Evidence based design for healing in cancer care centers

EVIDENCE BASED DESIGN FOR HEALING IN CANCER CARE CENTERS

Submitted By Arya Rakesh Guide Ronson Raju Koshy

B. ARCH DISSERTATION

December 2020

C.A.T COLLEGE OF ARCHITECTURE TRIVANDRUM Mulayara P.O, Thiruvananthapuram This report is the property of the institution and the author. It should not be reproduced without prior permission

C.A.T COLLEGE OF ARCHITECTURE TRIVANDRUM Mulayara P.O, Thiruvananthapuram Arya Rakesh

B.Arch Dissertation Evidence Based Design for Healing In Cancer Care Centers

Approval The following study is hereby approved as a creditable work on the subject, carried out and presented in a manner, sufficiently satisfactory to warrant its acceptance as B.Arch Dissertation, a pre-requisite to the B.Arch Degree program for which it has been submitted.

It is to be understood that by this approval the undersigned do not necessarily endorse or approve the statements made, opinions expressed or conclusions drawn therein, but approve the study only for the purpose for which it has been submitted and satisfies as to the requirement laid down in the academic programme.

Dissertation Guide

Dissertation Coordinator

Ronson Raju Koshy

Reshmi Ravindran

Bijey Narayan

Assistant Professor

Associate Professor

Professor

Date:

Date:

Date:

External Invigilator

HOD (Architecture)

Internal Invigilator

C.A.T COLLEGE OF ARCHITECTURE TRIVANDRUM Mulayara P.O, Thiruvananthapuram

CERTIFICATE

This is to certify that Ms Arya Rakesh has worked under my supervision on Evidence Based Design for Healing in Cancer Care Centers towards the partial fulfilment of the requirement for the award of the degree of Bachelor of Architecture under the A.P.J Abdul Kalam Technological University, Kerala.

This is his/her original work and can be submitted as a B.Arch Dissertation.

Guide

Ronson Raju Koshy Assistant Professor Date:

DECLARATION

I hereby declare that the Dissertation titled “Evidence Based Design for Healing in Cancer Care Centers” was carried out by me during the year 2020 in partial fulfilment of the requirement for the award of the degree of Bachelor of Architecture under the A.P.J Abdul Kalam Technological University, Kerala. This dissertation is my own effort and has not been submitted to any other University.

Arya Rakesh

Thiruvananthapuram December 1.02.2021

Student Name & Signature

ACKNOWLEDGEMENT

It gives me great pleasure and satisfaction in submitting this research paper report on “Evidence Based Design for Healing in Cancer Care Centres”. So, it becomes my duty to express my regards to them. On the outset of this research paper, I would like to express my special thanks of gratitude Mr. Jayakumar, the principal, who gave me the opportunity to work on this topic and made me present my views on the topic through the paper.

I would like to express my gratitude to my guide, Mr.Ronson Raju Koshy, as he has been continuously helping me by channelling my research in the right direction, far above the level of simplicity.

Thanking you!

January 2021 Thiruvananthapuram

Arya Rakesh ( B-Arch,

S9)

ABSTRACT

Research on evidence-based design (EBD) has shown the ability of environmental design to facilitate better outcomes for patients to reduce or prevent harm in cancer care centers.

While healthcare has focused primarily on fixing the body, there is an increasing awareness that our healthcare system should do better by promoting physical and mental well-being and this requires expanding the focus to healing. Cancer is a deadly disease that affects the patients physically and mentally. Thus it is essential to create a positive environment for the patients to heal as the physical body has a fantastic ability to “self-heal” when put into positive healing environments. This paper intent to understand the concept and aspects of healing and how healing can be facilitated through architecture with the help of EBD. Parameters are coined by a comparative study of the case studies where they are rectified by the means of questionnaire to know how the parameters can be implemented in a state like Kerala. Proper guidelines at the end are introduced that facilitates healing through architecture. The parameters contribute to the process of healing and thus will be very beneficial for the cancer patients if they are implemented in the design of future cancer cares since this study is done through evidence based design.

Keywords: Healing, healing in architecture, evidence based design, cancer care centers

TABLE OF CONTENTS 1

2

3

INTRODUCTION ................................................................................................................................. 1 1.1

AIM / RESEARCH QUESTION ................................................................................................................. 1

1.2

OBJECTIVES ........................................................................................................................................ 1

1.3

METHODOLOGY .................................................................................................................................. 2

1.4

SCOPE ................................................................................................................................................. 2

1.5

LIMITATION ........................................................................................................................................ 2

HEALING CANCER ............................................................................................................................ 3 2.1

CANCER .............................................................................................................................................. 3

2.2

WHAT IS HEALING ? ............................................................................................................................. 3

2.3

ASPECTS OF HEALING? ......................................................................................................................... 4

2.4

ROLE OF ARCHITECTURE IN HEALING ? .................................................................................................. 5

2.5

EVIDENCE BASED DESIGN ................................................................................................................... 5

LITERATURE CASE STUDY ............................................................................................................. 7 3.1

MAGGIE’S CANCER CARE, MANCHESTER ............................................................................................. 7

HOME-LIKE .................................................................................................................................................. 8 VIEW AND ACCESS TO NATURE ...................................................................................................................... 8 NATURAL LIGHT .......................................................................................................................................... 8 ACOUSTICS .................................................................................................................................................. 8 INDOOR PLANTS ........................................................................................................................................... 8

4

3.2

MAGGIE'S GARTNAVEL GLASGOW, UNITED KINGDOM .......................................................................... 8

3.3

MAGGIE’S OLDHAM CANCER CENTRE .................................................................................................. 9

DATA COLLECTION ........................................................................................................................ 11 4.2

QUESTIONNAIRE ................................................................................................................................ 11

INFERENCE ................................................................................................................................................. 22 5

GUIDELINES ..................................................................................................................................... 23 5.1

VIEW AND ACCESS TO NATURE .......................................................................................................... 24

5.2

HOME –LIKE ENVIRONMENT .............................................................................................................. 26

5.3

NOISE CONTROL ................................................................................................................................ 28

5.4

BARRIER-FREE ENVIRONMENT ........................................................................................................... 28

5.5

NATURAL LIGHT ............................................................................................................................... 31

6

CONCLUSION.................................................................................................................................... 34

7

BIBLIOGRAPHY ............................................................................................................................... 35

LIST OF FIGURES i.

Figure 1: Optimal healing environment framework (SAKALLARIS BR, MAY 2015; DUBOSE J, 2018) ..................................................................................................... 4

ii.

Figure 2: Aspects of healing with respect to healing outcomes. (SAKALLARIS BR, MAY 2015; DUBOSE J, 2018).................................................................................. 5

iii.

Figure 3: Causal model for architectural impact on healing. (SAKALLARIS BR, MAY 2015) ............................................................................................................... 5

iv.

Figure 4 : Maggie’s Cancer Care, Manchester (source : (maggies-cancer-centremanchester-foster-plus-partners) ................................................................................ 8

v.

Figure 5 :Maggie's Gartnavel Glasgow, United Kingdom source : (dezeen, 2011)...... 9

vi.

Figure 6 : Maggie’s Oldham Cancer Centre source : (dRmm, 2017) ........................ 10

vii.

Figure 7 : Statistics showing rising cases no.of cancer cases (Ghosh, 2018) ............. 11

viii.

Figure 8 : ................................................................................................................. 12

ix.

Figure 9 : ................................................................................................................. 12

x.

Figure 10 : ............................................................................................................... 13

xi.

Figure 11 : ............................................................................................................... 14

xii.

Figure 12 : ............................................................................................................... 14

xiii.

Figure 13 : ............................................................................................................... 15

xiv.

Figure 14 : ............................................................................................................... 15

xv.

Figure 15 : ............................................................................................................... 16

xvi.

Figure 16 : ............................................................................................................... 17

xvii.

Figure 17 : ............................................................................................................... 17

xviii.

Figure 18 : ............................................................................................................... 18

xix.

Figure 19 : ............................................................................................................... 18

xx.

Figure 20 : ............................................................................................................... 19

xxi.

Figure 21 : ............................................................................................................... 20

xxii.

Figure 22 : ............................................................................................................... 20

xxiii.

Figure 23 : ............................................................................................................... 21

xxiv.

Figure 24 : ............................................................................................................... 21

xxv.

Figure 25 : ............................................................................................................... 21

xxvi.

Figure 26: (open-green-spaces) ................................................................................ 24

xxvii.

Figure 27 : (the-garden-island-countyard-renewal-epos-architecture) (landscape-adesign)..................................................................................................................... 24

xxviii.

Figure 28 : (vietnam-interior-green-space-house; thong-nishizawa-architects) ......... 25

xxix.

Figure 29 : (the-garden-island-countyard-renewal-epos-architecture) (all-about-watergarden) .................................................................................................................... 25

xxx.

Figure 30 : (new-therapeutic-garden) ....................................................................... 25

xxxi.

Figure 31 : (vietnam-interior-green-space-house) (the-garden-island-countyardrenewal-epos-architecture) ....................................................................................... 26

xxxii.

Figure 32 : (rss&utm) .............................................................................................. 26

xxxiii.

Figure 33: (alexanderson-arquitectos-photo) (outdoor-living) .................................. 27

xxxiv.

Figure 34: (more-great-public-spaces) (alexanderson-arquitectos-photo) ................. 27

xxxv.

Figure 35: (the-gandel-wing-hospital-bates-smart) ................................................... 27

xxxvi.

Figure 36 : (osf-healthcare-childrens-hospital) ......................................................... 28

xxxvii.

Figure 37 : (acousticalsurfaces, 2020) (therapeutic-benefits-of-plant) ...................... 28

xxxviii.

Figure 38 : (roberto-burle-marx-botanical-garden) (maggies-centres) ...................... 29

xxxix.

Figure 39 : (ballarat-regional-integrated-cancer-centre) (walk-landscape-landscapecollaboration) .......................................................................................................... 29

xl.

Figure 40 : (osf-healthcare-childrens-hospital) (dRmm, 2017) ................................. 29

xli.

Figure 41 : (patient-experience/what-your-waiting-room-saying-patients) (mechanical-engineering-design) ............................................................................. 30

xlii.

Figure 42 : (ballarat-regional-integrated-cancer-centre) (maggies-cancer-caringcentre) ..................................................................................................................... 30

xliii.

Figure 43 : (aiatopten) (dRmm, 2017) ...................................................................... 31

xliv.

Figure 44 : (ballarat-regional-integrated-cancer-centre) (aiatopten) .......................... 31

xlv.

Figure 45 : (maggies-cancer-centre-manchester-foster-plus-partners)....................... 32

LIST OF TABLES xlvi.

Table 1 : Inference from Maggie’s Cancer Care, Manchester ..................................... 8

xlvii.

Table 2 : Inference from Maggie's Gartnavel Glasgow, United Kingdom ................... 8

xlviii.

Table 3 : Inference from Maggie’s Oldham Cancer Centre ........................................ 9

xlix.

Table 4 : Comparative analysis of the case studies with respect to the parameters .... 10

l.

Table 5 : .................................................................................................................. 12

li.

Table 6 : .................................................................................................................. 12

lii.

Table 7 : .................................................................................................................. 13

liii.

Table 8 : .................................................................................................................. 13

liv.

Table 9 : .................................................................................................................. 14

lv.

Table 10 : ................................................................................................................ 14

lvi.

Table 11 : ................................................................................................................ 15

lvii.

Table 12 : ................................................................................................................ 15

lviii.

Table 13 : ................................................................................................................ 16

lix.

Table 14 : ................................................................................................................ 16

lx.

Table 15 : ................................................................................................................ 17

lxi.

Table 16 : ................................................................................................................ 17

lxii.

Table 17 : ................................................................................................................ 18

lxiii.

Table 18 : ................................................................................................................ 19

lxiv.

Table 19 : ................................................................................................................ 19

lxv.

Table 20 : ................................................................................................................ 20

lxvi.

Table 21 : ................................................................................................................ 20

lxvii.

Table 22 : ................................................................................................................ 21

lxviii.

Table 23 : ................................................................................................................ 21

lxix.

Table 24 :Questionnaire prepared for psychotherapy councilors............................... 22

lxx.

Table 25 : Final parameters that facilitate healing through architecture .................... 23

lxxi.

Table 25 : Relationship between architectural features and aspects of healing .......... 33

EVIDENCE BASED DESIGN FOR HEALING IN CANCER CARE CENTERS

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1

INTRODUCTION

The physical body has a fantastic ability to “self-heal” when put into positive healing environments. This healing is enabled by the power of the body to ‘tap into our internal pharmacies’ by responding to the spaces around them. Certain elements in environments like colour, light, and natural landscapes can contribute to the body’s ability to self-heal.

The application of science to design has had a remarkable impact on healthcare facilities and healthcare over the years. Evidence-based design (EBD) uses scientific methods to build the links between design and outcomes such as safety and efficiency to support design decisionmaking in healthcare. EBD creates safe, efficient spaces, but patients and families come to healthcare organizations seeking a healing experience.

Winston Churchill expressed the effect of architecture and our surroundings with the comment that: “We shape our buildings and later they shape us.” The intent of this dissertation is to explore how we can extend what we know from EBD about health impacts of spatial design to the more elusive goal of healing and how architecture can supplement healing and provide spaces and events where healing can happen.

1.1

Aim / Research Question The aim of the study is to extend the knowledge of evidence-based design by identify

active ingredients in the healing process and to propose guidelines that enhance the healing process facilitated through architecture to maximize the healing potential for the cancer patients in Kerala.

1.2

Objectives 

To understand healing ,aspect of healing and role of healing on architecture



To understand the concept of the evidence based design and choose case studies to study



Derive the parameters that can facilitate healing through architecture



Compare the parameters with the aspects of healing to understand how the parameters help in healing



To prepare questionnaire to learn how the parameters can be implemented in Kerala



Suggest guild lines to facilitate healing through architecture in Kerala

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C.A.T

1.3

Methodology

1.4

Scope The parameters contribute to the process of healing and thus will be very beneficial for

the cancer patients if they are implemented in the design of future cancer cares since this study is done through evidence based design

1.5

Limitation Due to the Covid 19 pandemic, there was a limitation in getting responses of the patients

in the expected amount.

The study is only confined to Kerala as there is growth in no. of people affected by cancer.

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C.A.T

2 2.1

HEALING CANCER

Cancer The World Health Organization has estimated that approximately 70% of cancer

patients worldwide will be in developing countries by 2020. (WHO, 2008). Cancer patients, such as extreme exhaustion, anxiety, and emotional weakness, bring some unique challenges to the hospital. Fatigue is one of the main challenges that can be overcome during chemotherapy. The diagnosis of cancer is associated with a lot of anxiety and uncertainty, and treatment options are frequently vague and uncertain about the outcome. For various therapies, operations, and examinations, cancer patients have to spend a great deal of time in the hospital.

The conditions in which they are put dramatically impact their capacity for healing. Hospitals need to take a holistic approach to managing the physical illnesses, psychological wellbeing, emotional hardships, and physiological responses of a patient in order to realistically work towards truly understood recovery by understanding the environments in which patients live.

2.2

What is healing?

The definition of healing developed by the Samueli Institute provides a good foundation

to start with. ‘‘Healing is a holistic, transformative process of repair and recovery in mind, body, and spirit resulting in positive change, finding meaning, and movement towards selfrealization of wholeness, regardless of the presence or absence of disease’’ (SAKALLARIS BR, MAY 2015)This definition allows for the possibility of healing even when cure is not a possibility. While ‘‘cured’’ is a definitive end or final state, ‘‘healing’’ is a journey with many possible routes.

‘Healing is facilitated by an optimal healing environment (OHE), one where the individual is surrounded by elements that facilitate the innate healing process’ (SAKALLARIS BR, MAY 2015) 2.The OHE framework (Figure 1) illustrates the four environments and eight constructs that make up an OHE. The four healing environments in the OHE framework— internal, interpersonal, behavioural, and external—were used to further understand the findings of this literature review and their possible influence on healing.

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C.A.T

Figure 1: Optimal healing environment framework (SAKALLARIS BR, MAY 2015; DUBOSE J, 2018)

2.3

Aspects of healing?

In a study conducted by the Centre Of Health Design, where various literature

reviews of evidence based designs Ulrich et.al with the addition of the Medical Subject Headings terms –MeSh (Standard terms used in the National Library of Medicine for healing)came to a conclusion that there are four major categories that categorize the healing experience. They are: 

‘Psychological: Environmental support for managing emotions and reactions, especially the ability to diffuse aggression and avoid or mitigate anxiety and depression.



Self-efficacy: Environmental facilitation of a sense of coherence and control and the ability to adapt to and accept new situations.



Social: Environmental support for developing and maintaining relationships and connections with others.



Functional: Environmental support for safely performing the basic activities of daily living with minimal assistance.’ (DUBOSE J, 2018)

The following table shows the categorization of aspects of healing with healing outcomes which helps to attain optimal healing environment.

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C.A.T

Figure 2: Aspects of healing with respect to healing outcomes. (SAKALLARIS BR, MAY 2015; DUBOSE J, 2018)

2.4

Role of architecture in healing?

According to the health environment research, the built environment can

facilitate healing through a variety of mechanisms. For some cases, architectural elements have direct impact on healing, but for the mostly, architecture influences behaviours that impact the healing experience as is exemplified by Figure 2. Healing is much more depends on participation and receptivity of the individual. Built environment can encourage or hinder healing, but healing is ultimately a very personal process that is heavily influenced by individual characteristics and social relationships. ‘The environment cannot cause healing to occur but can facilitate engagement in behaviours and emotions that support healing; the environment can induce physical and emotional responses such as happiness, joy, and relaxation; and the built environment can enhance individual control and functionality—all of which are antecedents to healing’5.

Figure 3: Causal model for architectural impact on healing. (SAKALLARIS BR, MAY 2015)

2.5

Evidence Based Design Evidence-based design, as the Centre for Health Design calls it, is a healthcare

design approach that is anchored in the use of validated design elements that influence patient Dissertation 2020 5

C.A.T health, well-being, and safety, as well as the health and morale of employees. It is based on the idea that without coping with an unsupportive healing environment, patients should be able to devote their resources to healing. Typically, hospital architecture is designed to maximize the treatment of equipment rather than persons. Instead of the spiritual and emotional and experiential needs of patients, most hospitals today are built to fulfil the needs of technology.

Dealing with disease is not only physical for most people, but it is also mental and spiritual. In the recovery process, a healthy uplifting and sensuous atmosphere may also be a component of patients faced with their mortality. In hospital design, the need for healing spaces is particularly needed in cancer centres because of the machinery needed and the unique design necessary in this specific department. As defined by the architectural critic, Charles Jencks, these centres are usually "machines for curing people." People usually visit the cancer centre, undergo their scheduled therapy, and leave. He claimed that architecture could become a sort of placebo that would help in the recovery of cancer patients with the incorporation of the senses in healthcare design.

The Centre for Health Design defines EBD as “the deliberate attempt to base building decisions on the best available research evidence with the goal of improving outcomes and of continuing to monitor the success or failure for subsequent decision-making” (blog, 2018). It can be used for all design decisions.

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3

LITERATURE CASE STUDY

Placebo therapy is a pseudo-medical procedure that tends to be real, but is not necessarily real. Via the mind, this therapy attempts to heal the body. Such a treatment effect can be seen very well in Charles Jencks 2010, who believed in the architectural placebo effect,

by Maggie Centres. A study for the International Design and Emotion Conference states that ‘Judging from the discussion with the users, Maggie's London can be named a success. In this case, the combination of a good architect and the ability to begin with user specifications that are clearly formulated and well understood results in a building that meets the requirements.’

(ANNEMANS, 2012) Intimately, architecture and the human experience are interconnected.

Our mental, social and physical well-being is profoundly influenced by space and form, affecting the ways we perceive the everyday rhythms of our lives. Buildings are never neutral; they affect individuals and the surrounding context positively or negatively. Maggie's Centres is a distinctive typology, an idea envisioned by Margaret Keswick Jencks, a terminally ill woman who believed that good design was required for cancer treatment environments.

Decades later, Maggie's centres are now spread around the world, locations where free treatment for cancer patients is offered.

3.1

Maggie’s Cancer Care, Manchester The goal in the centre of Manchester designed by Foster + Partners was to create a

building that is welcoming, friendly and without any of a hospital or health centre’s institutional references, a light-filled, homely space where people can gather, talk or just reflect. That is why there is an emphasis on natural light, greenery and views in the building; with a greenhouse to provide fresh flowers, and a focus on nature's healing qualities and the outdoors. (maggiescancer-centre-manchester-foster-plus-partners)

Inference: There is an emphasis on natural light, greenery and garden views in the centre. Landscaped courtyards punctuate the rectilinear plan. The building is opened by sliding glass doors to a garden setting. Each treatment and counselling room faces its own private garden on the eastern façade. The south end of the building extends to a greenhouse, a celebration of light and nature, offering a garden retreat, a place for people to gather, work with their hands and enjoy nature's healing qualities and the outdoors. The centre combines a variety of spaces, from intimate private niches to a library, exercise rooms and places to gather and

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C.A.T share a cup of tea. The heart of the building is the kitchen, which is centred on a large, communal table to give a home like environment. Wood provided for acoustic purpose as well.

Table 1 : Inference from Maggie’s Cancer Care, Manchester

Home-like

View and

environment

access to

Natural Light

Acoustics

Indoor Plants

nature

Figure 4 : Maggie’s Cancer Care, Manchester (source : (maggies-cancer-centre-manchester-foster-pluspartners)

3.2

Maggie's Gartnavel Glasgow, United Kingdom This centre designed by Rem Koolhaas aims to create a truly unique environment,

which will help to facilitate the programme of support, by making people feel safe, inspired and valued, whilst garden design complements the centre beautifully. The striking, singlestorey building built in 2011 is formed as a ring shape around a landscaped internal courtyard, and is nestled among the woodland in the grounds of Gartnavel General Hospital. (dezeen, 2011) Inference: Glazed walls afford views of the surrounding trees, planted in glades. The building comprises a sequence of L-shaped, interlocking rooms around a landscaped courtyard therefore providing natural light into the spaces. Spaces are provided in such a way that circulation are free flowing. A ring of loosely arranged interconnecting spaces contains counselling rooms, a large multipurpose space, a kitchen, dining room and offices. By avoiding a familiar configuration of insular rooms, the fluent spatial sequence at Maggie’s Gartnaval fosters the sense of empathetic community central to the Maggie’s philosophy. Noise producing spaces are provided away from patient rooms.

Table 2 : Inference from Maggie's Gartnavel Glasgow, United Kingdom

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C.A.T Barrier free

Natural Light

environment

View

and Home- like

access

Noise Control

to environment

Nature

Figure 5 :Maggie's Gartnavel Glasgow, United Kingdom source : (dezeen, 2011)

3.3

Maggie’s Oldham Cancer Centre The design of Maggie’s Oldham is less about form and more about content. A simple

yet sophisticated wooden box of surprises. Supported on slender columns, the building floats above a garden framed by pine, birch and tulip poplar trees. (dRmm, 2017) Inference: From a central oasis, a tree grows up through the building, bringing nature inside. On entering, the visitor is met with a space, light and unexpected views down to the garden below, up to the sky. The use of wood at Maggie’s Oldham is part of a bigger design intention to reverse the norms of hospital architecture, where clinical institutionalised environments can make patients feel dispirited and it acts as an acoustic material that absorbs noise. Large no of common spaces are provided next to the courtyard. Privacy was key factor as curtains were provided in common space.

Table 3 : Inference from Maggie’s Oldham Cancer Centre

Acoustics

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View to Nature

Natural light

Room Layout and Special arrangement.

Privacy

9

C.A.T Figure 6 : Maggie’s Oldham Cancer Centre source : (dRmm, 2017)

With the inferences of the case studies, a comparative analysis is done in Table 4 of the three literature case studies. From that, the major parameters that facilitate healing through architecture are identified as follows: 

Barrier-free Environment



View and access to nature



Natural light



Noise control



Home-like environment

Table 4 : Comparative analysis of the case studies with respect to the parameters

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C.A.T

4

DATA COLLECTION

In a survay conducted by the National Health Profile in 2016,Kerala has the highest hike in no of cancer patients.Thus this helps to focus the study to Kerala.

Figure 7 : Statistics showing rising cases no.of cancer cases (Ghosh, 2018)

4.2

Questionnaire A questionnaire was prepared on the basis of the factors mentioned above to

incorporate evidence based design to understand the preference of the patients battling cancer.

It was circulated to patience primarily from two cancer centres which are famous for the treatment of cancer in Kerala, i.e. Cochin Cancer Centre, Kochi and Regional Cancer Centre, Trivandrum. This was done to understand the patients’ existing current condition and their preference for implementing the factors that facilitates healing through architecture.

4.2.1 Questions The questions include whether they are satisfied with the present hospital conditions, what makes them feel more at home, whether there is sufficient natural light in rooms, open spaces, meeting spaces, and why, is there enough open spaces, is the hospital barrier free, preference for rooms with view to nature, preference for open courtyards, central plaza, open to sky spaces, healing garden etc.

4.2.2 Responses The responses from patients who are battling cancer (mostly first and second stage) and two psychotherapy councillors who treat cancer patients are structured below: Dissertation 2020

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C.A.T

4.2.2.1 Q1) Do you feel better in the hospital environment or in a home environment?

Table 5 :

Hospital Home Neutral

10 70 20 Figure 8 :

4.2.2.2 Q2) Are you satisfied with the present hospital conditions?

Table 6 :

Yes No Neutral

40 45 15 Figure 9 :

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C.A.T

4.2.2.3 If no ,why?

Table 7 :

Unclean No space to go other than canteen Hate hospital rooms Less facities

10 20 60 10

Figure 10 :

4.2.2.4 Q3) What among the following makes you feel more at home?

Table 8 :

Kitchen space Outdoor rooms ,terraces and balcony Common interaction spaces Change of hospital colours into pastel colours Spaces to interact

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2 25 30 40 15 13

C.A.T Figure 11 :

4.2.2.5 Q4) By providing kitchen spaces, would it help you feel more like home?

Table 9 :

Really good Good Not that good Bad

5 15 45 35 Figure 12 :

4.2.2.6 Q5) Is there sufficient natural light in your room?

Table 10 :

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C.A.T Yes No Neutral

14 81 5

4.2.2.7 If not, why do you think there is no light?

Table 11 :

Lack of fenestrations Poor room layouts Facing corridors Bad orientation of the building Small window openings Windows not working properly

31 10 9 33 6 13 8

40 30 5 10

Figure 13 :

4.2.2.8 Q6) What do you prefer in case of bringing more natural light Table 12 :

More fenestrations Balconies and terraces Bigger and wider opening Pocket courtyard near the spaces

18 42 23 17

Figure 14 :

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C.A.T

4.2.2.9 Q7) Presently is the cancer centre noise free?

Table 13 :

Yes No Havnt noticed yet

40 50 20

Figure 15 :

4.2.2.10 If no,why Table 14 :

Nursing station next to the room No use of accoustic materials Don’t know why

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23 64 13 16

C.A.T Figure 16 :

4.2.2.11 Q8) Is spaces in your cancer centre barrier free?

Table 15 :

Yes No

5 95 Figure 17 :

4.2.2.12 Q9) What among the following do you prefer to make the centre barrier free?

Table 16 :

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C.A.T Easy way finding Quality Corridor Minimising the risk of fall and infection Proximity to open or common spaces Privacy

10 30 20 20 20

Figure 18 :

4.2.2.13 Q10) How is the quality of the corridor?

Table 17 :

Cluttered Unclutered and Obstruction free Spacious Non spacious

60 5 5 30

Figure 19 :

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C.A.T

4.2.2.14 Q11) In your opinion ,what is lacking in the hospital environment Table 18 :

Views to nature Garden spaces with healing elements such as waterbody,softscape,therapetic garden etc Access to nature and open spaces Indoor plants

25 30 30 15

Figure 20 :

4.2.2.15 Q12) would you prefer spaces such as open courtyard, central plaza, open to sky spaces in the hospital?

Table 19 :

Yes No Dissertation 2020

80 20 19

C.A.T Figure 21 :

4.2.2.16 Q13) If community interaction spaces, spaces for family and relatives, recreational facilities, open spaces are provided then, will you use such spaces?

Table 20 :

Yes No Neutral

80 5 15 Figure 22 :

4.2.2.17 Q14) Do you prefer rooms with nature view or wall?

Table 21 :

Nature view Wall

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97 3 20

C.A.T Figure 23 :

4.2.2.18 Q15) Is there access to nature? If no, what type of spaces do you prefer?

Table 22 :

Yes No

30 70 Figure 24 :

4.2.2.19 If yes, specify the existing provision to access to nature.

Table 23 :

Central plaza Corridors General landscape areas Balcony

25 65 20 10

Figure 25 : Dissertation 2020

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The questionnaire were prepared to understand the point of view of psychotherapy councillors who treat cancer patients: Table 24 :Questionnaire prepared for psychotherapy councilors

Inference The data attained through the questionnaire and literature case study inferences are condensed to guidelines which can facilitate healing through architecture.

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GUIDELINES

In order to achieve the aspects of healing through EBD, subsequent design considerations are listed below that can facilitate healing through architecture to enhance and impact the wellbeing of patients positively. Guidelines are cumulated from the results of case studies, behavioural and environmental sciences reference and questionnaires responded by patients.

Table 25 : Final parameters that facilitate healing through architecture PARAMETRS Easy way finding Quality of Corridor Barrier-free Environment

Minimizing the risk of fall and infection Proximity to open spaces Privacy Open Spaces Access to nature

View and access to nature

Views and Vistas Indoor plants Water body Therapeutic garden Calm and Quite Environment

Noise control Acoustic Materials Qualitative daylight Natural light

Human comfort Fenestrations Facilities

Home-like environment

Spaces for family and relatives Outdoor rooms, terrace and balcony Colour

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C.A.T 5.1

View and Access to nature

5.1.1 Open spaces Open and free environment helps in fast recovery. Open spaces provide openness and liveliness in healing spaces. It can be provided centrally between spaces or as pocket courtyards. Large and open windows, windows with deep sill sized, positioned according to views to give more sense of openness, easiness and calmness. Landscaped areas which helps in creating greenery around are beneficial.

Figure 26: (open-green-spaces)

5.1.2 Access to Nature Nature has got therapeutic abilities. Access of landscape to patients offer a feeling of liberty and seclusion. Contact and access to nature will help in enhancing the healing process.

Buildings should be designed to create outdoor spaces w.r.t landscape, climate and places.

Open or central courtyards, corridors that are landscaped on the sides. Large sliding doors that helps to connect inside and outside spaces.

Figure 27 : (the-garden-island-countyard-renewal-epos-architecture) (landscape-a-design)

5.1.3 Indoor plants Not all patients can have access to nature every day, so indoor plantation is the option for that. Creepers and flower beds could be planted in the windows and balcony. It helps the patients to reduce stress, anxiety and pain intensity.

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Figure 28 : (vietnam-interior-green-space-house; thong-nishizawa-architects)

5.1.4 Water Body Water body has a therapeutic effect on human health. Pools with scenery view as well as flowing streambeds have ability to relax the mind. Fish tanks and fountain can reduce anxiety and pain psychologically. However, physical contact with water body should be avoided because there is high chance of getting infection through it.

Figure 29 : (the-garden-island-countyard-renewal-epos-architecture) (all-about-water-garden)

5.1.5 Therapeutic Garden As nature has healing ability, there are various trees, herbs and shrubs that are beneficial for cure of different diseases. Flowering plants which flowers throughout the year can be provided. Serpentine pathways with water fountain visually and specially linked with balcony and exterior spaces.

Seating in garden could vary from movable chairs and tables to a curvilinear seat-wall, for different comfort levels and positions in sun and shade. Use of earth toned tint can be used to decrease the amount of glare.

Figure 30 : (new-therapeutic-garden)

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C.A.T 5.1.6 Views and Vistas Most of the spaces in cancer centres should have views and vistas to nature. Openness and views to outside makes the room feel more lifted and spacious. Calming and stimulating views decrease blood pressure. The quality of outside view depends highly on the site selection, building orientation, ward layout, bed position and window designs. Use of sliding door, operatable windows will be beneficial.

Figure 31 : (vietnam-interior-green-space-house) (the-garden-island-countyard-renewal-epos-architecture)

5.2

Home –like Environment

5.2.1 Facilities Spaces for recreational activities include indoor games, watching tv, newspapers, access to guided imagery. If there is a common space for such activities, it should be at the heart of the building for social gathering and communal spaces .Spaces such as community dining, activity rooms etc. helps to draw the attention of the patients away from their problems momentarily.

Figure 32 : (rss&utm)

5.2.2 Spaces for Family and Relatives Social support and care of the friends and family contributes to emotional and psychological wellbeing .There should be spaces for the friends, family and relatives within or near the patient’s ward, it leads to faster recovery. Visual connection of the family members with the patient most of the time leads to the satisfaction of the family. Whether it is a social Dissertation 2020

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C.A.T support group or a family member, sympathy and compassion offered by caring individuals are essential.

Figure 33: (alexanderson-arquitectos-photo) (outdoor-living)

5.2.3 Outdoor rooms, terraces and balconies A retreat which fosters casual interaction, it could be atrium, terraces, exterior garden, rooftop courtyards, outdoor rooms ,landscapes organized around central courtyards. It could be the small enclosed landscaped interaction space with large trees and outdoor seating.

Balconies with seating spaces can be provided in individual rooms or each floors.

Figure 34: (more-great-public-spaces) (alexanderson-arquitectos-photo)

5.2.4 Colour Subtle colours such as pastel colours can be provided to stipule and soothe the mood of the patients. Typical hospital colours are to be avoided .Colours schemes and tones has a prominent contribution in healing.

Figure 35: (the-gandel-wing-hospital-bates-smart)

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C.A.T 5.3

Noise control

5.3.1 Calm and quite atmosphere Noise in the built environment adds up the burden of illness. Patients prefer a serene environment. Noise creating spaces such gathering spaces, canteen etc should be kept away from the space where the patient resides.

Figure 36 : (osf-healthcare-childrens-hospital)

5.3.2 Acoustic Materials Sound is critical in healthcare centres. Materials that help in absorbing maximum noise should be used. Natural material from wood to artificial gypsum ceiling can be used. A good hospital noise reduction system brings relief and calm to patients during their visits or convalescence.

Figure 37 : (acousticalsurfaces, 2020) (therapeutic-benefits-of-plant)

5.4

Barrier-free Environment

5.4.1 Easy way finding Difficulty in finding the way creates stress and anxiety for the patients. Cancer centres can have easy way finding by providing art, colour, texture, materials and signage’s for ease of patients. Graphics on walls or windows can be provided. Landmarks can be provided to the centres such as central plaza etc. for the lease to locate the patients themselves.

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Figure 38 : (roberto-burle-marx-botanical-garden) (maggies-centres)

5.4.2 Quality Corridor The quality of corridors are very important .The corridor should be centrally placed and should have minimum necessary length with visual connectivity to open spaces. The corridor links rooms for patients and staffs should have interaction spaces like an atrium, plants, quite places etc. Narrow and cluttered corridors and dead ends should be avoided.

Figure 39 : (ballarat-regional-integrated-cancer-centre) (walk-landscape-landscape-collaboration)

5.4.3 Minimizing the risk of fall and infection Spaces should not have obstructions as it should have minimum risk of fall. Non slippery, carpets and anti-slid tiles should be provided. The materials used should not have the danger of spreading infection.

Figure 40 : (osf-healthcare-childrens-hospital) (dRmm, 2017)

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5.4.4 Proximity to open spaces All the interacting spaces such as gathering and activity should not be too far away from the wards and should be centralized to increase involvement and interactions. It should be accessible and beneficial to all patients. There should be good internal connections between spaces.

Figure 41 : (patient-experience/what-your-waiting-room-saying-patients) (mechanical-engineering-design)

5.4.5 Privacy Privacy is a key factor in healing. Most of the patients prefer single bed rooms over double or multi bed rooms as it offers more privacy and dignity. All spaces should respect the privacy of the patients. Use of curtains, partition walls, noise reducing materials and finishes can be helpful in providing privacy in general wards.

Figure 42 : (ballarat-regional-integrated-cancer-centre) (maggies-cancer-caring-centre)

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C.A.T 5.5

Natural Light

5.5.1 Qualitative Daylight Light plays a critical role in the daily affairs that we can hardly imagine our existence without it. It also plays a key factor in our psychological and physiological health of the patients. To optimise the quantity of natural light, orientation of building, design of openings and fenestrations etc. are to be considered while designing. Choice of material and colours in interiors and visual comfort also plays an important role .Light should not create undesirable glare.

Figure 43 : (aiatopten) (dRmm, 2017)

5.5.2 Human Comfort Every patients have their own respective level of comfort. Liberty of regulating the function of windows and to control the light through curtains and blinds should be provided.

Lack of natural light reaching the wards causes discomfort in patients. Patients find daylight to be gratifying and calming severally.

Figure 44 : (ballarat-regional-integrated-cancer-centre) (aiatopten)

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C.A.T 5.5.3 Fenestration Providing correct size, shape and amount of fenestration is a crucial aspect according to the climate. Provision of light wells and Jalli can also help in bringing natural light into the building in a regulating amount.

Figure 45 : (maggies-cancer-centre-manchester-foster-plus-partners)

Finally, these guidelines are compared with the aspects of healing as shown in the table below to understand how these guidelines help to facilitate healing through architecture as shown in Table 25.

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Table 26 : Relationship between architectural features and aspects of healing

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CONCLUSION

Research on evidence-based design (EBD) has shown the ability of environmental design to facilitate better outcomes for patients to reduce or prevent harm in cancer care centers.

While healthcare has focused primarily on fixing the body, there is an increasing awareness that our healthcare system should do better by promoting physical and mental well-being and this requires expanding the focus to healing. Cancer is a deadly disease that affects the patients physically and mentally. Thus it is essential to create a positive environment for the patients to heal as the physical body has a fantastic ability to “self-heal” when put into positive healing environments. This paper intent to understand the concept and aspects of healing and how healing can be facilitated through architecture with the help of EBD. Parameters are coined by a comparative study of the case studies where they are rectified by the means of questionnaire to know how the parameters can be implemented in a state like Kerala. Proper guidelines at the end are introduced that facilitates healing through architecture from the data attained through the case studies. The parameters contribute to the process of healing and thus will be very beneficial for the cancer patients if they are implemented in the design of future cancer cares centres since this study is done through evidence based design.

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