Basic Horse Riding Tips for Beginners

Horse riding is good fun, and a very healthy sport for all ages to take part in, but it should always be kept in mind that riding can be a dangerous activity. So with this in mind I have written these few tips on safety and horsemanship to help you enjoy your sport.

If you are new to riding then you should definitely take some lessons from a good qualified instructor first. Your instructor will teach you all the basics about horse riding and will advise you on all the relevant safety measures that you should take when around horses.

Although this is very basic information you should still follow these rules at all times. Never ever walk around behind a horse. When a horse can hear something behind it and can only barely see some movement, out of fear many horses will kick out, it should be remembered that a kick from a horse can cause serious injury and may even prove fatal!!

Next, wear a suitable riding hat or helmet, there is no fun in landing on your head when you have been thrown or fallen from a horse. Also you should wear appropriate foot ware, riding boots if possible these will help you to keep your feet in their stirrups.

Riding solo is not to be recommended, if you fell and were injured you could be in serious trouble before you were found. Even if you are an experienced rider on a calm intelligent animal and were going into the forest to ride alone you should still tell someone what route you are taking and when you expect to return.

How you handle the reins is crucial to controlling your horse and keeping good balance. Keep your hands low just above the front of the saddle this will help to keep your centre of gravity low and help you to be stable in the saddle.

Now if you have a healthy well adjusted animal to ride, within reason there are few boundaries on what you and your horse can do. Whether you wish to walk, trot, canter or gallop the only barrier is the skill of the rider.

The most important safety skill of riding is being able to stop your horse where and whenever you want. If you have maintained the correct hand position and grip on the reins while riding it should be relatively easy to stop your horse, just pulling your hands back firmly will pull the horse’s head down and bring him to a halt.

Directing a horse is also easy if they are given the proper signals. If you wish to turn to the right just pull back on the right reins and apply pressure to the horses belly with your right boot, and for turning left do exactly the same with the left reins and boot.

The Importance of Having Physician Lists Handy

Selling pharmaceutical products, medical equipment and services is the niches’ niche. Previously companies and corporations that handle these sort of business transactions often do their marketing internally or have special relationships set up with either health group collectives or certain factions of government supported or aided organisations. Like other businesses, giant pharmaceuticals to even smaller retailers or wholesalers of medical equipment and services (including pharmaceutical grade drugs) have shifted part of its marketing strategies to the virtual worker – where the internet and offline direct marketing can increase their reach and profit margins. This is where the importance of having physician lists handy would be applicable to the direct marketing manager – giving them a highly targeted and volumous list of potential sale leads.

The amount and variance of products that can be found within this niche market is both wide and sometimes overlapping. From general practitioners to dentists, there are many products that either have a general market appeal or specialised products that can enhance the methods and operations of specialist medical practitioners all over the world. Because the lists are highly concentrated and more often than not verified multiple times, you are ensured of having a several groups of potential clients you can use to call and follow up on.

The medical industry is booming all over the world – with U.S.A being a prime example of a country that is on the cutting edge of the medicine. Many companies and laboratories are coming up with newer, better and more advanced methods and traditional means of information dissemination just cannot keep up with these developments. These companies are reviewing their methods of personal door to door selling or direct mail – because of the limitations of their workforce and the time taken for leads to be generated. Product insertion into the marketplace also takes quite a bit of time with this method.

This is where the internet comes in, especially with the advances of online marketing and digital fax – an ability to reach over thousands of prospective in a short period of time. Having a physician list handy means you can acquire and target which market to sell to and how the brand of the product you are selling can resonate with certain individuals. It also allows the direct marketing agent to target several overlapping markets and introduce new, revolutionary products that have a wide application. Marketing by its nature should never be limited and having as wide and as targeted a reach as possible means better sales and more leads.

Invest in a good physicians list – it can mean make or break, especially when you are dealing with such a niche market. Competition is quite stiff as well as you have quite a number of corporations jostling for selling space both offline and online. Lists like these have changed – becoming marketing necessities rather than just a complement to strategy. Specifics work wonderfully here and they have helped a lot of people make a tremendous amount of money just working from home.

Santorini Car Hire

Renting a car in Santorini can give you that extra security and freedom that will make your holiday to Santorini from being good, to becoming exciting.

Before you start your visit to Santorini, it is always important to decide on the places you long to see. If you are sure about which places you would like to see, it would be sensible to reserve your holiday previously, this also goes for hiring a car in Santorini. Many car hire agencies in Santorini offer cheaper bookings for travelers that book weeks in advance; you can even claim back up to 30% or even up to 50% if you are reserving during the weekend. Taking a trip during the off peak season means that you will be able to get a discount on your overall holiday, this also means that car rental during this period is at its cheapest.

If you are renting a car from Isl-Santorini Airport, there are many things you will need to think about if you want your rental to run relaxingly. One of the most important to remember to bring both your driving license (and of course your passport!) with you, you need to own a valid license and an International Driving permit (IDP). It is necessary that you keep your passport to hand and also your IDP with you at all times when you are on the road.

With a car rental in Santorini, you will be able to travel around the whole of this mini island, from its picturesque beaches, to the diverse settings especially the views of its volcano. Although the two popular beach towns of Kamari and Perissa are very close, the mountains between them means that you will need to drive around the mountain as there is no road connecting the two small beach towns. The small towns of Oia and Fira are unusually built into the side of a cliff! This, as well as the Minoan ruins in Akrotiri are all easy to drive to in your hired car.

If you are looking to hire a car in Santorini, there are many rental agencies spread along the islands, providing visitors many choices, from luxury range of cars to the more cost-effective cars. If you settle on hiring a car, you will have the freedom to create your own travel plans that suits you and your family. Even though a small Island, to enjoy you stay in Santorini, book with a car rental agency to make your vacation a more memorable experience.

What is Involved With a Career in Travel Nursing

Becoming a registered nurse has many advantages as well as the gratitude felt from helping others. Working as a nurse has changed over the years and it is no longer simply finding a job in a hospital or nursing home. The careers in nursing are virtually limitless. Travel nursing is an exciting option; however, there are many things to consider before taking the position.

If you are outgoing and thrive on meeting lots of new people, this is a perfect position for you. With a career in travel nursing you can meet people from all walks of life as well as experience how other countries operate in the medical field.

Another excellent benefit with traveling is the option of choosing your preferred climate. If you currently live in a state with horrible winters and are desperate to find warmth in the winter, you have a choice to choose sunny places to work.

The traveling can feel brutal at times so you have to really enjoy traveling. The assignment lengths vary for each job but overall you will be changing locations that could include other countries, approximately every three months or less. To some the extensive traveling can be exhausting so it is important to enjoy it but take care of you in the process.

While you are on an assignment you must be on time to work. It will be tempting to visit the area where you have been assigned and you do have the opportunity, but it must be done on your on time and not when you should be at work. The location you have been assigned to needs your full focus and time.

Though you may come across a lot of new faces, there will be times when you feel alone. You are in a new place with family and friends still at home. This can be overwhelming for some so be prepared to spend a vast amount of time alone.

Also take into consideration your spouse or children. They should be okay with you being gone for long periods of time. This type of work can be hard on relationships so you should make your family aware of the requirement needed for the position.

The rewards will outweigh the sacrifices for many choosing this career. This position takes extreme concentration and focus as well as the desire to do extensive traveling. The money is amazing but you will have to most definitely give up some of the family time.

If this is a career you think might interest you, go online and search for agencies specializing in travel nursing. There are many agencies that hire for this type of position but make sure the company is a reliable agency before agreeing to a position. The agency is responsible for the travel expenses and should be clarified as to amount prior to accepting a location. This form of work can be extremely exciting and rewarding so if you are just completing your degree or have been at it a while, consider the options available.

Effects of stress

Do you have problems with anxiety or stress?You must know all effects of stress. Stress isn’t some thing that isn’t important and if you think that it is you will be in trouble. Stress can result on your healthy and that is very bad. You can have problem with healthy because you didn’t rid of your problems and stress.
Usually when you have stress your heart beats faster you are upset and you increase blood pressure.
But more about that below. There are lot of advices and effects that I will explain to you below
1.You have to think that you will relief stress and he will gone. That isn’t so hard. Just relax and think on better stuffs and don’t say that you have problems with stress anymore and forgot about them. There are much stress reliefs techniques that you can choose and help yourself. Choose what is best for you and enjoy. You will see that is very helpful.
2.Also you maybe think that when you drink alcohol or smoke cigarets you help to relief stress. But that isn’t good. You can become depend from cigarets or alcohol and that will produce more stress,depression and problems. So you have to find the healthier ways and reliefs techniques to rid of stress.
3.I already said that you must find the best relief technique for you. That is very important because it isn’t your body exactly same like with some other man or woman. That is important because not everyone experience stress in the same way.
4.You probably don’t know but stress can result on your physical look. That mean that you can look older than you are and I know that anyone want that. So relax you wont do anything if you think just on your problems.
5.You can help in reducing stress if you change some your usually things that you do. For change you can start do exercises or take a diet. That will motivate you and you will feel better. Maybe your stress is reduced by some bad things that you do and change them if you think that they aren’t good.

Finding the Right Travel Nursing Placement Agency

Travel nursing is becoming one of our nation’s fastest growing professions, and it’s no surprise. If you love seeing new places and enjoy exciting new experiences that evoke the feeling of taking an extended vacation, then the career of a traveling nurse might be just what the doctor ordered! Travel nursing enables many people to stay on vacation for two to six months in free luxury accommodations while earning high hourly wages at the same time.

Yet despite all these advantages, many nurses describe to me that they’ve shied away from the traveling profession. Why? Because bad experiences with placement agencies have left them with nothing but a negative impression. They’ve been underpaid or lacked benefits, and I can’t tell you how many nurses have complained to me about inadequate housing or recruiters who were unkind, uncaring, and just plain unavailable. The sad result is that nurses end up jumping from one agency to the next, always in search of the perfect package that’s never there.

In this light, choosing the right staffing agency requires a nurse to consider everything that is offered. Some nurses emphasize pay as their top priority. Others require an excellent benefits package. Many travel RNs are location-specific and want to experience the lifestyle in the country’s hot spots. Career flexibility is often a pivotal factor, along with customer service. The bottom line is, your agency choice depends largely upon one of the four following criteria.

SALARY

No question about it, there are some agencies that offer more money than others. So the first thing to remember is that agencies may base salaries upon things like location availability, need-to-fill assignments, and cost of living.

Some agencies must offer noticeably higher rates if they expect to fill certain assignments where nurse-to-patient ratios are very low, or where a facility has extreme patient needs. If you’re a nurse who is attracted by very high dollars, be alert for a potentially desperate situation you might be entering, and the workload it could bring. You may make more money, but you’ll earn every dollar and more.

Location also factors into salary. The California bay area and many larger east coast cities definitely offer more lucrative pay rates. It’s also much more expensive to live in those places, so recognize the relationship that exists between salary dollars and cost of living. I’ve seen nurses return from Hawaii saying they had a great vacation and made a lot of friends–but their purses were lighter, not heavier from the experience. You might get less money in an exotic location and come back with more money from a not-so-exotic location. My point is, your criteria will determine your priorities.

BENEFITS

What some companies may lack in salary, they make up for with benefits. Many agencies offer benefits programs that revolve around monetary bonuses or discounted luxury housing; and I have even observed a trend with several newer companies that offer entirely free housing to all their nurses. Take note, however, that those agencies may not ante up the really high salaries. It’s a trade-off, so they compensate you with benefits to save you daily, monthly, and annual expenses. Every nurse should be aware of what benefits they need the most, and then ask their recruiters to assist in developing a package that is tailored to their individual needs.

CUSTOMER SERVICE

To many traveling nurses, customer service and aid are the most important attributes a placement agency possesses. If you called ten agencies and only talked with one live recruiter, it’s probably best to narrow it down to the agency where individual placement specialists were easily available. After all, if you’re ready to proceed with a new assignment you’ll want an agency that can make it happen fast and has recruiters available who already understand your criteria. In fact, your criteria may change from one assignment to another, so customer service is paramount. Determine what you want and then find out which agencies can make it happen.

FEATURED LOCATIONS AND HOT SPOTS

While for some nurses, salary, benefits, and career flexibility might be the number-one interest, many others just want the obvious–to travel and see the world. If you’re an adventurer who cares more about the travel experience than the money, then you’ll need an agency that can offer you the locations you want.

Not every agency can send you just anywhere. Figure out where you want to go, and then call around to discover who can send you there.

A travel nursing career is absolutely one of the best, most rewarding choices any nurse can make, but it’s important to select a company who will partner with you every step of the way. Before you jump in, do your homework and research all the best placement agencies. Finding the agency that fits your unique wants and needs will drastically increase your chances of success and happiness in your career.

Internet Marketing Strategy

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Internet marketing is the same as traditional marketing, others are not. Here are seven things you need to know your online marketing is successful. When you write Xu copy, you should take the time to understand what works and what does not. There are two mistakes almost every amateur search engine copywriting.

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Internet marketing is still essential to any business’s overall marketing strategy. Mentioned before with all the benefits of internet marketing, people still buy magazines, billboards went out to check to see their mail, watch TV, and shopping. No matter how fast-paced and wide internet of communication, people go out together, talking about going to the gym. Thus, while Internet marketing is absolutely valid and important, demising certain value of the cost of traditional marketing any business, many potential customers. Another thing, when we say that internet marketing, it is not only figures we choose to click on ads. The list also includes security, advertising, advertising social networks, groups, discussion boards and many others. Accordingly, the online marketing activities can effect the number of people exposed. However, one disadvantage is that people started to become one of the, and would even read the advertising information advertising or know (even people in the security list), and delete without opening them. When someone on the Internet, they would like to read / write e-mail, chat with friends, read and post / reply comments, play fun games. As a internet marketing goal is to build a top priority for Internet users. Also, try and spam and unsolicited e-mail and advertising, more and more people away from Internet advertising in general, unless they are some specific content. A variety of Internet marketing strategy is free and paid online marketing can make more money. 12-month Internet Millionaire Review – Russell Brunson is a 12-month millionaire fraud?. As the market one of the most controversial books, and now the Internet millionaire’s 12 months still constitute a major buzz everywhere. A great professional internet marketing make money online. Internet marketing can be a lucrative industry, if some big Internet-related skills and knowledge development to do so successfully. Must also identify and develop the necessary strategies to make money online. Pay per click advertising, online advertising and link exchange programs, is marketing, can be used to make the Internet industry to make money online there are some important programs.

Internet marketing are not the result of a well-defined, integrated internet strategy; rather, they are a response to competitors activities or customers demand. Through the site has existed for more than a year, marketing staff and senior management will Uncategorizedly question its effectiveness. This is usually the point in a coherent Internet marketing strategy needs to become apparent. As a result, starting in the sum of electronic marketing strategy, is when a company’s existing website, which is to review the existing site and its purpose is to improve the effectiveness of the future. There is no evidence that the development and implementation of a strategy to be significantly different approach to electronic marketing. Strategic planning for enterprise development or strategic marketing to comply with the established framework should still be. The framework provides a logical order to follow up to ensure that the strategic focus of all development activities included. It can be said, however, with the e-market strategy for a highly sensitive process of rapid response mode, the events in the market need. Soviet-style five-year planning application does not seem to fit, the best approach is a new process of electronic marketing strategy is a continuous improvement. Check fee (2002) pointed out that e-commerce or e-marketing strategy process models tend to agree with the following features:

There are many ways to market your product using a large number of online with Google AdWords or Yahoo’s Overture advertising network, eBay, members network, cost per click marketing. In addition, there are many second tier cost of sales and earnings per share network. You need to have a good network marketing strategy, using the Internet to provide online marketing tool. With Internet marketing company, will help you to get your website in search engine advertising and optimization services provided by many of the results, but eventually you need to determine what kind of network marketing will give you the best of a product line. It used to be you bought CPM (cost per thousand) in large-scale campaign Web site and hope that the good performance of these ads and get traffic to your website. Now, there are many choices, there is usually a for each event better than the other run. It appears that the use of network marketing the best way to get return on investment cost per click online marketing tool, the strategic point. Google AdWords and Yahoos Overture CPC programs have dominated the world of network marketing in the past two years, they only get bigger and stronger. Network marketing companies have sprung up to help beginners learn how to use AdWords and Overture to the best of their ability to rope. If you want to build a brand, then the cost per click will not be online marketing solutions. Instead of the online brand, you will go to a CPM campaign, is a straight line costs. The targeted ads, and now there’s online advertising spending is due to leave the television and radio have been gradually transferred to the Internet. Why do you want, if you are advertising with the radio or TV, you can actually track the individual results of the work online. We believe that many ad networks and affiliate program will gradually fade out in the next several years, while Google and Yahoo Zhudao even with their own, targeted search results and more per click advertising network. Internet changes quickly, any company want to optimize their online marketing presence needs to adapt and adjust to the latest technology.

Network marketing is the three capacities: transport infrastructure, marketing, application development, marketing methods and permissions. Practical ability of the network in sports marketing when three similar shift manual gearbox, driving a car, both in mechanics.

Internet marketing is the same where you live, because it is a global market.

They do not have banner ads, because they are cheaper than print. In Facebook, because their children that they should be. If you start what you want for your site’s business focus and you concentrate all energy on helping to improve the preliminary results of this goal, Name of the Dong Xi you Keyi try, to see if they are how they work. Or you can look at things, said: “I do not see how it can help me achieve my goal. Now, if you ignore something, it is possible that they will actually become extremely important, and you ‘local employees realize that you
made a mistake. but only the larger error is ignored, since you are overriding, or try to do everything hafway and accomplish nothing.

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Internet marketing is clear, the next question is usually, “Yes, but where I start?.” For new and existing customers a direct entry point. In the days passed, and when people want to find a business, they turned to the yellow pages. Today, your customers will find you on the Internet, if you are not there, they will turn to the next thing, they did find: 1,

Network Marketing is your competitor doing? How do your competitors in the domestic major search engine rankings? What kind of traffic from their own site? Use the right tools, this valuable information can be found in your competitors.: What is it your product or service for the customer to resolve or do not provide any good? In what ways you can best illustrate this advantage? Clear and consistent information on the positioning of your products in the market based on a solid understanding is very important to all offline and online marketing efforts.: How much money can you get customers and still make a profit? What is each customer, you get the value of life expectancy? This is the answer you need to determine the effectiveness of any network marketing program running on key issues.

Internet marketing is falling over themselves trying to shift dollars from offline to online marketing. I believe the idea is that network marketing will give them better to reduce the U.S. dollar in a tight economic returns. While it is certainly a solid strategy for mobile Internet, it pays to put it a little thought, the first: Verify your infrastructure. Offline dollars in your move to online, to ensure that you can actually use all of the online customer service. Do you have in place of? You can quickly adjust the landing page and website copy? No sense, if you put in to send visitors to a site, sucking money from online advertising. If you are from offline to online money like two weeks to generate a 5:1 return, reducing the Prozac and think twice to come back. The biggest mistake I see their budget, the company’s transformation, is that they think this is a line ‘run and do’ things. Marketers and their bosses think they can create a landing page or start a PPC campaign, and then forget about it for a month. And this cycle works in print or television, it will not work online. Line is highly, highly repetitive, and requires constant attention. So you save a lot of advertising money into the labor force.

Characteristics of network marketing is definitely a good start in the Internet market, but if you do not know how to drive traffic to your site, these things will be wasted.

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Internet marketing is just too numerous to mention in this article. If you access the Internet value-added services, web savvy, you will see how much of this marketing can increase your business type.

Network marketing is online marketing, network marketing, network marketing. Internet marketing is very important, but the madness of growth with social media, I strongly recommend listening skills is to know how to do twitter, Facebook and YouTube. Many marketing media, relying on the three to take home the bacon only. The building is a long list of network marketing, a necessary component of success. List building simply means that a user list, you can communicate regularly via e-mail. In order to start building a list, you first need to establish what is called a capture page. Pages, your visitors will be asked to provide some free gifts, to share their names and e-mail. It can be a free report, e-books, video or presentation software. Many merchants also offer free electronic can receive daily early bird tips and notifications.

In today’s competitive (and noise) market, we must combine all the right online marketing tools, to create a truly effective and comprehensive marketing program. All, of course, is up and around the central site, but to create opportunities, improve customer response, increased brand awareness, the site of the network through a comprehensive marketing strategy, including search engine optimization, PPC, social media tools to support marketing, and so on.

Linked network marketing ideas and technology and business strategy design, development, Internet advertising and marketing. Search engine marketing, email marketing, display advertising, affiliate marketing, display advertising, blog marketing, display advertising, viral marketing. Internet marketing is the media running along the different stages of customer engagement cycle through search engine marketing, search engine optimization in a specific site, e-mail marketing and Web 2, banner ads. Network marketing has become more and more organizations use to promote the network media key and very effective. ‘The establishment of a website’ or ‘promotion site’ is the foundation, but not the basis of network marketing.

Somewhere behind that website is a real goal, the real organization. Internet marketing strategy includes all of the online advertising products and services, including market research, email marketing, websites, and direct sales.

Car Rental Rates – How to Get the Best Car Rental Rates

Car rental rates are obviously dependent on which dealership you opt for and how long you need the vehicle for. To get the best car rental rates you must be certain of the period in which you are going to require the vehicle for. For example, you would not want to rent a car for 3 days, to find out you need it for an additional 3 days this is where dealerships will charge for days the vehicle is required for, at their daily rate; savings are to be made when you book for a week if there is any chance of requiring the vehicle for longer. Agencies operate on weekly and daily rates; it always pays to look into the weekly rate as this is usually lower than a per day rate.

If you want to find the best car rental rates you must shop around. Car rental rates are constantly changing due to supply and demand and obviously change in line with the season. You will need to book far in advance should you want a rental car over any holiday period. Make sure you enquire about special holiday rates as some rental agents will give away a day extra for free over these periods. Make sure you are certain of you required dates over these periods as agencies cancellations over these periods will incur large fees.

To find the best car rental rates when it comes to long distance trips, it pays to book well in advance and ask your travel agent of any deals that are not publicly advertised. If you are planning a road trip to Las Vegas for tonight, you’ll have wanted to have booked at least a week ago to get the best rates and avoid disappointment. Remember that reservation only guarantees a reserved rate, you must specify if you are after a specific vehicle.

If you think the weekend car rental rates you are getting are too good to be true, then they probably are. You will want to ask for any hidden costs, such as insurance, state taxes, varying fees for drivers of different ages and refueling charges. Ask your rental agent of any compulsory insurance fees, as these hidden costs are generally what makes the advertised costs so well, read the disclaimer! Some states in America give rental car agents permission to charge extra fees on their rentals to cover the costs of licensing their cars. This is fee is generally 6% of the total rental costs. The majority of states in America do not require rental agents to inform the customer of this fee, so make sure you ask before hiring.

To get the cheapest, most value for money rental car rates you will need to shop around, be sure of the duration you require the vehicle for, make sure you ask about any hidden fees and always book well in advance.

Planning and Design of Behavioral Healthcare Facilities

Behavioral Healthcare Facilities: The Current State of Design

In keeping with most districts of healthcare, the marketplace has seen a boom in the construction of Behavioral Healthcare facilities. Contributing to this increase is the paradigm shift in the way society views mental illness. Society is placing a heavier value on the need to treat people with serious addictions such as alcohol, prescription and elicit drugs. A large percentage of people suffering from behavioral disorders are afflicted with both mental and addictive behaviors, and most will re-enter communities and either become contributors or violators.

These very specialized facilities do not typically yield the attention from today’s top healthcare designers and their quantity accounts for a small fraction of healthcare construction. However, Behavioral Healthcare projects are increasing in number and are being designed by some very prominent architectural firms such as Cannon Design and Architecture Plus. Many are creating state-of-the-art, award-winning contemporary facilities that defy what most of us believe Behavioral Healthcare design to be.

Changing the Way We Design Behavioral Healthcare Facilities

As with all good planners and designers, A+D (along with facility experts) are reviewing the direct needs of patient and staff while reflecting on how new medicine and modern design can foster patient healing rates, reduce environmental stress, and increase safety. This is changing the face of treatment and outcome by giving the practitioner more time to treat because they require less time and resources to “manage” disruptive patient populations.

The face of Behavioral Healthcare is quickly changing. No longer are these facilities designed to warehouse patients indefinitely. And society’s expectations have changed. Patients are often treated with the belief that they can return to their community and be a contributor to society. According to the National Association of Psychiatric Health Systems (NAPHS), depending on the severity of illness, the average length of stay in a Behavioral Healthcare facility is only 9.6 days.

What has changed?

Jaques Laurence Black, AIA, president and principal of New York City-based daSILVA Architects, states that there are two primary reasons for the shortened admission period:

1. Introduction of modern psychotropic drugs that greatly speed recovery

2. Pressures from insurance companies to get patients out of expensive modes of care

To meet these challenges, healthcare professionals are finding it very difficult to effectively treat patients within the walls of antiquated, rapidly deteriorating mental facilities. A great percentage of these facilities were built between 1908 and 1928 and were designed for psychiatric needs that were principled in the belief to “store” not to “rehabilitate.”

Also impacting the need for Behavioral Healthcare construction is the reluctance of acute-care facilities to provide mental health level services for psychiatric or addiction patients. They recognize that patient groups suffering from behavioral disorders have unique health needs, all of which need to be handled and treated only by very experienced healthcare professionals. This patient population also requires a heightened level of security. Self-harm and injuring staff and other patients are major concerns.

The Report of the Surgeon General: “Epidemiology of Mental Illness” also reports that within a given year about 20% of Americans suffer from a diagnosable mental disorder and 5.4% suffer from a serious mental illness (SMI ) – defined as bipolar, panic, obsessive-compulsive, personality, and depression disorders and schizophrenia. It is also believed 6% of Americans suffer from addiction disorders, a statistic that is separate from individuals who suffer from both mental and addiction disorders. Within a given year it is believed that over one-quarter of America’s population warrants levels of mental clinical care. Even if these statistics were cut in half, it cannot be denied as a serious societal issue.

With a growing population, effectively designing in accordance with such measures is at the heart of public health.

Understanding the Complexity of Behavioral Healthcare Design

Therefore, like Corrections, leading planners and designers specializing in Behavioral Healthcare are delving deeper to better understand the complexity of issues and to be the activist to design facilities that promote treatment and healing – and a safer community.

The following is a list of key design variables that are being studied and implemented:

1. Right Sizing

2. Humanizing Materials and Color

3. Staff-Focused Amneties and Happiness

4. Security and Safety

5. Therapeutic Design Tenants

Right-sizing

Today’s Behavioral Healthcare facilities are often one-story single buildings within a campus size. Often debated by Clients due to costs, this design preference is driven by the demand for Uncategorized light, window views to nature for all patient areas, and outdoor open-air gardens “wrapped” within. All of this provides soothing qualities to the patient, reduces their anxieties, counteracts disruptive conduct and helps to reduce staff stress.

“When you look at the program mix in these buildings, there’s a high demand for perimeter because there are a lot of rooms that need Uncategorized light. Offices, classrooms, dining areas, community rooms, and patient rooms all demand Uncategorized light, so you end up with a tremendous amount of exterior wall, and it forces the building to have a very large footprint.” – James Kent Muirhead, AIA, associate principal at Cannon Design in Baltimore

These design principles are also believed to improve staff work conditions. Unlike a multi-story complex, at any moment staff can walk outdoors and access nature, free from visual barriers, and within a building that more accurately reflects building types that both patients and staff would encounter in their communities.

In addition to right-sizing for the overall building footprint, is right-sizing for internal patient and staff support area. Similar to the move we have seen in Corrections to de-centralize support spaces, Behavioral Healthcare is moving to decentralized nursing/patient units called “neighborhoods.” With mental health facilities there is a large concern with distances and space adjacencies in relation to the patient room and patient support areas such as treatment and social spaces. Frank Pitts, AIA, FACHA, OAA president of Architecture Plus, Troy, NY, advocates neighborhoods that average 24-30 beds arranged in sub-clusters, called “houses”, of 8-10 beds. Thus, each neighborhood consists of three houses. Often these layouts will include a common area where patients congregate and socialize, with a separate quiet room so patients can elect to avoid active, crowded areas. In addition Pitts states, “There’s a move away from central dining facilities. So, while facilities will still have a central kitchen, it’s a whole lot easier moving food than it is patients.” However, it is important for the facility to mimic normal outside daily life routines, so patients are encouraged to frequently leave their neighborhoods to attend treatment sessions, and outdoor courtyards.

Humanizing Materials & Color

In all facilities that play a role in rehabilitation, design strives to create spaces that humanize, calm, and relax. Behavioral Healthcare patients need to feel that they are in familiar surroundings; therefore, the architectural vocabulary should feel comfortable and normal. Since these facilities are about rehabilitation (when possible) and encouraging patients to merge back into society, the facility should feel like an extension of the community. Their spaces should reflect the nature and architecture of the surrounding region and thus so, no two facilities should look too much alike.

“Our a
pproach to designing these facilities is to view the facility as an extension of the community where patients will end up when they’re released. Interior finishes also depend on geography because you want to replicate the environment patients are used to. You want to de-stigmatize the facility as much as possible.” – Tim Rommel, AIA, ACHA, OAA, principal with Cannon Design in Buffalo, NY.

Therefore, materials and colors within these spaces want to feel familiar to one’s region and everyday life. To soothe the psyche and rehabilitate, they want to feel soft and comfortable, yet visually stimulating. An interior that is overly neutral or hard in appearance is not appropriate. Materials should reduce noise, and colors should lift the spirit. This can help to create an environment in which the patient can learn, socialize, and be productive while easing anxieties, delivering dignity, and modifying behavior. As stated previously, behavioral studies advise the use of softer interior materials-like carpeting, wood doors and tile. Doing so translates directly to both patient and staff well-being, particularly staff safety, and makes for a nicer place to work. In addition, staff have more resources to “treat” instead of manage heated situations. When staff experiences are eased and satisfied, morale is boosted and life-saving rules and policies are more likely to be enforced.

Staff-Focused Amenities & Happiness

While reducing staff stress and fatigue through a healing supportive environment seems like an obvious goal, there are relatively few studies that have dealt with this issue in any detail. More attention has been given to patient outcomes. However, many leading hospitals that have adopted therapeutic tenants into their newly built environments have seen vast improvement through their “business matrixes” and financial reporting.

In one example, the Mayo Clinic, a national leader in implementing healing design in its facilities, has reported a reduction of nursing turnover from a national annual average of 20% to an annual 3%-4%. In another example, when Bronson Methodist Hospital incorporated evidence-based design into its new 343-bed hospital, they cited their 19%-20% nurse turnover rate dramatically dropped to 5%.

Now, both the Mayo Clinic and Bronson Methodist Hospital have had to initiate a waiting list for nursing staff seeking positions. This converts to better-trained and qualified staff, and a reduced error rate. Therefore, more health facilities are investing in staff support areas such as lounges, changing rooms, and temporary sleep rooms. Within these staff spaces and in the hospital throughout, facilities are also recognizing the need for upgrade materials, better day lighting, and an interesting use of color: One soon realizes that the need of patients and staff are interwoven, each impacting positively or negatively the other.

Security & Safety

Without debate, self harm and harm to staff is one of the biggest concerns mental health facilities manage. Often the biggest safety and security concern is the damage patients can do to themselves. “There are three rules I had drummed in me,” says Mark Hanchar; Director of Preconstruction Services for Gilbane Building Company, Providence, R.I. “First, there can’t be any way for people to hang themselves. Second, there can be no way for them to create weapons. Third, you must eliminate things that can be thrown.” Hanchar says that the typical facility is, “a hospital with medium-security prison construction.” This means shatter proof glass, solid surface countertops (laminate can be peeled apart), stainless steel toilets and sinks (porcelain can shatter), push pull door latches and furniture that cannot be pulled apart and used as a weapon. These are just to name a few.

Additionally, removing barriers between patients and nursing staff is a safety consideration. Frank Pitts, AIA, FACHA, OAA president of Architecture Plus, says what may be counter-intuitive for safety precautions, “Glass walls around nursing stations just aggravate the patients.” Removing glass or lowering it at nursing stations so patients can feel a more human connection to nurses often calms patients. There is also discussion of removing nursing stations altogether; decentralizing and placing these care needs directly into the clinical neighborhoods and community spaces. Pitt says, “The view is that [nursing staff] need to be out there treating their patients.”

Therapeutic Design Tenants

As medicine is increasingly moving towards “evidence-based” medicine, where clinical choices are informed by research, healthcare design is increasingly guided by research linking the physical environment directly to patient and staff outcomes. Research teams from Texas A&M and Georgia Tech sifted through thousands of scientific articles and identified more than 600 – most from top peer-reviewed journals – to quantify how hospital design can play a direct role in clinical outcomes.

The research teams uncovered a large body of evidence that demonstrates design features such as increased day-lighting, access to nature, reduced noise and increased patient control helped reduce stress, improve sleep, and increase staff effectiveness – all of which promote healing rates and save facilities cost. Therefore, improving physical settings can be a critical tool in making hospitals more safe, more healing, and better places to work.

Today’s therapeutic spaces have been defined to excel in 3 categories:

1. Provide clinical excellence in the treatment of the body

2. Meet the psycho-social needs of patients, families, and staff

3. Produce measurable positive patient outcomes and staff effectiveness

Considering the cost of treating mental illness, which is exceedingly high, and wanting facilities to have effective outcomes, a further practice of incorporating therapeutic design is increasing. The National Institute of Mental Health (NIM H) approximated in 2008 that serious mental illnesses (SMI ), costs the nation $193 billion annually in lost wages. The indirect costs are impossible to estimate.

The estimated direct cost to clinically treat is approximately $70 billion annually and another $12 billion spent towards substance abuse disorders. In addition to the increased need of care and the boom in Behavioral Healthcare construction, it becomes an obligation to make certain that we as facility managers, architects, designers and manufacturers therapeutically plan and design these facilities.

Notably, in 2004, “The Role of the Physical Environment in the Hospital for the 21st Century: A Once-in-a-Lifetime Opportunity,” published by Roger Ulrich P.H.D., of Texas A&M University, was released. In a culmination of evidence-based research, research teams found five design principles that contributed significantly to achieving therapeutic design goals.

The report indicates five key factors that are essential for the psychological well-being of patients, families and staff, including:

1. Access to Nature

2. Provide Positive Distractions

3. Provide Social Support Spaces

4. Give a Sense of Control

5. Reduce or eliminate environmental stress

Access to Nature

Studies indicate that nature might have the most powerful impact to help patient outcomes and staff effectiveness. Nature can be literal or figurative – Uncategorized light, water walls, views to nature, large prints of botanicals and geography, materials that indicate nature and most importantly, stimulating color that evokes nature. Several studies strongly support that access to nature such as day-lighting and appropriate colorations can improve health outcomes such as depression, agitation, sleep, circadian rest-activity rhythms, as well as length of stay in demented patients and persons with seasonal affective disorders (SAD).

These and related studies continue to affirm the powerful impact of Uncategorized elements on patient recovery and stress reduction. Thus, it is clea
r that interior designs which integrate Uncategorized elements can create a more relaxing, therapeutic environment that benefits both patients and staff.

Positive Distractions

These are a small set of environmental features that provide the patient and family a positive diversion from “the difficult” and, in doing so, also negate an institutional feel. These can be views to nature, water walls, artwork, super imposed graphics, sculpture, music – and ideally all of these want to be focused on nature and, when applicable, an interesting use of color. Therapeutic environments that provide such patient-centered features can empower patients and families, but also increase their confidence in the facility and staff. This helps with open lines of communication between patient and caregiver.

Social Support Spaces

These are spaces designed partially for the patient but mainly for the comfort and socialization of family members and friends of the patient; therefore, family lounges, resource libraries, chapels, sleep rooms and consult rooms all play a role. When family and friends play a key role in a patient’s healing, these spaces encourage families to play an active role in the rehabilitation process.

Sense of Control

In times when patients and family feel out of control, it is very healing for the facility design and staff to provide it back when appropriate. Although, this cannot always be done suitably in mental healthcare facilities. However, when applicable, these design features include optional lighting choices, architectural way-finding, resource libraries, enhanced food menus, private patient rooms and

optional areas to reside in. A few well-appointed studies in psychiatric wards and nursing homes have found that optional choices of moveable seating in dining areas enhanced social interaction and improved eating disorders. When patients feel partially in control of their healing program and that the building features are focused to them, an increased confidence of the quality of care enters and tensions lower.

As with all therapeutic design, this allows the caregiver to use their resources healing in lieu of “managing” patient populations.

Reduce or Eliminate Environmental Stress

Noise level measurements show that hospital wards can be excessively noisy places resulting in negative effects on patient outcomes. The continuous background noise produced by medical equipment and staff voices often exceeds the level of a busy restaurant. Peak noise periods (shift changes, equipment alarms, paging systems, telephones, bedrails, trolleys, and certain medical equipment like portable xray machines are comparable to walking next to a busy highway when a motorcycle or large truck passes.

Several studies have focused on infants in NIC Us, finding that higher noise levels, for example, decrease oxygen saturation (increasing need for oxygen support therapy), elevate blood pressure, increase heart and respiration rate, and worsen sleep. Research on adults and children show that noise is a major cause of awakening and sleep loss.

In addition to worsening sleep, there is strong evidence that noise increases stress in adult patients, for example, heightening blood pressure and heart rate. Environmental surfaces in hospitals are usually hard and sound-reflecting, not sound-absorbing causing noise to travel down corridors and into patient rooms. Sounds tend to echo, overlap and linger longer.

Interventions that reduce noise have been found to improve sleep and reduce patient stress. Of these, the environmental or design interventions such as changing to sound-absorbing ceiling tiles, are more successful than organizational interventions like establishing “quiet hours.”

Conclusion and Additional Information

The information contained in this excerpted report is intended as a guide for architects, specifiers, designers, facility planners, medical directors, procurers, psychologists and social workers which have a stake in providing improved facilities for behavioral healthcare patients. It is a portion of a report entitled “The Contributions of Color” authored by Tara Hill, of Little Fish Think Tank. Ms. Hill was commissioned by Norix Group Inc., in 2010 to research the role color plays in the safe operation of correctional facilities and behavioral health centers. More in-depth information specifically about the psychological influence of color and behavioral healthcare facility design can be found by reading the full report.

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