Mounting evidence indicates that buildings can be a significant cause of human illness and environmental degradation. According to the United States (US) Environmental Protection Agency, indoor air pollution is one of the top five environmental risks to public health in the US. This may be related, to a large extent, to the fact that US citizens spend as much as 95% of their time indoors. Health care leaders, designers, and architects, recognizing the connection between health and the buildings in which much time is spent, are engaging in sustainable design and construction for healthy, ‘green’ buildings. The purpose of this article is to assist nurses in understanding the impact that unhealthy buildings can have on nurses and nursing practice and to provide tools and resources to assist nurses in transforming the health care industry with the goal of creating healing environments and reducing the negative environmental impact of the health care industry. First definitions, current initiatives, and motivations related to sustainable designs will be presented. Next sustainable health care design strategies, such as site planning, clean transportation, water conservation, healthy materials selection, indoor environmental quality, and also the benefits of sustainable design will be discussed. The article will conclude by sharing a variety of resources nurses can use to create healing environments in health care settings.
Key words: hospital design, nursing recruitment, nursing retention, performance, ‘green’ building, sustainable hospitals, sustainable design
Since the early years of nursing, leaders such as Florence Nightingale and Lillian Wald have recognized the role of nurses in protecting health from environmental harms, such as unsanitary and unclean conditions, and poor quality food, air, and water. Nurses know that a healthy environment impacts the health of people, families, communities, and populations. This knowledge is a foundational element of nursing practice. In her First Rule of Nursing, Nightingale said that nurses must, "keep the air within as pure as the air without" (Nightingale, 1859/1926, p. iv). Because, as Mood (1995) has noted, environmental health is a "good fit with the values of the nursing profession regarding disease prevention and social justice" (p. vii), registered nurses have a crucial role in assessing and addressing environmental health issues.
Currently the health care industry is in the middle of a huge construction boom. According to Hylton (2007), $200 billion in health care construction in the US is planned for the next decade. Nurses constitute the single largest group of workers in the health care industry; and they are the most trusted profession in the country. Thus, it is essential that nurses responsibly recognize and address the biological, chemical, radiological, and physical environmental hazards of the facility where they work to promote their own health, as well as the health of their patients, and the community-at-large. Increasingly the health care industry construction boom will include a transformation of design, construction, and operational practices with the goal of reducing its environmental impact. The success of this transformation depends on the involvement, support, and commitment of the nurses working in these health care agencies.
The purpose of this article is to assist nurses in understanding the impact that unhealthy buildings can have on nurses and nursing practice and to provide tools and resources to assist nurses in transforming the health care industry with the goal of creating healing environments and reducing the negative environmental impact of the health care industry. First definitions, current initiatives, and motivations related to sustainable designs will be presented. Next sustainable health care design strategies, such as site planning, clean transportation, water conservation, healthy materials selection, indoor environmental quality, and also the benefits of sustainable design will be discussed. The article will conclude by sharing a variety of resources nurses can use to create healing environments in health care settings.
This section will provide an overview of the elements of sustainable design. It will offer definitions of words/phrases often used in discussing healthy design, present sustainable design guidelines, and share various motivations for constructing sustainable health care buildings.
In 1987, the United Nations (UN) (1987/1999) report of the world commission on environment and development, often known as the Brundtland Commission Report, defined "sustainable development" as "…meeting the needs of the present without compromising the ability of future generations to meet their own needs" (para. 2). Since then, the term has been extended to buildings, with sustainable buildings referring to buildings that use energy, water, and other resources efficiently, and that provide safe and productive indoor environments. According to a
…sustainable design…is likely to become a defining force of this century
The terms ‘green design’ and ‘green building’ are synonymous with "sustainable design." Sustainable design encompasses all aspects of building design, including land use considerations, energy demand, water use, building materials, and indoor environmental quality. Broadly speaking, this includes everything from transportation impacts to habitat restoration, to energy conservation, all with a strong focus on achieving safe and productive indoor environments. This broad definition is a direct response to the earlier efforts at ‘energy conservation’ which yielded tight, inadequately ventilated buildings which gave rise to a multitude of indoor air quality (IAQ)-related concerns, such as mold, asthma, and multiple chemical sensitivities, which are associated with Building Related Illness (BRI) and Sick Building Syndrome (SBS). The US Environmental Protection Agency (EPA) has estimated that up to 20% of the US population experiences BRI and SBS symptoms, a percentage not surprising in a nation where people average 95 percent of their time indoors (89 percent in building interiors and 6 percent in automobiles) (Frumkin, Frank, & Jackson., 2004).
Health Care Industry Sustainable Design Guidelines
The health care industry is strategically engaged in this market transformation to sustainable, healthier buildings – leading the dialogue and definition of what constitutes a high performance, healthy building. The Green Healthcare Construction Guidance Statement, released by the American Society of Healthcare Engineering in 2002, described the important principles of protecting health at three levels:
- protecting the immediate health of building occupants
- protecting the health of the surrounding community
- protecting the health of the larger, global community and natural resources.
The Green Guide for Health Care (Green Guide) (See Table), developed to address the immediate need for a sustainable design tool customized for health care facilities, built upon these principles. Sponsored by Hospitals for a Healthy Environment (H2E), the Green Guide is a metric tool and self-certification system for best practice strategies in sustainable hospital building design, construction, and operation. More than 10,000 registrants (including more than 1,200 hospital administrators and medical professionals) have downloaded this open source document; and it has quickly become a valuable tool in moving sustainable thinking into health care projects. More than 115 health care projects in the US have enrolled in the Green Guide Pilot process. Combined with the 100 LEED registered projects, close to 50 million square feet of health care projects are engaging at some level in sustainable design and construction as of this writing.
|Table. Internet Resources.|
Motivation for Sustainable Health Care Buildings
There are a number of reasons why hospitals are making the effort to build sustainable design, or ‘green buildings.’ First, the surge of interest in global warming (climate change) is accelerating regulatory initiatives at state and local levels that either require or provide incentives for sustainable construction. The Mayor’s Climate Change Agreement (U.S. Council of Mayors, 2005) pledges reduction of carbon dioxide (CO2) to7% below 1990 levels by 2012 to comply with Kyoto Protocol goals. This Agreement already has more than 300 cities as signatories. The Winship Cancer Center at Emory University in Atlanta, Georgia, for example, achieved certification by the LEED as part of the university commitment to construct sustainable buildings for all new campus structures (Stanley, Beaman & Sears, personal communication, September 9, 2006). Providence Newberg Medical Center, Providence, Oregon, reduced energy demand and purchased ‘green power’ as part of a community commitment to reducing climate change impacts (Guenther & Vittori, in press).
Secondly, in environmentally progressive communities, sustainable building is viewed an important component of leadership. Not surprisingly, many innovators cite community support as an important reason for their decision. For example, the Lacks Cancer Center at St. Mary’s Healthcare, Grand Rapids, Michigan, has credited a tour of a local LEED®-certified furniture manufacturing facility with initiating interest (Guenther, Vittori, Atwood, 2006). This Center points to the large number of LEED-registered projects in their community as evidence of a broader commitment to the environment. For a surprising number of projects, the decision to develop industrial sites that had been environmentally damaged, lead to a broader consideration of sustainable building values. These previously damaged sites, classified by the USEPA as ‘Brownfields,’ often require significant clean-up and removal of toxic chemicals and contaminated soil prior to new building development. Both Dell Children’s Medical Center, located in Austin, Texas, on the former Austin Municipal Airport site, and the Boston, Massachusetts, Spaulding Rehabilitation Hospital, located in the former Charleston Navy Yard are examples of new sustainable campus developments in urban areas built on former industrial land in an effort to remain within urban areas (Guenther et al.). The replacement projects they are undertaking in these areas will require significant remedial work and site restoration. Yet these organizations remain committed to the effort involved in restoring these sites for future generations.
Thirdly, increasing numbers of health care organizations undertake sustainable design initiatives because they believe it is simply the right thing to do. Many religious-based organizations point to explicit "stewardship" values in their missions and goals; and academic medical centers often view environmental leadership as a core component of excellence. Guenther et al. (2006) have noted that this value is exemplified by Roger Oxendale, President and CEO of Children’s Hospital
…increasing numbers of health care organizations undertake sustainable design initiatives because they believe it is simply the right thing to do.
Finally, for some, a focus on sustainable building has emerged from their experiences with pollution prevention in their organization’s environmental operations departments, as they have personally seen the need for more conscious attention to the environment. Some agencies are using the financial savings associated with reduced, regulated medical waste to fund Environmental Manager roles which can begin to focus on the broader goals of improved environmental performance.
Sustainable Health Care Design Strategies
Typically, sustainable design tools organize sustainable building strategies into five major topic areas: site planning, energy, water, materials, and indoor environmental quality. Much of the success of sustainable design processes is due to the ‘integrated’ nature of sustainable design processes, as many of the sustainable design and operations strategies impact each other. For example, increasing daylight in buildings impacts energy demand and also promotes healing. An
Nurses, as people who…have extensive background in science and health, have much to offer this integrated-design process.
Site Planning and Access to Nature
Sustainable building challenges design teams to return to a land-planning ethic that takes a "restorative approach" to the earth as well as the patients served. Boulder Community Hospital, Boulder, Colorado (the first LEED®-Certified hospital), for example, returned 32 acres of its 49 acre site to protected, open-space areas after the development process restored degraded wetlands (K. Abelkis, personal communication, July 12, 2006). The emergence of "healing gardens" on many health care campuses creates opportunities to employ vegetated roof, sometimes called ‘green roof,’ strategies for stormwater retention. At Legacy Salmon Creek, Vancouver, Washington (a 220-bed community hospital), horticulture therapy gardens have been merged with vegetated roof technology to capture stormwater and recharge groundwater, which would otherwise be lost from a fully developed, paved site (Robert Frasca, FAIA, ZGF Architects; personal communication, July 12, 2006).
Another key component of sustainable site strategies is reducing automobile dependence for hospital staff and visitors. Sustainable urban hospitals advocate for public transportation improvements; suburban and rural hospitals look for opportunities to launch ‘clean transportation’
Another key component of sustainable site strategies is reducing automobile dependence for hospital staff and visitors.
In many parts of the United States, potable water supplies are over-stressed, requiring water conservation strategies. Hospitals are water-intensive; in many communities, they are among the top ten water users. Caritas-Norwood, a community hospital in Boston, Massachusetts, implemented a series of water conservation retrofits on their campus that now return more than 15 million gallons of water to their community annually (Massachusetts Water Resource Authority, n.d.). This project has paid for itself in less than two years. Replacing turf grass with native, drought-tolerant plantings, known as ‘xeriscaping,’ both saves water and reduces the application of chemical herbicides and pesticides. It may also reduce landscape maintenance costs.
New, ultra-low, water-use fixtures are making their way into hospitals. Examples of these fixtures include waterless urinals in which no water is used, dual-flush or ultra-low flush toilets, which use only 1.0 to 1.2 gallons per flush, and auto-occupant control faucets, which are controlled by electronic sensors or timers. In the early years of product development, low-flow fixtures were generally considered unreliable or less effective, but new testing standards and engineering innovations have produced a new generation of effective, reliable, product offerings.
Healthy Materials Selection
The production, use, and disposal of building products (and their associated chemicals) is another focus area in health care construction. "Creating Safe and Healthy Spaces: Selecting Materials that Support Healing" is a primer on evaluating the life-cycle impacts and health impacts of building materials. In this primer, researchers Rossi and Lent (2006) have outlined a methodology for environmental transformation and have reported how Suzen Heeley, Director of Design at Hackensack (New Jersey) University Medical Center (HUMC), has noted the importance of avoiding environmental pollutants while creating a visually healing environment for the 192-bed Gabrellian Women’s and Children’s Pavilion.
HUMC staff learned that standard particle board millwork, doors, fiberglass insulation, paints, adhesives, and sealants are all commonly made with urea formaldehyde and other volatile organic compounds (VOCs) that are known or suspected carcinogens or asthma triggers. Hence they opted for agricultural board cabinets (wheatboard and strawboard) and recycled denim for insulation, along with low-VOC paints and adhesives. Building materials that contain recycled items, and that are themselves recyclable at the end of their useful lives, are becoming more readily available.
Kaiser Permanente, the largest non-profit insurer and medical provider in the US, has used its $20 billion capital program to transform the market availability of healthier, sustainable products with which to build and furnish health care facilities, particularly in the area of polyvinyl chloride (PVC) substitution. PVC produces dioxin (a potent human carcinogen) during manufacture and disposal; flexible PVC building products often contain heavy metal stabilizers and phthalate plasticizers (reproductive toxicants). While the scientific certainty of the impact of these chemicals on humans has yet to be established, Kaiser Permanente has moved forward with phasing out use of such materials, thus operationalizing the principle of precaution. PVC-free carpet and resilient flooring, wall protection systems, wall-coverings, and window treatment are now readily available.
Indoor Environmental Quality
An increasing focus on quality, indoor environments emphasizes the importance of daylight and access to the outdoors for building occupants. This is supported by research linking worker productivity with access to daylight and views of nature (Kats, 2006; see also ‘Benefits of Sustainable Health Care’ in this article). Ulrich (1984, 1991; Ulrich, Lumden, & Eltinge, 1993) has
An increasing focus on quality, indoor environments emphasizes the importance of daylight and access to the outdoors for building occupants.
Benefits of Sustainable Health Care
For health care buildings there is a 1:10:200 relationship between the cost of building construction and the 30-year operation of the building, meaning every dollar spent on capital construction requires ten dollars related to building operation (fuel and repairs), and two hundred dollars related to salary expenses (the cost of health care staff) over the first 30 years. This relatively high proportion of cost related to salary suggests that long-term, financial benefits can come from investing in sustainable building design and operation.
Hospitals are noting these financial benefits of incorporating sustainable designs in a variety of ways. One area of financial savings relates to decreased demands for energy and water, which yields direct financial gains through reduced utility expenses. Most early adopters of sustainable health care structures soon noted reductions in energy and water in the range of 15 to 25 percent below a ‘standard building’ baseline. Such a significant reduction can result in a considerable financial savings over five to eight years, which is considered a reasonable payback period for a return on the investment. As energy prices become more volatile, the "financial risk avoidance" aspect of reducing energy demand becomes more significant.
An additional benefit of sustainable design is the reductions of greenhouse gas emissions. Boulder (Colorado) Community Hospital, for example, described how its high-efficiency, partial-load, low-emission boilers reduced annual nitrous oxide (NOx) emissions by 70 percent, carbon dioxide (CO2) by 50 percent, and energy fuel consumption by 20 percent over standard boilers.
Although material substitutions may have initial cost premiums, often due to their recent introduction and relatively limited initial markets, innovative materials often have benefits above and beyond their sustainable features in maintenance, life span, and other areas. Because new materials give manufacturers a chance to introduce a "better" product, the improvements are often multi-faceted. Resilient flooring is a good example of this. Synthetic-rubber (resilient) flooring, although offering modest improvements in terms of the environment, appears to reduce maintenance costs and offer improved slip resistance (reduced worker
As energy prices become more volatile, the “financial risk avoidance” aspect of reducing energy demand becomes more significant.
Many sustainable building strategies also yield worthwhile social and health benefits, some of which can be translated into financial terms. For example, Kats (2006) has reported that improved access to daylighting improves worker productivity in factories and schools; and Ovitt (1996) has reported research studies indicating daylighting may decrease medical error rates, a reduction which can save lives and also costs associated with medical errors. Additionally, hospitals that have completed sustainable buildings have described both social and financial benefits, such as increased patient satisfaction and market share (Guenther et al., 2006).
Another benefit of sustainable workplace design is the positive effect it has on those who work in these buildings, an effect which enhances the organization’s recruitment efforts. The PricewaterhouseCooper (PwC) study, completed for the Commission for Architecture and the Built Environment (CABE) (2004) reported the following findings:
- well-designed health care buildings contributed to enhanced performance and motivation, leading to better health outcomes for patients
- good design was a factor in nurses’ choice of hospitals
- nurses wanted to be consulted regarding new hospital designs because they believed they could play a positive role in improving the design aspects of the areas in which they work, and requested they be consulted early in the design process, especially when planning the organization of space, storage, and lighting on nursing units
- the civic value of the sustainable hospital design was important to nurses and helped to engage the community
A hospital is often one of the most valuable assets within a local community and the perceived value of that facility…influence staff perceptions of their work setting.
This study concluded that a focus on design be a priority. A hospital is often one of the most valuable assets within a local community and the perceived value of that facility, both the positive and the negative, influence staff perceptions of their work setting. In this study 100% of nurse managers interviewed believed that the hospital design directly related to recruitment and retention of nurses. As hospitals continue to promote themselves as environmental stewards in their communities, nurses and other personnel will want to work in those facilities having an environmentally friendly design.
Nurses Role in Sustainable Design
The International Council of Nurses (ICN) has stated well the close relationship between nursing and environmental health, noting:
The concern of nurses is for people’s health – its promotion, its maintenance, its restoration. The healthy lives of people depend ultimately on the health of Planet Earth – its soil, its water, its oceans, its atmosphere, its biological diversity – all of the elements which constitute people’s natural environment. By extension, therefore, nurses need to be concerned with the promotion, maintenance and restoration of health of the natural environment, particularly with the pollution, degradation and destruction of that environment being caused by human activities (ICN, 1992, p. 2).
The ICN, and also the American Nurses Association, including several of its state constituents, are among the many nursing organizations that are members of Health Care Without Harm (HCWH, 2001), an international coalition whose mission is to transform the health care industry so it is no longer a source of environmental harm by eliminating pollution in health care practices without compromising safe care. These groups are actively working to change the impact that health care practitioners have on the environment. Nurses around the world in many different health care settings are engaging in decisions and inserting nurses’ voices in building design and operations. At times this is not easy; nevertheless the outcomes for nurses and patients make this an important activity for nurses at the bedside and especially for nurse managers. The following paragraphs will discuss ways in which nurses can work to make their environments healthier for all by participating in environmental stewardship and countering environmental myths.
Participating in Environmental Stewardship
As frontline health care workers, nurses have a unique role as environmental health activists within health care facilities is that they can create positive change from within. The Institute of Medicine (IOM, 1995) described in its report, Nursing, Health, and the Environment the importance of increasing the environmental awareness and knowledge of all nurses and added that the nursing role ought to include a focus on increasing public understanding of environmental health risks. Given the shortage of nurses and their resulting heavy work loads, it is hard to suggest to nurses they need to add one more activity to their daily workload. Yet, that is exactly what must happen. The good news is that there are many tools and resources available for nurses to do this work.
These resources are provided by HCWH and various other multidisciplinary, environmental groups (See Table). One such group, Hospitals for a Healthy Environment (H2E) offers hands-on tools for practitioners to help them eliminate mercury, reduce waste, and engage in other activities to create safe workspaces and promote health within the hospital environment. Also the Luminary Project, a website featuring nurses’ efforts to improve one’s health by improving the health of the environment, contains information regarding ways nurses are helping hospitals implement
Nurses around the world in many different health care settings are engaging in decisions and inserting nurses’ voices in building design and operations.
Get Involved Right Away. Most design and construction decisions are made months and often years before the first ground is broken so it is critical to get involved early in the process. Nursing presence at the table cannot wait until the construction is under way. Rather the principles of sustainability must be incorporated into the thinking of the facility even before an architect is chosen and continue through all aspects of operations. Nurses should be actively involvement in the selection of the architect and work to influence the facility to hire someone with healthy building design experience. Nurses should continue to be involved with all committees throughout the facility’s planning and implementing the building program.
Educate yourself. Learn about the benefits of healthy buildings and share that information with peers and colleagues. Review the Green Guide for Health Care( www.gghc.org). Invite experienced design professionals to your meetings and learn how different firms approach sustainable design. Find out how your facility will be making design and operation decisions that will lead to the hiring of design professionals.
Recognizing and Countering Environmental Myths
In initiating any change, such as planning sustainable buildings, one encounters road blocks and obstacles. Most of the time, these roadblocks and obstacles are based on myths related to lack of information and a misunderstanding of the change initiative. The Luminary Project website lists some of these myths associated with sustainable health care building and provides very helpful arguments nurses can use to counter these myths as presented below.
Myth 1: Healthy building is the architect’s responsibility and nurses don’t need to be involved. Nothing could be further from the truth. Hospital construction requires a close collaboration between architects, designers, construction, and the people who are going to be using and working in these buildings. Who is more appropriate than nurses to be engaged from the beginning in the design and construction of their facilities?
Myth 2: Healthy buildings cost more and I don’t want to increase hospital expenses. Achievement of sustainability through an integrated balance of materials and systems has shown that sustainable buildings can be as cost effective as conventional projects – particularly when the life cycle of materials is considered. In fact multiple studies demonstrate that healthy buildings pay for themselves through improved employee health and reduced operational and maintenance costs.
Myth 3: Healthy buildings don’t perform well and will create a workplace that will make my job more difficult. A growing number of sustainable and healthy ‘green buildings’ are proving that they can be more efficient to operate while creating a healthier work place.
Myth 4: Healthy Building is a passing fad. The demand for increased energy-efficient and material-efficient buildings is growing and is expected to increase, particularly in light of the growing scarcity and expense of energy and water. Health care organizations spend over $6.5 billion on energy each year to meet patient needs. Many facilities continue to experience rising energy costs. Between 2005 and 2006, 33 percent of hospitals experienced an increase in annual energy costs by 11-25%. Hospitals around the country are protecting the environment and their bottom line by committing to reduce their energy and water consumption. Specific strategies ranging from conventional energy efficiency measures to cutting-edge technologies that can reduce energy and water are being used in health care setting.
Myth 5: Materials for healthy buildings are not available. Actually new and innovative products are joining the market every day as a result of the increased demand for them. Hospitals are driving change in the market by demanding new and improved products.
Myth 6: Interest in sustainable building is located in California or outside my area. The ‘green building’ movement is rapidly spreading around the world. Many cities like Washington, D.C. and Boston are passing legislation that requires new construction to meet sustainable building guidelines, such as the LEED® guidelines. Federal and state governments have many ‘green building’ programs in place for federal and state agencies.
It is not difficult to imagine that if Florence Nightingale were here today, she would be continuing the work she started so long ago, namely providing high quality, safe patient care by organizing nurses and others to demand healthy buildings, fighting for an adequate budget for these buildings, reviewing blueprints, checking material specification lists, questioning air flow patterns, and demanding more daylight. In addition, she would be educating nurses and patients about the importance of healthy building design and encouraging them to get involved in all aspects of the planning, design, and operations of health care facilities. In Nightingale’s absence, it is up to today’s nurses to demand sustainable buildings that contribute toward a healing environment for our patients, a healthy place in which to work, and buildings that do not emit toxic materials that pollute our air, water, and land and cause disease.
This article has provided definitions related to sustainable design, described current initiatives, and discussed motivations related to healthy indoor environments. It has also offered sustainable health care design strategies, such as site planning, clean transportation, water conservation, healthy materials selection, and indoor environmental quality, and discussed the benefits of sustainable design. It has concluded by sharing a variety of resources nurses can use to create healing environments in health care settings. The tools and resources identified in this article can assist nurses in using their power as nurses to engage in this transformation of the health care industry with the goal of creating healing environments and reducing the environmental impact of the health care industry.
Robin Guenther, FAIA
Robin Guenther, Fellow, American Institute of Architects, is principal of Guenther 5 Architects, a twenty-person, New York City firm with extensive experience in health care design. Her work has been published nationally and internationally in magazines such as The Architectural Review, Interior Design, Contract, Architectural Record, and Healthcare Design. Last year Robin was awarded The Center for Health Design’s Changemaker Award for her efforts to continuously improve and support change in the healing environment. She is a Co-Coordinator of the Green Guide for Health Care and serves on the Leadership in Energy and Environmental Design (LEED) for Healthcare Committee. She is currently completing her first book, "Sustainable Healthcare Architecture," to be released in 2007 by Wiley and Sons.
Anna Gilmore Hall, is the Executive Director of Health Care Without Harm (HCWH), an international coalition of over 440 organizations in more than 50 countries, working to transform the health care industry. HCWH’s vision of the health care industry is one which does no harm and is committed to preventing disease and promoting the health of people and the environment. To that end, it is working to implement healthy and ecologically sound alternatives to health care practices which pollute and contribute to disease
Prior to joining the HCWH staff, she was the Director of the Center for Occupational and Environmental Health at the American Nurses Association where she was responsible for developing and implementing environment policy issues for the largest nursing organization in the United States. She is a nursing luminary, a nurse creatively and strategically improving people’s health by improving the health of the environment and providing leadership to promote systemic change. She serves on several health care boards and advisory committees, and is Chairperson of the Board of Directors of Hospitals for a Healthy Environment (H2E) and the editorial board of CleanDesign magazine. Anna has received certification (CAE) in association management from the American Society of Association Executives
© 2007 OJIN: The Online Journal of Issues in Nursing
Article published May 31, 2007
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