Publications IPH Magazine Revista IPH Nº 15 Humanizing the Hospital
Humanizing the Hospital
Gúliti Ricardo Fagundes Nascimento
Introduction
The humanization of healthcare facilities concerns the building structure resulting from architecture projects whose purpose is to achieve a standard that leads to users' satisfaction and well-being by making use of a set of tools and organizing the environment in a way that soothes the individual.
Brazil lacks studies regarding hospital humanization since this concept may at times be used to describe the building of a facility or the service it provides for the population.
Nonetheless, some people in the hospital industry believe the humanized environment is already a reality since it would be a prerequisite to draw clients. On the other hand, others are of the opinion that a humanized environment must have volunteer workers. Therefore, scientific knowledge provides a better understanding of how the environment interfere on people's health. We also know there are some factors that can both harm or benefit a treatment, so it is important to consider the nature of a hospital and medical assistance's work changes over time, adding new values to reach more quality of life for clients where improving the healthcare facility becomes part of patient care.
Fontes (2004) believes the humanization of healthcare facilities is being considered when designing a new building plan. The author arguments:
"The most recent health plans in architecture have been applying the concept of humanizing care, representing a new and holistic focus on the patient who is seen as part of a context instead of a bunch of symptoms and pathologies to be studies by isolated medical specialties". (FONTES, 2004. p.59).
We must concern patients as a whole, freeing the space from noises; vibrating colors; textures; and air pollution, attempting to get them in contact with nature with openings that allow them to see the outside. Moreover, indoor gardens have been used as an alternative to improve que quality of buildings.
Color is a powerful stimulant that may affect humor and sensitiveness, producing foremost impressions, emotions and sensorial responses that might disturb our state of awareness, trigger a desire, set off our imagination and evoke feelings of attraction or repulse, therefore acting upon us as either a stimulating or soothing energy Costi (2002, p.115).
One must consider the use of colors since it contributes for therapeutic process and body and mind balance. When used accurately it boosts well-being. However, it is advisable to level the use of colors with proper illumination to achieve functional and cozy spaces that provide stimulus and feelings to their occupants.
Lida (2002) affirms color visibility, contrast, and purity is what catch our attention, and to achieve that it must be toned down (using white) or darken (with black). However, contrasting colors - yellow over blue background; green over magenta; or red over cyan -can be tiring if the space requires permanent attention.
It is also noteworthy that in Brazil most of healthcare facilities fail to provide any sort of illumination, treating every room the same whereas each space should be considered according to its need and purpose.
Therefore, the light must be regarded not only as a sole visual resource but also as its benefits to our health. To ensure all hospital activities - procedures; exams; entertainment; and monitoring - are carried out satisfactorily and safely it is important to set up illumination systems for that purpose (ANVISA, 2007).
Natural illumination should be available in the building to enhance its structural quality and patient's recovery, besides reducing energy use and the need of artificial light and air-conditioning. Finally, colors and illumination when combined might help with patient's recovery, promoting significant progress in the course of treatment as well as leading to a more humanized, pleasant and comfortable spaces.
As a result, a patient-driven institution requires a number of factors, being the physical building one of them. For the architectonic plant to cover patient needs as much as possible, it is key to evaluate the building after operation begins, which should be one of the stages of the project (CARPMAN et al., 1986; MALKIN, 1992).
Nevertheless, the effort is made to consider the aspects of humanization to design comfortable spaces for the patients and seek solutions with the purpose of fulfilling technical and human needs by developing spaces for entertainment and socialization, which will be used as therapeutic actions to ensure patient's mental and physical well-being. The building then must present a physical structure that is open to the use of new technologies to develop more humanizing conditions.
Methodology
We undertook a quantitative work of literature review focusing on discussing solutions concerning environmental comfort that enhances physical quality of the space and the humanization process within hospitals in general. Our references included scientific articles; books; academic papers; and online libraries such as ANVISA's Environmental Comfort in Healthcare Facilities Manual, and the National Guidelines for Hospital Humanization.
Acoustic Comfort
A hospital requires special acoustic comfort conditions. There is the need to comply with the level of noise recommended by technical standards, however there are places and situations where unnecessary and loud noise is produced, and unnecessary noisy is the cruelest lack of consideration (apud HOSKING, 1999, p. 163).
Architect and engineer Jarbas Karman states that among all deficiencies found in the construction of healthcare facilities the noises and vibrations are the ones who leave us with hardly any alternative for afterward maintenance. Also, according to him, hospital special equipment is noisy and therefore call for specific implementation with appropriate and limited localization (KARMAN, 2011, p. 78).
J. C. Yoder, doctor and professor at University of Chicago's Pritzker School of Medicine, believes the noises produced within hospitals put patients at risk. He arguments that "hospitals should take action to reduce night noises to promote patient's comfort and recovery, since lessen noises might be a simple way to adopt careful attitudes" (YODER, 2012, p. 1).
Consequently, it is advisable to be prudent and knowledgeable when choosing coating material to correct acoustic performances, combining hygienic and acoustic elements. Deciding on the proper flooring may make it easier to keep a healthy environment hence contributing for the control of hospital infections and the comfort of patients and other users. Such material must be resistant to abrasion, or other impacts it might suffer; washing; chemical products for disinfection; and deterioration caused by circulation of people and equipment (MIGUEZ, 2013, p. 2).
Some floor coating material, like floor blanket or vinyl planks, rubber or linoleum, might reduce noise reverberation in the hospital environment. Besides rubber and vinyl coatings, there are some special conductive flooring for operating rooms and other environments with specific grounding conditions (ANVISA, 2014).
The ceiling coating could enhance the acoustic comfort inside healthcare facilities, there are fixed and removable ones, and for each type there are factors to consider regarding its contribution for noise cutback. The prevention and control of infections must also be taken into account respecting asepsis and cleaning recommendations, seeing as RDC #50 says the appropriate materials for wall, flooring and ceiling coating in critical and semi-critical areas must be resistant to washing and use of disinfectant (BRASIL, 2002, p. 107).
Some specific noises within healthcare facilities cause outstanding discomfort for both patients and professionals who directly deal with support activities. There is usually little control over those noises causing great amount of human discomfort in the hospital environment (ANVISA, 2014).
Even so, we must observe the sound reverberation impact that each material can have over the environment and the acoustic discomfort they might cause.
Visual Comfort: Illumination and Colors
To measure the quality of the environment for health assistance we ought to consider the visual comfort arranged by light and color elements aiming at alleviating the work to be done.
According to the Brazilian National Standards Organization (ABNT), on its NBR ISO/CIE 8.995 - 1 - Illumination at working places (2013, p. 1).:
"Good lighting enables the visualization of the environment, allowing people to see each other, move safely, and perform visual tasks in an efficient, accurate and safe manner avoiding eye fatigue and discomfort. Illumination might be natural, artificial, or a combination of both."
Therefore, the use and intensity of light must be a concern when planning hospital environments, visual comfort might encourage an active participation in the therapy. The space design must consider the user lighting demands and the natural conditions of the environment.
Thereby, the solutions must include apertures overlooking outdoor landscapes with the use of architectonic materials and elements that respect users' privacy, such as brise-soleil and balconies, as well as other architectonic elements that leverage natural conditions. (ANVISA, 2014).
In the areas intended for admissions, where patients might spend many hours or days, certain artificial illumination conditions and the possibility to see the outside may bring comfort and the important perception of time due to the circadian rhythm. The project should also contemplate the specificity of the activity carried out in every environment and the ergonomic impact lighting has over users. For emergency rooms; operating rooms; intense care unities; and other critical areas, the effects of visual impact caused by excessive illumination might lead to relevant emotional discomforts, bringing about displeasure and stress, feelings that harm the quality of the assistance. (ANVISA, 2014).
Nonetheless, an important approach to be considered in healthcare facility plans willing to offer the best high-quality comfort is the FGI recommendations regarding natural illumination and a view to natural landscapes whenever possible (FGI, 2010, p. 15).
Colors
Using chromatic references to set an ambience for health buildings has become a current practice. Humanized solutions, such as surgery centers with windows between rooms and outdoor windows and different colors for each room, an intensive care unity with similar features with visualization of outdoor chromatic conditions might contribute to a less unfeeling hospital, but at the same time keep the formality its procedures and functions require. (ANVISA, 2014).
The architectonic plan is an elemental link between clients' expectations and the effectiveness of the actions carried out in the building, which assume two roles: offer the services it was built for and provide therapeutic aid in addition to medical care. If the building architecture fails to achieve its therapeutic role, it is expected that at least it will not interfere negatively with patients' treatment. (ANVISA, 2014).
The space architecture and ambience play a key role in humanization. If drugs have the power to relieve physical pain, colors might mitigate the monotony of long-lasting confinement. The colors on healthcare facility walls represent abstract values that are perceived differently by each patient. One way or the other, the colors will not change the quality of the service, although they might provide a much-needed sensation to patients.
Colors have various functions and effects over the individual: biological and psychological effects; and it give a sense of security while organizing and orientating the space (COSTI, 2002; GRANDJEAN,1998; IIDA, 1997).
Colors are the most noticeable aspects, they establish a social, geographic and cultural link with the person's age and sensitiveness. There are no standard colors defined, no chromatic treatment can be regarded as a rule, there is no sole solution, though it is often useful to design a space the patient can relate to culturally, which resembles his/her home, imparting affection (ROMANELLO, 2006, p. 84).
Nonetheless, healthcare environments require attention since they receive a great diversity of people. Color is a powerful language that can affect much more than just our mental capacity, humor and time perception. They can also influence our perception of volume, shape, space and perspective (HOSKING, 1999, p. 119).
Theoretical reference
Over the past decades, hospitals have become a space to heal numberless diseases. The concern to have ventilated and well-illuminated areas to ensure activities and soothe the exhausting stay of patients encourages increasing discussions and improvements for those spaces.
"Humanize means to give humane conditions to anything or any place. It is a value while respects human life. It embraces social, ethic, educational and psychic circumstances inherent to every human relationship." (VASCONCELLOS, 2004, p.23).
Hospital buildings evolved throughout time following new technologies, the concerns regarding the hygiene and the architectonic solutions that prioritize natural illumination and ventilation (COSTI, 2002).
Consequently, the influence of the light on hospital environments - whether in spaces used by patients or workers - has been dealt by some professionals using new illumination approaches (FONSECA, 2000 apud HOREVICZ e DE CUNTO, 2007).
Toledo (2006) believes the client's perception of hospital buildings in Brazil has been little explored when considering the concept of humanization, diminishing the chances of fulfilling their expectations and needs, which will reflect on the quality of the plant and on the humanization of hospital environments.
He adds that workers and clients have visual requirements for quantitative elements regarding illumination. But the plants usually adopt time-honored standards that are not always the most appropriate ones, which lead to either flawed solutions or solutions that fail to meet the needs intended (TOLEDO, 2006, p. 96).
Zumtobel (2008) assumes the natural light is a key factor for this sort of environment during the day; during the night, there must be a planning of the main activies with the use of artificial illumination. In places lacking natural illumination, there is the possibility to create, with artificial illumination, the effects of day light including its changes throughout the day, which might reduce anxiety, arousing well-being and helping to appease family members or visitors. On that account, the illumination project of a hospital is as important as planning the whole building, especially if regarded as the main factor to promote the humanization of the physical space (ZUMTOBEL, 2008).
Mezono (1995) highlights hospital humanization is also the humanization of the society as a whole, noting that a violent, iniquitous and exclusionary society interferes with the context of healthcare facilities, especially hospitals. Humanizing hospitals means doing whatever it takes to make it more suitable for the people, respecting their rights.
By that means, properly ventilated and illuminated hospital buildings with enjoyable premises speed up patients' healing process, since they feel more comfortable to face their exhausting admission routine.
In Brazil, humanization standards are established by the Ministry of Health through governmental programs, such as the National Program to Humanize Hospital Care (PNHAH); the Humanization Program during Prenatal and Birth (PHPN); and the National Humanization Policy (PNH) (VAITSMAN; ANDRADE, 2005). HumanizaSUS was developed with the purpose of offering humanized assistance for those depending on the National Health Service (SUS) because it is believed investments must be made on improving the management of institutions and the services provided to the population as well on equipment, technologies and the renovation of facilities (BRASIL, 2002).
Actions taken within national health bodies and hospitals have driven us towards important progress in the relationship between clients and professionals, besides better organizing the service, taking better care of facilities, improving access and the communication with the hospital, as well as providing training for the implementation of humanization projects (BRASIL, 2002).
Humanization can be understood as the democratization of the relationship between workers, clients, and managers. The National Humanization Policy (Humaniza/SUS) is seen as a role model to a more effective care assistance that focuses on communication, exchange of information and knowledge, conversation, listening one another, and sharing decisions among workers, managers and clients (KLOCK et al., 2006).
In spite of that, integrating these hospital environments requires a humanization process that has become more natural to healthcare facilities because the way clients and workers recognize the space will set the bar for the interaction between user and space, which can be either positive or negative for recovery.
"The quality of a hospital might speed up the healing process, therefore reducing hospital time and consequently the costs with keeping hospitalized patients. Humanizing these spaces puts the focus on the patient, making the relationship between body, mind and soul indivisible. Therefore, we consider the quality of the environment and the physical or psychological influence it has on the patient, a key contribution for the recovery process." (LINTON, 1992, p. 126).
Conclusion
This article discussed humanization as the main area in hospital architecture in healthcare facilities.
In Brazil, the concept of humanized environment is still new, given that hospitals are major constructions that require various technical specificities, unique flows and a consistent theoretical foundation to be planned, which involves a reassessment of the real purpose of the hospital building developing areas that might indeed contribute to patient's recovery.
Humanizing healthcare facilities is of the foremost importance. Besides playing a part in the therapeutic process of the patient it also contributes for the quality of the healthcare services provided by the professionals established there.
Finally, integrating indoor and outdoor spaces is important within the hospital environment for patients - who feel better and recover faster - and workers - who are able to perform better once they have a more pleasant and less stressful working environment; ensuring relevant reduction in costs due to abridged time in the hospital and less consumption of drugs. Such practice involves everyone and could be put into practice effective immediately, all we need is to change the way we look at one another.
References and Additional Bibliography
ASSOCIAÇÃO BRASILEIRA DE NORMAS TÉCNICAS (ABNT). Iluminação de Ambientes de Trabalho. Parte 1: interior. ABNT NBR ISSO/CIE 8.995-1. Rio de Janeiro, abr. 2013, 46 p.
BRASIL. ANVISA. Agência Nacional de Vigilância Sanitária. Conforto Ambiental em Estabelecimentos Assistenciais de Saúde / Tecnologia em Serviços de Saúde. Brasília: 1ª edição, Agência Nacional de Vigilância Sanitária, 2014.
BRASIL. ANVISA. Agência Nacional de Vigilância Sanitária. Resolução RDC nº 50, de 21 de fevereiro de 2002. Regulamento Técnico para planejamento, programação, elaboração e avaliação de projetos físicos de estabelecimentos assistenciais de saúde. ANVISA Publicações Eletrônicas 2002.
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CARPMAM, J. R., Grant, M., & Simmons, D. A (1986). Design that cares: planning health facilities for patients and visitors. Chicago: American Hospital Association.
COSTI, M. (2002). A influência da luz e da cor em salas de espera e corredores hospitalares. Editora EDIPUCRS, 1ª edição, Porto Alegre.
THE FACILITY GUIDELINES INSTITUTE (FGI). Guidelines for design and construction of health care facilities - 2010 edition. American Society for Healthcare Engineering of the American Hospital Association (ASHE). Chicago, 2010.
FONTES, M. P. Z. (2004) Humanização na Arquitetura da saúde: a contribuição do conforto ambiental dos pátios e jardins em clima quente e úmido. In ENTAC 2004 -trabalho completo em cd room. São Paulo: Encontro Nacional de Tecnologia do Meio Ambiente Construido.
HOREVICZ, E.; DE CUNTO, I. A Humanização em Interiores de Ambientes Hospitalares. Revista Terra e Cultura, Nº 45, Ano 23, dezembro 2007, Centro Universitário Filadélfia, Cornélio Procópio, 2007.
HOSKING, Sarah; HAGGARD, Liz. Healing the hospital environment. Design, management and maintenance of healthcare premises. E & FN SPON. Taylor and Francis Group. London, 193 p., 1999.
KARMAN, Jarbas. Manutenção e Segurança Hospitalar Preditivas. São Paulo: Estação Liberdade: IPH, 2011.
KLOCK, Luciana Lúcio; GALVÃO, Claudia Raff; CHANES, Marcelo. Administração hospitalar: instrumentos para a gestão profissional. In: FEDERIGHI, Waldomiro José Pedroso. O enfoque do planejamento estratégico na gestão hospitalar. São Paulo: Edições Loyola, 2006, p. 73- 117.
LIDA, Itiro. Ergonomia: Projeto e Produção. São Paulo: Edgard Blucher, 2002.
LINTON, Patrick E. Creating a total healing environment. In: Symposium on Healthcare Design, S, 1992, San Diego. Innovations in Healthcare Design: selected presentations fron the first five Symposia on Healthcare Design. New York: Sara O. Marberry, 1995.
MALKIN, J. (1992). Hospital Interior Design. Nueva York: Van Nostrand Reinhold.
MEZONO, J. C. Gestão da qualidade na saúde: princípios básicos. São Paulo: J. C. Mezono, 1995.
MIGUEZ, Claudia. A aplicação sustentável de pisos vinílicos nos estabelecimentos assistenciais de saúde. Artigo. Informativo ABDEH: Ambiente Saudável, São Paulo, p. 2, 2013.
ROMANELLO, Isabella. Il colore: espressione e funzione. Guida ai significati e agli usi del colore in arredamento, architettura e design. Milano: Ulrico Hoepli Editore S. P. A., 2006.
TOLEDO, L. C. Feitos para Curar: Arquitetura Hospitalar e Processo Projetual no Brasil. Rio de Janeiro: ABDEH, 2006, 127 p.
VAITSMAN, J; ANDRADE, G, R, B. Satisfação e responsividade: formas de medir qualidade e humanização da assistência à saúde. Ciência e a saúde coletiva. Rio de Janeiro, v.10, nº 3, p. 599 - 613, [s.d]. 2005.
VASCONCELOS, R.T.B. Humanização de ambientes hospitalares: características arquitetônicas responsáveis pela integração interior/exterior. 2004. Dissertação (Mestrado). Faculdade de Arquitetura e Urbanismo, Universidade Federal de Santa Catarina, Florianópolis, 2004.
YODER, J. C. et al. Hospital Noise Puts Patients at Risk. AJN, Arch Intern Med, v. 112, n. 4, apr. 2012.
ZUMTOBEL. Lighting Hand Book. Debindorn/Austria, dez. 2008. Disponível em: <www.zumtobel.com/healthcare>. Acesso em 01 de dezembro de 2017.
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