The Architecture of Healing Spaces, A Literature Review

The Architecture of Healthy Spaces A review in health care architecture Saba Fatima 1 Reviewed by: Aditya Singaraju 2, Dr. S. Kumar 3 1. M. Arch (Environmental Design), JNAFAU, Hyderabad, India 2. Assistant Professor, Department of Architecture, JNAFAU, Hyderabad, India 3. Professor, Department of Architecture, Principal, JNAFAU Contact: sabafatima2801@gmail.com January 2019

Abstract: Built- environments inevitably impact and shape the activities within them, and associated with them. Architecture and behavioural psychology are closely interlinked with each other and it is through this collaboration that the users of a space identify their sense of self and identity. Particularly in the field of health-care design and healing environments, the psychological and physiological impacts of architecture can be felt by its users predominantly on a subconscious level. This paper discusses existing literature and research studies on impacts of built-environments of healing spaces on recovery times, psychology, and productivity of patients, their family and staff. The review summarises the evolution of healing and health-care spaces and studies evidences that transpire changes in design practice. It is divided into three parts — A brief review of the evolution of health care spaces, Environmental psychology and the role of nature in healthy health-care spaces, and a summarised report on approaches to design of healing spaces.

Keywords: Healing spaces, Health-care design, Evidence-Based Design, Biophilic design, Environmental psychology.

“We shape our surroundings and our surroundings shape us.” – Winston Churchill Introduction: All environments – built, unbuilt, natural – emanate a degree of impact around them. And while architects tend to think architecture matters, not everyone else does. To many people buildings are not very interesting. It is what goes on inside them, and their association with them that matters. However, although only few people think about architecture, almost everyone feels it. Such holds especially true for healthcare spaces and learning environments (Day, 2004). These days, we notice that the hospitality industry places more importance on user comfort than do the designers, administrators, and managers of health-care industry.

This trend questions the architectural approach that leads to the construction of healing spaces, as, clearly it does not appear to prioritise user well-being and productivity. With the

advent of sustainable practices in the late 80s, various impacts of built-environments on nature, environment, and ecology are continually studied and acted upon. Of all the many impacts buildings have, the one on human health is perhaps the most paramount, yet, overlooked at times.

Part 01 Evolution of health care spaces: The healing-environments proposition is not a recent discovery. Interests in healing environments dates as far back as 2,300 years ago (Abbas, 2012) (Alibaba, 2014). The origins of the modern hospital, like those of medicine itself can be traced to the civilisations of Egypt, Greece and Rome – with a fusion of religion and healing. The Bethlem Royal Hospital in London, the oldest known psychiatric hospital in the world, began as a monastery. St. Bartholomew Hospital, famously Figure 1 The opportunity of the St. Thomas's Thames-side known as ‘Barts’, was found in 1123 by site was used by the architect and used later for patients requiring 'veranda' treatment. a monk named Rahere, and thrives to London Metropolitan Archives (Haggard, 1999) this day. These historic hospitals of Europe, characterised by cloisters and squares, atria and gardens, emphasized space, light, and tranquillity and the need for rest and relaxation, even if the then medical practice itself was often brutal and very selective (Clare, 1999) (Haggard, 1999). St. Thomas Hospital was one of England’s grandest hospitals, with six blocks of pavilion wards built at right angles to the river and the long, narrow site replaced courtyards with riverside ‘veranda’ treatment, a common practice until the 1960s.

The earliest documented general hospital was built in 805, in Baghdad, by the vizier to the caliph Harun al-Rashid. (U.S. National Library of Medicine, 1994). In some parts of the Arab world, a hospital was called a ‘bimaristan’ — Persian and Urdu for ‘a place for the sick’. Unlike the exclusive attitude adopted in Europe, the bimaristans were all-inclusive and multifunctional, acting as a treatment centre, a recovery home for patients, a psychological asylum, and a retirement home for those without families or carers. The Syrio-Egyptian hospitals built int the twelfth and thirteenth centuries displayed a circular plan with four central ‘iwans’ or vaulted halls, with many rooms around it, including the pharmacy, kitchen, and dining areas, storage and staff areas. Each ‘iwan’ was usually provided with fountains to enable the supply of clean water and baths (U.S. National Library of Medicine, 1994). “…Dear father, if you’d like to visit me, you will find me in the surgery department and joints treatment. When you enter the main gate, go to the south hall where you will find the department of first aid and the department of disease diagnosis then you will find the department of arthritis. Next

to my room you will find a library and hall where doctors meet together to listen to lectures given by professors; also this hall is used for reading….On the right of the hospital court lies a large hall for those who recovered. In this place they spend the period of rest and convalescence for some days.

This hall contains a library and some musical instruments.”

The translation of a young Frenchman’s letter from a Cordoba hospital in the 10th Century -The Islamic Scientific Supremacy. Ameer Gafar Al-Arshdy.1990, Beirut, AL-Resala Establishment (Tschanz, 2017)

With time, users became peripheral as technology became the prime focus of hospital designs. The onset of industrial revolution had indirect health consequences on communities apart from the obvious urban and geographical demographic ones. During the 19th century, infectious diseases, among which were tuberculosis, typhoid, and smallpox, were responsible for numerous fatalities in Europe and North America. In 1880, urban areas in the United States had fifty percent higher mortality rate than rural areas, despite only about six percent of the population living in cities, a steep penalty for ‘Urbanism’. By 1940, that ‘urban penalty’ had been largely eliminated (Williamson, 1982) (Haines, 2001) . To a large degree, these were solved through environmental and clinical public health interventions – sanitation and inoculation (Vittori, 2008). Consequently, a substantial contribution to health improvements were through improved urban planning, indicating a corresponding partnership between public health and public infrastructure. Today, up to one thirds of global diseases, are related to environmental factors such as poor nutrition, contaminated water, indoor smoke, vectorborne diseases, obesity and unhygienic living conditions. (Vittori, 2008) Over the years, studies have been conducted to establish whether there is convincing enough scientific evidence, that built-environment impacts healthcare quality and particularly outcomes for patients, family, staff, management, and in turn capital. The conclusion of these studies can potentially act as guidelines/evidence for best-practice. However, it must be understood that studies from a certain period in time or location differ from another, and it would be unintelligent to standardize any particular study as the norm. ‘Evidence’ may be a popular user preference, a response to a prevailing situation, the findings of a research/experiment, or even common sense. For instance, the pavilion or Nightingale ward as seen in St. Thomas Hospital in London, was developed during 1858 in response to the Sanitarian movement in England — a movement against prevailing unhygienic urban conditions — it consisted of a long ward with beds on each side between opposing series of window for cross-ventilation.

Part 02: Environmental psychology and role of nature in healthy health-care spaces: Environmental psychology: Environmental psychology is the study of effects of transactions or interactions between individuals and their physical settings. Through these ‘interactions’, individuals influence their environments and in turn, are influenced by them (Society, n.d.). Architectural psychology draws on environmental psychology. It deals with spatial qualities of a space, and its legible capacity by the users. Perceptions of spaces, behaviour of people in a certain space, its accessibility and inclusiveness of variation in terms of age, abilities and disabilities, gender and minorities, and the experience, and satisfaction it provides to people defines its psychological impact (Lehman, n.d.). George Herbert Mead, a distinguished pragmatist from the University of Chicago argues that a person develops a ‘self’ (self-image) and self-validation through his or her transactions with other people. (Bednar, 1977) The psychological impact of built spaces is a broad spectrum, within which are emotional effects, cognitive effects, developmental effects and social effects. To read an architecture, the environment of that space is fragmented into ‘Environmental language’, ‘Environmental cognition’ and ‘territoriality’. ‘Environmental language’ that does not treat all people as spatially normal renders them illiterate and excluded from the society of that space.

‘Environmental cognition’ is a means for users to relate to their space through memories, spatial cognition, wayfinding. ‘Territoriality’ refers to the innate human need to have a sense of belonging to spaces, and validate their ‘self’ with their surroundings.

‘Evidence’ on impact of nature on healing environments: Evolutionary theory asserts the popular discourse that throughout the thousands of years of human evolution, we have developed a partly genetic positive predisposition and inclination towards nature (Appleton, 1975) (Orions, 1986) (Kaplan, 1989) (Ulrich, 1983) (Ulrich, 2008).

Although, perceptions and responses to artificial stimuli such as colours vary from person to person and across cultures, diverse cultures and socio-economic groups show high similarities in responding positively to nature views. (Ulrich, 1993).The most influential model in medicine and health psychology for explaining pain and alleviation of pain, is gate control therapy (Wall, 1965) (Wall, 1982) (Ulrich, 2008). It shows a direct co-relation by proving that the more captivating a nature distraction, the greater is the pain alleviation. This implies that nature exposures may tend to engross the brain more and hence create a distraction from the pain, if they involve audio as well as visual stimulation, and are more realistic. (Vingerhoets, 2005) (Ulrich, 2008). A study by Roger Ulrich in 1984 on hospitals found that improved environments reduced treatment times by twenty-one percent and use of certain analgesics by fifty-nine percent. This study revolutionised modern health-care architecture studies. It corelated patient’s access to view of nature, and recovery time, and proved that window views could positively impact healing. Ulrich examined hospital records of patients who had

undergone gall bladder surgery in a suburban Pennsylvania hospital during 1972-81. He chose forty-six patients — thirty women and sixteen men — whose beds were near windows that overlooked either an orchard of trees, or a brick wall. Half the patients had views of nature and the other half did not (Sternberg, 2009). Among the health parameters that Ulrich recorded were, dosages and types of pain medication, and length of hospital stays. The studies revealed that patients who had orchard-view beds recovered one day sooner than those with the brick-wall outside their windows. Additionally, the patients with nature views did not require as strong pain-medication as did the ones without nature-views (Sternberg, 2009). Furthermore, through studies compiled by the ‘Centre for Health Design’, it has been found that a hospital environment connected to nature can reduce anxiety and pain, and can lower blood pressure and heart rate. Similar conclusive results were found when studying the impact of daylighting on patients: lower blood pressure, improved postoperative recovery, reduced need for pain medication and shorter hospital stays. (Ulrich, 1992). Studies in both simulated and real environments have consistently found that viewing nature produces significant physiological restoration within three to five minutes at most, as evidenced, for example, in brain electrical activity, blood pressure, heart activity, and muscle tension. (Ulrich, 1983) (Ulrich, 1991) (R. Parsons, 1998)

Figure 2-1Systolic blood pressure during recovery from stress in persons exposed to nature settings or urban settings lacking nature. (Ulrich, 2008) Figure 2-2 Muscle tension (forehead) during recovery from stress in persons exposed to nature settings or urban settings lacking nature. (Ulrich, 2008)

Rachel and Stephen Kaplan, known for their research on the effect of nature on people’s relationship and health, developed an environmental psychology model- Kaplan and Kaplan preference model (1989) on the basis of findings from studies on landscape evaluations. The four experimental factors considered by Kaplans were coherence, legibility, complexity, and mystery in user environments. These factors were chosen on basis of their engaging, stimulating, and creativity-inducing capabilities in people. It has since been concluded that, people, at home or work-spaces, outperform in environments that comply with the Kaplan and Kaplan model.

Present or Immediate (Two-dimensional plane)

Future or Promised (Three-dimensional world)

Understanding/ Making sense

Exploration/Involvement

1. Coherence (making sense)

3. Complexity (involvement)

(the event to which the scene seems to hang together)

(information richness of the scene, fractals)

2. Legibility (the promise of making sense)

4. Mystery (the promise of involvement)

(the predicted navigability of the scene upon further exploration)

(the promise of the scene offering additional info upon further exploration)

Table 1 Relationship between factors predicting environmental preference (Kaplan, 1989) (Cisek, 2010)

Studies consistently show that people prefer natural scenes over scenes of the builtenvironment. The Kaplans’ work on ‘restorative environments’ and ‘Attention Restoration Theory’ accentuate the restoration effect of nature. It is argued that there are two types of attention.

1) directed attention – finite, builds up mental fatigue 2) involuntary attention – likeliness to meditation According to Kaplans, nature is restorative because it reduces mental fatigue through its capacity to hold people’s involuntary attention. It is reasonable therefore, to conclude that healing environments benefit — both physically and psychologically — from the inclusion of nature (biophilia) and its representation in design.

Part 03: Approaches to the design of Healing Spaces Practice Approaches Evidence-Based Design: Kirk Hamilton, a pioneer of evidence-based design (EBD) in healthcare architecture, defines Evidence-Based design as follows; “..Evidence-based design is a process for the conscientious, explicit and judicious use of current best evidence from research and practice in making critical decisions..” (Hamilton, 2007). Much like ‘Healing Environments’, Evidence-Based practice in itself is not a new phenomenon. Architects, designers and builders have been using evidence in the form of data, codes, spatial programs and client/user requirements for as long as spaces have been built (D. Kirk Hamilton, 2009). What draws scrutinized attention to this strategy is a change in the culture of built environment, its curators and users. During the 1960s and 70s, architects started focussing on the impacts of built environments. (D. Kirk Hamilton, 2009). Studies such as those cited above (Part 2), become an insight and reference for practitioners to incorporate beneficial design elements. The economic benefits of EBD are often questioned, however, being a systematic approach, EBD potentially caters to the needs of users, clients, and developers and is therefore more efficient and sustainable.

Biophilic Design: Biophilia is the inborn inclination humans possess to gravitate towards nature, its systems, and processes. Biophilic design emphasizes the necessity of maintaining, enhancing and restoring the beneficial experience of nature in built environments. Although the term ‘Biophilic design’ was coined fairly recently, it was the way buildings were designed for much of human history, dating back to the perhaps mythical ‘Hanging Gardens of Babylon’. The human brain responds functionally to sensory patterns and cues emanating from the natural environment. Numerous studies have concluded that people living in proximity to open spaces report fewer health and social problems, and this has been identified regardless of rural and urban residence, level of education and income. Even the presence of limited amounts of vegetation such as grass and a few trees has been correlated with enhanced coping and adaptive behaviour.

Biophilic design isn’t about greening of buildings or simply increasing their aesthetic appeal through insertion of trees and shrubs. It’s about inter-relation, dependence, inclusivity, and place of nature and human society within each other’s realms (Kellert, 2005) (Kellert, 2008) As proven, biophilia has positive impacts on humans, and this feature can be positively exploited to reduce stress, improvement of well-being, alleviating and distracting from pain in patients. Although the elements of biophilic design are many, some of the features, forms, patterns and processes of the theory are summarized in table 2.

Environmental features

Natural Shapes and forms

Colour Water Air

Faรงade greening Geology and landscape

Botanical Motifs Tree and columnar supports Animal (mainly vertebrate) motifs Shells and spirals Egg, oval and tubular forms Arches, vaults, domes Shapes resisting straight lines and right angles Simulation of natural features Biomorphy Geomorphology

Habitats and ecosystems Fire

Geomorphology Biomimicry

Sunlight Plants Animals Natural materials Views

Natural pattern and processes Sensory variability Information richness Age, change and patina of time Growth and efflorescence Central focal point Patterned wholes Bounded spaces Transitional spaces Linked series and chains Integration of parts to wholes Complementary contrasts Dynamic balance and tensions Fractals Hierarchically organized ratios and scales

Table 2: Elements and Attributes of Biophilic design (Kellert, 2008)

Conclusion: An optimal design amalgamation of evidence-based and biophilic concepts in health-care design seem almost unavoidable in any efficient healing space as they cater to elementary physical and psychological human needs.

Design Approach through Evidence-Based Biophilia Colour: Colours produced by light are a kind of energy. This energy affects the functions of our body, as well as our psychology, and emotions. Colours have long been known to have physiological and psychological effects on people. They influence anxiety, pulse, blood flow and arousal, and affect bodily functions, and emotions with the energy produced by light. Studies have demonstrated the benefits of colours where the development of brain in regions of creativity, productivity and learning are concerned.

European doctor Ponza conducted various experiments in 1875 by using coloured glass, walls and furniture in various rooms. The colours Ponza used were red and blue. A man refusing to eat for days started desiring food. An aggressive patient put in a blue room calmed down in a period of one hour. In 1942 Goldstein conducted studies on patients and observed the colours can have positive and negative effects. One of the most important studies is related to Parkinson patients. While the colour red caused a deterioration in the pathological problem observed in Parkinson patients, green led to improvements. Brain-damage patients also reacted negatively to the colour red. In 1974 K.W. Jacobs and F.E. Hustmyer proved certain colours to be more stimulating than others. He showed through experimental studies, that red can be more stimulating than green, which, in turn is relatively more stimulating than blue and yellow (Boya, 2017).

Across cultures and even individuals, colours are perceived differently and uniquely. As people have varied preferences and associations, we need to distinguish between individual and what are cultural responses.

Table 3 demonstrates some universal effects of colours Colour Physiological Effects Red Speeds the Metabolism Blue Slows down metabolism Yellow Stimulates thyroid gland Table 3: Colours and their physiological effects

Colour Green Pale Pink

Application Helps activate autistic children Helps calm hyperactive children

Psychological Effects Application Universal colour for calmness and peace Supportive of Physical and Mental activity Appropriate for kindergarten and child environments; Known to have calming effects on inmates Warmth, energy Enthusiasm

Yellow Orange Table 4: Colours and their psychological effects

It must be understood that the psychological effects of colours aren’t rigid and are subject to individual perspective. For example, while green has shown to induce calmness, it is also symbolising of envy in some cultures; and while the psychological effects of red include excitement, it commonly symbolises danger.

Some of the most reliable experiments available on the effect of colour on attitude and behaviour have been done by NASA. Their aims could be advantageously transferred straight to any hospital or home where people are copped up for a long time in one place and are still expected to co-operate and behave well. This is one such example: The investigation and use of colour in space system design is necessary in helping to provide visual stimulation, volume enhancement and in creating moods to relieve the monotony of prolonged confinement. Colour schemes are planned in relation to room volume and function, the purpose of the mission and desired behavioural aspects.

Following is the conclusion of NASA’s work- ‘The association of colours with definite mental conditions and moods is general. No absolute relationships have been established and the subject is open to individual interpretation… The problem of individual difference in habituality concerns the colour of living areas. Personal preference depends on such factors such as the individual’s familiarity with certain colours and colour combinations and the emotive connotations they may have for him/her.’ (Barbara K. WIse, 1988)

Daylighting: The sparkle and quiver of a candlelight, despite the inadequacy in its brightness, has a life that mechanical lights cannot possibly achieve. So also does a daylit room, with its windows creating an interplay of lights, hues, and shadows from numerous sky directions. (Day, 2004) Mono-directional light, even if natural, isn’t as ambient as multi-directional. Natural light feels ‘alive’. Indeed, it is invigorating in a biological sense — growth and other hormones that are controlled by human body glands are stimulated by light, specifically, gentle rhythmical living light (daylight) with its many moods, colours, and forms endlessly changing throughout the day. Contrastingly, artificial light is monotonous, too direct and bright, and causes visual fatigue and headaches. Research also indicates that natural light enhances healing by increasing protein metabolism, decreasing fatigue, stimulating white blood cell production, increasing the release of endorphins, decreasing blood pressure, and generally promoting emotional well-being. (Ott, 1985) (Alibaba, 2014). Sunlight is also responsible for stimulating circadian rhythms- a natural physiological process that dictates physical, mental and behavioural cycles in the human body.

Landscape- Healing gardens: “Small pleasures must correct great tragedies, Therefore of gardens in the midst of war, I bloody tell.”

(Sackville-West, 1946) Landscape, is the view from one standpoint, whether stationary or moving. It may not necessarily have mountains, waterfalls and canyons, but it must hold the subconscious distraction of a person and have a horizon to qualify; otherwise it is a mere ‘outlook’ (Haggard, 1999). In context of ‘hospital landscape’, the presence of adjacent buildings, sometimes towering, and miscellaneous urban characters is almost inevitable. During the 1800s, the Victorian ‘lunatic asylum’ were what the locals called ‘Funny Farm’ with its abundance of ‘landscape features’ and outdoor spaces including tennis courts, shrubberies, lakes and ‘fine prospects’. In a survey done of one psychiatric hospital’s grounds, the variety of trees and shrubs, the walks and tennis courts, and all the equipment were superb as recently as 1990.

In a survey undertaken by ‘English Nature Science’ on people’s reaction to landscape, it appears that children favour natural scenes but the preference fades during development.

Women have a slightly higher appreciation of plant life, and men appreciate spaces of scale.

Water seems to be a favourable feature to all, while there are some apparent differences of preference due to culture and background.

A surprising finding was that natural features in urban areas were not heavily used by people, perhaps out of habit or lack thereof, even by those who identified them as ‘favourable’. It may be that just the sight of an open habitat or wildlife is a comfort, or even passing it and knowing it is there. It reinforces the importance for a hospital to use its land for the pleasure, and recovery, of even those who see it only through ward windows.” (Haggard, 1999)

Noise: While designing for healing spaces, an understanding of the difference between ‘noise’ and ‘sound’ is necessary. Sounds such as distant chirping of birds, flowing of water, and rustling of leaves in the wind are a welcome distraction and are referred to as ‘live’ sounds. Spaces designed for extreme silence portray a ‘dead space’ feeling. Moreover, in a health-care facility, silent spaces may have adverse effects, as they tend to accentuate the beeps and sounds of machinery, which in turn may induce irritation and anxiety in patients, family, and staff. Intermittent noises such as trains, are less of a shock if you see and hear them approaching. Noises from living sources like school playgrounds can be less irritating if you can see what’s going on. The sounds that need to be abated are lower levels sounds/noise like background fan noise that interfere with sleep, digestion and thought. When these becomes ever-present, we soon stop noticing ambient low-level noise, which may become an insidious stress builder. There are well-established technique for noise abating design through use of vegetation as obstruction to noise, zoning of areas based on noise sensitivity (ICU vs the general war) etc.

Role of SPA (Salus per Aquam) therapy – Health from Water: Water is considered the elixir source of life. It covers more than 70% of the Earth’s surface, and makes up 70% of our bodies. Water has been proven to be the antidote of anxiety, with its calming effects, a useful trait to calm overwhelmed patients and family. Contact with water also helps counter a dull mind by engrossing it in indirect attention. ‘SPA’ therapies are a common feature of the hospitality industry where people choose to relax in close vicinity to water bodies and features such as resorts, beaches, lakes, pools, waterfalls or simply listening to soothing sounds of a fountain. Having more design options for water features inspires architects and designers to incorporate nature and water through direct involvement in builtspaces. ‘Aquatecture’ , a new approach to design, uses water to create actual structure of the spaces (Wylson, 2013). The walls in waiting areas and common spaces can be made of technology-controlled flowing water. This type of architecture fuses the need for psychological interaction with water and architecture. (Clouse, 2016)

Facilitating socio-petal behaviour through design Socio-petal spaces are spaces that are designed to bring people together. While social inclusivity in design is necessary to promote communication and interactivity among users, we also require a proportionate amount of socio-fugal spaces, that accommodate individual’s desire for privacy too (such as private sections of a garden / secret gardens, etc. discussed).

Creating socio-petal architecture is a means of promoting indirect group therapy through facilitation of interactions between different patients and family. Creation of such spaces is not highly complex and only requires an understanding of the kind of space and features that make a space desirable for lounging/lingering. It can be achieved through a well-designed waiting space, a cafeteria, a garden or even corridors.

For instance, widenings in a corridor with a window seat, induce casual social meetings; others like lifts stifle such interplay. Similarly, some shapes, like round tables, bring people into community, and others, like uninterrupted corridors or long rooms don’t. A narrow, low, not quite straight, invitingly textured and lit passage for unhurried uses, like those of a monastery cloister, can be a real delight.

Conclusion: Following qualitative strategies can be adapted while designing healing environments based on research evidence studied above.

1. Coloured flowers for colour inspired moods / colour planting / Coloured elements in the space rather than large areas of coloured paints. Don’t force colours, rather create natural subtle experiences of them.

2. Include traditional and cultural medical plants, indigenous plants, ‘private’/’secret’ gardens for secluded time.

3. Create ‘living architecture’ with natural subtle sounds instead of extremely sound proof-ed ‘Dead Architecture’.

4. Water features with depths such as ponds may pose a risk of drowning. Alternative installations may be considered such as water-walls with water running vertically down a solid surfaced in cycles. One water feature used more commonly is fish tanks. They allow for very contained environment, easily placeable and capture the curiosity of onlookers, especially children. The motion of water and the soothing colours of fish and vegetation inside the tank are highly engaging Future research may be oriented towards establishing and quantifying evidence-based characteristics that influence behavioural patterns and physiological as well as psychological well-being of the health-care facility users. Design implementation strategies may be explored and suggested.

Saba Fatima, M.Arch Environmental Design, Jawaharlal Nehru Architecture & Fine Arts University, India

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Saba Fatima, M.Arch Environmental Design, Jawaharlal Nehru Architecture & Fine Arts University, India