Sheila J. Bosch, PhD, LEED AP, EDAC Rosalyn Cama, FASID, EDAC Eve Edelstein, MArch, PhD, EDAC, AssocAIA, F-AAA
It has been suggested that color has a therapeutic effect, although few empirical observations exist. Edelstein et al. (2008) reviewed citations from biomedical literature and found that while influence of the colored light on health was supported by several decades of rigorous research into circadian rhythms, there was a paucity of consistent data on the influence of applied color on health.
Tofle et al. (2004) note that “oversimplification of the psychological responses to color pervades the popular press, and direct applicability to architecture and interior design of healthcare settings seems, “oddly inconclusive and nonspecific” (p. 5). They assert, “The attempt to formulate universal guidelines for appropriate colors in healthcare settings is ill advised (p. 5).”
Schuschke and Christiansen (1994) also found that “no compelling scientific reasons can be given for coloration in the hospital.” For example, their study of 68 patients found heterogeneity in their choice of sick-room color in clinics and could not support specific or absolute color solutions. Nonetheless, in all 68 subjects, a preference for light colors for all objects such as ceiling, wall, floor, curtain, furniture, and linen were reported.
Color for Signage in Healthcare Settings
For many years, color has been used to inform wayfinding. Gibson, MacLean, Borrie, and Geiger (2004) examined the behavior of 19 (all male; mean age of 84.3 (SD = 4.1) residents in a long-term care dementia unit following the renovation of the unit. The renovation was intended to make the unit feel less “institutional” and create an entrance to each room that was more visibly distinct, using “color, texture and cosmetic architectural structure.” Patients who were able to find their way to their rooms were interviewed using five free-response questions that allowed residents to share information regarding environmental cues that assisted them in this task. Residents who could not successfully find their room were not interviewed.
Thirteen of the 19 participants reported that color was used to help them find their rooms. Structure (e.g., room number, name plate) was the second most often reported cue (12 of 19 participants). Generalization of results from this study are limited by its small sample size, narrow age range, and the medical condition of participants.
The use of color and graphic images may be vital factors in healthcare design. As hospitals have a wide range of visitors and patients with different levels of visual impairments and disabilities, making comprehensible signage is essential. In the United States, color coding has been developed to reduce confusion and aid in decision making by specifying color stereotypes: warning information in red, caution information in yellow or amber, and advisory information in another color clearly discriminable from red or yellow/amber.
ANSI and the ISO have introduced similar universal color-coding standards (ISO 3864-1) and include green for safety. These ISO standards for safety colors, signs, and graphics are specifically designed to reduce accidents and injuries in public facilities, such as hospitals, worldwide. However, color in signage must be used with caution. For example, red-green color blindness and red-blue combinations can be difficult to resolve and have been shown to cause eyestrain thought to be due to the different focusing levels required as these colors are on the opposite end of the visible spectrum of the human eye.
The Americans With Disabilities Act reviews signage guidelines, recommending that the finish and contrast of the characters and background of signs be eggshell, matte, or other nonglare finish, and that characters and symbols contrast with their background by 70%.
Rousek and Hallbeck (2011) report that with normal vision, 38% of participants had trouble recognizing signage during a wayfinding task; most commonly small lettering (18%), insufficient illumination (18%), insufficient contrast between the background and letters (10%), and mounting signage too high (8%). Studies simulating visual impairment by having subjects wear goggles showed many participants (70%) in their wayfinding study had trouble recognizing signage. The most commonly reported issues were improper illumination (38%), unexpected positioning (36%), and failing to notice the signage (14%). Sixty of the participants felt the signs were too small.
They studied the use of signage color in the healthcare setting. Participants (n = 50) with healthy eyes were asked to respond to various pictograms (some with color and some black and white only) using three questionnaires, both with and without goggles designed to simulate 5 types of visual impairments (diabetic retinopathy, glaucoma, cataracts, macular degeneration, or hemianopsia).
The researchers found that color contrast improved signage comprehension and concluded from the limited set of colors and graphics tested (black, blue, white, red, green), that a combination of red and white backgrounds with black font was preferred. It should be noted that the font, size, scale, and color contrast are very important, along with the intelligibility of the design graphic itself.
Consider functional factors:
- Effect of lighting and materials on color.
- Ages of people who will use the space.
- Is the space for patients, staff, or visitors, and what is the typical length of time these people will be exposed to these colors?
- The nature and severity of the illness.
- The impact of illness or medical condition on color blindness or perception.
- Suitability of color palette for women, men, and children.
- Types of tasks: amount of contrast desired for the level of visual acuity and amount of contrast required.
- Is the goal to emphasize or to camouflage?
- Is the goal to organize spaces using color as the cue?
- How much contrast is desirable?
- Interaction of texture can cause the same color to look different.
- Use as cueing device in wayfinding.
- Use to denote hazards or warn of danger.
- Geographic and cultural bias: In northern climates with long, harsh winters, warm colors might be more appropriate than cool; in the West, the quality of light is a warmer and more intense color than in the East; in tropical areas, strong saturated colors (hot pink, orange, peacock, purple, lime) are often favored.
The use of color has long been one of the most subjective aspects of interior design and especially so in healthcare settings. This may account for the fact that many of the newer hospitals are devoid of color. For those who seek validation through evidence-based research, it is very difficult to design color studies for the actual setting of a healthcare facility, therefore, there is little that is definitive in the way that practitioners might wish to find clear principles that can be applied to the healthcare environment.
Nevertheless, there is much value in the assembly of studies noted in this paper to enable the confident practitioner, armed with basic color theory, to understand the sensitivities of each type of patient and each setting and to be able to successfully enhance patients’ experiences. Design practitioners educated and trained in the application of color theory and the principles noted above may be timid because the risk of criticism is high. Risk seems to be reduced by the specification of a neutral color palette but can also be reduced with proper evidence to support a broader palette.
The lack of color (white walls) is unfamiliar to some, considered modern by others, and, for many years, has been one of the hallmarks of what has been referred to as an “institutional” environment. Consider this publication a baseline that perhaps will stimulate much more research about the influence of color. But for now, go forth and use color. The more you do it the more confident you will become.
Source: Bosch, S. J., Cama, R., Edelstein, E., & Malkin, J. (2012). The application of color in healthcare settings. Concord, CA: The Center for Health Design.ISO 690