CREATING

A HEALING
ENVIRONMENT

Recommendations for Private Practice Design

PEEK Project 2017

Cade Motteram
LA TROBE UNIVERSITY
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CONTENTS

Introduction 2-3

Key Recommendations 4-10

Visual Environment 4-5

Lighting 6

Sound and Music 7-8

Colour Theory 9

Air Quality 10

Clinical Framework 11

Application in Practice 12-14

Upwell Health Collective 12-14

Future Considerations 15

References 16-19

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I N T RO D U C T I O N

In todays dynamic healthcare environment, physiotherapists are uniquely positioned

to provide the community with evidence-based education, assessment, treatment,
management, and prevention for a range of health conditions. However, it is of this authors
opinion that the current private practice approach appears to greatly under-estimate the
impact the physical environment in which patients are treated has on staff, clients, and the
wider community.

Recently, the international hospital sector has recognised such importance, and have
implemented evidence-based design recommendations, coined the creation of a healing
environment, that has shown to lead to shorter length of stay, increased repeat business,
fewer episodes of patient psychological distress, lower staff turnover, higher staff and patient
satisfaction and mental well-being, reduced per-patient costs, and even lower reported
degrees of patient pain (Dijkstra, Pieterse, & Pruyn, 2006; Iyendo, Uwajeh, & Ikenna, 2016;
Laursen, Danielsen, & Rosenberg, 2014; Srivastava, 2017). Yet, despite the visual, auditory,
olfactory, and physical environmental recommendations that are seemingly transferable
across both public and private sectors, the literature appears devoid of specific private
practice guidance in this field (Laursen et al., 2014; Ulrich et al., 2008).

Whilst relevant empirical research is lacking, the Australian Physiotherapy Association

(APA) has previously acknowledged the challenge private organisations are likely to face in
meeting increasing industry demands from clients and staff. A 2013 report outlining the
predicted state of the private sector as at 2025 notes that central to future clinic success will
be an understanding and appropriate proactive approach to various strategic drivers that are
likely to shape operational activities and practice needs (Australian Physiotherapy
Association, 2013). Most notably, these include meeting heightened consumer expectations
regarding the quality and value-for-money of services, implementing new models of care to

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create and capitalise on new opportunities, developing a strategic point of difference for
increased competitiveness, and solving issues leading to poor staff retention and satisfaction
rates (Australian Physiotherapy Association, 2013). Whilst the APA details its opinion on the
methods of action to achieve such strategic success, recommendations are largely based
around service offerings, information technology, and personnel characteristics, with no
regard for the physical clinical environment.

In order to bridge this author-identified gap between evidence in optimal private

practice design and the necessary steps to meet such future clinical requirements in a more
holistic manner, it is therefore a key objective of this project to analyse and critically evaluate
current healing environment literature. Relevant findings will then be summarised,
presented, and extrapolated in context of private practice where necessary, so as to provide
the wider physiotherapy industry with an innovative and unique framework of subsequent
recommendations to guide clinical design decisions for continued operational success and
improved client, staff, and community health outcomes. Finally, these recommendations will
be practically illustrated via review of a current healing environment private clinic, with
conclusions and future considerations within this area of research discussed thereafter.

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K E Y R E C O M M E N DAT I O N S
VISUAL ENVIRONMENT

The visual environment consists of all those factors impacting the aesthetics and
intangible feel of private practices and can have significant impact on how clients and staff
perceive the quality of provided healthcare (Ulrich, Berry, Quan, & Parish, 2010). However,
despite robust evidence clearly linking thoughtful, emotive, and visually pleasing clinical
design to reduced stress, blood pressure, and heart rate, less self-reported client pain, and
higher client and staff satisfaction (Ulrich et al., 2010), many hospitals negatively view this
endeavor as one that is costly, time-consuming, and ultimately distracting to daily operations
(Iyendo et al., 2016; Ulrich et al., 2010). It therefore follows that if public health systems are
of this opinion, then logically, private practices with a key objective of producing
organisational profit, are likely to share similar concerns.

Whilst it is acknowledged that variability exists across the private physiotherapy

sector regarding the financial, logistical, and temporal abilities to implement such changes,
there remains numerous options for achieving appealing clinical environments. For instance,
there is strong positive evidence for incorporating views of nature and utilising natural
materials and elements where possible (Altimier, 2004; Dijkstra et al., 2006; Huisman,
Morales, van Hoof, & Kort, 2012; Iyendo et al., 2016). This may include strategically-placed
windows to allow natural-world views, installing indoor greenery such as vertical hanging
gardens, incorporating wildlife or water-based artwork and sculptures/installations such as
fish tanks and water features, and ensuring reflective surfaces producing glare are minimised
via use of matte coatings and wood-based materials (Altimier, 2004; Dijkstra et al., 2006;
Huisman et al., 2012; Iyendo et al., 2016); the latter, a consideration likely of most relevance
for those clinics treating chronic pain, vestibular, or neurological conditions.

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In addition, the spatial layout of practice furniture and fittings has the potential to
affect the degree of social interaction amongst staff and clients and can subtly dictate the
sense of client connectedness with the organisation and its treating clinicians (Huisman et
al., 2012). Arranging waiting rooms with chairs side by side discourages conversation and
fosters a sense of isolation in clients healthcare journey (Huisman et al., 2012). In contrast,
open-planned, circular arrangements can create a feeling of community and work in unison
with the overall aesthetics to stymie clients sense of injury or illness via positive distraction
(Huisman et al., 2012); a phenomenon which may otherwise potentially persist in the
traditionally unattractive, medically-focused physical environments of many older practices
that is author-hypothesized to perpetuate destructive health attitudes and beliefs.

Nonetheless, it is well documented that with consideration for such factors, results
can produce staff who are more engaged, alert, as well as cognitively creative (Dijkstra et al.,
2006; Srivastava, 2017), thus possibly leading to more innovative treatment choices and an
ultimate improvement in quality of care. For clients, this may result in stronger clinic-client
relationships (Iyendo et al., 2016), the perception of feeling more comfortable and valued as
individuals (Srivastava, 2017), improved health and functional outcomes (Iyendo et al., 2016),
and a theorized enhancement in clinic reputation and subsequent number of potential
clients.

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LIGHTING

Intimately tied to the visual environment is that of private practice lighting.

Commonly used artificial or fluorescent light, whilst likely to be often unavoidable, has
shown to contribute to visual fatigue such as eye strain, and the onset of headaches of
varying degree (Altimier, 2004; Dijkstra et al., 2006). Lighting is therefore an important
element in practice design and one which can significantly impact the health of both clients
and staff. Research has demonstrated that exposure to ultraviolet light stimulates the bodys
innate healing processes via a reduction in blood pressure, proper melatonin and sleep
regulation, enhanced protein metabolism and white blood cell production, reduced fatigue
and pain, and increased release of endorphins leading to improved mood and well-being
(Iyendo et al., 2016). In addition, natural lighting is cost and energy-efficient, and has been
linked to improved staff enthusiasm and job satisfaction, reduced anxiousness and tiredness,
as well as enhanced staff attention leading to fewer clinical errors in the hospital setting
(Altimier, 2004; Dijkstra et al., 2006; Iyendo et al., 2016).

Practically, private clinics may consider the orientation of buildings and window
placement to maximise natural exposure (Ulrich et al., 2010), implementing diming switches
in treatment and multi-purpose rehabilitation/yoga rooms to promote relaxation and a sense
of comfort (Li, Lam, & Wong, 2006), and replacing fluorescent, energy-inefficient bulbs with
softer, climate-friendly alternatives (Ulrich et al., 2008). It is important to note, however, that
there is a careful balance required between providing sufficient light to allow optimal clinical
operation in addition to ensuring the safety of staff and patients in navigating within the
clinic, and achieving the desired ambience and subsequent physiological and psychological
outcomes listed above (Ulrich et al., 2008).

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SOUND AND MUSIC

The beneficial use of therapeutic sounds and music has long been established in
psychology and neurological rehabilitation (Ulrich et al., 2008). However, similar application
in the private practice setting has received little empirical attention (Ulrich et al., 2008). From
a hospital stand-point, exposure to soothing sounds, the masking of urban and operational
noise and listening to relaxing music has been shown to help alleviate stress, anxiety and
work-induced fatigue, stimulate productivity and cognitive arousal, reduce self-reported pain
levels, enhance memory, promote physical rehabilitation and general well-being, improve
communication, and facilitate rapid physiological sympathetic nervous system recovery
(Iyendo, 2016; Iyendo et al., 2016; Laursen et al., 2014).

In contrast, unwanted noise can have severe impact on both physical and mental
health with sleep disruption, increased heart rate and respiration, higher rates of hospital re-
admission, elevated blood pressure, and increased self-reported mental fatigue and
perceived job stress impacting clinicians ability to provide optimal care (Iyendo, 2016;
Iyendo et al., 2016). In addition, it has been reported in the literature that hospital patients
are highly concerned with treatment room acoustics and the potential for others to overhear
private health conversations (Ulrich et al., 2008). Hence, physiotherapy clinics should be
aware of such concerns and strive to provide facilities that simultaneously ensure adequate
privacy whilst also avoiding distracting, overtly loud or unwanted auditory environments.

Other recommendations include the use of noise-absorbing ceiling tiles (Dijkstra et

al., 2006), pleasant natural-based sounds such as those from water fountains, ocean waves,
rain showers, and chirping birds (Iyendo, 2016; Iyendo et al., 2016), playing instrumental or
soothing music for both relaxation and the dampening of outside urban noise (Iyendo, 2016;
Srivastava, 2017), as well as considering the beneficial auditory effects of indoor plants which
have been demonstrated to reflect, diffract, and absorb various frequency sounds, argued to
be as effective as adding carpet (Iyendo et al., 2016).

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Key to creating healing acoustics, however, is recognising that sound and music is a
subjective concept of appreciation with the potential to evoke either positive or negative
emotions depending on individual characteristics, a process largely impossible to predict
(Iyendo, 2016). Nevertheless, it is clear that through adherence to the above
recommendations, a combination of both positive audio and pleasing visual environments
produce more effective results than visual elements in isolation (Ulrich et al., 2010).

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C O L O U R T H E O RY

Appropriate colour design is an integral aspect of providing an environment in which

individuals feel calm, cheerful, and productive (Iyendo et al., 2016). Research suggests that
palette selection can significantly influence emotional and physiological function, with effects
on mood, anxiety and stress, blood pressure, the nervous system, respiration, and muscle
tension (Dalke, Littlefair, & Loe, 2004; Iyendo et al., 2016). In a healthcare context, colour can
assist in the healing process and create a sense of familiarity and comfort in otherwise often
confronting and stark environments (Altimier, 2004; Iyendo et al., 2016).

Ensuring colours are well-blended and complementary, as well as strategically placed

such as in the use of signage for clinic recognition and branding in addition to way-finding
within practices for ease of navigation (Dalke et al., 2004; Iyendo et al., 2016), may
theoretically allow for more satisfied private practice staff and clients, potentially leading to
reduced employee turn-over and increased repeat business. Whilst robust evidence for
specific colour recommendations appears to be lacking, previous studies have suggested that
physical activity taken place in natural settings may produce lower degrees of self-reported
exertion, stress, and anxiety as a result of cognitive distraction, similar in principle to that of
listening to music (Gladwell, Brown, Wood, Sandercock, & Barton, 2013).

Expanding these findings, it could be argued that the use of indoor gardens, in
combination with natural and earthy colours such as greens and blues, may replicate such
physiological and psychological effects. However, it stands to reason that colour selection
must be made in response to the specific environment and its individual purpose. Waiting
rooms and consultation areas may benefit from warmer, soothing tones, whereas exercise
and rehabilitation spaces may prosper in more striking and stimulating shades.

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AIR QUALITY

Poor ventilation and airflow is a factor that is thought to contribute to the indoor
health hazard, termed sick building syndrome [SBS] (Huisman et al., 2012). Symptoms of
SBS include dry skin, mucous dysfunction of the eyes, ears, nose, and throat, as well as
headaches and general lethargy (Huisman et al., 2012). Whilst private practice clients are
unlikely to spend extended time in such an environment, the effects on staff may lead to
increased absenteeism, reduced productivity, and depressive-like symptoms (Huisman et al.,
2012; Iyendo et al., 2016; Srivastava, 2017).

Clinics should therefore consider ensuring air conditioning and heating systems are
periodically cleaned and appropriately maintained, and assess the need for air-filtering
devices if poor air quality persists (Srivastava, 2017). Interestingly, the use of essential oil
diffusers in dental practice waiting rooms has shown to contribute to reduced pre-treatment
anxiety, improved mood, and an increase in feelings of relaxation amongst female patients
(Dijkstra et al., 2006). These findings therefore suggest that aromatherapy may be a useful
option in particular settings such as womens health practices, and during pilates or yoga
treatment sessions.

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CLINICAL FRAMEWORK

Indoor Greenery Circular Seating

Wood Materials
Matte Surfaces
Visual
Environment
Wildlife/water-based Art Nature Views

Air-filtering Devices Climate-friendly Bulbs

Aromatherapy

Diming Switches

Natural Light
Ventilation

Air Quality Lighting

Healing
Regular Air System Maintenance Environment Building/window Orientation
Match with Purpose PurposeRoom

Well-blended/complementary Colours Instrumental Music

Natural Sounds
Soothing Music
ColoursCoothing Music
Colour Sound
Greens
Blues

Theory and Music

Use Strategically Match with Purpose Noise-absorbing Materials/plants
PurposeRoom

Figure 1. Healing Environment Clinical Framework - Private Practice

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A P P L I C AT I O N I N P R AC T I C E
UPWELL HEALTH COLLEC TIVE

In May 2017, Upwell Health Collective (Upwell) of Camberwell, Victoria, established

itself as a market leader in the development of private practice healing environments.
Physiotherapist and owner, Matthew Stanlake, set out to create an allied health collaboration
whereby clients can receive assessment, treatment, and management for a number of health
concerns across multiple professions within a single clinic (M. Stanlake, personal
communication, August 15, 2017). As part of this vision, Upwell has implemented many of
the evidence-based recommendations of this projects clinical framework and clearly
recognises the importance of providing clients and staff with an environment conducive to
improving health outcomes.

Central to this endeavor, is Upwells visual environment. As can be seen below, the
reception and waiting area utilises aesthetically-pleasing materials such as wood, exposed
construction elements, and complementary colours, in addition to providing circular, relaxed
seating. The result is one which promotes a sense of familiarity, modernism, and attention to
detail, differentiating itself from traditional practice design.

(Upwell Health Collective, 2017)

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In addition, Upwells use of indoor plants and hanging gardens throughout the clinic
creates a degree of serenity and enthusiasm, and ensures that unwanted urban noise is
absorbed and diffracted. The functional/rehabilitation gym also replicates natural
environments with artificial green tracking and further hanging plants, potentially reaping
the benefits of such design choices as mentioned previously.

(Upwell Health Collective, 2017) (Upwell Health Collective, 2017)

The clinics open-plan layout, encouragement of natural light with numerous, large,
well-placed windows, as well as alternative, softer lighting in treatment and massage rooms,
also maximises the interiors collaborative approach and presents an environment which
feels considered and specific to each areas functional purpose. Client privacy is also
maintained with separate consultation rooms that have been designed akin to wellness
studios, whilst still allowing for clinical practice to operate efficiently and effectively.

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(Upwell Health Collective, 2017) (Upwell Health Collective, 2017)

As a result of Upwells innovative approach, clients and staff are likely to feel more
valued and perceive the quality of care to be of a higher standard, in turn potentially
producing increased retention and satisfaction rates (Iyendo et al., 2016; Ulrich et al., 2010).
Furthermore, through such healing environment concepts, the practice is creating a unique
selling point and strategically positioning itself in a competitive industry for commercial
success; that which is simultaneously helping to improve the health of key stakeholders, as
well as meet the predicted challenges of the future, as set down by the APA. In order to
benefit the wider physiotherapy community, it is therefore recommended that more private
practices adopt similar behaviours and strive to achieve greater holistic provision of
healthcare services.

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F U T U R E C O N S I D E R AT I O N S

Whilst the modern shift towards a more neurobiopsychosocial model of care has
been a considerable step forward in recent professional practice, there remains uncertainty
regarding optimal physical environment characteristics of private practices and their effect
on staff, clients, the general population, and commercial success. This project presents those
recommendations supported by empirical evidence in the design of clinical environments,
however, research has largely focused on factors impacting the public hospital sector.
Therefore, it is argued that the private physiotherapy profession would greatly benefit from
similar studies assessing the efficacy of design recommendations and their impacts,
undertaking consultation with healthcare consumers, as well as a standard cost-benefit
analysis in implementation of such decisions.

At present, it is clear from the literature that private practices should consider factors
of the visual environment, lighting, sound and music, colour therapy, and air quality for
evidence-based improvement in health and organisational outcomes. This project concisely
displays these recommendations as a clinical framework to assist clinics in identifying,
understanding, and evaluating these factors for optimal success. However, it must be noted
that this framework is likely not exhaustive, and with each private practice of unique
circumstance, recommendations must be individually assessed for those of most benefit and
clinical relevance.

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REFERENCES

Altimier, L. B. (2004). Healing environments: For patients and providers. Newborn and Infant
Nursing Reviews, 4(2), 89-92. doi:10.1053/j.nainr.2004.03.001

Australian Physiotherapy Association. (2013). InPractice 2025: Final report. Retrieved from
https://www.physiotherapy.asn.au/DocumentsFolder/APAWCM/Resources/InPractice_
2025.pdf

Dalke, H., Littlefair, P. J., & Loe, D. (2004). Quantifying healthcare design: Beyond colour and
light. Building Research & Information, 32(6), 544-547.
doi:10.1080/09613210412331313016

Dijkstra, K., Pieterse, M., & Pruyn, A. (2006). Physical environmental stimuli that turn
healthcare facilities into healing environments through psychologically mediated
effects: Systematic review. Journal of Advanced Nursing, 56(2), 166-181.
doi:10.1111/j.1365-2648.2006.03990.x

Gladwell, V. F., Brown, D. K., Wood, C., Sandercock, G. R., & Barton, J. L. (2013). The great
outdoors: How a green exercise environment can benefit all. Extreme Physiology &
Medicine, 2(3), 1-7. Retrieved from https://extremephysiolmed.biomedcentral.com/

Huisman, E. R. C. M., Morales, E., van Hoof, J., & Kort, H. S. M. (2012). Healing environment:
A review of the impact of physical environmental factors on users. Building and
Environment, 58, 70-80. doi:10.1016/j.buildenv.2012.06.016

Iyendo, T. O. (2016). Exploring the effect of sound and music on health in hospital settings: A
narrative review. International Journal of Nursing Studies, 63, 82-100.
doi:10.1016/j.ijnurstu.2016.08.008

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Iyendo, T. O., Uwajeh, P. C., & Ikenna, E. S. (2016). The therapeutic impacts of environmental
design interventions on wellness in clinical settings: A narrative review. Complementary
Therapies in Clinical Practice, 24, 174-188. doi:10.1016/j.ctcp.2016.06.008

Laursen, J., Danielsen, A., & Rosenberg, J. (2014). Effects of environmental design on patient
outcome. A systematic review. Health Environments Research & Design Journal, 7(4),
108-119. doi:10.1177/193758671400700410

Li, D. H. W., Lam, T. N. T., & Wong, S. L. (2006). Lighting and energy performance for an office
using high frequency dimming controls. Energy Conversion and Management, 47(10),
1133-1145. doi:10.1016/j.enconman.2005.06.016

Srivastava, C. (2017). Effect of clinic design on patient care: Perceptions of medical staff and
patients. Intersect: The Stanford Journal of Science, Technology, and Society, 10(2), 1-
12. Retrieved from http://web.stanford.edu/group/ojs3/cgi-bin/ojs/index.php/intersect

Ulrich, R. S., Berry, L. L., Quan, X., & Parish, J. T. (2010). A conceptual framework for the
domain of evidence-based design. Health Environments Research & Design Journal,
4(1), 95-114. doi:10.1177/193758671000400107

Ulrich, R. S., Zimring, C. M., Zhu, X., DuBose, J., Seo, H., Choi, Y. Joseph, A. (2008). A review
of the research literature on evidence-based healthcare design. Health Environments
Research & Design Journal, 1(3), 61-125. doi:10.1177/193758670800100306

Upwell Health Collective. (2017). Gym [Image]. About. Retrieved from

https://upwellhealth.com.au/

Upwell Health Collective. (2017). Pilates [Image]. About. Retrieved from

https://upwellhealth.com.au/

Upwell Health Collective. (2017). Reception [Image]. About. Retrieved from

https://upwellhealth.com.au/

Upwell Health Collective. (2017). Treatment room [Image]. About. Retrieved from
https://upwellhealth.com.au/

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Upwell Health Collective. (2017). Yoga room [Image]. About. Retrieved from
https://upwellhealth.com.au/

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