Belonging is more than a feeling—it is a critical determinant of how people experience healthcare. Research consistently shows that when patients feel a sense of belonging, they are more likely to trust providers, disclose sensitive information, and adhere to treatment plans, all of which directly affect outcomes.
As part of its commitment to health equity, Providence, a comprehensive healthcare organization with 51 hospitals and more than 1,000 clinics across seven states, has pledged $50 million toward a Fellowship program aimed at addressing disparities faced by marginalized populations.
This past year, as part of the initiative, Providence partnered with NBBJ (Portland, Ore.), to launch the “Design for Belonging” initiative, focused on creating more inclusive and welcoming healthcare environments.
This initiative aims to provide practical tools for design and clinical leaders to evaluate and improve spaces through the lens of belonging. The overarching goal: ensure that the built environment not only functions effectively, but also communicates respect, acceptance, and equity to all who enter.
Providence’s Design for Belonging initiative
The project team selected emergency departments (EDs) as the starting point for this initiative for two key reasons. First, EDs benefit from robust data collection, including post-visit patient experience surveys and metrics such as “Left Without Being Seen” and “Code Gray” (emergency situations that involve a potentially combative or aggressive person) incidents, offering insights that other departments may lack. Second, they often serve as the “front door” to the health system—particularly for marginalized communities that may lack consistent access to primary care.
To guide this work, the team turned to the concept of “ambient belonging.” The term, defined in the study “Contending with group image: The psychology of stereotype and social identity threat,” published in a 2009 Journal of Personality and Social Psychology article by Sapna Cheryan and colleagues, describes the cues within an environment that shape whether people feel they belong.
In the study, women in STEM fields reported decreased belonging in spaces decorated with stereotypically male or “geeky” objects. The implication was clear: design choices can unconsciously send signals about who a space is for—and who it isn’t.
This became the foundation of our project’s guiding question: How can Providence foster ambient belonging within its facilities, and is there a business case to support these strategies?
Researching the healthcare built environment
To better understand how the built environment influences a sense of belonging, the project team engaged the Providence patient and caregiver community.
First, a survey was developed that focused on recent experiences in six Providence EDs across Oregon. The survey targeted the initial phases of the ED visit to determine perceptions of comfort, safety, clarity of signage, and inclusivity of design elements. Participants were asked to identify specific architectural elements that had a positive impact on their experience while waiting.
The survey also touched on experiences that can be shaped by architecture, such as access to privacy when sharing personal information during check-in.
Additionally, demographic information was collected to identify trends among specific populations and elements valued across all groups. More than 1,600 responses and extensive written commentary were assembled into a robust dataset to guide the overall analysis.
The second phase of research included individual interviews and focus groups with patient and caregiver representatives to provide deeper understanding into environmental perceptions and give context to the survey data.
One example that was very polarized in the survey data and focus groups was the presence of a uniformed security officer. Consistent across all EDs, the first encounter for patients and families was with the security officer and the screening process. While for some, this enabled a feeling of safety, for others it was the opposite: feelings of distrust and lack of safety which led to avoidance or heightened anxiety.
How are human needs and ambient belonging connected?
Building on these insights, the project team began to see a broader pattern: the link between ambient belonging and Maslow’s hierarchy of needs. Interestingly, this connection emerged from an unfiltered piece of patient feedback. In response to a question about the ED waiting room, a patient stated that when they were sick and in pain, they didn’t care what the artwork looked like.
This comment was deeply revealing and underscored a fundamental truth: feelings of belonging cannot take root when basic needs are unmet. The team began to recognize that while design interventions can foster inclusion and comfort, their impact is limited if patients are in physical distress, unsafe, or uncertain about receiving timely care.
This aligns directly with Maslow’s framework: unless physiological needs are addressed first, patients are unlikely to reach higher levels of emotional well-being, such as safety, connection, or acceptance.
For healthcare designers, this insight is critical—the signals of belonging must be layered on top of a foundation of functional, human-centered care.
The Design for Belonging Playbook
Recognizing the need for actionable tools, the project team developed the Design for Belonging Playbook. Designed for architects, interior designers, facility managers, and clinical leaders, the Playbook offers three core components:
- The Scorecard: A tool for assessing existing spaces against four levels of ambient belonging: Basic Needs, Safety, Connection, and Acceptance, with possible scores of up to 100 points. Using the scorecard, teams are enabled to evaluate performance and prioritize interventions based on evidence rather than assumptions.
- Design Intervention Matrix: A framework linking common challenges to a spectrum of scalable design solutions, categorized by both the belonging level addressed and the scale of investment required. For example, to address noise sensitivity, a near-term/budget-friendly solution might be installing sound-absorbing panels, while a long-term intervention could involve redesigning sub-waiting zones for quieter environments.
- Design Intervention Strategies: Expanded guidance with visual examples of how design attributes—such as lighting, layout, or furniture diversity—can support belonging. For instance, inclusive artwork or community-centered graphics signal acceptance and representation.
Together, these tools empower teams to respond to the unique needs of their communities.
Tying ambient belonging to HCAHPS scores, patient feedback
After visiting six EDs in the Portland metro area and using the scorecard to evaluate each space, the research team was able to begin identifying connections between ambient belonging scores and some of the metrics tracked at each hospital.
While analysis of these connections is ongoing, early findings from the collaboration between Providence and NBBJ point to clear and compelling trends, connecting different sections of the ambient belonging framework and tying ambient belonging to patient feedback from Press Ganey surveys and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores.
Several key conclusions have emerged that reinforce the connection between the built environment and the patient experience. One of those ideas is that basic needs are foundational to ambient belonging.
Facilities scoring low in the basic needs category of the scorecard (worth 21 of the total 100 points) also scored low in overall ambient belonging. This reinforces a core tenet of the research team’s work: without physical comfort—such as access to water, thermal comfort, seating, and privacy—patients are unlikely to experience a deeper sense of inclusion or emotional safety.
This is crucial for design teams and clinical leaders to understand; before investing in higher-level design interventions, organizations must ensure fundamental comfort and safety.
What’s the future of inclusive design in healthcare?
Early results of comparing ambient belonging scores to patient survey data demonstrate that the built environment plays a critical role in shaping perceptions of care.
Ambient belonging is not merely conceptual—it’s a measurable and meaningful factor that directly influences engagement, satisfaction, and equity.
By leveraging design as a tool for systemic change, healthcare designers and clinical leaders can move away from uniform solutions and toward adaptive strategies that honor the people and communities each space is intended to serve.
Speakers at 2025 Healthcare Design Conference + Expo
The authors will share more on this topic at the 2025 HCD Conference + Expo, Oct. 25-28 in Kansas City, Mo., during the interactive roundtable, “Design for Belonging: Creating an Inclusive Future for Built Environments,” from 2-3 p.m. on Sunday, Oct. 26. For more information about the session and to register for the conference, visit hcdexpo.com.
Find updates and additional information on the 2025 HCD Conference + Expo here.
Lauren Cole, MS-ID, EDAC, Associate IIDA, is system director of design strategy at Providence Health (Renton, Wash.) and can be reached at [email protected]. Jessica Radecki, AIA, LEED AP, EDAC, L S SGB, is senior associate and healthcare director at NBBJ (Portland, Ore.) and can be reached at [email protected].
