"Designing for Health" is a monthly, web-exclusive series from healthcare interior design leaders at PerkinsWill that focuses on the issues, trends, challenges, and research involved in crafting today's healing environments. This month's topic:

A Seat at the Table: Can Furniture Selections Influence Patient Outcomes?

By Matthew DeGeeter, Moira Gannon, Jamie Huffcut, Helen Lanes, and Emily Oline

Despite the constant interface between furniture and patients, visitors, caregivers, and staff, it is mostly overlooked as an evidence-based design strategy. According to "A Review of the Research Literature on Evidence-Based Healthcare Design" by Ulrich and Zimring published in the Spring 2008 edition of the Health Environments Research & Design Journal [HERD Journal], "well-designed physical settings play an important role in making hospitals safer and more healing for patients, and better places for staff to work." While the review evaluates the importance of the physical setting, furniture is mostly overlooked. Utilizing the paper's results including "Improving Patient Safety Through Environmental Measures," "Improving Other Patient Outcomes Through Environmental Measures," and "Improving Staff Outcomes Through Environmental Measures," we posit: can evidence-based design also inform furniture selections? While visiting healthcare furniture manufacturer Nemschoff in Sheboygan, Wisc., our team engaged in discussions with company leadership, factory managers, and product representatives in order to evaluate furniture's potential influence on patient outcomes and use as an evidence-based design strategy.

Well-designed healthcare furniture could reduce the spread of infection in all areas of the hospital, from the lobby to clinical spaces. Furniture must be easily cleaned and maintained. Fabrics need to resist stains and withstand multiple cleanings per day. Specifically, Nemschoff's durable wood finish withstands bleach. Ancient methods of utilizing silver and copper are reemerging as ways to prevent antimicrobial growth on fabric and textiles. Moisture barriers prevent the transmission of fluids into the seating foam while removable fabric covers ease cleaning and replacement. Smooth surfaces along with minimal edge details also limit the areas that can harbor microbial growth. Clean-out areas ease maintenance and prohibit the growth of microbes around the seat.

Since patients are often transferred while in a treatment chair, the furniture must incorporate safety elements. Casters with a center lock and steer ease the caregiver's efforts in moving a patient from one location to another. Footrests attached to the chair keep the patient's feet off the floor and in a comfortable, ergonomic position. Specific Nemschoff treatment chairs provide an additional safety feature such as the ability to recline fully-flat for the performance of emergency procedures.

Transferring a patient between bed and chair is a risky maneuver for both patient and staff. A chair with a fold-away arm eases the transfer process. With caregivers consistently suffering from musculoskeletal injuries due to ineffective patient lift approaches, simplifying the process of moving a patient protects the safety of both the patient and caregiver.

Studies show that pain is heightened for patients experiencing stress, specifically tension and irritation. Quantifiable ergonomic research parallels that of evidence-based design. Bariatric and orthopedic patients have different ergonomic needs in order to be comfortable, and well designed furniture must account for these specific needs. For oncology patients, having intuitive controls for lowering backs and raising footrests without excessive effort or assistance from staff increases patient independence as well as frees staff to better perform their jobs in providing medical aid. Certain Nemschoff reclining patient chairs offer two mechanisms for moving the seat back: one in easy reach for the patient and the other in easy reach for the caregiver. One Nemschoff treatment chair even offers the amenities of heat and massage, specifically designed for oncology patients to regulate their body temperatures during treatments.

Bonnie Phipps, chief executive officer of St. Agnes HealthCare, was actively engaged in leading the furniture selection process for their new facility. Due to the importance of making the right decisions, St. Agnes asked various patients and families to "test drive" a variety of furniture. This feedback was critical in determining the right solutions for their patient population. Phipps recognized that if they had not engaged users in the selection process that they "may have only made our choices based on durability and cost."

In waiting areas, simply stretching a chair's width may not yield a comfortable seat for the bariatric patient. Bariatric seating must account for comfortably entering and exiting the chair as well as aesthetically not be screaming "oversized" chair. These factors could reduce stress from the start of the healthcare experience and create a feeling of inclusion. For the family, comfortable, ergonomically designed furniture that can be easily moved and arranged in small groups provides the opportunity for interaction. Multiple seating options give patients and family a choice for the type and placement of their chair and increase their sense of control. Certain waiting room furniture has high backs that can increase a sense of privacy.

Staff stress can be influenced with furniture. In areas of respite, staff can gain a sense of control over their environment with multiple seating options. They have the choice of sitting as a group to collaborate or independently to rejuvenate. At nurse stations and alcoves, ergonomically designed chairs, stools, and desks work together to create a healthier work environment.

As evidenced through a literal furniture fair in the atrium at the Children's National Medical Center (Children's National), Beth Benner, director of construction, division of construction and facilities, reinforced the need to "test all furniture selections with a wide variety of constituents" before purchase. During the five-day furniture fair at Children's National, everyone and anyone was allowed to fill out a survey on the chairs including children, parents, volunteers, staff, clinicians, maintenance engineers, concierge employees, project managers and administration.

Benner noted "although one might think that parents are not aware of the ability of furniture to relieve stress and reduce infection, many parents specifically commented in their surveys that certain chairs were more apt to stay clean, that certain sized chairs allowed them to sit next to their child without the interruption of a chair arm, and they desired to have a comfortable chair within the patient room that could serve as a second sleep surface."

In the patient room, research proves it is important to include the family in the healing process. Incorporating a sofa or chair that converts into a daybed provides a place for visitors to stay the night with the patient. This interaction becomes a mental distraction from the healthcare environment and can help to increase overall patient satisfaction.

No matter the scale of the healthcare facility, it is important to incorporate sustainable furniture into the design. Low VOC finishes and dry construction methods limit the amount of toxic chemicals that enter the hospital and are inhaled by all users. As such, furniture can contribute to improved indoor air quality and create a better environment for all to work and heal.

In conclusion, can furniture selection influence patient outcomes? Yes, there is potential, and it merits further study. Utilizing evidence-based design strategies while making furniture selections may contribute to creating a healing environment. Given the constant use that furniture receives from patients, family, and caregivers, furniture selection may have a reciprocal effect on evidence-based design and as such, may create its own place as a design strategy for improving patient outcomes.

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Matthew DeGeeter, LEED AP, Allied Member ASID, Associate IIDA, is a designer with the Healthcare Market Sector for Perkins+Will in Washington DC. He can be reached at matthew.degeeter@perkinswill.com

Moira Gannon, LEED AP, ASID, is an interior designer with the Healthcare Market Sector for Perkins+Will in Washington DC. She has experience coordinating projects throughout Perkins+Will nationally and can be reached at moira.gannon@perkinswill.com

Jamie Huffcut, LEED AP, Allied Member ASID, Associate IIDA, is a designer with the Healthcare Market Sector for Perkins+Will in Washington DC. She is dedicated to creating healing spaces and can be reached at jamie.huffcut@perkinswill.com

Helen Lanes, AAHID, LEED AP, IIDA, is a Senior Associate at Perkins+Will in Washington DC with 20 years of healthcare focused, client driven, and award winning experience. She can be reached at helen.lanes@perkinswill.com

Emily Oline, Associate IIDA, is a designer with the Healthcare Market Sector for Perkins+Will in Washington DC. She can be reached at emily.oline@perkinswill.com

Data and content for this article was developed from the following sources:
Borkow, G., and Gabbay, J. (2004, September 2). "Putting Copper into Action: Copper-Impregnated Products with Potent Biocidal Activities." The FASEB Journal Express. Article10.1096/fj.04-2029fje.

The Business and Institutional Furniture Sustainability Standard. Business and Institutional Furniture Sustainability Standard. [PDF file].

Cramer, D., and James, P. (2006, September). "Considerations for Developing Healthcare Furniture." HealthCare Design.

International Ergonomics Association (2000). About HFES: What is Human Factors Ergonomics? June 27, 2008.

Malkin, J. (2008). A Visual Reference for Evidence-Based Design. Concord, CA: The Center for Health Design.

Nelson, A., Baptiste, A. (2004, September 30). "Evidence-Based Practices for Safe Patient Handling and Movement". Online Journal of Issues in Nursing. Vol. 9 (Number 3), Manuscript 3.

Ulrich, R.S., Zimring, C., Zhu, X., DuBose, J., Hyun-Bo, S., Young-Seon, C., Xiabo, Q., and Joseph, A. (2008). "A Review of the Research Literature on Evidence-Based Healthcare Design." Health Environments Research and Design Journal, Vol. 1 (Number 3), 61-111.

Past installments of "Designing for Health" are available here:
"Shifting Culture, Shifting Service Lines: Is Tiger Woods the New "Grandmother"?"
"Research Informing Design"
"Peace and Quiet"
"A Prescription to go Paperless"
"Healthcare Facilities Want You to Take Notice"