Safe and Restorative Physical Surroundings
In a nutshell . . . .
This page introduces you to the fifth of the six ideas that give life to the Therapeutic Milieu, Safe and restorative physical surroundings. Probably the earliest, very detailed guidelines focused mainly on patient safety in nursing in Ireland, dating from the early 1800s, are reviewed. Later historical documents emphasise the importance of both safety and the restorative, or healing, influence of patients' physical surroundings.
You will find that historically, the restorative quality of patients' hospital or home surroundings were considered very important, that is, their healing, soothing and uplifting influence. But more recently, concern with the healing potential of patient's physical surroundings has been replaced by concern with functional and cost efficiency of patients' surroundings.
Recent research is outlined which indicates a return of concern for the healing effects of patients' physical surroundings which can also be cost-effective, for example, the healing effects of full spectrum lighting.
Suggestions for practice are given – as well as examples which indicate that sensitivity and prudence are important in considering the meaning patients' surroundings may have for them.
Safe and restorative physical surroundings is the fifth concept of the Therapeutic Milieu not because it is any less important than the foregoing Therapeutic Milieu concepts, but because it concerns the outward life of nurses and the people they care for and complements the foregoing concepts, concerned mainly with the inward life.
Safe and restorative physical surroundings are created by the actions nurses' take to protect patients from physical harm and promote healing. Such surroundings are meticulously clean and orderly, free from potentially harmful physical factors, as quiet as possible, and maximise the effects of naturally occurring healing elements such as light, fresh air and colour.
Because urses have a long history of establishing and maintaining safe and restorative physical surroundings for persons who are sick, injured or vulnerable, it is not surprising that this concept emerged from the historical data from which Careful Nursing was developed.
Background of concept
One of the earliest objective concerns of nurses, especially in hospitals, was the creation of safe and restorative physical surroundings for vulnerable, sick or injured people (Dock & Stewart 1920). For example, in Ireland in the early 1800s lay nurses at the Hardwick Fever Hospital in Dublin, one of city's House of Industry (Workhouse) hospitals, paid the greatest possible attention to creating safe and restorative surroundings for their patients.
These nurses, working in close collaboration with the hospital's attending physician, John Cheyne (of Cheyne-Stokes breathing fame), drew up and Dr. Cheyne published nursing practice guidelines which emphasized the nurses' primary responsibility for patients' safety and for the cleanliness, ventilation and order of patients' surroundings, including the orderly conduct of visitors to the hospital (Cheyne 1817). Dr. Cheyne had the highest praise for the nurses, declaring that they allowed nothing to escape their observation.
The Crimean War journals of the early 19th century Irish nurses (1820s–1860s), whose nursing practice forms the basis for Careful Nursing, attest extensively to their concern with maintaining the cleanliness and safety of patients' physical surroundings, both in patients' homes and in hospitals (Luddy 2004).
The concerns of the Irish nurses were bought to nurses' attention internationally by Florence Nightingale in her landmark book, Notes on Nursing (1860/1969). Nightingale addressed in detail nurses' responsibility for establishing and maintaining cleanliness, ventilation, fresh air, good light, minimal noise, well-ordered furniture, lack of clutter, and adequate personal space. Nightingale also noted the soothing effect a patient can experience from being able to look at a beautiful object, a particular colour, or the natural world.
The concept of safe and restorative physical surroundings fell naturally into the Therapeutic Milieu dimension of the professional practice model. It is easily recognized by contemporary nurses as an important nursing concept, based on their experience in practice and the many references to its importance and maintenance in the nursing literature.
While all health professionals participate in maintaining safe and restorative physical surroundings, it is nurses' professional responsibility to take the lead in creating and maintaining these surroundings. In hospitals our leadership in this area is reinforced by our 24/7/365 presence in clinical settings.
In contemporary society we commonly delegate some activities that maintain these surroundings to care assistants or contract them to companies, for example cleaning. Nonetheless, it is still our responsibility to ensure that the activities are carried out to the highest possible standard.
Safe physical surroundings
Protection of patients, ourselves and others from harm caused by physical objects, especially in busy and sometimes over-crowded hospital surroundings, is of the highest priority. From experience in practice we can categorize physical objects into macroscopic, such as furniture, equipment, or electric leads trailing across a floor, and microscopic, such as bacteria.
Protection from macroscopic objects most often concerns removal of clutter from hallways and patient rooms, particularly equipment that is waiting to be cleaned or charged. Protection from microscopic objects invariably means meticulous, on-going cleaning, and when necessary wearing protective equipment and garments. Protection from infection, or infection control, is one of the greatest safety concerns in healthcare.
The design of a hospital or healthcare building itself may contribute to or detract from the safety of its physical environment. For example, its floors may provide for more secure or less secure walking stability. The width and position of its doors may influence their safe use. The size and shape of its rooms may be more, or less, likely to facilitate care of patients as well as cleaning and elimination of bacteria.
As nurses, we are in a perfect position to advocate for safe healthcare buildings. Schweitzer et al., (2004) propose that because of the rise of science, development of complex medical/surgical diagnostic techniques and treatments, and increasing emphasis on efficiency and cost-effectiveness, modern hospitals have become noisy and cluttered. As a result, little attention is now given to the healing potential of patients' physical surroundings, or to the potentially harmful effects of some physical surroundings.
Restorative physical surroundings
Safe physical surroundings are a necessary foundation for restorative physical surroundings. Schweitzer et al., (2004) note that the healing and restorative effects of a patients' physical surroundings have been known for many centuries. Likewise, Biley and Freshwater (1998) observe that many hospitals of earlier times were situated and designed to promote convalescence; that is, to help restore patients' health; but that this aim has been mainly replaced by promotion of instrumental and functional efficiency.
Restorative surroundings help facilitate relaxation, calmness, and healing. Schweitzer et al., (2004) review in detail research-based healing effects of certain physically sensed factors such as colours and aromas, fresh air and good ventilation, ambient temperature, calming sound, full-spectrum lighting, artwork, certain types of music, and a view of the natural world. While these restorative influences may not be possible in all homes and hospitals, they can be introduced and adapted in many settings.
Some of these influences may cost more, but whether cost-containment should always come before healing influence is worth considering. For example, full spectrum lighting, which is similar to natural sunlight, costs more than fluorescent lighting. However, research findings demonstrate its significant healing effects in many types of healthcare settings (Schweitzer et al., 2004).
Further, research has shown that full spectrum lighting can be effective in reducing infection (Wiltshire et al., 2015). Full spectrum lighting could be more cost-effective in the long run. Some physical environmental influences may be easier to establish in some types of settings. For example, many can be successfully implemented in long-term care facilities (Komarek, 2004). But some can also be implemented in hospital intensive care units (Bazuin & Cardon, 2011).
Suggestions for practice
Our creation and maintenance of safe and restorative physical surroundings depends on our being ever-watchful and not taking our familiar physical surroundings for granted. Weiss-Krupa et al. (2011) make the point that "the smallest missed detail can have the biggest impact" on safety (p. e55). As critical care nurses they were aware of the always-possible need to move patients quickly from critical care units during an emergency. But they realized that the usually cluttered units and surrounding hallways, sometimes crowded with equipment and transfer beds, would make this very difficult.
Weiss-Krupa et al. (2011) adapted a system from the United States Navy called "Walk the Deck". This involved developing a comprehensive check-list of all physical threats to safety in and around their clinical units. Then, twice a day a senior nurse's aide would "walk the units" (p e55) doing a thorough inspection according to the checklist and then meet with the charge nurse to resolve any safety threats. Over three months, compliance with safety standards increased from 5-10% and units and hallways were consistently clearer. This is an innovative approach which could be adapted to many settings.
Another innovative research approach to improving safety, this time in a hospital outpatient haemodialysis unit, is reported by Marck et al. (2014). Using nurses' focus group stories about the physical safety and quality of the unit and photos taken on a nurse-led photo walk-around of the unit, they identified several common threats to unit safety including clutter, poor air quality, sources of infection, and tripping hazards from hoses. Conducting the study deepened their awareness of the complexity of maintaining safe surroundings. It also stimulated a rich dialogue among nurses about identifying safety threats and enhancing safety. This approach could also be followed or adapted for use in many settings.
Words of caution
Admission to the unfamiliar surroundings of a hospital
Many of us will have had the experience of caring for older persons who find themselves unexpectedly admitted to a hospital. They are sometimes deeply shocked by the sudden change from their home surroundings to those of a hospital and can easily become disoriented. Experience suggests we can help them avoid this state by encouraging them to keep small meaningful personal objects close to them. These may include a pillow, a blanket, a piece of clothing, photos or other small objects. It would be unwise to mistake such personally grounding objects for bedside clutter.
The importance of meaning in home surroundings
Consider the story of a community health nurse who once a week visited an elderly gentleman in his tiny, city council-owned flat. He had friends but no living family members. He was well-oriented to present time and very quick and witty in conversation. But, like himself, everything in his comforting little home was old and not as clean as we might think necessary.
Due to a decline in his health he was admitted briefly to a community hospital for assessment. While he was there well-meaning friends took the opportunity to spring clean his home. Everything was washed, walls were painted; and curtains, some furniture and kitchen items were replaced.
When the nurse next visited she found her elderly gentleman sitting at a new table on a new chair trying to come to terms with his new, relentlessly clean and ordered physical surroundings. With soft, sad eyes he met the nurse's gaze despondently; "I feel like I'm in a sepulchre", he said (a stone tomb in which a body is buried). He continued along alright for a while but never really recovered.
As professional nurses, our responsibility and leadership in relation to the creation and maintenance of safe and restorative physical surroundings for persons who are sick, injured or vulnerable is long-standing. Threats to patients' safety and the restorative quality of their surroundings change over time in response to advances in science and healthcare, and to changes in economic conditions.
Currently, threats to creation of restorative surroundings may be overlooked in the interests of technical needs and functional efficiency. Judgements about threats to patient safety and the restorative quality of their surroundings are always to be made humanely in relation to patients' personal needs.
Safe and restorative surrounding 'I will' statements
Sit quietly in a chair, close your eyes and take a moment to relax and recall your experience of stillness.
Bring to mind your practice experiences over the past three months.
On a scale of 1 to 10, how do you rate your attention to creating the safest possible physical surroundings in your practice area?
On a scale of 1 to 10, how do you rate your attention to creating the best possible restorative surroundings in your practice area?
Based on your assessment of your current level of attentiveness to creating safe and restorative physical surroundings for the people for whom you care, decide what you will do to further develop your responsibility to create safe and restorative physical surroundings in your practice setting.
Examples of nurses' safe and restorative surrounding 'I will' statements:
. . . always notice whether patients' bedside area needs to be cleaned or tidied
. . . evaluate standard of cleaning being provided in the ward
. . . . . . . . . . . . . . . . . . . . . . . . . monitor patient visiting to ensure it is not disruptive or stressful for patients
. . . . . . . . . . . . . . . . . . . . . . . . . increase my awareness of how physical surroundings could help patients relax
Bazuin, D. & Cardon, K. (2011). Creating healing intensive care unit environments: physical and psychological considerations in designing critical care areas. Critical Care Nursing Quarterly, 34, 259-67.
Biley F.C. & Freshwater, D. (1998). Spiritual care and the environment: a new paradigm for nursing? Complementary Therapies in Nursing & Midwifery, 4, 98-99.
Cheyne, J. (1817). Medical report of the Hardwick Fever Hospital. The Dublin Hospital Reports and Communications in Medicine and Surgery, 1, 1-56.
Dock LL & Stewart IM (1920) A Short History of Nursing from the Earliest Times to the Present Day. G.P. Putman's Sons, New York.
Komarek, A.G. (2004). Creating a healing environment. Nursing Homes: Long Term Care Management, 53 (10): 78, 80-1, 123-4.
Luddy M. (ed.) (2004) The Crimean Journals of the Sisters of Mercy 1854-1856. Dublin, Four Courts Press.
Marck, P., Molzahn, A., Berry-Hauf, R., Hutchings, L.G. & Hughes, S. (2014). Exploring safety and quality in a hemodialysis environment with participatory photographic methods: a restorative approach. Nephrology Nursing Journal, 41,(1), 25-35.
Meehan, T. C. (2012). The Careful Nursing philosophy and professional practice model. Journal of Clinical Nursing, 21, 2905–2916.
Nightingale, F. (1860/1969). Notes on Nursing. New York: D. Appleton and Company/ New York: Dover Publications.
Schweitzer, M., Gilpin, L. & Frampton, S. (2004). Healing spaces: elements of environmental design that make an impact on health. The Journal of Alternative and Complementary Medicine, 10, Supp. 1, S-71–S-83.
Weiss-Krupa, M., Caplan, J. Kubis, S. & Roberts, K.E. (2011). Walking the deck: standing tall for a safe environment. Critical Care Nurse, 31(2) , e55.
Wiltshire, M.M., Dale, C. & Simmons, S. (2015). Impact of Full Spectrum Ultraviolet Light Disinfection on Recurrent Clostridium Difficile Cases Within a Skilled Nursing Facility. American Journal of Infection Control 43 (6) Supplement, S25.
Therese C. Meehan © July 2020