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Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale School of Nursing & Midwifery

Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

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Page 1: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Nursing & Humanities:Accommodation

The History of British Hospital Architecture &

Evidence-Based Design in Hospital Architecture

Ian Noonan

Florence Nightingale School of Nursing & Midwifery

Page 2: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

17th-19th Century British Hospital Architecture

Florence Nightingale School of Nursing & Midwifery

Page 3: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

What this session will cover

• Asylum architecture – 17th-19th centuries

• Florence Nightingale’s ideas on hospital design

• Influence of Nightingale’s ideas

Page 4: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Early modern hospitals

St Bartholomew’s 1723

18th century, James Gibbs. Two vast paintings by William Hogarth.

Page 5: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

17th century asylum - Bethlem• Most people suffering from insanity were in prisons, hospitals,

private madhouses or cared for by relatives at home, but were often treated brutality.

• Bethlem founded in 1247 as the Priory of St Mary of Bethlehem. Treated the insane from the 14th century

• Bethlem at Moorfields, 1676 – original building on the site of Liverpool Station by then dilapidated

• Designed by fashionable architect Robert Hooke in baroque style• 150 metres long corridor• Sarah Rutherford claims it was ‘the most impressive building in the

City of London’

Page 6: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

But inside, a long gallery used as a day room, with individual 12 by 8 feet cells of it. 120 patients slept on straw palliases, some dangerous patients confined to their cells all the time.

Page 7: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Bethlem, third site

1815 - Move to St George’s Fields, Southwark.

The old building was crumbling.

Larger number of small wards.

From 1840s, less emphasis on restraint (abandoned from 1850s), and more on work and leisure.

State criminal lunatic asylum at the back of the building from 1857. Overcrowded and unpopular with Bethlem governors – run by the Home Office. Replaced by Broadmoor in 1864.

1857 – no more pauper patients as county asylums now existed. Remained charity aiming at poorer of the middle classes. From 1882, a few fee-paying patients for the first time.

Page 8: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

St Luke’s and others

St Luke’s, 1815

18th century – 10 more asylums on the edge of towns, e.g. Norwich, York, Newcastle.

Private sector madhouses taking patients for fees growing in number.

Not intended as a ‘madhouse’. New model institution. Bethlem had a long waiting list, so St. Luke’s set up by Batty founded with public subscriptions in 1751. First to call itself an asylum. It banned sightseeing. Admitted medical students – committed to science.

Page 9: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

The York Retreat

Quaker charitable asylum.

Belief in moral treatment which became very influential

Exercise encouraged. Farms and gardens in the grounds.

Page 10: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

First Yorkshire Asylum, Wakefield

Impressive building in its own park, surrounded by a belt of trees, reached by a long drive with a lodge, walled airing courts for exercise without risk of escape.

1808 Lunatics Act – permitted counties to raise funds for asylums. Sites had to be on the edge of urban centres, in an airy position, and close to medical assistance.

Page 11: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Hanwell1831 – Middlesex Asylum at Hanwell opened.

John Conolly, the psychiatrist at Hanwell believed in the patients’ comfort and care. His asylum and beliefs were hugely influential.

He wrote The Construction and Government of Lunatic Asylums in 1847 in which he described hospital design and materials including windows, carpets, privies, baths, furniture, linens, pianos, gardens.

Moral management and normal life

Page 12: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Colney Hatch, second Middlesex Asylum, Freirn Barnet

Architecture competition – 39 leading architects invited to tender designs

S.W. Daukes Esq won the competition. Started in Jan 1849, finished Nov, 1850

‘showcase of Victorian asylum reform’

Opened by Prince Albert in 1851

Had at the time the longest corridor in Europe

Page 13: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Colney Hatch continued

Foreign visitors to the Great Exhibition encouraged to visit – guidebook produced.

Farm, Chapel, Stable and Cemetary.

Model for future European asylums.

As big as a large village.

3000 patients by 1900

Page 14: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Claybury4th Middlesex Asylum

Was planned as the ‘crowning glory’ of Middlesex Asylums

Much better built at great cost, leading to great complaints.

Wards for 21-30 patients, but split into smaller rooms – great staffing costs.

Page 15: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale
Page 16: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Styles of architectureClassical Greek Revival – 1818-1831

Tudorbethan – 1840s and 1850s

Gothic – 1860s-1880s

Queen Anne – 1900

But also Italianate used – eg Colney Hatch, and St Thomas’

Page 17: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Panopticon

Page 18: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Domesticating InsanityFrom 1850s, move towards domesticity as therapy. Wards, furnished with aviaries, pictures, flowers, books. Even excursions out of hospital grounds.

Page 19: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Nightingale’s Notes on Hospitals

‘It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm …’

Aims of her book

‘1st, a general account of the sanitary condition of existing hospitals;

2nd, a statement of those structural defects in hospitals which have influenced the progress of medicine and surgical cases while under treatment in them;

3rd, the principles of construction which ought to be kept in view in building new hospitals;

4th, improved plans for hospitals and convalescent institutions’

5th – gathering hospital statistics

Page 20: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

• London Hospitals – mortality rate 90.5%

• Large Towns – 83%

• County and Provincial Hospitals – 39%

• Spa etc. hospitals 12.5-15%

(from Registrar General’s reports)

‘Careful observers are now generally convinced that the origin and spread of fever in a hospital, or the appearance and spread of hospital gangrene, erysipelas, and pyaemia generally, are much better tests of the defective sanitary state of a hospital than its mortality returns.’

Page 21: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

‘One insensibly allies together restlessness, languor, feverishness, and general malaise, with closeness of wards, defective ventilation, defective structure, bad architectural and administrative arrangements, until it is impossible to resist the conviction that the sick are suffering from something quite other than the disease inscribed on their bed-ticket – and the inquiry insensibly arises in the mind, what can be the cause? To this query many years’ experience of hospitals in various countries and climates enables me to answer explicitly as the result of my own observation, that, even admitting to the full extent the great value of the hospital improvements of recent years, a vast deal of the suffering, and some at least of the mortality, in these establishments is avoidable.

What, then, are those defects to which such results are to be attributed?

I should state at once that to original defects in the sites and plans of hospitals, and to deficient ventilation and overcrowding accompanying such defects, is to be attributed a large proportion of the evil I have mentioned.

The facts flow almost of necessity from ascertained sanitary experience. But it is not often, excepting perhaps in the case of intelligent house-surgeons, that the whole process whereby the sick, who ought to have had rapid recoveries, are retained week after week, or perhaps month after month, in hospital, is continuously observed. I have known a case of slight fever received into hospital, the fever pass off in less than a week, and yet the patient, from the foul state of the wards, not restored to health at the end of eight weeks.’

Page 22: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Problems with overcrowding –

Example of the old Hotel Dieu, Paris, with open wards of 500 beds on one of the floors – the hospital would have 2000-7000 patients at a time – there were more beds on other floors, but this meant that often many patients per bed, sometimes on a rota.

She believed there should be a law of cubic space per bed, and ventilation

Page 23: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Guy’s, 1799

Nightingale complained that English hospitals were built with one or two closed courts with high walls so that the air was stagnant before it reached the wards. This problem existed in ‘nearly all the older hospitals, and in many even of recent construction.’ She even complained about three sides of a square causing this giving the example of the London Hospital.

Page 24: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale
Page 25: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Lariboisiere - PavilionsLariboisiere, Paris, became a model for pavilions. However, it was not popular in France – the atmosphere being ‘detestable’. But this was due to artificial ventilation rather than opening windows.

‘What is all that luxury of magnificent windows for but to admit fresh air? To shut up your patients tight in artificially warmed air, is to bake them in a slow oven. Open the Lariboisiere windows, warm it with open fires, drain it properly, and it will be one of the finest hospitals in the world.’

Page 26: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

WindowsAir and Light

‘Natural ventilation, or that by open windows and open fire-places, is the on;y efficient means for procuring the lifespring of the sick – fresh air. But to obtain this the ward should be at least fifteen to sixteen feet high, and the distance between the opposite windows not more than thirty feet. The amount of fresh air required for ventilation has been hitherto very much underrated, because it has been assumed that the quantity of carbonic acid produced during respiration was the chief noxious gas to be carried off. The total amount of this gas produced by an adult in twenty-four hours is about 40,000 cubic inches ….’

‘Deficiency of light’ – second only to air in ‘importance for the sick’Need direct sunlightSays the ‘effect of light on health and disease has long been recognised in the medical profession’Need to be able to see flowers out of the window, be able to read by the light of it.

Some foreign hospitals, in countries where the light is far more intense that in England, give one window to every bed. The window-space should be one-third of the wall-space. The windows should reach from two or three feet of the floor to one foot of the ceiling. The escape of heat may be diminished by plate or double glass. But while we can generate warmth, we cannot generate daylight, or the purifying and curative effect of the sun’s rays.’

Page 27: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

St Thomas’Florence objected to rebuilding St Thomas’ on the Thames. She wanted it in the suburbs, thinking Blackheath was ideal, with a casualty department in Southwark and a rail link to the main hospital, ‘like the war wounded’.

She campaigned by attempting to influence Prince Albert, one of the hospital’s governors, and asking Sir Harry Verney to raise the matter in Parliament.

44 locations considered – Florence described the chosen one as a ‘mudbank’

Seven Italianate Pavilions, opened 1871, Wards adhering to Florence’s rules

Page 28: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Nightingale’s influence

Pavilion style hospitals were the hospital design of choice in 19th century hospitals, except for a few departures such as round hospitals

She was consulted about the designs of many hospitals, e.g. Derbyshire Royal Infirmary, Buckinghamshire Infirmary.

Her ideas and the pavilion hospitals in France at Lariboisiere and Vincennes were influential in the design of Rochester Hospital, Surrey County Hospital, Guildford, Hampshire County Hospital, Winchester, and many others in towns like Leeds, Stoke-on-Trent and Blackburn.

Page 29: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

References and Recommended Reading

• Mark Bostridge, Florence Nightingale: The Woman and Her Legend (London, Viking, 2008).

• Florence Nightingale, Notes on Hospitals, Longman Green, 1863.

• Roy Porter, Madness

• Harriet Richardson

• Sarah Rutherford

• Elaine Showalter, The Female Malady:

Page 30: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Evidence-based architecture &

hospital design

Page 31: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Why Evidence-Based Design?

• Quicker labour, shorter recovery time (Kolb, 1980s)

• Patient Safety (St Joseph's, West Bend Wisconsin, 2003)

• Reduction in staff turnover• Improved staff health & safety• Increased effectiveness of patient care• Reduction in errors

(Centre for Health Design, 2006)

Page 32: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Is it new?

• Depends on how we define evidence

• History of theory influencing design:

• Madness - Asylum• Miasmic disease –

Nightingale Ward

• Infectious disease – Pavilion Hospital

• Infection Control/Germ theory – Isolation

• Psychological development – Interaction & Play

• Care in the Community – Invisible Hospitals

Page 33: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

“First we shape our buildings and afterwards our buildings shape us”

“First we shape our buildings and afterwards our buildings shape us”

Winston Churchill, 24th November 1951

Page 34: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale
Page 35: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale
Page 36: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale
Page 37: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Plan and elevation drawings of Isolation Hospital, Southport

Page 38: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale
Page 39: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Royal Army Medical Corps Muniment Collection, Album of photographs of the King George V Military Hospital, Stamford Street, London, First World War

Page 40: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

University Children's Hospital, Vienna: doctors in the Heubner section for infectious diseases. Photograph, 1921

Page 41: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale
Page 42: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

What is evidence-based design?

• “Everything we do has consequences for people and their relationships. The art of architecture is not only to make things beautiful – nor is it only to make useful things, it is to do both at once – like a tailor who makes clothes that look good and fit well” (Hertzberger, 1991 p174)

• But as well as looking good and fitting well, what about function: waterproof, warm, protective…?

Page 43: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Sailer et al 2008

• Based in the concept of Evidence-Based Medicine

• “Evidence based design is less well defined and less rigorously constructed”

• “Best available information from credible research… [and] evaluation of projects”

• Questions whether experiential learning (on the job) is a form of research

• Is this the same debate as in Nursing?

Page 44: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Architecture & Nursing: Shared experience of resistance to evidence

• Tendency for the practitioner to value experience over research evidence

• Epistemological approach using empirical as only one “way of knowing”

• Poor generalisability• Poor evaluation of rigour and application• Lack of repetition• “Research” not weighted in terms of

hierarchy of evidence

Page 45: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

• “Evidence-based design is not an easy, straight-forward practice. Not only is architectural research still a very young field, it is also very unusual in a discipline that draws so much on intuition, artistic inspiration, learning-by-doing, and practical experience.” (Sailer et al 2008)

Page 46: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Current best evidence – Ulrich et al (2005)

• Systematic review of over 600 peer-reviewed studies. Criteria for “rigorous and high impact”, but no control for type of studies therefore literature review rather than meta-analysis.

• Identified four areas linking the physical environment to patient and staff outcomes:– Reduce staff stress and fatigue and increase

effectiveness in delivering care– Improve patient safety– Reduce stress and improve outcomes (patient)– Improve overall healthcare quality

Page 47: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Reduce Staff Stress and Fatigue and Increase Effectiveness in

Delivering Care

• Improve staff health and safety through environmental measures

• Increase staff effectiveness, reduce errors, and increase staff satisfaction by designing better workplaces

Page 48: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Improve Patient Safety

• Hospital Acquired Infections• Reducing infection caused by airborne

pathogens• Reducing infections by increasing hand-washing• Effect of number and location of

sinks/dispensers on hand-washing• Reducing infections with single-bed rooms• Reducing medication errors• Reduce patient falls• Improve patient confidentiality and privacy

Page 49: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Reduce Stress and Improve Outcomes

• Reduce noise

• Improve sleep

• Reduce spacial disorientation

• Reduce depression

• Provide nature and positive distraction

• Provide social support

• Improve communication [with] patients

Page 50: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Improve Overall Healthcare Quality

• Provide single-bed patient rooms

• Reduce length of stay

• Increase patient satisfaction with quality of care

• http://www.youtube.com/watch?v=fvIEUCatq7g&feature=player (play from 1.48)

Page 51: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Recommendations

• Provide single-bed rooms in almost all situations. Adaptable-acuity single-bed rooms should be widely adopted. Single rooms have been shown to lower hospital-induced nosocomial infections, reduce room transfers and associated medical errors, greatly lesson noise, improve patient confidentiality and privacy, facilitate social support by families, improve staff communication to patients and increase patients’ overall satisfaction with health care

Page 52: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Recommendations cont.

• New hospitals should be much quieter to reduce stress and improve sleep (and other outcomes)– Single rooms, sound absorbing ceilings, noiseless pagers, etc.

• Provide stress-reducing views of nature• Develop “way-finding” systems• Improve ventilation

– Improved filters, pressurization and vigilance during construction

• Improve lighting– Access to natural light and full-spectrum lighting

• Design ward layout and nurses stations to reduce staff walking and fatigue, increase patient care time and support staff activities such as medication supply, communication, charting and respite from stress

Page 53: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Design

A&E

• Design council toolkit to reduce violence and aggression:

• http://www.designcouncil.org.uk/AEtoolkit/

General

• “We envision a world where every hospital, health clinic, treatment center, doctor’s office, and residential care facility is designed to improve both the quality of care and outcomes for patients, residents, and staff” Center for Health Design

• http://www.healthdesign.org/

Page 54: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

Limitations

• Evidence-based architecture case-study based

• Low hierarchy of evidence

• Replication not sought by architects

• Cost-benefit analysis not clear

• Recommendations based on project analysis

• Influenced by consumer preference and expectations rather than evidence?

• But – significant health outcomes

Page 55: Nursing & Humanities: Accommodation The History of British Hospital Architecture & Evidence-Based Design in Hospital Architecture Ian Noonan Florence Nightingale

References• Joseph A (2006) The role of the physical environment in promoting health,

safety, and effectiveness in the healthcare workplace The Center for Health Design Issue Paper 3 www.healthdesign.org (accessed 2/2010)

• Kroll K (2005) Evidence based design in healthcare facilities Building Operation Management http://www.facilitiesnet.com/healthcarefacilities/article/Evidence-Based-Design-in-Healthcare-Facilities--2425 (accessed 11/2009)

• Prior L (1988) The architecture of the hospital: a study of spatial organization and medical knowledge The British Journal of Sociology 39 (10) 86-113

• Suttell R (2007) Evidence based design shapes healthcare facilities… Buildings 1.1.2007 http://www.allbusiness.com/construction/construction-buildings-residential/3997431-1.html (accessed 12/2009)

• Ulrich R et al (2005) The role of the physical environment in the hospital of the 21st century: a once-in-a-lifetime opportunity The Center for Health Design http://www.healthdesign.org/research/reports/pdfs/role_physical_env.pdf (accessed 2/2010)