Beyond Comfort: Could the Way We Position Patients Change How They Experience Radiotherapy?

For many patients, radiotherapy begins before the treatment beam is switched on. It begins with an unfamiliar room, unfamiliar technology and a series of instructions that place them in the hands of their treatment team. Patients are asked to lie down, remain still and, moments later, the clinical team leave the room to deliver the treatment. 

Research has consistently shown us that being in a healthcare environment can heighten a person’s feelings of uncertainty, vulnerability and loss of control [1]. Environmental psychology, healthcare design, communication research and radiotherapy anxiety literature have all taught us that visual awareness, environmental orientation, face-to-face interaction and perceived control may all influence how patients experience healthcare environments. 

Understanding the Environment Around Us 

Psychologists have long recognized that the environments we occupy influence how safe and in control we feel. 

An interesting concept is the Prospect-Refuge Theory, first proposed in 1975 by Appleton [2]. The theory suggests that people tend to prefer environments where they can survey their surroundings while also feeling protected.  

In simple terms, this means being able to see our surroundings helps us to orient ourselves within an environment, reducing uncertainty and contributing to feelings of safety [3].  

This theory has clear applications in the healthcare setting and specifically traditional supine radiotherapy where a patient lying flat may have limited visual access to the room, the equipment and the people around them. An upright patient, in comparison, may be better able to orientate themselves within the treatment environment; observe the treatment space, understand where staff are positioned and maintain awareness of what is happening.  

This does not mean upright positioning automatically reduces anxiety, but it supports a plausible hypothesis: greater visual access supports environmental orientation, helping patients understand what is happening around them and reducing uncertainty. 

The Importance of Feeling in Control 

A central concept in healthcare design is perceived control. One of the best-established concepts in healthcare design is Ulrich’s Theory of Supportive Design which proposes that healthcare environments are less stressful when they support a sense of control, social support and positive distraction [4].  

For radiotherapy, this is important because treatment often involves unavoidable loss of control. Patients are positioned by others, asked to remain completely still, look directly ahead and are left alone in the treatment room while staff monitor them from outside. If upright positioning allows the patient to see more of the room, communicate more naturally and understand what is happening around them, it may support perceived control even when actual control is limited. 

Seeing Eye to Eye 

But feeling in control isn’t influenced solely by our surroundings. It is also shaped by how we interact with the people caring for us. In radiotherapy we see close and often long-standing relationships between patients and the team of therapeutic radiographers delivering their treatment. Research on clinician posture and communication has highlighted the importance of eye contact and eye-level interaction. A 2024 systematic review examined whether clinicians standing over patients or communicating at eye level influenced patient perceptions. The review found that eye-level communication was generally associated with more positive patient perceptions, including trust, satisfaction and rapport [5]. 

This is relevant because body position can shape the perceived power balance between patient and clinician. A patient lying down while clinicians stand above them, as we see in traditional supine radiotherapy, may experience a greater sense of passivity or vulnerability. Upright positioning has the potential to support more equal, face-to-face interaction, allowing communication to occur at eye level rather than from a physically dominant position. 

What Healthcare Design Can Teach Us 

The relationship between patients and the clinical team is only one part of the treatment experience. Equally important is the environment in which those interactions take place.  

Healthcare design increasingly recognizes that the physical characteristics of healthcare environments influence not only safety and efficiency, but also how people experience care. Healthcare environments should help people orient themselves within complex clinical spaces. The ability to see what is happening around us contributes to situational awareness, helping us interpret our surroundings and anticipate what comes next. 

Although Lim and Zimring’s conceptual framework [6] was developed primarily to understand healthcare environments from an organizational perspective, the same principles raise interesting questions for radiotherapy. During treatment, patients are unable to move freely around the environment. Instead, their experience is shaped almost entirely by what they can see, hear and understand from a fixed position. 

In this context, visual access becomes more than an architectural feature. It may help patients remain oriented within an unfamiliar environment. Being able to see the treatment room, the equipment and the healthcare professionals caring for them may help patients better understand what is happening around them, reducing uncertainty and supporting a greater sense of perceived control.  

While this hypothesis has not yet been tested directly in radiotherapy, it provides a plausible explanation for why treatment position may influence the patient experience. 

Could Upright Positioning Change More Than Comfort? 

Upright radiotherapy may offer opportunities to improve the psychological experience of treatment, beyond the potential physical benefits that have traditionally been discussed. The ability to sit or stand, see the treatment environment, maintain face-to-face communication and remain visually connected to staff may help patients feel more oriented, less passive and more involved in their care. This aligns with wider principles of person-centred healthcare, where dignity, autonomy and emotional experience are considered alongside technical precision. 

Future research should directly investigate patient-reported outcomes in upright radiotherapy using qualitative data to explore perceived control, environmental awareness, vulnerability, anxiety, comfort and trust.  

A Different Way of Thinking About Patient Experience 

Perhaps one of the most interesting aspects of upright radiotherapy is not simply that it allows patients to sit or stand, but that it encourages us to reconsider how patients experience treatment as a whole. 

For decades, innovation in radiotherapy has focused on improving how accurately we treat disease. As new technologies emerge, perhaps we should also ask how we can improve the experience of the person receiving that treatment. 

Position may be one part of that answer. 

 References 

1. Andrade, C. et al. Do the hospital rooms make a difference for patients’ stress? A multilevel analysis of the role of perceived control, positive distraction, and social support. Journal of Environmental Psychology. 2017 (53): 63-72. https://doi.org/10.1016/j.jenvp.2017.06.008. Appleton J. The Experience of Landscape. London: Wiley; 1975. 
2. Dosen AS, Ostwald MJ. Evidence for prospect-refuge theory: A meta-analysis of the findings of environmental preference research. City, Territory and Architecture. 2016;3:4. 
3. Ulrich RS. Effects of interior design on wellness: theory and recent scientific research. J Health Care Inter Des. 1991;3:97-109. PMID: 10123973. 
4. Parmar M, et al. Does clinician position matter? A systematic review of standing versus sitting at eye level during physician-patient interactions. Journal of General Internal Medicine. 2024. 
5. Lim L, Zimring CM. A Conceptual Visibility Framework for Linking Spatial Metrics With Experience and Organizational Outcomes. HERD. 2020 Oct;13(4):225-239. doi: 10.1177/1937586720916825.