (Dilani and Malkin, 1998). Therefore, aesthetics are an important factor in life, whether one is sick or healthy, old or young. A person continually senses and experiences the environment consciously, as aesthetic, unaesthetic, or insignificant. Its beauty, harmony, and balance, or the lack of these qualities is cognitively assimilated. However, this cognitive awareness is not necessary for aesthetics or their lack to influence health. The aesthetic sense need not convert these impulses into words; it has its own ‘language’ and communicates continually through all the senses, to every cell of the body and to the mind, to influence the individual positively or negatively. ‘‘Dr. Deepak Chopra asserts that every cell in our immune system continually listens in on our silent internal conversation and that one can imagine the cells of the immune system as intelligent small entities similar to brain cells y’’ (Watson, 1988). High-quality holistic health care should have as its goal the maintenance of all areas that influence health. ‘High-quality’ implies that the aesthetic aspect should also be taken into consideration. The abstract, theoretical, and ideal are as important as the concrete, measurable, and observable in holistic health care. ‘‘Art captures expresses and recreates humanity and life, in all its diverse forms. Art is the life’s spirit y the soul seeks beauty!’’ (Ulrich, 1984). Some hospitals are attentive to the aesthetic aspects of the environment and have a concrete plan to address them. Others seem to have no understanding of its importance. The decisive factor is not necessarily economic. The prevailing philosophy and ideology of the hospital administration and its employees can be equally important. There is a great deal of knowledge of and research undertaken today regarding different areas of aesthetics. The significance of colors and their influence on an individual exemplifies an area in which it is important that the decisions made are not arbitrary, but are based on existing research and knowledge. In San Francisco in 1978, Angelica Thieriot established an organization, an expert group consisting of architects, doctors, nurses, and people interested in art, among others, who developed and laid the foundation for the ‘Planetree model’. The theoretical basis of the model was developed through the cooperation of the group and was the result of their reactions to the health service they had experienced at the hospitals where they had been patients. They viewed the health service as cold and inhuman, and as not giving first priority to the patient and his family. The Planetree philosophy is built around the idea that health services and hospitals and the services they provide are for the patient. In other words, the patient is their principal concern. The patients and their families must, as far as possible, feel
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secure and at ease. Openness and freedom, autonomy and the right to be consulted are of prime importance. An aesthetic environment and a comfortable milieu are sought, so that an atmosphere conducive to well-being is created. Hospitals that are designed and run in accordance with the Planetree philosophy have had many positive responses in many countries. Late twentieth-century neuropsychological theory suggests that the human forebrain can best be considered as a limbic system and a frontal neocortex. The limbic system is the seat of the emotions; it deals with the nonrational. In contrast the neocortex is the thinking brain, but is itself divided into lateral hemispheres with rather different functions. In short, the left hemisphere is Apollonian: verbal, mathematical, logical, deductive and orientated towards the external environment, whereas the right hemisphere is Dionysian: holistic, intuitive, spatial, patternrecognizing, and concerned with inner spaces y We have a psychological need to satisfy all three systems’ demands for input, and individual wellness depends on the balance of input to all three areas (Ulrich, 1985) The literature leads us to conclude that the aesthetic dimension has great importance for human health, in recovery and well-being when sick, and is a positive factor in the care of terminally ill patients. 1.2. Purpose and research question The purpose of this article is to report the results of a study into whether and how aesthetics are prioritized in the strategic plans of Norwegian general hospitals. The research question is: To what degree are the aesthetics of hospital surroundings addressed in the strategic plans of general hospitals in Norway?
2. Methods 2.1. Data sampling Hospitals were requested to supply their strategic plans concerning the aesthetic domain for the past 2 years. A second request was sent to those who did not respond. In the request letter, the project was described and a short summary of the investigation was given. Sixty-four of 86 hospitals (74%) answered, providing information and copies of their strategic plans. Two hospitals submitted information by telephone and another two hospitals supplied information by letter, with no strategic plan enclosed. Our intention was to survey the plans for establishing the aesthetics of
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hospital surroundings in general. The received material was considered representative. 2.2. Method of analysis Before the work with the material could start a formulary, a matrix was constructed that was suitable for the numeric recording of all occurrences of the word ‘aesthetic’ and similar words that are related to the aesthetic domain. After reading and analyzing other studies by Beil-Hildebrand (1992), Ulrich (1984, 1991, 2001), and Wikstro¨m (1997), it was decided to focus on 11 main categories, with subcategories. Although this study deals with aesthetic categories, ‘aesthetic’ and ‘quality’ themselves are included as categories because we were interested to know if these words were mentioned, and the contexts in which they were included in the strategic plans. Some of the tactics used by Miles and Hubermans (1984) to generate meaning were used to draw conclusions from the material: counting, noting patterns, clustering, etc. Principally, we undertook to find words that showed how aesthetics were addressed in the strategic plans and how each hospital followed these directions. In this way, it was possible to determine the intentions behind these strategies and to quantify the aesthetics-related words in the strategic plans for further statistical analysis. All documents and hospitals were registered numerically, and all documents were analyzed for words from the main categories or subcategories. The frequencies of occurrence were noted, but in this context, were recorded only once for each hospital. Table 1 illustrates the categories and subcategories that were considered in analyzing the strategic plans. The main categories are shown in the upper line (Z), and the subcategories in lines A–I.
3. Results The strategic plans were analyzed to determine whether and in what way aesthetics were addressed. This graphic Fig. 1 illustrates the results of the analysis. Each column represents the total findings for the main categories (including subcategories) in the documents, according to their occurrences in the strategic plans. In presenting the results, important factors will be indicated in relation to each category. Category 1: Harmony. Subcategories are properness considered as tidiness, balance, harmony, hygiene, laughter, humor, play, and entertainment. These words/ideas were recorded in the documents from 12 hospitals in different contexts. Category 2: Food. Subcategories are appearance, color, and service. Food was mentioned in only one
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Competance desciding Panel Quality Specialists Commite` Holism Beautiful Lovely Nice Tasteful Sense Perception Sensibility Sense perception Plants Flowers Trees View Air Ventilation Noise Song Music Nature sounds Unpleasant sounds Furniture Curtains Walls Ceiling Floor Textiles Curtains Furniture Sun Electric Lamps Armatur Patient room Livingroom Ekstern rooms Corridor Staff room Bathroom Shower W.C. Colour Appearance Service Properly Tidiness .Balance Entertainment Hygiene Laughter Humor Play Smile
Painting Sculpture Pictures Tapestries Decor Mosaics Water
Z Quality: registered as z Aesthetics Nature Sound Design Colors Light Room Art Food Harmony
Table 1 Categories and subcategories of the terms analyzed for their occurrence in strategic plans
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document, in a supporting letter that stated: ‘‘The kitchen is renowned for serving delicious and nutritious food’’. There were no further specifications. Category 3: Art. Subcategories are painting, sculpture, pictures, tapestries, decor, mosaics, and water decor. Art is mentioned in four documents, paintings in three, sculpture in three, pictures in three, tapestries in none, decor in seven, mosaics in two, and water decor in two. Among the documents received, in which references to these subcategories were quite spare, one hospital reported that it had engaged a color designer, a qualified interior decorator, who planned the use of color and the aesthetics of the hospital surroundings. She had been engaged together with the architects, right from the start, and the results were very satisfying for both the patients and the professional staff. Otherwise, very few references were found in the documents. Letters attached to the received documents stated: ‘‘It is a pity, but we have written very little about how we want to address aesthetics.’’; another stated: ‘‘Unfortunately, we have very little in print about this aspect of the hospital environment. Aesthetics is very important in hospital surroundings. In earlier times, the aesthetics were a natural part of daily tasks and duties. Today, this function receives less attention and it has become more the exception than the rule to attend to the aesthetics of the surroundings.’’ Category 4: Rooms. Subcategories are patient rooms, living rooms, external rooms (medical rooms, group rooms, cleaning rooms, and linen rooms), corridors, staff rooms, and bathrooms (W.C. and shower). There was nothing in the documents concerning the aesthetics of these rooms; nothing concerning the guidelines for choosing colors, textiles, designs, etc.; and nothing on the existing criteria for decision making or the expected influence on patients and staff. When these areas are mentioned, it is in reference to technical or maintenance procedures. Category 5: Light. Subcategories are sun, daylight, electrical or artificial light,fittings and lamps. Only two hospital documents contained any reference to these areas. One hospital mentioned bad ventilation, lack of daylight in working rooms, narrow and small rooms for working routines, etc. in the context of health, milieu and security (HMS). Offices were cited as having very little access to daylight and insufficient ventilation. Category 6: Colors. Subcategories are walls, ceilings, floors, textiles, curtains, and furniture. Very few references were found to these areas and no concrete philosophy has been given as guidelines. Colors are mentioned in documents from seven hospitals. Category 7: Design. Subcategories are furniture and curtains. Design is mentioned in three of the strategic plans. ‘Design’ refers to and concerns everything in the room: all forms, patterns, sizes and dimensions, etc. It might also include the design of materials, or of furniture and utensils.
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70 Serie1 60
Hospials
50 40 30 20 10
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Categories Fig. 1. Occurrence in documents of words from each category.
Category 8: Sounds. Subcategories are noise, song, music, nature sounds, and irritating or unpleasant sounds. This category appears in five documents. Category 9: Nature. Subcategories are plants, flowers, trees, view, air, and ventilation. These categories were found in 10 documents. Category 10: Aesthetics. Subcategories are beautiful, lovely, nice, tasteful, sense, perception, and sensibility. These words were found in nine documents or strategic plans. A few comments from the letters attached are included: ‘‘When analyzing our strategic plans, we found that very little has been written concerning our thoughts and priorities in aesthetic areas in the hospital. To do better in this field, we hope to obtain a copy of your investigation, when finished’’; another letter stated: ‘‘You are investigating a neglected area. In our hospital, we have no philosophy concerning the importance of aesthetics in hospitals, but as we are now building a new hospital, I will, as a leading director, personally see that this theme is included in the project’’. Category 11: Quality. Subcategories are competence, committee, panel, specialists/professionals, and holism. Words from this category was found in documents from 36 hospitals. This might be due to the Hospital Law of 1994 (Helsedirektoratet), which requires that all hospitals establish a quality control group. The law does not include specific details on the group’s responsibilities, nor any definition of the word ‘quality’ in the context of hospitals or patients. ‘Quality’ is defined as a degree of excellence, relative nature, general excellence, attribute, trait, faculty, social standing. 4. Discussion By analyzing the received material, we have drawn the conclusion that very few guidelines concerning the
aesthetics of hospital surroundings are finding their way into today’s strategic plans. Even though aesthetics are considered important, there are very few directions given. To ensure that this area receives attention, it is necessary to have clear and concise guidelines in strategic plans, on what to do and how to do it. To illustrate how the ideas were used in the documents, a few examples from the strategic plans are given, to show their relevance or otherwise to aesthetics. One document stated: ‘‘Surroundings shall be designed so that the patient is comfortable, feels safe, is rested and attains well-being’’. However, no specifications on how these feelings could be achieved and no further instructions are given. Another document states: ‘‘The prosperity, well-being and competence of the professionals are the most important contributions to meeting the patient’s needs’’. One letter refers to a positive experience in a psychiatric ward: ‘‘y we are happy that you are working on a project concerning aesthetics in the general hospitals of Norway. Firstly, I wish to point out that aesthetics is more an attitude that depends on the individual than one that is found in the guidelines of strategic plans. In our experience, when aesthetic standards are improved, patients cause less damages to furniture, bric-a-brac etc. y’’. Another letter states: ‘‘Your letter has prompted us to include, as soon as possible, concrete guidelines concerning the aesthetics at our hospital. Your investigation has already caused the inclusion of guidelines concerning aesthetics in the hospital strategic plan y’’. These two examples underline the need for aesthetics and the importance of producing guidelines for the best way to address these issues.
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4.1. Harmony
4.5. Light
Harmony and its subcategories are all important in the context of the patient’s recovery and well-being. Harmony relates to the wellness of the soul and has psychosomatic effects. The antiseptic effects of hygiene are most evident. However, hygiene also influences the patient’s sense of comfort and well-being.
One letter that accompanied the documents stated that our request had been presented to the technical leader and to the domestic economy coordinator at their hospital. They regretted to say that there was very little found in their documents specifically concerning aesthetics. However, thanks to conscientious colleagues, a pleasant milieu had been achieved for patients, staff, and relatives. There was no mention of the design of light sources, but it appears that an electrician was consulted for this purpose. Research clearly indicates that light is of great importance to both the recovery and rehabilitation of patients, and also affects the health and wellbeing of staff. This area is a field with potential for improvement (Ulrich, 2001; Ku¨ller, 1987, 1981).
4.2. Food The serving of the food is important to tempt the patient’s appetite. The portion itself must be adjusted for the individual patient. The way the food is cut, arranged on the dish so that the colors are in harmony, and of course the freshness of the food and how well it is prepared are all important if a patient has little or no appetite. The food must be aesthetic and tempting, served and presented in a stimulating way. None of these issues is mentioned in any of the strategic plans. In a well-composed meal, colors will be used intentionally. Colors signal the nutritional value of the product, and can in themselves influence the appetite. For instance, yellow/orange can be stimulating and green products can give renewed strength.
4.3. Art Different artistic experiences can stimulate the patient; they can also be distracting, entertaining, and restful. The outside world can be brought into the hospital. Art can also be provocative and challenging. In perceiving art, the viewer is also a cocreator in that he interprets and shapes the art according to his own experience. Art reveals another reality. It might be a manifestation of the human longing for something ‘higher’, because art can confer a feeling of being part of a higher reality.
4.4. Room The proportions and lines, the architecture and the colors of rooms must be harmonious. For instance, a very high ceiling in a small room can give a feeling of being in a shaft, or if too low, might be perceived as ‘getting a ceiling in the head’. It is also important that colors are used in accordance with the results of research and scientific knowledge to influence human needs and reactions. Rooms should be at a comfortable temperature, with sufficient ventilation to avoid unpleasant smells and odors, which may derive from other patients in the room.
4.6. Colors Colors are an important part of our daily existence, and of our surroundings. Colors imprint the aesthetic environment and scientific research shows that colors have a great effect on individuals. The patient’s room should be comfortable and pleasant to stay in, and colors are important in that context. The same is true for other rooms. Dark and gloomy colors can lead to an analogous state of mind, whereas gaudy colors can lead to irritability, aggressiveness, increases in blood pressure, and general feelings of unpleasantness. A patient who must remain on his back, day after day, will not be positively affected by a view of a grayish ceiling with glaring neon lighting from metal boxes. Colors send energy impulses to the body that influence it in a positive or negative way. Research has shown that the chromatic strength of the color and its nuance are more effective than the color itself (Ku¨ller and Lindsten, 1992; Ku¨ller and Mikellides, 1993; Mikellides, 1988; Cold, 1998). ‘‘Introduction of the Natural Colour System (NCCS) has made it possible to interpret the world of colors, even from a phenomenological perspective’’ (Ku¨ller and Mikellides, 1993, p. 299). Colors can be aesthetically pleasant in themselves and can also be part of an aesthetic wholeness. Only one hospital had a structured plan for the use of colors in patient environments. The apparently opposite words ‘sound’ and ‘silence’ can be united in the essential meaning of ‘to listen’. The body registers and reacts not only to the sounds that are audible to the ear. Sound is made by molecular oscillations that procreate. Animals often have much better hearing than humans. There is great variability in the auditory senses and in the pain thresholds affected by sound. Communication is not sound dependent, even if language is an important part of communication and words are largely transmitted by sounds. The sound or sounds that express words often convey more than the word itself. The sound or tonal value can often say
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something else, even contrary to the etymological meaning of the word. Not everyone is lucky enough to have pleasant speech. It is often said that ‘‘each bird sings with his own beak’’. The same is true of talking. The human voice carries information about age, sex, mood, etc., of the speaker. Most people can learn clear diction, with which words are formulated and spoken clearly, and sound levels can be modulated to suit the situation. A patient might jump in his bed if a shrill voice yells ‘‘good morning’’! Similarly, whispering can be annoying and distracting. A pleasant well-modulated voice can be soothing and calming, and create an atmosphere of security and pleasure. Sounds can be very dominating, especially if a patient is very sensitive and alert to sounds. Irritating noises like scrambling, rustling, slamming doors, and clacking shoes in the corridors at night can be very annoying and disturbing for a patient. Can song and other noises be used as positive modes of treatment in the same way music can? Sounds can be used as a method of communication and positive results have been achieved in the treatment of pain. Different sounds, such as song and music, can add beauty to surroundings, but can also induce anxiety, fear, and agitation (Robertson, 2001; Pope Spies, 1995). 4.7. Design The way furnishings are shaped and molded, the materials used, and so on, all influence the comfort and appeal of interiors. The architecture of the room is also a matter of design, the harmony between the height and breadth of the patient’s room, windows that embrace the outside world, give light and variation. The arrangement of furnishings should be pleasant to look at, to touch, and to handle (Porteous, 1982). Their functionality is also important (Ulrich, 2001; Dilani and Malkin, 1998; Watson, 1988). 4.8. Nature Contact with nature has a positive effect on man and leads to better health and well-being. Nature is in many ways a person’s right or can be seen as an archetypical element. A research report from an X-ray ward evaluated the health and contentment of the staff who undertook their daily work in the ward, where the main occupation was the examination of radiographs. The staff had suffered a bad climate for a long time, and the sick-leave rate was high. The ward installed fullspectrum daylight bulbs and 25 groups of green plants in the 80 m2 premises. There was a significant reduction in health problems and sick leave was reduced by 25%. The best result was a 32% reduction in tiredness, a 33% reduction in ‘heavy head’, a 45% reduction in headaches, and a 31% reduction in sore throats (Fjeld, 1998a, b).
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4.9. Plants Plants have a favorable effect on the indoor climate. It has been shown that patients with a view to vegetation or green areas from their sickbeds have shorter convalescences, fewer complications, and less painkilling or sleep-inducing medications. Normal blood pressure is also more prevalent in this patient group than in the control group (Ku¨ller and Laike, 1998). A similar project was undertaken by Ulrich in a hospital in Pennsylvania in 1984, with similar positive results (Ulrich, 1991). 4.10. Quality In the strategic plans examined, the notion of quality was found in many combinations, but on closer analysis, there was no mention of it in the context of aesthetics. Quality specification and quality assurance are both necessary in the health services in the care of patients and the working environment of staff. Good working conditions and surroundings are important for the work effort, pleasure, and the capacity to offer a high standard of nursing care. High-quality working conditions reduce stress factors, strengthen immunity, and heighten the contentment factor. This confirms how important it is to be aware of and address the aesthetic dimension in hospitals and we maintain that quality concerns all areas physical, psychological, ethical, aesthetic, intellectual, mental, and spiritual. In training student nurses, it should be emphasized how important it is that patients receive holistic care that individuals are taken care of in physical and psychological ways, socially and spiritually, in terms of material culture, body, and soul. The human being, sick or healthy, is a whole living organism, each part of which interacts continuously with the other parts; no part is unaffected by inner or outer influences. One can distinguish the parts, but the whole being is in fact one, like a coin that has two sides but is still one. The demand for quality must be comprehensive if patients are to receive optimal care. The positive effects of pleasant and aesthetic surroundings indicate the importance of focusing on and emphasizing the achievement of firstclass care. Aesthetic surroundings also have a positive influence on relatives and others visiting patients and hospitals. Since 1987, the Picker Institute in Boston has been involved in research regarding patient satisfaction with hospitals and institutions. Two hundred thousand patients have been interviewed from 500 different hospitals or institutions regarding their well-being and contentedness, and their ability to control their surroundings in patient rooms—light, noise, temperature, contact with nature, etc. The results showed that, when patients could choose, they selected a hospital/institution based on criteria other than medical and profes-
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sional ones, which are taken for granted. Parameters that mattered in making patients and their relatives feel secure were the quality of their physical surroundings, whether their requests and preferences were considered, personal control, respect, manners, and the climate of communication (Fjeld, 1998b). The results from the present study show that patients at Norwegian hospitals do not have many choices if they value a high aesthetic standard. This does not reduce the value of these findings. On the contrary, it confirms the importance of focusing on this dimension. These results are valuable concerning the economic cost savings that can be achieved by emphasizing the aesthetics as mentioned. Man has an almost unbelievable ability to adapt and survive, but if he is to perform his best and not be exhausted, aesthetic factors must be considered. ‘‘Scientists at John Hopkins Medical Center report that they have found relatively few reports concerning this area (70 published articles), but still considerable evidence that aspects of the aesthetics of the environment have a considerable effect on patient recovery’’ (Sandelowski, 1986). When hospitals are built or rehabilitated, it seems that aesthetics are considered and considerable amounts of money are often allocated to art and decor. This is very positive, but it is critically important that professionals from different areas are engaged and that patients are consulted. It is important that research results are taken into consideration and used, and that the importance of how colors, light and air, space and lines, design, nature, etc. influence health, well-being, and rehabilitation is recognized. It must remembered that the patient is the person who is most affected, but the aesthetics of the surroundings also influence the staff. A hospital requires different artistic decorations from those of other buildings. A sculpture or a painting, for instance, can have quite other connotations for a patient than it has under different circumstances. Research has shown that contact with nature and vegetation confers better health and greater well-being (Ulrich, 1984, 1985; Fjeld, 1998b). The prophylactic influence of aesthetics on the immune system, the salutogenetic effect of aesthetics on health and wellness should be the focus of our attention. It is a serious oversight that research results have not influenced holistic care. The consequence is that many patients remain in hospital for longer terms and undergo more tiring and painful rehabilitation, and greater economic expenses are incurred by the hospital. In the education of student nurses, it is possible to open their eyes, to make them more observant, to heighten their aesthetic outlook. The same is true for the professional staff. Much can be done by each group if they are aware of the importance of the aesthetics of the hospital environment and their effects on patients and their own well-being. This study confirms the assump-
tion that aesthetics are given a low priority in many hospital strategic plans. No concrete goals or directives regarding the aesthetics of the environment are included, or are only very sparsely documented. It is an ethical duty to attend to this area, for both patients and staff, because it concerns and affects human dignity (Kant, 1790; Pope Spies, 1995; Na˚den and Sæteren, 2006).
5. Conclusion The intention of this research was to determine the degree to which the aesthetic dimension is addressed in the strategic plans of Norwegian general hospitals. The aim was to find which directions and decrees the professional caring personnel and the daily management has, accordingly how to attend to the aesthetic surroundings. We concluded that references to the 11 categories, into which the aesthetic dimension was divided to analyze the strategic plans, were almost absent from the strategic plans. Study of the literature and research shows the importance of this sphere to both patients and employees (Ulrich, 1991, 2001; Fjeld, 1998b; Wikstro¨m, 1997). The results of this study confirm the need to explore the degree to which patients are comfortable and how they evaluate the aesthetics of the hospital environment, their thoughts about their influence on their health, wellbeing, and recovery. The same is true for the professional staffs which in this project were nurses.
Acknowledgement Thanks to Oslo University College, Faculty of Nursing, for financing this research.
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ARTICLE IN PRESS S. Caspari et al. / International Journal of Nursing Studies 43 (2006) 851–859 Kant, I., 1790. Kritik der Urteilskraft. Translated to Norwegian by E. Hammer. Pax Publishing Company A/S, Oslo. Ku¨ller, R., 1981. Non-visual effects of light and color. Annotated bibliography. Document D15. Swedish Council for Building Research, Stockholm. Ku¨ller, R., 1987. The Effects of Indoor Lighting on Wellbeing and the Annual Rhythm of Hormones. Arbetsmiljo¨fonden, Stockholm. Ku¨ller, R., Lindsten, C., 1992. Health and behavior of children in classrooms with and without windows. Journal of Environmental Psychology 12, 305–317. Ku¨ller, R., Mikellides, B., 1993. Simulated Studies of Color, Arousal, and Comfort. Environmental Simulation. Research and Policy Issues. Plenum Press, New York, pp. 163–190. Ku¨ller, R., Laike, T., 1998. The impact of flicker from fluorescent lighting on well-being, performance and psychological arousal. Environmental Psychology Unit, School of Architecture, Institute of Technology, Lund, Sweden. Mikellides, B., 1988. Colour and Psychological Arousal. Proceedings of the 10th Conference of IAPS, vol. II. Delft University Press, Delft. Miles, M.B., Hubermans, A.M., 1984. Qualitative Data Analysis. A Sourcebook of New Methods. Sage Publications, London. Na˚den, D., Sæteren, B., 2006. The cancer patient’s perception of being and not being confirmed. Nursing Ethics, 13.
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Pope Spies, D., 1995. Music, noise, and the human voice in the nurse–patient environment. Image. Journal of Nursing Scholarship, Sigma Theta Tau International 27 (4), 291–296. Porteous, D., 1982. Approaches to environmental aesthetics. Journal of Environmental Psychology 2, 53–66. Robertson, P., 2001. Music and health. In: Dilani, A. (Ed.), Design and Health—The Therapeutic Benefits of Design. Elanders Svenskt Tryck AB, Stockholm. Sandelowski, M., 1986. The problem of rigor in qualitative research. Advances in Nursing Science 8, 27–37. Strati, A., 1998. Organization and Aesthetics. Sage Publishing House, London. Ulrich, R., 1984. View through a window may influence recovery from surgery. Science 24, 420–421. Ulrich, R., 1985. Aesthetic and Emotional Influences of Vegetation. A Review of the Scientific Literature. Uppsala University, Uppsala. Ulrich, R., 1991. Effects of interior design on wellness. Theory on recent scientific research. Journal of Health Care and Interior Design, 3. Ulrich, R., 2001. Effects of healthcare environmental design on medical outcomes. In: Dilani, A. (Ed.), Art, Design & Health. Svensk Byggtja¨nst, Stockholm. Watson, J., 1988. Nursing. The Philosophy and Science of Caring. Little, Brown and Company, Boston. Wikstro¨m, B.-M., 1997. Estetik och omva˚rnad [Aesthetics and Caring]. Studentlitteratur, Lund, Sweden.
International Journal of Nursing Studies 43 (2006) 851–859 www.elsevier.com/locate/ijnurstu
The aesthetic dimension in hospitals—An investigation into strategic plans Synnøve Casparia,, Katie Erikssonb, Dagfinn Na˚dena b
a Oslo University College, Faculty of Nursing, Oslo, Norway A˚bo Akademi University, Department of Caring Science, Wasa, Finland
Received 29 March 2006; accepted 8 April 2006
Abstract Background and rationale: The underlying assumption was that the aesthetics of the hospital surroundings are often neglected. Aims: This article is the first part of a larger study into the aesthetics of general hospitals. The aim of the study is to throw light on the influence of aesthetics on the health and well-being of patients and the professional personnel, and to examine how aesthetic considerations are dealt with. We present a survey of how the aesthetic dimension is planned and it is considered important in the strategic plans of Norwegian general hospitals. Methods: Data were sampled by analyzing the strategic plans of somatic hospitals. Sixty-four of 86 hospitals responded (74%). Concepts were categorized in a matrix of 11 main categories, each with subcategories. The method was quantitative, in that the analyzed material was amenable to counting. Results: Very few concrete guidelines or directions for the aesthetic dimension have been included in written documents. This indicates that the aesthetic area is a neglected field in the directions for the daily management of hospitals. Conclusions: The research available today on the contribution of environmental aesthetics to health, rehabilitation, and well-being suggests that it is important to have concrete guidelines recorded in strategic plans. This field concerns the maintenance of high quality in the caring professions. r 2006 Elsevier Ltd. All rights reserved. Keywords: Aesthetic environment; Aesthetic research; Hospital aesthetics; Patient environment; Survey
What is already known about the topic?
Aesthetics contributes to health and wellness. The aesthetic dimension is a need for the human being.
What this paper adds
There
are few concrete guidelines concerning aesthetics in somatic hospital strategy plans. High quality in nursing care includes the aesthetic dimension.
1. Introduction Corresponding author. Tel.: +47 22453844;
fax: +47 22453799. E-mail address: [email protected] (S. Caspari).
Our investigation started with an examination of the strategic plans of Norwegian general hospitals, to find
0020-7489/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2006.04.011
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whether and how aesthetics are considered important, and how the instructions that address aesthetic issues are formulated. Research has shown that aesthetically pleasing surroundings can have an important effect on patient health and well-being. This has been demonstrated by the reduced use of medications, fewer infections, better sleep, improved blood pressure, and shorter admissions (Ulrich, 2001). Aesthetic surroundings can also be stimulating for nurses and other healthcare professionals, resulting in a higher working capacity, greater job satisfaction, and fewer sick leaves (Fjeld, 1998b). 1.1. Literature review Aesthetics is, among other things, a philosophical discipline that concerns the fine arts and problems connected with artistic understanding in general, that is art philosophy. The term ‘‘aesthetic’’ is a Germanic form of the Greek term ‘‘aisthesis’’. The Latin term ‘‘aesthetica’’ can be translated as perception, sense, feeling, awareness, knowledge of the fine arts, and the standards used to understand them. In this study, the idea is used to describe the qualities of the surroundings that might influence the health and wellness of patients and of the professional health-care personnel. Analysis of the workplace and the work environment is often dominated by traditional scientific evaluations, logical rational analyses that ignore the aesthetic dimension (Strati, 1998). Aesthetics influence a person’s feelings, both physical and psychological. Both aesthetic and nonaesthetic surroundings create an impression and affect a person consciously or unconsciously (Ulrich, 1991; Beil-Hildebrand, 1992; Ku¨ller and Lindsten, 1992). Aesthetically pleasing surroundings will improve a person’s affective condition and contribute to a feeling of well-being (Ulrich, 2001; Fjeld, 1998a; Ulrich, 1991; Ku¨ller and Mikellides, 1993). Therefore, aesthetics has great importance, perhaps more than we imagine. There must be a congruence between the person and nature, between the person and his or her surroundings. Research has shown how important feelings are for an individual’s physical and mental health. A person’s feelings of well-being and happiness, of harmony and balance, directly influence his or her health and counteract destructive stress factors, among other things. Stress factors in the environment can have a negative effect on the immune system (Fjeld, 1998a; Dilani and Malkin, 1998; Watson, 1988). The aesthetic dimension covers a large range of concepts. It might include colors, art, insufficient daylight, blinding light, outlook to dull surroundings, limited choices, and restricted personal space, which can all create additional stress and increase the risk of illness. Research in psychology, the health-care sciences,
and medicine has provided insight into how a healing environment can be created and how it affects the body and soul (Dilani and Malkin, 1998). Therefore, aesthetics are an important factor in life, whether one is sick or healthy, old or young. A person continually senses and experiences the environment consciously, as aesthetic, unaesthetic, or insignificant. Its beauty, harmony, and balance, or the lack of these qualities is cognitively assimilated. However, this cognitive awareness is not necessary for aesthetics or their lack to influence health. The aesthetic sense need not convert these impulses into words; it has its own ‘language’ and communicates continually through all the senses, to every cell of the body and to the mind, to influence the individual positively or negatively. ‘‘Dr. Deepak Chopra asserts that every cell in our immune system continually listens in on our silent internal conversation and that one can imagine the cells of the immune system as intelligent small entities similar to brain cells y’’ (Watson, 1988). High-quality holistic health care should have as its goal the maintenance of all areas that influence health. ‘High-quality’ implies that the aesthetic aspect should also be taken into consideration. The abstract, theoretical, and ideal are as important as the concrete, measurable, and observable in holistic health care. ‘‘Art captures expresses and recreates humanity and life, in all its diverse forms. Art is the life’s spirit y the soul seeks beauty!’’ (Ulrich, 1984). Some hospitals are attentive to the aesthetic aspects of the environment and have a concrete plan to address them. Others seem to have no understanding of its importance. The decisive factor is not necessarily economic. The prevailing philosophy and ideology of the hospital administration and its employees can be equally important. There is a great deal of knowledge of and research undertaken today regarding different areas of aesthetics. The significance of colors and their influence on an individual exemplifies an area in which it is important that the decisions made are not arbitrary, but are based on existing research and knowledge. In San Francisco in 1978, Angelica Thieriot established an organization, an expert group consisting of architects, doctors, nurses, and people interested in art, among others, who developed and laid the foundation for the ‘Planetree model’. The theoretical basis of the model was developed through the cooperation of the group and was the result of their reactions to the health service they had experienced at the hospitals where they had been patients. They viewed the health service as cold and inhuman, and as not giving first priority to the patient and his family. The Planetree philosophy is built around the idea that health services and hospitals and the services they provide are for the patient. In other words, the patient is their principal concern. The patients and their families must, as far as possible, feel
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secure and at ease. Openness and freedom, autonomy and the right to be consulted are of prime importance. An aesthetic environment and a comfortable milieu are sought, so that an atmosphere conducive to well-being is created. Hospitals that are designed and run in accordance with the Planetree philosophy have had many positive responses in many countries. Late twentieth-century neuropsychological theory suggests that the human forebrain can best be considered as a limbic system and a frontal neocortex. The limbic system is the seat of the emotions; it deals with the nonrational. In contrast the neocortex is the thinking brain, but is itself divided into lateral hemispheres with rather different functions. In short, the left hemisphere is Apollonian: verbal, mathematical, logical, deductive and orientated towards the external environment, whereas the right hemisphere is Dionysian: holistic, intuitive, spatial, patternrecognizing, and concerned with inner spaces y We have a psychological need to satisfy all three systems’ demands for input, and individual wellness depends on the balance of input to all three areas (Ulrich, 1985) The literature leads us to conclude that the aesthetic dimension has great importance for human health, in recovery and well-being when sick, and is a positive factor in the care of terminally ill patients. 1.2. Purpose and research question The purpose of this article is to report the results of a study into whether and how aesthetics are prioritized in the strategic plans of Norwegian general hospitals. The research question is: To what degree are the aesthetics of hospital surroundings addressed in the strategic plans of general hospitals in Norway?
2. Methods 2.1. Data sampling Hospitals were requested to supply their strategic plans concerning the aesthetic domain for the past 2 years. A second request was sent to those who did not respond. In the request letter, the project was described and a short summary of the investigation was given. Sixty-four of 86 hospitals (74%) answered, providing information and copies of their strategic plans. Two hospitals submitted information by telephone and another two hospitals supplied information by letter, with no strategic plan enclosed. Our intention was to survey the plans for establishing the aesthetics of
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hospital surroundings in general. The received material was considered representative. 2.2. Method of analysis Before the work with the material could start a formulary, a matrix was constructed that was suitable for the numeric recording of all occurrences of the word ‘aesthetic’ and similar words that are related to the aesthetic domain. After reading and analyzing other studies by Beil-Hildebrand (1992), Ulrich (1984, 1991, 2001), and Wikstro¨m (1997), it was decided to focus on 11 main categories, with subcategories. Although this study deals with aesthetic categories, ‘aesthetic’ and ‘quality’ themselves are included as categories because we were interested to know if these words were mentioned, and the contexts in which they were included in the strategic plans. Some of the tactics used by Miles and Hubermans (1984) to generate meaning were used to draw conclusions from the material: counting, noting patterns, clustering, etc. Principally, we undertook to find words that showed how aesthetics were addressed in the strategic plans and how each hospital followed these directions. In this way, it was possible to determine the intentions behind these strategies and to quantify the aesthetics-related words in the strategic plans for further statistical analysis. All documents and hospitals were registered numerically, and all documents were analyzed for words from the main categories or subcategories. The frequencies of occurrence were noted, but in this context, were recorded only once for each hospital. Table 1 illustrates the categories and subcategories that were considered in analyzing the strategic plans. The main categories are shown in the upper line (Z), and the subcategories in lines A–I.
3. Results The strategic plans were analyzed to determine whether and in what way aesthetics were addressed. This graphic Fig. 1 illustrates the results of the analysis. Each column represents the total findings for the main categories (including subcategories) in the documents, according to their occurrences in the strategic plans. In presenting the results, important factors will be indicated in relation to each category. Category 1: Harmony. Subcategories are properness considered as tidiness, balance, harmony, hygiene, laughter, humor, play, and entertainment. These words/ideas were recorded in the documents from 12 hospitals in different contexts. Category 2: Food. Subcategories are appearance, color, and service. Food was mentioned in only one
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Competance desciding Panel Quality Specialists Commite` Holism Beautiful Lovely Nice Tasteful Sense Perception Sensibility Sense perception Plants Flowers Trees View Air Ventilation Noise Song Music Nature sounds Unpleasant sounds Furniture Curtains Walls Ceiling Floor Textiles Curtains Furniture Sun Electric Lamps Armatur Patient room Livingroom Ekstern rooms Corridor Staff room Bathroom Shower W.C. Colour Appearance Service Properly Tidiness .Balance Entertainment Hygiene Laughter Humor Play Smile
Painting Sculpture Pictures Tapestries Decor Mosaics Water
Z Quality: registered as z Aesthetics Nature Sound Design Colors Light Room Art Food Harmony
Table 1 Categories and subcategories of the terms analyzed for their occurrence in strategic plans
A B C D E F G H I
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document, in a supporting letter that stated: ‘‘The kitchen is renowned for serving delicious and nutritious food’’. There were no further specifications. Category 3: Art. Subcategories are painting, sculpture, pictures, tapestries, decor, mosaics, and water decor. Art is mentioned in four documents, paintings in three, sculpture in three, pictures in three, tapestries in none, decor in seven, mosaics in two, and water decor in two. Among the documents received, in which references to these subcategories were quite spare, one hospital reported that it had engaged a color designer, a qualified interior decorator, who planned the use of color and the aesthetics of the hospital surroundings. She had been engaged together with the architects, right from the start, and the results were very satisfying for both the patients and the professional staff. Otherwise, very few references were found in the documents. Letters attached to the received documents stated: ‘‘It is a pity, but we have written very little about how we want to address aesthetics.’’; another stated: ‘‘Unfortunately, we have very little in print about this aspect of the hospital environment. Aesthetics is very important in hospital surroundings. In earlier times, the aesthetics were a natural part of daily tasks and duties. Today, this function receives less attention and it has become more the exception than the rule to attend to the aesthetics of the surroundings.’’ Category 4: Rooms. Subcategories are patient rooms, living rooms, external rooms (medical rooms, group rooms, cleaning rooms, and linen rooms), corridors, staff rooms, and bathrooms (W.C. and shower). There was nothing in the documents concerning the aesthetics of these rooms; nothing concerning the guidelines for choosing colors, textiles, designs, etc.; and nothing on the existing criteria for decision making or the expected influence on patients and staff. When these areas are mentioned, it is in reference to technical or maintenance procedures. Category 5: Light. Subcategories are sun, daylight, electrical or artificial light,fittings and lamps. Only two hospital documents contained any reference to these areas. One hospital mentioned bad ventilation, lack of daylight in working rooms, narrow and small rooms for working routines, etc. in the context of health, milieu and security (HMS). Offices were cited as having very little access to daylight and insufficient ventilation. Category 6: Colors. Subcategories are walls, ceilings, floors, textiles, curtains, and furniture. Very few references were found to these areas and no concrete philosophy has been given as guidelines. Colors are mentioned in documents from seven hospitals. Category 7: Design. Subcategories are furniture and curtains. Design is mentioned in three of the strategic plans. ‘Design’ refers to and concerns everything in the room: all forms, patterns, sizes and dimensions, etc. It might also include the design of materials, or of furniture and utensils.
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70 Serie1 60
Hospials
50 40 30 20 10
tic s Q ua lit y
e
st he
Ae
at ur N
t C ol ou rs D es ig n So un d
gh
m
Li
oo R
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y Fo od
m ar H
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os
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Categories Fig. 1. Occurrence in documents of words from each category.
Category 8: Sounds. Subcategories are noise, song, music, nature sounds, and irritating or unpleasant sounds. This category appears in five documents. Category 9: Nature. Subcategories are plants, flowers, trees, view, air, and ventilation. These categories were found in 10 documents. Category 10: Aesthetics. Subcategories are beautiful, lovely, nice, tasteful, sense, perception, and sensibility. These words were found in nine documents or strategic plans. A few comments from the letters attached are included: ‘‘When analyzing our strategic plans, we found that very little has been written concerning our thoughts and priorities in aesthetic areas in the hospital. To do better in this field, we hope to obtain a copy of your investigation, when finished’’; another letter stated: ‘‘You are investigating a neglected area. In our hospital, we have no philosophy concerning the importance of aesthetics in hospitals, but as we are now building a new hospital, I will, as a leading director, personally see that this theme is included in the project’’. Category 11: Quality. Subcategories are competence, committee, panel, specialists/professionals, and holism. Words from this category was found in documents from 36 hospitals. This might be due to the Hospital Law of 1994 (Helsedirektoratet), which requires that all hospitals establish a quality control group. The law does not include specific details on the group’s responsibilities, nor any definition of the word ‘quality’ in the context of hospitals or patients. ‘Quality’ is defined as a degree of excellence, relative nature, general excellence, attribute, trait, faculty, social standing. 4. Discussion By analyzing the received material, we have drawn the conclusion that very few guidelines concerning the
aesthetics of hospital surroundings are finding their way into today’s strategic plans. Even though aesthetics are considered important, there are very few directions given. To ensure that this area receives attention, it is necessary to have clear and concise guidelines in strategic plans, on what to do and how to do it. To illustrate how the ideas were used in the documents, a few examples from the strategic plans are given, to show their relevance or otherwise to aesthetics. One document stated: ‘‘Surroundings shall be designed so that the patient is comfortable, feels safe, is rested and attains well-being’’. However, no specifications on how these feelings could be achieved and no further instructions are given. Another document states: ‘‘The prosperity, well-being and competence of the professionals are the most important contributions to meeting the patient’s needs’’. One letter refers to a positive experience in a psychiatric ward: ‘‘y we are happy that you are working on a project concerning aesthetics in the general hospitals of Norway. Firstly, I wish to point out that aesthetics is more an attitude that depends on the individual than one that is found in the guidelines of strategic plans. In our experience, when aesthetic standards are improved, patients cause less damages to furniture, bric-a-brac etc. y’’. Another letter states: ‘‘Your letter has prompted us to include, as soon as possible, concrete guidelines concerning the aesthetics at our hospital. Your investigation has already caused the inclusion of guidelines concerning aesthetics in the hospital strategic plan y’’. These two examples underline the need for aesthetics and the importance of producing guidelines for the best way to address these issues.
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4.1. Harmony
4.5. Light
Harmony and its subcategories are all important in the context of the patient’s recovery and well-being. Harmony relates to the wellness of the soul and has psychosomatic effects. The antiseptic effects of hygiene are most evident. However, hygiene also influences the patient’s sense of comfort and well-being.
One letter that accompanied the documents stated that our request had been presented to the technical leader and to the domestic economy coordinator at their hospital. They regretted to say that there was very little found in their documents specifically concerning aesthetics. However, thanks to conscientious colleagues, a pleasant milieu had been achieved for patients, staff, and relatives. There was no mention of the design of light sources, but it appears that an electrician was consulted for this purpose. Research clearly indicates that light is of great importance to both the recovery and rehabilitation of patients, and also affects the health and wellbeing of staff. This area is a field with potential for improvement (Ulrich, 2001; Ku¨ller, 1987, 1981).
4.2. Food The serving of the food is important to tempt the patient’s appetite. The portion itself must be adjusted for the individual patient. The way the food is cut, arranged on the dish so that the colors are in harmony, and of course the freshness of the food and how well it is prepared are all important if a patient has little or no appetite. The food must be aesthetic and tempting, served and presented in a stimulating way. None of these issues is mentioned in any of the strategic plans. In a well-composed meal, colors will be used intentionally. Colors signal the nutritional value of the product, and can in themselves influence the appetite. For instance, yellow/orange can be stimulating and green products can give renewed strength.
4.3. Art Different artistic experiences can stimulate the patient; they can also be distracting, entertaining, and restful. The outside world can be brought into the hospital. Art can also be provocative and challenging. In perceiving art, the viewer is also a cocreator in that he interprets and shapes the art according to his own experience. Art reveals another reality. It might be a manifestation of the human longing for something ‘higher’, because art can confer a feeling of being part of a higher reality.
4.4. Room The proportions and lines, the architecture and the colors of rooms must be harmonious. For instance, a very high ceiling in a small room can give a feeling of being in a shaft, or if too low, might be perceived as ‘getting a ceiling in the head’. It is also important that colors are used in accordance with the results of research and scientific knowledge to influence human needs and reactions. Rooms should be at a comfortable temperature, with sufficient ventilation to avoid unpleasant smells and odors, which may derive from other patients in the room.
4.6. Colors Colors are an important part of our daily existence, and of our surroundings. Colors imprint the aesthetic environment and scientific research shows that colors have a great effect on individuals. The patient’s room should be comfortable and pleasant to stay in, and colors are important in that context. The same is true for other rooms. Dark and gloomy colors can lead to an analogous state of mind, whereas gaudy colors can lead to irritability, aggressiveness, increases in blood pressure, and general feelings of unpleasantness. A patient who must remain on his back, day after day, will not be positively affected by a view of a grayish ceiling with glaring neon lighting from metal boxes. Colors send energy impulses to the body that influence it in a positive or negative way. Research has shown that the chromatic strength of the color and its nuance are more effective than the color itself (Ku¨ller and Lindsten, 1992; Ku¨ller and Mikellides, 1993; Mikellides, 1988; Cold, 1998). ‘‘Introduction of the Natural Colour System (NCCS) has made it possible to interpret the world of colors, even from a phenomenological perspective’’ (Ku¨ller and Mikellides, 1993, p. 299). Colors can be aesthetically pleasant in themselves and can also be part of an aesthetic wholeness. Only one hospital had a structured plan for the use of colors in patient environments. The apparently opposite words ‘sound’ and ‘silence’ can be united in the essential meaning of ‘to listen’. The body registers and reacts not only to the sounds that are audible to the ear. Sound is made by molecular oscillations that procreate. Animals often have much better hearing than humans. There is great variability in the auditory senses and in the pain thresholds affected by sound. Communication is not sound dependent, even if language is an important part of communication and words are largely transmitted by sounds. The sound or sounds that express words often convey more than the word itself. The sound or tonal value can often say
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something else, even contrary to the etymological meaning of the word. Not everyone is lucky enough to have pleasant speech. It is often said that ‘‘each bird sings with his own beak’’. The same is true of talking. The human voice carries information about age, sex, mood, etc., of the speaker. Most people can learn clear diction, with which words are formulated and spoken clearly, and sound levels can be modulated to suit the situation. A patient might jump in his bed if a shrill voice yells ‘‘good morning’’! Similarly, whispering can be annoying and distracting. A pleasant well-modulated voice can be soothing and calming, and create an atmosphere of security and pleasure. Sounds can be very dominating, especially if a patient is very sensitive and alert to sounds. Irritating noises like scrambling, rustling, slamming doors, and clacking shoes in the corridors at night can be very annoying and disturbing for a patient. Can song and other noises be used as positive modes of treatment in the same way music can? Sounds can be used as a method of communication and positive results have been achieved in the treatment of pain. Different sounds, such as song and music, can add beauty to surroundings, but can also induce anxiety, fear, and agitation (Robertson, 2001; Pope Spies, 1995). 4.7. Design The way furnishings are shaped and molded, the materials used, and so on, all influence the comfort and appeal of interiors. The architecture of the room is also a matter of design, the harmony between the height and breadth of the patient’s room, windows that embrace the outside world, give light and variation. The arrangement of furnishings should be pleasant to look at, to touch, and to handle (Porteous, 1982). Their functionality is also important (Ulrich, 2001; Dilani and Malkin, 1998; Watson, 1988). 4.8. Nature Contact with nature has a positive effect on man and leads to better health and well-being. Nature is in many ways a person’s right or can be seen as an archetypical element. A research report from an X-ray ward evaluated the health and contentment of the staff who undertook their daily work in the ward, where the main occupation was the examination of radiographs. The staff had suffered a bad climate for a long time, and the sick-leave rate was high. The ward installed fullspectrum daylight bulbs and 25 groups of green plants in the 80 m2 premises. There was a significant reduction in health problems and sick leave was reduced by 25%. The best result was a 32% reduction in tiredness, a 33% reduction in ‘heavy head’, a 45% reduction in headaches, and a 31% reduction in sore throats (Fjeld, 1998a, b).
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4.9. Plants Plants have a favorable effect on the indoor climate. It has been shown that patients with a view to vegetation or green areas from their sickbeds have shorter convalescences, fewer complications, and less painkilling or sleep-inducing medications. Normal blood pressure is also more prevalent in this patient group than in the control group (Ku¨ller and Laike, 1998). A similar project was undertaken by Ulrich in a hospital in Pennsylvania in 1984, with similar positive results (Ulrich, 1991). 4.10. Quality In the strategic plans examined, the notion of quality was found in many combinations, but on closer analysis, there was no mention of it in the context of aesthetics. Quality specification and quality assurance are both necessary in the health services in the care of patients and the working environment of staff. Good working conditions and surroundings are important for the work effort, pleasure, and the capacity to offer a high standard of nursing care. High-quality working conditions reduce stress factors, strengthen immunity, and heighten the contentment factor. This confirms how important it is to be aware of and address the aesthetic dimension in hospitals and we maintain that quality concerns all areas physical, psychological, ethical, aesthetic, intellectual, mental, and spiritual. In training student nurses, it should be emphasized how important it is that patients receive holistic care that individuals are taken care of in physical and psychological ways, socially and spiritually, in terms of material culture, body, and soul. The human being, sick or healthy, is a whole living organism, each part of which interacts continuously with the other parts; no part is unaffected by inner or outer influences. One can distinguish the parts, but the whole being is in fact one, like a coin that has two sides but is still one. The demand for quality must be comprehensive if patients are to receive optimal care. The positive effects of pleasant and aesthetic surroundings indicate the importance of focusing on and emphasizing the achievement of firstclass care. Aesthetic surroundings also have a positive influence on relatives and others visiting patients and hospitals. Since 1987, the Picker Institute in Boston has been involved in research regarding patient satisfaction with hospitals and institutions. Two hundred thousand patients have been interviewed from 500 different hospitals or institutions regarding their well-being and contentedness, and their ability to control their surroundings in patient rooms—light, noise, temperature, contact with nature, etc. The results showed that, when patients could choose, they selected a hospital/institution based on criteria other than medical and profes-
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sional ones, which are taken for granted. Parameters that mattered in making patients and their relatives feel secure were the quality of their physical surroundings, whether their requests and preferences were considered, personal control, respect, manners, and the climate of communication (Fjeld, 1998b). The results from the present study show that patients at Norwegian hospitals do not have many choices if they value a high aesthetic standard. This does not reduce the value of these findings. On the contrary, it confirms the importance of focusing on this dimension. These results are valuable concerning the economic cost savings that can be achieved by emphasizing the aesthetics as mentioned. Man has an almost unbelievable ability to adapt and survive, but if he is to perform his best and not be exhausted, aesthetic factors must be considered. ‘‘Scientists at John Hopkins Medical Center report that they have found relatively few reports concerning this area (70 published articles), but still considerable evidence that aspects of the aesthetics of the environment have a considerable effect on patient recovery’’ (Sandelowski, 1986). When hospitals are built or rehabilitated, it seems that aesthetics are considered and considerable amounts of money are often allocated to art and decor. This is very positive, but it is critically important that professionals from different areas are engaged and that patients are consulted. It is important that research results are taken into consideration and used, and that the importance of how colors, light and air, space and lines, design, nature, etc. influence health, well-being, and rehabilitation is recognized. It must remembered that the patient is the person who is most affected, but the aesthetics of the surroundings also influence the staff. A hospital requires different artistic decorations from those of other buildings. A sculpture or a painting, for instance, can have quite other connotations for a patient than it has under different circumstances. Research has shown that contact with nature and vegetation confers better health and greater well-being (Ulrich, 1984, 1985; Fjeld, 1998b). The prophylactic influence of aesthetics on the immune system, the salutogenetic effect of aesthetics on health and wellness should be the focus of our attention. It is a serious oversight that research results have not influenced holistic care. The consequence is that many patients remain in hospital for longer terms and undergo more tiring and painful rehabilitation, and greater economic expenses are incurred by the hospital. In the education of student nurses, it is possible to open their eyes, to make them more observant, to heighten their aesthetic outlook. The same is true for the professional staff. Much can be done by each group if they are aware of the importance of the aesthetics of the hospital environment and their effects on patients and their own well-being. This study confirms the assump-
tion that aesthetics are given a low priority in many hospital strategic plans. No concrete goals or directives regarding the aesthetics of the environment are included, or are only very sparsely documented. It is an ethical duty to attend to this area, for both patients and staff, because it concerns and affects human dignity (Kant, 1790; Pope Spies, 1995; Na˚den and Sæteren, 2006).
5. Conclusion The intention of this research was to determine the degree to which the aesthetic dimension is addressed in the strategic plans of Norwegian general hospitals. The aim was to find which directions and decrees the professional caring personnel and the daily management has, accordingly how to attend to the aesthetic surroundings. We concluded that references to the 11 categories, into which the aesthetic dimension was divided to analyze the strategic plans, were almost absent from the strategic plans. Study of the literature and research shows the importance of this sphere to both patients and employees (Ulrich, 1991, 2001; Fjeld, 1998b; Wikstro¨m, 1997). The results of this study confirm the need to explore the degree to which patients are comfortable and how they evaluate the aesthetics of the hospital environment, their thoughts about their influence on their health, wellbeing, and recovery. The same is true for the professional staffs which in this project were nurses.
Acknowledgement Thanks to Oslo University College, Faculty of Nursing, for financing this research.
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