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Research Findings of Behavioral Health The Adaptation on Healthcare Architecture

Dissertation 1 Written Draft: Introduction and Literature Review

Lee Run Sen

0308226

Master in Architecture DIS70104

Semester 3

Dissertation 1

School of Architecture, Building & Design Taylor’s University Submitted in partial fulfillment of the requirements of the degree of Master of Architecture


ABSTRACT Many recent studies discuss on architecture environment settings may be synthesised to establish enabling environments of recovery. Whereas clinical intervention may attempt to identify the underlying causation of illness, the negative experiences of the existing physical conditions of hospital buildings are discouraging with dull and stressful environment. Thus, an alternative model such as salutogenic design, meaning “the origins of health,� a measurable aspect of design could help a building’s inhabitants maintain physical and mental well-being, and lead them to healthier and potentially longer lives. On the other hand, there are many research findings had been done in relation to behavioural healthcare that allow designers to make informed choices while designing a building. Using salutogenic design as the main research framework, it is worth to understand how can research findings in behavioural healthcare translated and frame within the salutogenic design as a method to form healing environment to promote recovery in patient. Using this as the premise for study, this dissertation aims to study some cases in relation to research findings in the discipline of behavioural health. It takes on case study research method by studying a setting or phenomenon embedded in its real-life context. The data collection of the cases is undertaken

by

theming

the

architectural

drawings

and

pattern

documentation. This project will reveal the application of research findings in the discipline of behavioural healthcare, which formed under the framework of the salutogenic design in creating a healing environment for the patients. The findings of this study may provide recommendations and better solutions in ensuring a healthier built environment for all. Keywords:

Architectural

Healthcare facility design.

design,

Behavioural

research-based

design,


DECLARATION This is to certify that: The dissertation comprises only my original work towards the Master of Architecture except where indicated in the preface. Acknowledgements have been made in the text to all other material used. The dissertation is comprised of between 10,000 and 15,000 words in length, exclusive of figures, tables and bibliographies.

---------------------------------------Lee Run Sen Date:


PREFACE This is an original dissertation by the author, Lee Run Sen, submitted in total fulfillment of the requirements of the degree of Master of Architecture. It contains work and research done from August 2017 to July 2018. The idea of behavioral research based design was a theoretical idea developed from multidisciplinary perspectives. The dissertation focuses on research findings in behavioural healthcare using salutogenic design as a framework to create healing environment that promote recovery in patient. The research is made solely by the author with references to the sources. The information and research gathered will be beneficial to aspiring designers and architects of the built environment, medical professionals including doctors, therapists and administrators, and patients.


ACKNOWLEDGEMENTS I would first like to thank my dissertation supervisor Ms. Veronica Ng of Taylor’s University, for your selfless time and guidance throughout this project. Thank you to Professor Robert Powell, for your thoughtful mentorship, clarity and delight and your pragmatic understanding. Each of you has helped me find a well-rounded approach to this project. Your devotion to excellence allowed me to grow in ways I did not anticipate. Thank you to the many professors and colleagues who were willing to advise me. To my family and friends, thank you for providing me with unfailing support and continuous encouragement throughout my years of study and through the process of researching and writing my dissertation. This accomplishment would not have been possible without them. Thank you.


TABLE OF CONTENT Abstract 1.0

Chapter 1: INTRODUCTION 1.1

Background Study 1.1.1 Salutogenic Design 1.1.2 Research Findings in Behavioral Health Care 1.1.3 Relationship between Salutogenic Design and Research Findings in Behavioral Healthcare

2.0

3.0

1.2

Problem Statement

1.3

Research Questions

1.4

Aims and Objectives

1.5

Significance of Study

1.6

Research Methodology

1.7

Limitation and Expected Outcome

Chapter 2: Salutogenic Design and Healing Environment 2.1

Salutogenic Design and Healing Environment

2.2

Salutogenic Attributes that Promote Healing Environment

Chapter 3: Behavioral Health Research Findings 3.1

Relationship between Research Findings and Healing Environment

3.2

Relationship between Research Findings and Stress

3.3

Strategies of Research Findings on Healthcare Architecture 3.3.1 Orient functions around a central greenspace 3.3.2 Filter light according to function
 3.3.3 Reduce narrow and dark corridor
 3.3.4 Create clear views to/from staff work areas 3.3.5 Provide both private and semi-private patient rooms 3.3.6 Create levels of interaction in daytime spaces 3.3.7 Use healthy, safe and respectful materials and furnishings


4.0

5.0

Chapter 4: Case Study and Discussion 4.1

Justification on building selection & method

4.2

Comparison and Discussion

4.3

Summary of Case Studies

Chapter 5: Conclusion

Appendix Bibliography


CHAPTER 1 INTRODUCTION 1.1

Background Study

1.1.1 Salutogenic Design In recent years, the term ‘salutogenic’ has become a buzzword for marketing architecture for health and nursing care. The term was coined to describe a model for socioenvironmental influences on health. It becomes theory in healing environments today which eliminates stress factor from patients. It is a new area of exploration by architects today that looks into approaches that focus on factors supporting human health and well-being rather than on factors that diagnose and eradicate diseases (pathogenic approach). It is based on the broader theory developed by Aaron Antonovsky, a professor of medical sociology in 1979 derived from the Greek word 'salutogenesis' which translates to 'health origins'. Currently, the health care industry has generally adopted the pathogenic model which is primarily concerned with treating diseases or injuries once they occur. As a result, clinical practices often neglect a patient's psychological, social and spiritual needs. For decades, patients walk into hospitals after they face an injury or fall sick due to the pathogenic approach, which only focuses on disease curing. A salutogenic model however, works to prevent further damage due to illnesses by achieving and maintaining an optimal state of wellness and recovery. Salutogenic design aims to build structures that make people healthier and happier. For this reason, the model is applicable not only in healthcare settings, but has now begun to become a trend in many other sectors of architecture such as offices, houses, schools, correctional institutions and public places such as waiting areas, public plazas, malls, etc. Salutogenic design principles serve to create healthy built environments that support users and the local community through the application of holistic,


knowledge based approach in the process of delivery. The general principles of salutogenic design has the following criteria; spaces for social support, reduced sense of crowding, connection to nature, positive distractions, daylight, sunlight, good air quality, choice of colours, impact of music and culture (Alan Dilani, 2015). The salutogenic model also discusses the poetics of space, the link to how patients will heal as they experience a series of spaces that do not confine them to four walls. The dialogue between the healing space, nature and people through design ideals, are explained through Figure 1.1.

theory applied in eliminating stress from built environment and promoting health.

Salutogenic Design

Principles that translated Into intangible sides of architecture

Access to Nature

Social Interaction

Natural Light & Ventilation

Sensory Stimulation

Figure 1.1 Salutogenic Design and the principles, Source-Author, 2017

Legible Environment


1.1.2 Research Findings in Behavioral Health Care Behavioural health care is a unique and vital component of the health care field. It differs from the majority of areas of health care in that it is aimed at addressing human action and interactions within society. “Behavioural” refers to, “underlying psychological processes such as cognition, emotion, temperament, and motivation; and to bio-behavioural interactions” (NIH, 2010). The practice of behavioural health, therefore, is then concerned with the health, or the “as a state of complete physical, mental and social wellbeing” (WHO, 2005), of these actions. This field works to provide services that promote healthy human behaviour in society. Behavioural health is frequently broken down further into two main areas of care: mental health and substance abuse. This dissertation examines in particular behavioural health care, both mental health and substance abuse, as this setting presents arguably the most stringent requirements for the safety and wellness of the patients. Persons with behavioural health problems have historically had problems finding and receiving care. Even though the percentage of persons with mental health and substance abuse disorders is relatively high, barriers such as stigma, lack of transportation to care, a shortage of care providers, and poorly designed facilities among other causes prevent patients from receiving the care that they need. Recent changes in attitude towards behavioural health recognizing it as a medical condition has begun to combat some of these issues. However, the need is still great. Behavioural health care addresses disruptions in an individual’s ability to function within society. According to the World Health Organization (WHO), “mental health is related to the promotion of well-being, the prevention of mental disorders, and the treatment and rehabilitation of people affected by mental disorders” (2013). The National Alliance for Mental


Illness (NAMI) frames mental disorders, or mental illnesses, as medical conditions that disrupt “a person’s thinking, feeling, mood, ability to relate to others and daily functioning” (2013). This medical condition can often have drastic effects on the individual’s ability to respond to the typical needs of daily living. According to the Commission on Youth Membership, when a person has an extreme inability to cope with these demands, they can be described as having “serious emotional disturbance” (2010). The term “serious emotional disturbance” (SED) is used in a variety of federal statutes in reference to a specific behavioural health problem which affects or prevents an individual’s participation in society socially, academically, or emotionally. When a person has an SED, professional health care services work to address this disruption and help them to fully recover. The rate of SEDs in Malaysia is alarmingly high. Studies have documented that, depending on the criteria used, somewhere between 4% to16% between the ages of 9 and 17 can be diagnosed with SED (Commission on Youth Membership, 2010). When a person with a mental illness, whether or not it is an SED, seeks behavioural health care, this care is oriented towards helping the patient to address this disruption in their thinking, feeling, mood and ability to relate to others. This treatment is not intended to be episodic, it is aimed at helping the patient to develop their mental health to fully recover as part of a lifetime process. The other primary cause of behavioural health problems is substance abuse. Substance abuse refers to any use of psycho-active substances (alcohol or drugs) that harm the well-being of the individual. Frequently, persons who receive treatment for substance abuse problems have developed a dependence syndrome. Dependence syndrome refers to the mental and physical phenomena that result from repeated substance use. It typically results in strong urges to take the substance despite its harmful effects. Substance abuse problems are characterized by the user’s difficulty


to control the use of the drug, a priority placed on the drug compared to the other activities of daily life, an increased tolerance to the substance, a tendency to overdose, and withdrawal symptoms when the individual is not under the effects of the drug (WHO, 2013). These symptoms directly affect one’s health and ability to function. Therefore, as with mental health care, when a person with a dependence on a substance seeks behavioural health care, this care is aimed at providing strategies to not only heal from this dependence, but also at providing preventative measures to avoid this problem in the future. Behavioural health care applies the principles derived from behavioural science to persons who no longer express healthy behaviour in society, due to either or both of the reasons listed above. The goal behind this care is to help the individual take responsibility for their actions and become active and productive members of society. This aid not only benefits the individuals receiving care, but also their friends, family, and surrounding community by allowing these persons to give back to society as a whole. Appropriate behavioural health care for patients serves not only the individuals being cared for, but also the public good. For the individual, it has a clear and easily discernible benefit as it helps guide them along the recovery process and give them the necessary skills to heal. The World Health Organization recognizes that “people with good mental health are able to achieve and maintain optimal psychological and social functioning and well-being.
They have a sense of identity and self-worth, sound family and peer relationships, an ability to be productive and to learn, and a capacity to tackle developmental challenges and use cultural resources to maximize growth” (2005). By helping those with mental health problems to recover, these individuals can move beyond the potentially crippling path of their illness to become stronger, more competent individuals.


Beyond that, by helping these individuals become productive members of society, this society itself receives the benefits. The World Health Organization notes that “the good mental health of patients is crucial for their active social and economic participation (2005). It is in the best interest of society itself to invest time and energy into the behavioural health and wellness of all of its individuals. Once these patients have learned how to recover, they can go on to participate fully within the larger community.

1.1.3 Relationship between Salutogenic Design and Research Findings in Behavioral Healthcare Salutogenic theory is not a perfect model of health (Mittelmark & Bull, 2013), but as theory, it does have a scope and perspective that other ways of understanding health lack (Antonovsky, 1996). Salutogenesis is a way of understanding the entire spectrum of wellness and illness, regardless of specificity and detail. In other words, it provides an overarching narrative structure that transcends the individual differences between people, and the differentiation between diagnoses, circumstances and environmental variation. Salutogenic theory is thus useful for broad approaches to grappling the well-being and health spectrum, and as such, it is useful for managing indirect, complex, obscure or unknown factors in health conditions. Salutogenic theory has this higher-level validity that makes sense beyond the specific findings of particular experiments and design interventions (StrĂźmpfer,1998), and provides a basis for informed decision making in the absence of specific knowledge, or whenever circumstances are too complex to suggest easy solutions.

Thus, it is worth using salutogenic as a premise and bigger framework and study the relationship with more specific architectural research findings


in behavioural health care. While both using human stressors as the indicator in creating healing environment, they are having similarities in terms of the theory and principles as the guidance of healing tool in behavioural healthcare. The intervention between both salutogenic and research findings in healthcare is further explained on in Figure 1.1.

Figure 1.2 Salutogenic Design and Research Findings in Behavioral Healthcare Intervention, Source-Author, 2017


Designing a behavioural healthcare facility is generally accepted as a complex task in both functional and psychological. Today, creating healing environment with appropriate healing attributes such as daylighting, ventilation and noise levels could promote sustainability in behavioural healthcare design. This dissertation will further discuss the ways of achieving such positive aspects in using the principles mentioned earlier. Chapter 2 to 3 discuss how is the change of design in healing environment could contribute to faster recovery in patients in compared to current conventional designed healthcare system.

1.2

Problem Statement In Malaysia, behavioural health services are mainly provided in over 30

general hospital psychiatric units situated throughout the country. However, a review based on quantitative estimates, suggested a total of 1.4 million children in Malaysia with mental health difficulties that interfere with normal functioning and development did not received adequate services under good healing environment. (Peters, 2010) Behavioural healthcare centre had been highly institutional designed to restrain and isolate persons with mental health problems from society. These facilities have often been poorly designed under a misunderstanding of the needs of individuals with behavioural health issues, frequently thinking that they are incompetent or criminal and are therefore incapable of participating in the community. This belief is a result of stigma toward behavioural health. According to The Stars, “patients are made to shower naked in the open, sleep in a room without curtains, ignored, stigmatized and shunned.� (2017) Such is the condition of some patients in clinic who suffer from mental health problems in Malaysia.


Therefore, architects who create built spaces for behavioural healthcare centre need to understand the science of the spaces, arrangement and the important elements that promote healing. Physicians and nurses in the study carried out by Roger Ulrich 1984, noticed that a patient’s sudden interest in external things is the first sign that the healing process has begun. However, it appears that the current healing environment is not ideally designed. Patient’s negative experiences of the existing physical environment are described as depressing, confusing, dull, lack of natural light, stressful, noisy which causes sleep deprivation, anxiety isolation and physical restraint are noted in many studies of existing healthcare facilities. With these issues in mind, this dissertation aims to employ the current information available to promote an architectural approach to behavioural health settings that combats these issues and promotes recovery.

1.3

Research Question

1.3.1 Main Research Question Findings reveal how behavioral research findings based design using salutogenic design as framework in opposed to approaches in conventional healthcare facilities will improve the healing process of a patient. The main research question is “How can research findings in behavioural healthcare translated and frame within salutogenic design as a framework to create healing environment that promote recovery in patient?”


1.3.2 Sub-Research Questions

1.4

•

What are the principles derived from salutogenic design and their relationship with research findings in behavioural health care?

•

How does salutogenic design invoke through spatial experiences to provide a sense of peace and healing?

•

What is the relationship of research findings in behavioural healthcare and healing environment?

Aims and Objectives Based on the issues raised from prior and existing studies, the

dissertation aims to understand in what way research findings in behavioural healthcare can translated within salutogenic design as a framework to create healing environment that promote recovery in patient. In order to achieve the aim of this study, the objectives of the dissertation are: Firstly, to analyze the research findings related to behavioral health. This will be discussed by understanding the researches in architecture that promote healing. Secondly, to create a guide with design ideas for designers who aim to set up healing places. This is through identifying the case study that adapt behavioural health research findings and its beneficial outcomes.


1.5

Significance of Study There is a big gap in research findings in behavioural healthcare being

translated within salutogenic design as a framework to create healing environment that promote recovery in patient. The analysis on the behavioural health research findings of the case studies will benefits locals, academics, designers, planners and policy makers in aspects of building appropriate healing environment. The findings may be used as reference from a case study approach which can provide basis for future projects especially healthcare facilities. As a long-term research effort, this dissertation is planned as a part of understanding in what way behavioural health research findings can contribute to architecture design in search of pattern language that promote recovery in patients, which can be applied to different site and buildings. This new research data and resources will become a tool to reexamine the current healthcare building and serve as a reference for future modifications. It demonstrates how the built environment should be in order to enhance the health quality for all.

1.6

Research Methodology The research employs a qualitative approach in the review of

references and the analysis of case studies. Although the theoretical framework is shaped by valid references, a lack of Asian text and references presents a limitation in developing the notion of behavioral research design healthcare facility in the Malaysian context. Therefore, the main limitation of this dissertation would mainly base on literature reviews and case studies to examine and identify the behavioral research design quality of selected healthcare architecture.


Phase 1: Literature Review The preliminary study will involve journals and articles of behavioral research based design healthcare facility as a background research. It will involve the development history and its significance to public as healing environment for those in sickness. The study also involves the collection of the guidelines and research reports from various articles and reports regarding the behavioral health research findings. Phase 2: Confirming Case Studies The selection of case study will involve the following data collection methods: •

Architectural drawings collection

•

Photographic documentation

Phase 2a: Architectural Drawings Collection Architectural drawings collection is to identify the facilities provided in the selected case studies. It is also to have better understanding of the design layout that matches under the requirement of behavioral research based design. Phase 2b: Photographic documentation In addition, photography will be a source for documenting the real-life context on site. It serves as primary data of evidence showing the current condition of facilities at selected case studies. The checklists and photographic documentations will be analyzed qualitatively.


Phase 3: Data Analysis The lists of design requirements derived from literature review are completed based on the architectural drawing collection and photographic documentation. The collected data will be classified and presented in diagrams, tables and charts to be taken for further analysis based on the behavioral research based design quality of selected case studies.

1.7

Limitations and Expected Outcomes The research employs a qualitative approach in the review of

references and the analysis of case studies. Although the theoretical framework is shaped by valid references, a lack of Asian text and references presents a limitation in developing the notion of behavioural research based design healthcare facility in the Malaysian context. Therefore, the main limitation of this dissertation would mainly base on literature reviews and case studies to examine and identify the behavioural research based design quality of selected healthcare architecture. As the scope of behavioural research based design is broad, the dissertation focuses on the works of healthcare facility in order to analyze the research findings related to healthcare design as well as its beneficial outcomes.


Organization Chart of the Research:

Figure 1.3 Organization Chart, Source – Author, 2017


CHAPTER 2 Salutogenic Design and Healing Environment 2.1

Salutogenic Design and Healing Environment Salutogenesis is seen as an umbrella concept encompassing several

theoretical approaches and concepts that all have in common a resource approach to health. The first and most well-known is Antonovsky's Sense of Coherence Theory in 1979, originally based on an epidemiological study of women who had undergone extreme stressful life events, some of them victims of the Holocaust, but still, as anybody else, were able to fully live and manage life. In Antonovsky's view this was a systemic approach where the coherence between individuals and their supporting structures creates an interactive system. The key here is again how can a sustainable system for the support of life be created through the use of available resources. Another concept under the salutogenic umbrella is resilience dealing with the ability to withstand hardship in life and still manage. Both concepts underline the importance of life experiences that form a culture and community prepared to encounter any challenges and difficulties in a constructive way. In other words, creating a resilient salutogenic culture. It contributes to the architecture aspect in healing environment, and serve as an agency-led concept that seeks to identify the factors and mechanisms that foster good health and the principles of ‘keeping well’. It is suggested that a salutogenic approach to recovery options would draw upon the guiding principles of the framework towards advancing, individual level, recovery capital. These principles being:


(i)

The development of social/cultural capital within sociallyconstructed environments; in which

(ii)

Individual action (or agency) seeks to

(iii)

Manage ill health; recognise the challenges underlying illness and identify the resources that are available to improve health. In order to demonstrate the academic and applied value of the

proposed salutogenic framework to the issue of recovery from dependence, including the centrality of space and place in relation to behavioural health care, the following chapter will draw upon empirical research as well as theoretical and hypothetical frameworks from the discipline of behavioural health care and its research findings on how architectural principles could promote recovery in healing environment.


2.2

Salutogenic Attributes that Promote Healing Environment There are several attributes of healing environments that derived from

salutogenic design which have influences on patients, visitors and staff through their sensorial stimulation. 2.2.1 Lighting Research has indicated that proper lighting is an important issue in healthcare settings. Poor lighting, for example, has caused negative effects like eye fatigue and headaches. A balance of natural and artificial light needs to be achieved. Some types of artificial lighting have been shown to be beneficial such as ultraviolet light which decreases blood pressure, fatigue and increases protein metabolism and releases endorphins (Bloemberg, F. C, 2009). Other aspects of artificial lighting such as luminance level, lamp colour and flicker have been argued to affect mood and performance in a negative way. Warm, indirect lighting is recommended as it makes the environment more natural and cheerful. In hospitals, the emphasis is placed on indirect lighting in areas where patients might pass through while lying on a bed so that the light will not shine in their eyes. Esther Sternberg mentioned that natural daylight along with other natural elements is more beneficial than artificial light for psychological comfort (Sternberg 2013). A study by R. Ulrich, 1984, has shown that 73 percent of the respondents thought natural daylight was better for health than electric lighting. Patients who are exposed to increased amounts of natural sunlight during the recovery period after surgery experienced less stress and pain, used less medication and produced less pain medication


costs. This suggests that every room where natural healing is involved should have a window which will allow light to filter in and even provide positive diversion towards nature. 2.2.2 Ventilation Indoor air quality has a significant impact on health, especially in a tropical environment, where high rates of air temperature and humidity can be sources of annoyance for patients and staff. 2.2.3 Smell Healthcare facilities have a distinct smell of floor cleaners and other hygiene chemicals. Some smells may cause the patients to feel nauseated, such as the smell of food. This as opposed to fragrances of flowers and fragrant oils, does not induce a happy feeling. It is important that a patient feels happy with the mind to be able to heal, says Esther Sternberg, 2013. For instance, when the Queen of Sheba gave fragrant plants to King Solomon, the Romans went to the Holy Land and took them back to Rome for safe keeping with sentries because the fragrances were used to heal soldiers from battle during their recovery period. Good smell releases endorphins in the human brain and causes these molecules to have to boost features for the immune system (Esther, 2013). 2.2.4 Sound Hospitals can be considered as noisy or negatively distracting places. From the knock on the door, constant visitations from nurses and doctors, pushing of trolley in corridors, emergencies, speaker phones paging doctors and the loud pain felt by patients, these situations cause a patient to feel


more stressed as opposed to a quiet place for contemplation and peace which forms an important element in healing. Sound levels above 60dB are considered to have negative effects on rest and sleep for patients which can cause hypoxia and increased blood pressure. This does not mean that all sorts of sound have to be removed. Certain types of sound, such as birds chirping, soothing music have been proven to reduce anxiety and pain as it soothes a patient's mind. 2.2.5 Colour Alan Dilani (2015) discusses how colour can possibly affect the brain's activity and create a sense of well-being. Warm colours such as red, yellow and orange have an activating effect, while cool colours such as blue, purple and green are considered having a calming effect. 2.2.6 Views According to Roger Ulrich's research, a view toward nature is also an attribute that promotes a healing environment. Therefore, it is important to discuss how architecture can be filled with nature and other positive attributes.


CHAPTER 3 Behavioral Health Research Findings 3.1

Relationship between Research Findings and Healing Environment One of the driving beliefs of this dissertation is that the environment in

which care is delivered can promote or detract from the healing process. Mounting research suggests that buildings can, in fact, influence the ability and willingness of a patient to heal. In the behavioural health settings, one of the key recent findings is that the built environment can reduce aggression. Roger Ulrich, a leader in the field, notes that “The patient’s acute stress will be lessened after admission if the ward environment has been designed in evidence-informed ways to foster control and coping, mitigate crowding stress, minimize environmental stressors such as noise, and promote exposure to stress reducing or restorative features such as nature.” (Ulrich et al, 2012) However, many studies from the neurosciences or evolutionary biology are not linked to the built environment but rather to the impact of various stressors on human physiology and biochemistry. Here’s an example: Pert (1997) discusses how our thoughts influence our biochemistry from moment to moment. She does research in neuropeptides and has documented the effects of stressors on the immune system. Although a scientist may take issue with generalizing this to the effects of the built environment, it would seem that anything that makes patients feel comfortable, including the setting in which a medical procedure takes place, would impact their thoughts and biochemistry. In fact, there is research in the report (Ulrich et al. 2004) indicating that this has credibility, as explained below. Research indicates that speedier recovery time at home may occur as a result of a less stressful hospital experience (Kiecolt-Glaser et al. 1998). In fact, physical comfort in the hospital setting may even reduce mortality and


morbidity. Patients in this setting may require fewer narcotic pain medications, have less anxiety and depression, and have fewer postsurgical complications (Kiecolt-Glaser et al. 1998). A more comfortable, less stressful hospital experience leads to higher patient satisfaction which, in turn, is linked to increased patient compliance with drug regimens and recommended postsurgical care, including follow-up visits—all of which potentially affect clinical outcomes (Kiecolt-Glaser et al. 1998). Behavioural research based design focuses on the built environment, but, in addition, major forces guiding hospital design include patient safety, information technology interface, the family as a partner in care, and healing environments. They are actually overlapping in their impact. For example, fewer patient falls are likely to occur when family is present. Breaches in patient safety exist as issues apart from the design of the built environment in the form of medication errors, nosocomial (hospital- acquired) infections, and so forth, but it is also known that a design issue—single bed rooms—and possibly the standardization of layout (avoiding mirror-image rooms) enhance patient safety (Chaudhury, Mahmood, and Valente 2003; Ulrich et al. 2004). In fact, single bed rooms have become the standard of care in the AIA Guide- lines for Design and Construction of Health Care Facilities (2006).

3.2

Relationship between Research Findings and Stress In some respects, it can be said that the concept of healing

environments has evolved into design based on research findings, but it is mainly in the area of reduction of stress that this overlap occurs. Research that underpins the concept of a healing or psychologically supportive environment is drawn from the neurosciences, evolutionary biology and environmental psychology.


The most effective path to creating a healing (stress-reducing) environment is to inform design decisions by research. Stress could result from any situation that requires behavioural adjustment such as invasions of privacy, no control over noise, acute or chronic pain, separation from family and things familiar, feelings of helplessness, and loss of control over events and the immediate environment. Under stress, muscle tension increases; all forms of pain are worsened because hormones produced during stress lower the threshold for pain; blood pressure and respiration increase; and the overproduction of stress hormones can cause cardiac arrhythmias, depression, and insomnia as well as delay wound healing (Kiecolt- Glaser 1998). It is interesting to note that the negative effects of stress can be measured hours after the stressful event occurred. Worse yet, stress impacts the immune system, which is perhaps the most compelling reason to design environments that reduce stress and help patients relax and feel comfortable. Applying research to the effect of the built environment on a patient’s experience of stress, neuroscientists have been able to document which areas of the brain are affected by the perception of a healing environment, a setting that feels comfortable or that provides pleasure (Rabin 2004). A pleasant environment keeps norepinephrine levels low so that patients actually experience less pain, have more restful sleep, less anger, less muscle tension, and lower risk of stroke (Rabin 2004). The other major stress hormone, cortisol, can actually damage neurons in the hippocampus and it also affects the rate of wound healing. Elevated levels of both norepinephrine and cortisol impair the immune system (Rabin 1999).


3.3

Strategies of Research Findings on Healthcare Architecture As derived from the principles in salutogenic design as a framework,

which emphasize on the ways of architecture promote healing environment, behavioural research based design also share some similarities in the strategies that alleviate the patients in their healing environment. The goal of healthcare facility design has been to create healing environments. Sometimes well-meaning individuals interpret this as the application of wallcovering, nice colours, carpet, and artwork. While these cosmetic features may create a certain ambience that is pleasing to patients, a healing environment is one that is based on research in the following areas.

3.3.1 Orient functions around a central greenspace A centralized, open, and accessible greenspace not only provides a space for physical activity and interaction with nature, but also brings daylight into the core of the design. This design element can be used for way finding, improved visibility, and positive distraction. This strategy is rooted deeply in the goals of providing access to greenspace and bringing daylight into the facility. Because of this, a strong evidence base supports this strategy. Studies, such as one conducted by Akridge in 2005, indicate that having secure visual access to nature can create a positive distraction for the patient. As patients in behavioural health facilities are dealing with behavioural illnesses, this kind of positive distraction can serve to help the patient open their mind to the possibility of a life outside of their current condition and allow them to engage more fully in the recovery process. Not only this, but by placing a greenspace at the centre of the program, the


buildings themselves can form the security element and outer boundaries for the space, eliminating the need for fencing disrupting the space. Joseph, in 2006, noted that access to natural light has plenty of benefits to the individual. Daylight has been demonstrated to improve mood, chemical reactions within the body, and the body’s circadian rhythm. In addition, it promotes one’s ability to perform tasks effectively. Ulrich notes that exposure to daylight can reduce stress for both psychiatric and nonpsychiatric patients. By providing a centrally located accessible greenspace, patients can see and experience daylight throughout their daily experience, allowing them to more comfortably focus on the recovery process. A central greenspace not only has these biological effects on the individual, it also provides a secure space for patients to have physical access to the surrounding environment. Not only does it create a more accurate image of the functions of a society, it also provides a venue for physical activity, which, as discussed previously, can increase positive mood and decrease anxiety. The majority of the successful health centres studied had a prominent central greenspace as a major design driver for the facility. STARS Sub-Acute Treatment facility, seen in Figure 3.1, uses the central courtyard as an activity field including a half-basketball court. The Lesotho Child Counselling Unit (LCCU) seen in Figures 3.2 uses the central courtyard as the main circulation element for the building. The edges of the courtyard space form a covered walk that is connected to every room in the facility. This allows patients and staff alike to continually connect with their surrounding environment. Finally, Nye Vardheim Health Centre uses the central gardens pace as a way to connect the three levels of the facility by having it bridge the levels. Seating is integral to the architecture of the facility and is located along the perimeter of the garden space.


Figure 3.1 - STARS Sub-Acute Treatment Facility, Source - The Design Partnership, 2017

Figure 3.2 - Lesotho Child Counselling Unit’s Courtyard, Source - Article 25, 2017

As designers begin to create this greenspace, several considerations should impact its development. To serve as a way finding element, it should be placed not only central to the facility, but in such a way that it provides visual access to the various components of the facility (e.g. circulation


pathways, therapy spaces, community gathering spaces, patient wards). This space should be seen as an area with medium to high levels of activity. Special consideration should be given to ensuring the safety of these areas. Because of this they should be highly visible from staff work areas, activity spaces, and main circulation routes. In addition, special care should be taken with the design of this space to avoid an institutional or caged feel. Therefore, the greenspace should not only be a focal point for the facility, it should also serve a functional purpose. This space can be designed to accommodate group activity space, group therapy, or patient recreation activities among other things, depending on the unique needs of the population served.

3.3.2 Filter light according to function


Once a central greenspace has been established, care should be taken in how this daylight is delivered to each space. The next strategy, filter light according to function, speaks to the idea of bringing daylight into each treatment space in a manner which respects the activity occurring within the space. This strategy is tied both to the strategies of bringing daylight into interior spaces and providing privacy for the individual. As stated earlier, abundant and undistorted light can help to establish a positive mood and maintain a healthy body (Joseph, 2006). However, at the same time, varying levels of privacy are needed for the different parts of the recovery process. Adolescents in particular have demonstrated a strong desire for privacy (Gulak, 1991, Gabb, 1992). When the patients engage in the therapy process, a sense of privacy is vital to allow patients to feel capable of being open to the recovery process.


Therefore, visibility into and out of patient care spaces should be carefully considered in order to successfully implement this strategy. Spaces where patients might feel particularly vulnerable, such as private therapy spaces, should bring in daylight in a way that respects the privacy of the therapy occurring. Strategies such as clerestory windows, frosted windows, or louver systems in these spaces can provide a method of bringing light into these spaces without compromising the privacy of the individual. Choosing when and to what extend the light should be filtered allows for control of visibility both into and out of spaces according to the functions occurring within the space.

Figure 3.3 - Bessboro House, Public Courtyard, Source - McCullough Mulvin Architects, 2017

Areas for private and/or clinical activity should use indirect natural light to encourage a feeling of safety and intimacy in the space. Patient spaces should be designed so that views do not open to other rooms or gathering spaces. If patient rooms must be visible from other spaces, they should have some degree of separation, either through distance, foliage, or window treatments.


In contrast to these very private spaces, areas for large group, nonclinical activity can have high levels of visibility and natural light. This can help to establish positive energy and draw strong connections between the individual and their surrounding community and environment.

Figure 3.4 - Bessboro House, Private Courtyard, Source- McCullough Mulvin Architects, 2017

Figure 3.5 - Bessboro House, Active, Well Lit Space, Source - McCullough Mulvin Architects, 2017

In reality, many spaces will fall somewhere in between providing daylight and privacy and daylight and visual connections. Design solutions should respond to this gradient of need with varying degrees of exposure to light in these spaces. Architectural interventions such as fully or partially clouded windows or fixed or operable screens may be employed to help filter views in and out of critical spaces.


3.3.3 Reduce narrow and dark corridor Primary circulation should be simplified to create direct pathways without awkward transitional spaces. Spaces with poor visibility or feeling of isolation should be avoided. Shepley’s study of physical incidents found that the main spaces which caused tension in this facility are awkward transitional spaces. She notes that “transitional zones without territorial definition, such as hallways and entries, are sites of a significant number of negative behaviours” (Shepley, 1995). Additional studies of health care facilities, have noted that problems with way finding are a contributing factor to persons in health care facilities (Carpman & Grant, 2002). Finally, “crowding” in behavioural health facilities is strongly linked to patient aggression. Therefore, proper treatment of transitional spaces within these facilities can help to reduce violence and promote a truly healing environment.

Figure 3.6 – Outdoor Lounge Area along the corridor of Centre for Prevention and Rehabilitation, Source - EGM Architects, diagrammed by Author, 2017

To design a space that responds to this evidence, the needs of the patient as they travel from one space to another must be carefully considered. Long, narrow, double- loaded corridors should be avoided. Corridors should be open and clear to minimize blind spots from nurse stations (Hunt, 2013). Similarly, any form of transitional space should remain wide and have visual access to multiple functions at any given point. These transitional


spaces should provide the patients with cues to the types of zones that patients will enter as they travel through the facility.

Figure 3.7 Double Loaded Corridor Contributes to Patient Aggression, Source- The Design Partnership, diagrammed by Author, 2017

Patient rooms should open onto these clear and open spaces. Certain precedents have even oriented patient rooms around a central living space. Other facilities provide transitional space between the units and the main transition space. With this strategy, it becomes critically important to consider the amount of sound generated from this living space or transition spaces and how it will affect the quality of space within the patient room. Blind turns into or away from patient spaces should be avoided. These architectural interventions will allow for a high degree of visibility in the space and an avoiding of “crowding�.


3.3.4 Create clear views to/from staff work areas By providing open nurse stations along primary circulation and gathering spaces, the safety of the environment can be promoted. One of the main components of the vision for behavioural health facilities is that these environments help to reintegrate into society. As was seen in the wraparound model, community support is critical to the success of this concept. The staff of the behavioural health care facilities are the patient’s primary contact with society during the recovery process. Not only this, the staff also aims to be a mentor figure to these patients and a guide along this process. Therefore, patient to staff connections must be handled thoughtfully and sensitively. Karlin notes that, “when patients feel connected to staff, they are more likely to respond to or seek out these individuals in moments of distress, which can prevent or de-escalate personal crisis... facilitate staff interaction and connection with patients and discourage isolation or detachment” (2010). For the patient, the nurse station should not be seen as a barrier to the staff, but rather a checkpoint space that helps the staff to deliver care (Hunt, 2010). Staff should be encouraged to engage with the patients outside of this space as much as possible. This strategy will enable the patient to have the comfort of knowing that the staff members form members of their recovery team, further reducing feelings of alienation and isolation that can accompany behavioural health problems. Once a patient feels safe in their environment, they are then able to open up to the staff and begin to participate fully in the care delivery process. Strong connections between the staff and the patients is also desirable from the vantage point of the care providers. In the behavioural health care setting, the patient to staff relationship is a critical component of the recovery process. As staff are the patient’s primary point of contact with society and a guide along the process, it is important that patients are able


to see and interact with them as necessary. Therefore, staff in these facilities have a primary focus of visual and acoustic connection with patient gathering and circulation spaces (Duffy & Huelat, 1989). Additionally, encouraging nurse interaction with patients can help staff members to successfully moderate patient interactions and better notice trends in patient behaviour.

Figure 3.8 - Nurse Station Central Location at West Central Behavioural Health, Source - Stanley Beaman Sears, diagrammed by Author, 2017

Nurse stations should ideally be located along major circulation paths and group areas, promoting the staff’s ability to engage with patients while remaining unobtrusive and non-threatening. By placing the nurse station at critical intersection points of the facility, this function can not only open up potentially stressful points in the facility, they can also promote staff’s ability to provide care. Clear views to both gathering spaces and points of exit/entry for the patient spaces are critically important for the promotion of a safe environment. There are several “back of house” functions that staff need private access to (for instance, medication storage, linen, and even utility functions). Nurse stations should have support functions nested on the backside of the


station to allow a protected zone for private staff interactions, medications, etc. Functions that support the unit but are not needed frequently by the nursing and technician staff (mechanical, electrical, and IT support) can be located outside of the main care delivery space to facilitate ease of access without compromising patient spaces.

3.3.5 Provide both private and semi-private patient rooms By providing both private and semi-private (two person) rooms, the facility can accommodate a variety of patient needs. Little evidence supports either private or shared rooms for this group and setting. The evidence that does exist is contradictory. Therefore, it is proposed that a mix of private and semi-private is the most appropriate solution for flexible meeting constantly changing needs and patient profiles. Private rooms, while the typical space of choice in general medical facilities, have both strong benefits and disadvantages in a behavioural health care setting. They can provide a completely private and secure deescalation point for the patient (Grosenick and Hatmaker, 2000). Additionally, they can provide a sense of control for the patient (Novonta, Urbanoski, & Rush, 2011). However, many strongly argue against the use of private rooms, arguing that they foster a lack of connection to other patients and staff. Researchers such as Wilson, Soth, and Roback (1992), Ulrich (2012), and Chou (2002) argue for the potential of large semi-private rooms in clustered layouts to promote a sense of familiarity and collegiality among patients.


Figure 3.9 - Private Patient Rooms at Ferndene Mental Health, Source - Medical Architecture, 2017

Unlike the majority of acute inpatient health care, behavioural health facilities frequently use shared rooms for the patient. Sharing a room between at least two patients is considered to promote connections between the individual patient and their surrounding community. In addition, they can shorten corridor lengths in patient units. Even more importantly, it has been argued that semi-private rooms foster a sense of responsibility among patients (Shepley, 2013). Patients with suicidal ideations are less likely to have the opportunity to act on these tendencies, and roommates can notice trends in behaviour that may otherwise be unnoticeable to the staff. Shared rooms are used more frequently in substance abuse situations than in mental health. These rooms are perceived to foster a sense of community for the inhabitants and allow them to develop a sense of responsibility for their behaviour in this community.


Figure 3.10 - Shared Patient Rooms at STARS Subacute Treatment Centre, Source The Design Partnership, diagrammed by Author, 2017

However, there are also several arguments against a shared bedroom. Wolfe notes that anxious patients may find the social intimacy required in a semi-private space to actually be detrimental to the recovery process (1975). Considerable research on residential settings and prisons has shown that the number of persons sharing a bedroom, bathroom, or cell strongly correlates with higher crowding stress and lower privacy, perceived control, more disagreements with roommates, more illness complaints, and social withdrawal (Proshanski & Rivlin, 1970, Ulrich, 2012). In any configuration, patients with strictly substance abuse disorders should not share a room with patients with severe mental illness as this anecdotally does not foster recovery (Morgan, 2013). To this end, this dissertation supports the use of a variety of private and semi-private rooms in each unit. Upon entry into the unit, the patient should be assessed to determine the nature of space they need. Staff should assess not only the patient’s acuity level, but also their home environment to determine which setting would provide the most natural recovery process.


Like the private rooms, semi-private rooms should be designed to give each patient a space that belongs to them within the room. Each patient should have his or her own window, and the beds should remain visible from the entrance to the room (see Figure 3.11). Strategies such as dropped ceilings over the patient beds can help to reinforce this notion of privacy within a shared setting. There should be a clearly defined transitional space in the room in which the two patients are capable of interaction with one another. This helps to ease the transition from the individual patient space to the facility as a whole.

Figure 3.11 - Private vs. Semi Private Room, diagrammed by Author, 2017 Several design strategies can be employed in both the private and semi-private rooms. In both scenarios, patients should be provided with ample built in, open storage space. Additionally, patients should have a sense of control over their particular space. This feeling can be reinforced by giving the patient as much control as they are capable of (which will vary per patient). Hunt recommends the use of integral blinds in patient room windows (2014). As patients are capable of greater degrees of responsibility during their stay, they can be given control over these blinds, letting daylight into the space as desired. These strategies are meant to reinforce the notion that each patient deserves respect and as much control over their space as they are capable of while still maintaining an open and safe feel.


3.3.6 Create levels of interaction in daytime spaces The facility should be able to accommodate a range of activities in daytime program areas, ranging from individual or small group activity to large group activities. This strategy is to accommodate interactions at the individual, family, neighbourhood, and community level. By creating a variety of levels of interaction in daytime program areas, the environment supports patients willingly selecting to choose a setting that will help them to relieve in stressful situations. To genuinely respect individual dignity, promote connections to the environment, and facilitate reintegration into society, the patient must have the ability to choose to participate in each aspect of this vision as needed. “Services and supports must be individualized, built on strengths, and meet the needs of children and families across life domains to promote success, safety, and permanence in home, school, and community. The process must be culturally competent, building on the unique values, preferences, and strengths of children and families, and their communities” (Burns & Goldman, 1999). This strategy suggests “dedicating space for social interaction; clearly indicating a room’s intended use; making areas visually distinct so intended use of different parts can be delineated from their appearance; using colours to enhance activities and spaces; using various materials to provide different tactile and visual experiences; using lighting to help de ne space; and finally, making the spaces that have special meaning to patients stand out” (Gulak,1991). Figure 4.2, an outdoor patio at Worcester Recovery Center, begins to speak to these levels of interaction. A variety of seating options give the patient the dignity and respect to control how and where they interact with the space. The environment of this space is clearly understood, as the building wraps around the central garden space. The clustered seating is grouped together to create a larger group space, and the central field


permits large scale group activities. In this manner, the space can appropriate environmental cues to the user that they are able to engage in the recovery process as fully and completely as they are capable.

Figure 3.12 - Outdoor Areas at Worcester Recovery Centre, Source - Architecture +, 2017

To develop the levels of interaction, it is important to have a clear understanding of what these levels are and can be. The first level is respect for the individual. This level provides moments for reflection and deescalation for the individual. It is necessary throughout the facility, (or especially) in larger group activity spaces. The patient room can be seen as the initial point of individual freedom, but the ability to have privacy must extend past this space, as “residents are often not allowed free access to bedrooms during the day due to safety concerns� (Hunt, 2013). This can often be achieved through small scale places, such as pocket gardens, individual benches or seating. It is important to maintain visibility to these spaces, especially from staff work areas. The second level of interaction establishes a connection between the individual and their surrounding environment. This environment refers both to the built structures and to the surrounding landscape in which they are situated. Comfort with this level implies that the individual has an understanding of the space they are in, and feel free to engage with the


environment to the degree which they are capable of, whether it be through sitting in a window seat or through active use of a community or outdoor space. This level of interaction also implies that the patient has an understanding of their physical environment. This suggests that the facility is designed to encourage this understanding by providing previews of the spaces patients will enter and use before they reach them. Circulation should be, open, and direct. The building should be massed and articulated to represent the kind of interactions that take place on the interior of the space.

Figure 3.13 - Small Group Interaction, Source - EGM Architecten, 2017

The levels of interaction system should provide an opportunity for the patient to engage in their environment and community to the degree that they are able. Therefore, the built environment should provide ample opportunities for the individual to rest, see, and interact with people at varying levels. Larger community areas should be comprised of both spaces for larger groups to interact and smaller moments of interaction for those individuals who need to de-escalate or regroup. In the same way, areas for smaller interactions should have at a minimum visual connection to areas of larger group interactions. This strategy not only allows patients engage at these levels, it also simplifies wayfinding and provides a system to which the other strategies can be applied.


3.3.7 Use healthy, safe and respectful materials and furnishings Spaces should be designed using materials and structures that promote a safe and comfortable environment to promote place attachment. This strategy is rooted in the concept that when an individual feels a connection and responsibility for the environment, they are more likely to choose healthy actions in it. “To the extent that the environment of care in inpatient and other mental health settings is healing and recovery-oriented, it is likely to enhance patient safety� (DGMH, 2013). For this strategy to be effective, the environment must be both safe and respectful. This strategy counters the traditional Malaysia model for these facilities, which associates the idea of safety with a minimal, durable setting. Rather, true and healthy safety in an environment means giving the patient freedom to the degree that they are capable of using it. In a behavioural health facility, the environment has many opportunities to reflect this idea. Spaces should be designed to create a safe environment for the patient with the strongest immediate needs (for instance, a patient with suicidal ideations), while not impinging on the freedom of a patient who is capable of a much higher level of responsibility for their environment.

Figure 3.14 - Centre for Prevention and Rehabilitation, Source - EGM Architecten, 2017


Throughout the facility, anchor points should be avoided. Anchor points are places in the design of the building which could be used as for ligature attachment by suicidal patients. They are most frequently found in doors, windows, and at intersection points between furniture and the structure of the building. Special doors and windows can be used to allow for operability and safety (Hunt 2013). All furniture should be built- in, stationary, or difficult to dissemble, while still being of enduring quality. All materials should be chosen as long-term choices. Therefore, materials should be healthy, meaning that they do not emit toxins such as VOCs, and clean, reducing the spread of infection, for instance, anti-microbial carpeting. As a holistic environment, care should be taken to maintain the air quality of the space. As this space is treating mental rather than physical illnesses, designers have more flexibility with the design of HVAC system. It is critical that furniture and materials are chosen which avoids stigma and promotes the dignity of the individual.


CHAPTER 4 Case Study and Discussion 4.1 Justification on building selection & method In this chapter, the researcher has selected five case study buildings based on the following criteria: (i) the building is a healthcare related healing environment; (ii) the building focus on the inpatients group that recover in the centre; (iii) there are available resources or data of the building such as drawings, plans, publications and photographed images; and (iv) the analytical study has to be doable within one year period of time for the entire dissertation.

The buildings that fulfil the mentioned criteria are: - Psychiatric Centre Friedrichshafen - Housing for the Elderly - La Branche Home for the Disabled - Residential Care Home Andritz - Israeli Cancer Center The researcher will collect data base on available resources including a brief background study of each building, photographed images, and architectural drawings such as floor plans, sections and elevations; at the same time referring to publications such as magazines and interviews from official media, to carry out the analysis.


For each case study, the researcher will analyse the building in accordance to the fundamental concept of salutogenic design and behavioural based research findings as explained in Chapter 2 and Chapter 3, by identifying and comparing each design strategies applied to the buildings. The data will be analysed in relation to the principles of salutogenic design and behavioural based research findings.

4.2 Comparison and Discussion -Building 1, 2, 3, 4, 5 -Based on the Salutogenic Design Principles & Behavioural Based Research Findings


4.3 Summary of Case Studies

Psychiatric Centre Friedrichshafen

Housing for the Elderly

Orient functions around a central greenspace The building encloses a generously dimensioned green courtyard and exploits typologically the contour of the hillside by providing entrances on two different levels.

The rooms are generated as small cells that clump together organically around the courtyard, creating interstitials and areas of relation, both to the courtyard itself as the interior.

La Branche Home for the Disabled

Residential Care

Israeli Cancer

Home Andritz

Center

x

x

The building is designed to surround the existing trees in order to form several courtyards.


Filter light according to function

The large central therapy rooms with direct access to the patients´ garden are arranged on the lower floor by exploiting the possibilities of natural illumination along the slope.

The setup of the windows varied in sizes to cater different needs of spaces. Smaller size windows can be seen on patient’s room while bigger size windows on public spaces.

The building has various window sizes carefully designed to illuminate different interior spaces.

The large spanned windows in patient rooms enable the interweavement of the inside and outside space.

The building uses overhanging and cantilevered shading elements to enhance the interplay of light and shadow, privacy and public access, and the blurring of traditional building boundaries.

x

Reduce narrow & dark corridor

The building has well illuminated corridors which direct the view towards its centre courtyards.

The perimeter corridor becomes a place rich in nuances and spaces in the manner of a small town where people can speak in front of the door of their room-houses fleeing the classic configuration of such centre to lugubrious hospitals than to kind and welcoming buildings.

The perimeter corridors have large spanned windows to direct views to the outdoor public spaces.

The corridors are further diminished with the small rooms opened up into large interactive spaces.


Create clear views to/from staff work areas

x

x

x

x

There is a central nurse station set up to cater the needs of patients from four different wings.

Provide both private and semi-private patient rooms

x The building has both private and semi-private room cater for different needs of the patients.

It has both private and semi-private patient rooms.

x

It has both private and semiprivate patient rooms.

Create levels of interaction in daytime spaces It has several big spaces for activities to allow interaction of the patients as well as with family and friends.

The bigger hall is set up for activities among the elderlies.

There are several bigger size and rather high ceiling level rooms for public interaction.

The two-storey building consists of four wings arranged around a semi-public “village square�, designed to host various events.

There are different levels of public spaces created to cater the needs of patients.


Use healthy, safe and respectful materials and furnishings

x

The timber cladding is made of untreated silver fir as a reference to the local building tradition, particularly in the nearby Vorarlberg region of Austria. The vertical cladding, comprised of untreated wooden profiles, lends the building, through its transparency, an airy and open appearance.

The whole work has been governed by the use of simple and cost-effective materials, without fanfare. Geometry, spatiality, light and careful treatment colour and textures to get a warm and cosy interior protected by an abstract and rhythmic limit to the exterior.

The faรงade is cladded with vertically structured wooden board, giving a sense of calmness and warm feeling to the arrivals.

Load-bearing ceilings and walls are made of concrete while all other structural elements are wood.


CHAPTER 5

Conclusion


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Dissertation i dec 2017 0308226 Lee Run Sen  
Dissertation i dec 2017 0308226 Lee Run Sen  
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