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BY: PHILIP J. BOYLE, PhD

Illustration by Roy Scott

Trinity Health is pursuing its ongoing desire to understand better the elements of Catholic identity by focusing on the nature of a healing environment and incorporating its findings into the health care setting. Trinity's mission statement calls on us to be a "transforming, healing presence." Our health system has recently gained a deeper knowledge about the qualities of a healing environment, and, in the process, it discovered some surprising connections.¹

In 2016 Trinity Health, which is based in Livonia, Mich., and provides care in 22 states, embarked on a quest to investigate the nature of the healing environment from several practical concerns. Clearly, a healing presence is based upon the ability to offer clinical quality care of the highest level; however, the question remained whether there were other elements of healing that the system should promote for the good of patients and employees. Over the years, many conversations about "transforming, healing presence" were interpreted to mean a "healing environment." These conversations included a question that repeatedly arose during our internal ministerial assessment process, known as Promoting Catholic Identity.² The concern was: How could Trinity measure whether its ministries were maturing in their goals to be a healing presence?

Trinity's mission integration department asked: "What are credible measures of a healing presence/environment that can be woven in the triennial assessment of ministries? Is there a list of characteristics that should be evaluated?" Another practical concern materialized from cultural and religious tensions over what images and art should be displayed on Trinity Health campuses. For example, employees at all levels had intense discussions over whether every space needed a cross and Catholic images, or whether and how Trinity Health should make use of visual symbols to accommodate persons of all faiths?

The most significant impetus to examine a healing environment arose when Trinity Health purchased a limited heritage edition of The Saint John's Bible, coincidentally at the same time we were beginning to research the elements of a healing environment. The Saint John's Bible is the first hand-illuminated manuscript of the entire Bible in 500 years and contains more than 160 stunning, newly created images throughout its seven volumes. The creators of The Saint John's Bible had a vision statement to "ignite the spiritual imagination of all people." As the volumes of the Bible moved across several sites, we found the response to the Bible from staff and visitors sparked a broad discussion about the place of beauty in healing. The beauty of image and word in The Saint John's Bible folios almost single-handedly galvanized our commitment to the relationship of art and healing presence. The physical presence of the manuscript in several of the ministries convinced us of the need to systematically explore and make clearer the element of a healing environment as it relates to our mission statement and, more broadly, Catholic identity.

Thus, in 2017 Trinity Health Mission Integration embarked on an initiative to explore the elements that compose a 'healing environment' and investigate, in particular, the positive ways to nurture and advance a healing presence.

The goals of the Healing Environment Initiative were formulated to:

• Understand existing practices and guidelines currently operating within Trinity Health.
• Identify characteristics and additional guidelines to further describe, enhance and create a healing presence within Trinity Health facilities.
• Produce tools for mission leaders and executive leadership that will assist in advancing the characteristics of a healing environment.

The first step in the initiative entailed gathering a design team drawn from talent both inside and outside Trinity Health, including an architect, health care design professionals and theologians who think about the intersection of art and spirituality. Simultaneously, mission integration staff reviewed literature on a healing environment in health care. The review of "evidence-based design" research in health care pointed to the strong correlation between the built environments and the potential for physical and emotional healing.³ For example, natural light, images of nature and reduced noise have been shown to correlate with reduced anxiety and aid in healing. Noteworthy in its absence, the evidence-based design literature pays little attention to other elements that contribute to a healing environment.

The design group recommended that Trinity Health Mission Integration representatives, go out and see what constitutes a healing environment within Trinity Health. We were asked to conduct focus groups at a range of sites, speaking with key stakeholders — patients, employees, leadership and community members — about their experiences of a healing environment. They also advised us to conduct a walk-through of each organization and document with pictures how patients experience the environment as they move through their care. Staff visited 10 sites, including hospitals, senior-living residences and Programs of All-Inclusive Care for the Elderly, and interviewed 200 people in 20 focus groups, asking them simple questions about their experiences of a healing environment.

ENVIRONMENTAL CUES
The first theme that focus groups considered was: "Remember a situation where either you felt healed or experienced someone being healed. What was the incident? Who was there? What were the sights, sounds and aromas?" What we found was remarkable. Few respondents connected healing environment with physical space, although some settings with beautiful views and quiet disposed them to healing. Most healing experiences they recounted involved an encounter inside or outside health care with a person or a chaplain. They spoke of a ritual or homeopathic therapies; in short, what made an impression was a soothing interaction with someone or something tangible and tactile.

At first, what respondents reported as healing was unanticipated by the mission integration staff and design team, and the focus group reports seemed different from the elements of evidence-based design. But the design team's work and literature converged: Whether it is the provision of spiritual care, a ritual, or seeing a familiar picture or listening to soothing music, these interventions shared the ability to deflect a person's attention from pain and suffering and to open their spiritual imagination. Focus group interviews repeatedly indicated that design choices in the built environment could signal to patients they were in a place of healing, but more notable was attending to the whole person not only by treating the body with exceptional clinical care, but also attending to mind and spirit. These wholistic treatments have a truly recognizable impact on fostering a healing environment.

A second focus group question explored how employees experience healing in the workplace. Participants were asked: "Since you experience a lot of suffering and death in your work, and because even when you are doing your level best in your job, the pressures of health care often create distress, where do you go to make sense and meaning of these pressures?" Their answers were troubling from an employee engagement perspective. Too many employees recounted that the only place of refuge to make sense of pressures of their work was to hide in a bathroom stall. Others retreated to their cars. Very few sites reported they had safe spaces to cry, to grieve, to decompress, and to make sense of the difficult work they face daily. Even sites with rooms dedicated to refresh employees were not used widely, and if they were so designated, some had been repurposed for other uses.

This qualitative information flags an important management issue. Research draws a clear connection between employee well-being and patient satisfaction. If employees are upset, there is a probable negative effect on patient healing and satisfaction. Creating a healing environment for employees is a critical precondition for providing a healing presence to patients.

Focus group participants explored a third issue: "What spaces in this ministry give you peace or satisfaction and which ones create dissonance and distress?" Respondents noted that natural light, vistas, pleasing spaces whether private or communal, such as fireplaces or water features, enhanced a healing environment. As might be expected, areas that were noisy, looked messy or felt dirty, such as carpet with a sticky sensation, or that seemed sterile, created unwanted dissonance for patients and employees alike.

The mission integration staff conducted walk-throughs of the ministries, documenting with pictures how a patient might experience the different spaces. For example, they traced how a patient comes into the emergency department or to an admissions desk, and then travel to a patient room and on to labs or other health care services areas. The design team advised mission integration staff to be mindful how transitions felt from one space to another. Were the transitions jarring, or did they provide an unexpected view of something beautiful to deflect the mind from suffering?

One major observation was the difference between "on-stage" and "off-stage" settings, terms drawn from theater. On-stage settings in health care are lobbies and public rooms where patients, families and the public glean first impressions. Most on-stage settings were beautiful. Those that offered images drawn from nature and familiar local settings were comforting. Patients' rooms that had natural light and vistas to direct the patients' gaze were more cheering than those with no natural light or views. Sites that had local artists displayed in high volume created opportunities for patients to connect with the art and offer a point of deflection from their present health concerns. In contrast, a site that had the same abstract images throughout the institution were, at minimum, uninspiring. Most noteworthy, a newly opened PACE program that offers daily health care for low-income adults who have little financial resources for visual beauty, had enlarged pictures of nature and the community displayed throughout the sites, much to the enjoyment of the Program of All-Inclusive Care of the Elderly participants.

The mission integration staff experienced great variability in off-stage settings, where patients and supplies are transported but which are out of the public eye. Some off-stage settings provided beautiful transitions from spaces with ample familiar images, and one site even placed images on the ceiling for patients to enjoy as they were being wheeled on gurneys from here to there. At one site, transport employees acted like tour guides, emotionally and intellectually preparing and comforting patients as they wheeled them though the transitions patients were seeing and feeling. Other off-stage settings were jarring for patients and staff alike. Many corridors were long and painted unremitting white with no images to deflect a patient's anxiety. A good reason may exist for such sterile-looking environments, but perhaps there is also an underexplored opportunity to promote a healing environment.

THE BROADER MEANING
The design team reviewed the qualitative evidence and compared it with existing studies of evidence-based design and scholarship in art and theology. The process resulted in an emerging sketch of attributes that characterize a healing environment.

An overarching attribute provides a measure for all other attributes. Simply put, a positive healing environment can be evaluated in terms of the end-state of a patient's well-being, including senses of connection to people and community, lack of isolation, safety, restoration, hope and trust. The opposite is true. Interactions that destroy or diminish this sense of well-being inhibit healing.

A second attribute is the place of the spiritual imagination in creating a healing environment. Art, architecture, soft music and therapeutic touch share a common effect with spiritual care and rituals in that they dispose a person's spiritual imagination to something beyond their inner concentration on pain and suffering. When a patient is isolated in his or her pain, interventions that can spark the spiritual imagination provide a sense of hope and connection. Mission integration staff initiated the qualitative research to gather information on the built environment, but that broadened to include any means that ignites a person's spiritual imagination, including spiritual care as well as tactile elements that engage the whole person, body mind and spirit.

A related thought is that interior design, architectural elements, visually attractive images and other sensory prompts have the ability to unseat a person's expectation and create a transformative moment. Inviting visual frames or images allow for a particular kind of looking — a steady, intense or absorbed form of vision. This promotes a pondering where persons consider an image from various angles and ruminate on it. This is the beginning of the spiritual imagination. The built environment provides a transformative moment, shifting the emphasis from the interior life of the designer, architect or artist to the interior life of the person experiencing suffering and pain.

A third attribute that emerged is the place of beauty in a healing environment. As Scriptures attest and theologians have believed for centuries, beauty is an attribute of God. Environments that bring beauty to patients or those in suffering and pain bring an incarnational presence of the healing God. Perhaps not surprisingly, the arrival of The Saint John's Bible, containing modern abstract hand-painted images, ignited the spiritual imagination of employees and patients alike to a healing presence. Environments that offer beautiful natural views, art, music, poetry, human touch and the opportunity to spend time with animals, can open the spiritual imagination to healing in a way that allows God's healing grace to enter.

What needs to be stressed is the contrast between the volume of evidence-based design literature and design group observations and focus group feedback. Compared to the volumes of evidence-based design literature, there is much less current research in the literature on the spiritual aspects of healing, such as the place of sacraments, ritual, prayers and spiritual care. Consequently, the role and importance of spiritual imagination in healing is not squarely in the public eye.

Theologians have long observed that the spiritual imagination opens a window to experiencing beauty that draws the human spirit into places of comfort, joy, healing and wholeness. Therefore, any part of the built environment or of encounters with others while in the health care setting can open the spiritual imagination, whether through visual aspects, calming sounds, rituals or therapies with art or pets. This healing cannot be limited to patients and their families alone, but it should extend to our employees, who need private spaces to grieve and make sense of the difficult task of providing of health care to the sick and dying. Employees need places to recharge and fuel their own spiritual imaginations.

Trinity Health's research began with the hypothesis that the investigation into a healing environment would produce a checklist of what should or should not be displayed within our ministries. What emerged was something much more significant. To create a healing environment, the most important action is to adopt a posture of mindfulness and discernment toward all physical and spiritual elements that contribute to a sense of healing and well-being. This mindfulness about how created reality mediates healing is central to Catholic identity. Catholics believe that God became incarnate and therefore all created reality is a means to make present God's healing. Attention to the healing environment cannot be limited to clinical quality; our identity requires us to be intentional so that all that a patient sees, hears, touches, is an opportunity to mediate God's healing presence.

Trinity Health aspires to be a transforming, healing presence in the communities we serve. Trinity Health's study of the matter made it more evident that a healing environment requires quality clinical care, but also a built environment that includes beauty, meaning and connection to open a person's spiritual imagination through the senses. Gaining a deeper understanding of this phrase contributes not only to gaining clearer understanding of Catholic identity, but more importantly, to creating a transforming, healing environment for those we serve and those with whom we serve.

PHILIP J. BOYLE is senior vice president, mission and ethics, Trinity Health, Livonia, Mich.

NOTES

1. Trinity Health views its work to enhance healing environments as part of a broader effort in Catholic health care to better understand how Catholic identity should be reflected in patient care. See for example, M. Therese Lysaught, Caritas in Communion: Theological Foundations of Catholic Health Care (St. Louis: The Catholic Health Association of the United States, 2014) and CHA Ministry Identity Assessment (St. Louis: The Catholic Health Association of the United States, 2018).
2. Trinity Health's internal ministerial assessment process, called Promoting Catholic Identity, is based upon the framework for achieving performance excellence that is part of the Malcolm Baldrige National Quality Award program. The program raises awareness of quality management and evaluates the maturity of an organization's core institutional qualities. In Trinity Health's case, this includes being a healing presence.
3. For more on healing spaces, see Jennifer DuBose et al., "Exploring the Concept of Healing Spaces," Health Environment Research & Design (2016): 1-14. Kimberly Firth and Katherine Smith, "2007 Survey of Healing Environments in American Hospitals: Nature and Prevalence" (Samueli Institute, 2007): 1-34. Jaynelle F. Stichler and Kathy Okland, Nurses as Leaders in Healthcare Design: A Resource for Nurses and Interprofessional Partners (Nursing Institute for Healthcare Design, 2015).