How can biophilic hospital design aid mental health and patient recovery?

Biophilic Hospital Design - Forest Homes
Hospitals and medical centres are often regarded as negative spaces, due to their industrial and sterile designs and the associations we may have with them. But did you know that science has shown that biophilic hospital design and medical architecture can reduce stress and promote positive effects on health and wellbeing? Keep reading to understand more about biophilic hospital design, its benefits, why it matters; and examples to aid your future application of biophilic hospital design.

Biophilic design refers to the practice of increasing connectivity between people and the natural environment through mindful design of interior spaces. This philosophy can be incorporated into living spaces, working spaces, and even healing or medical spaces. The practice of biophilic design and architecture involves more than bringing plants into the equation.

What you'll encounter in this read:

1. What is Biophilic Hospital Design?
2. What are the benefits of Biophilic Hospital Design?
3. Why should we apply Biophilic Hospital Design?
4. How to apply Biophilic Hospital Design? Case Study: Östra Hospital Psychiatric Facility, Sweden

What is Biophilic Hospital Design?

Biophilic design and architecture can be applied to many different manmade ecosystems, including living spaces, working spaces, and medical spaces. 

Hospitals can often go against the needs of their visitors: lighting from above (sometimes even neon lights), indoor spaces with no outside view and scarce seating, often placed along the walls and increasing the levels of mental and physical stress of patients (Jencks and Heathcote 2010).

However, biophilic design is much more complex than a window overlooking nature or the presence of plants in the waiting halls or inside the hospital rooms. In the report, 14 Patterns of Biophilic Design (Browning et al. 2014) we can find a broad view of biophilic design tools and applications as well as opportunities to increase the health and well-being of individuals for the different care levels (stress reduction, cognitive performance and emotion and mood enhancement).

In particular, when it comes to biophilic hospital design, it is possible to convey or promote different types of experiences within hospital spaces. According to Browning et al. the 14 biophilic design patterns can be organized into three categories to illustrate the enhancement of user experience and its biological responses, and potential impacts in different care levels: nature in the space, natural analogues and nature of the space. See this article about the three main principles of Biophilic Design. This classification of the nature-design relationship by Browning et al. applied to hospital design provides a useful framework to understand how to best systematically integrate the individual’s experience into the design process and the benefits that derive from it.

 

Biohilic Hospital Design - Forest Homes

What are the benefits of Biophilic Hospital Design?

The positive effects on the health and performance of human beings in response to biophilic design of the built environment have been verified by extensive scientific studies in different settings: healthcare facilities, workplaces, children’s spaces, community spaces, etc. The reflection on the principles of biophilic design is particularly interesting when it is applied to healthcare facilities.

This is not only due to the high rate of critical and stress factors in hospitals for patients, their families as well as healthcare professionals, but also because the hospital and the city are two separate but interconnected systems, which are visited and used by the same individuals. This relationship is characterised by a certain exceptionality that is precisely due to the isolation of the hospital structure, which is essential to enable the medical practice.

Design has only recently started to adopt the patients’ point of view, considering not only their physical, but also their social and psychological needs; this has prompted interventions aimed at enhancing the physical, sensory and psychological comfort, improving wayfinding systems and increasing the clarity of the meanings communicated by space design.

Offers therapeutic support, improves ability to recover and patient wellbeing.

Modifying hospitals’ design by humanising spaces and especially through reconnecting with nature offers a therapeutic support that can positively impact on the patients’ psychological and physical well-being; it can also improve their ability to recover, with varying results depending on the different levels of treatment (diagnosis, therapy, recovery) and on the disease in question.

Improves staff's wellbeing, productivity, and therefore improves organisation's efficiency levels.

At the same time, space design can improve the efficiency levels of an organisation and contribute to economic benefits, both because the staff’s well-being increases, and because it reduces health-related costs. Rooms with plants (especially roses), natural ventilation and light, the sight of, and contact with, nature increase the staff’s productivity and organisational capability. These biophilic design choices also boost the activity of the parasympathetic nervous system, thereby decreasing stress levels and encouraging a general sense of well-being. By promoting staff’s health, biophilic design helps to reduce sick leave, while improving satisfaction and attention levels (Browning et al. 2012; Heerwagen 2000; Raanaas et al. 2011; Ikei et al. 2014; Nieuwenhuis et al. 2014).

Better management of emotions, fears and anxieties related to disease.

Moreover, extensive research that is supported by rigourous empirical data has shown that the beneficial effects of biophilic design are not only found through architectural solutions that encourage direct contact with the external natural environment, but are also obtainable by inserting green or elements of biophilic design within the interior spaces. Such interventions, especially if integrated, allow patients to better manage their emotions, fears and anxieties related to disease. Positive effects have also been verified from the physical standpoint.

Shorter post-operation hospitalisation, lower use of analgesics.

One of the earliest studies on the subject was conducted by Ulrich in the 1980s. From an analysis of the medical records of some surgical patients in a Pennsylvania hospital between 1972 and 1981, Ulrich noted that those who could see from their window a natural landscape had significant beneficial effects. In particular, patients with a room overlooking a green area had a shorter post-operation hospitalisation and lower use of analgesics compared to patients who were in similar rooms, but overlooking a built environment. According to Ulrich’s research, looking at greenery and nature reduces hospitalisation time by 8% (Ulrich 1984).

 

Biohilic Hospital Design - Forest Homes

Lower levels of stress, increased coping abilities.

Subsequent international studies have confirmed that 95% of patients and families exposed to direct contact with nature reported lowered stress levels, more positive thoughts and increased coping ability (Marcus and Barnes 1995). In addition, plants in rooms and rooftop gardens in hospitals improve patients’ psychological response to treatment, with lower levels of pain, anxiety and fatigue (Park and Mattson 2008; Matsunaga et al. 2011). Fractal structures and, more generally, natural patterns and shapes instigate a reduction of stress levels due to the stimulation of μ-opioid receptors, which are responsible for pleasure (Biederman and Vessel 2006).

Less perception of pain.

Natural light affects serotonin levels, inducing a lessened perception of pain in patients. A 22% reduction in the use of analgesics and a 21% drop in healthcare costs was observed. Moreover, natural light has positive effects on patients undergoing chemotherapy (Walch et al. 2005; Liu et al. 2005).

Positive effects on comfort, creativity and immune system.

Several studies have also demonstrated that the use of natural materials improves the patients’ perception of environmental quality and their recovery from illness. This is because natural materials enhance visual comfort (as they absorb more light than they reflect), and have positive effects on olfactory comfort (for instance through essential wood oils), creativity, overall health and the immune system (Tsunetsugu et al. 2013; Li 2010; McCoy and Evans 2002).

So can biophilic hospital design aid patient recovery? In short, yes. Numerous case studies and behavioral experiments have shown that medical centres which embrace biophilic or nature design see a positive change in the mood, productivity, and recovery of both staff and in-patients.

Why should we apply Biophilic Hospital Design?

Stress factors for patients in therapeutic environments are generally related to the inability to control the surroundings, especially in terms of physical and organisational spaces and timings of the place of care. Other stress factors include the lack of privacy, the presence of unfamiliar and often disturbing or potentially anxiogenic sounds and noises, artificial lighting with a low comfort level, and intense environmental smells, which are often familiar due to the association in the lives of most people with the experience of illness.

As our modern world advances, we have been seeing a returned embrace of the natural environment. The positive mental, emotional, and physical effects of adding nature to your spaces isn't limited to the home and the office. Medical architecture is also starting to return to our roots, so to speak, adding windows to let in natural daylight and views of outdoor courtyards, building with natural materials like wood, bamboo and stone, and taking a page from the ecosystems in which we used to dwell in private and public spaces.

 

Background on Hospital Design

Extract from SpringerOpen

The shape of the contemporary hospital has evolved from its initial division into pavilions that almost created a city within the city, to the present-day single-block buildings. This form and organisation have been encouraged and homogenised in Europe since the 1930s with totalitarianism; one may think of the architecture of healthcare facilities during Fascism, in particular tuberculosis sanatoriums to deal with typical poverty-related diseases. These developments have led to the gradual standardisation of healthcare practices for citizens as an affirmation of a democratic principle that was gradually strengthened in Europe since the 1950s, with the introduction of welfare policies. At the same time, the hospital’s architectural design has undergone major changes since the second half of the 20th century. These are certainly linked to the role the hospital has in contemporary society, but also to the recovery of values that are no longer just quantitative and functional, contrary to what happened until the first half of the 20th century. These “new values” translate into a “humanised” vision of spaces that, together with the latest technological discoveries and new treatment and care protocols, influence design choices in contemporary hospitals.

In other words, the change in direction happens with the transition from functions to experience, such that the city and the hospital tend to become increasingly similar, not so much for the hospital structure approaching the urban forms but for the inverse process. Architecture and the city enter the hospital redefining the dimension of the hospital through a progressive introduction, in addition to the diagnostic and therapeutic functions, of commercial, informational and recreational features that have redefined the sense of space and the role of the institution in its territory.

One of the first examples of this trend was the Harlem Hospital Pavilion project in New York with the creation, promoted in 1936 by the Works Progress Administration, of murals that depicted the history of working and leisure activities of the African-American population (the African diaspora from 18th-century African village life to slavery in America to 20th-century freedom). The hospital, in fact, plays a catalyst role within the urban environment, strives to reflect the common culture and tries to recuperate it and make it compatible with its identity. It therefore reflects the characteristics of the space and time in which it is located.

What clearly emerges in the historical and social evolution of hospital design and its relationship with the urban space and the people living in it and passing through it is that the hospital is a privileged place of research to highlight not only the advancement of scientific and medical knowledge (and how these affect quality of life indicators), but also the change in the relationship between humans, the built environment and nature.

However, this is a slow and inconsistent process often determined more by far-sighted physicians and the management of individual hospitals, than by a shared and repeatable approach to space design. This scenario reflects the ever-increasing polarisation between large hospitals with highly qualified staff and specialised equipment, where, at the same time, it is often possible to obtain a comfortable environment for the well-being of patients; and small local hospitals that have limited operating and diagnostic capabilities and are only peripheral nodes in the public healthcare network.

As a matter of fact, in most cases, the design of modern hospitals is still geared towards defining spaces in which the only design goal is the precise definition of environments that ensure the proper operation of clinical and surgical procedures, and only in the best-case scenarios, efficient organisational and administrative functions. Hospital architecture often still reflects medical and healthcare practices from the past: these technically and scientifically complex environments are characterised by information asymmetry, which at the same time expresses and defines the relationship between doctors and patients; this asymmetry emerges from a system of temporal and spatial rules that often sees users confused and disoriented, in a state of psychological inferiority to healthcare staff and the care environment in general. At the same time, hospitals are a crucial element of the public healthcare system, both from an economic and organisational standpoint, and from a symbolic point of view, as recognisable institutions in the community.

Biophilic Hospital Design - Forest Homes

In fact, since the days of Cà Granda di Filarete in Milan or of Brunelleschi’s Ospedale degli Innocenti in Florence, the hospital is not only an expression of the culture and sensitivity of designers, but also expresses a symbolic value attributed to it by the community that it is home to, which defines it as a monument, with a precise identity within the urban fabric. This symbolic value coincides with the functional and physical value given by the form, the materials and the internal order. After all, since as early as the Middle Ages, the life of the city itself has been revolving around the hospital in a mixture of religious, civil, ethical, political, economic and financial interests (Bevilacqua 2017).

The hospital remains a place that is not easily permeable to external culture, and despite the interventions of humanisation of spaces aimed at a broader hospitality and the process of interpenetration with the city, it is still a separate world in which the patient fails to fully perceive the organisational rules. At the same time, it is true that the interventions of humanisation have introduced the value of beauty and the recovery of the relationship between humans and nature in the architecture of the hospital, alongside the more economical and social factors. A beauty understood not as an end, from a Kantian perspective, but as an ethical way to allow the individual, as a temporary guest of the hospital, to accept the set of space-time rules that regulate it and be in an emotional condition that facilitates recovery and care (Tartaglia 2009).

A place perceived as dialogic, welcoming, understandable, aesthetically attractive and relaxing promotes the development of a greater sense of trust and activates a positive feedback to the information and the stimulations coming from outside. Stress factors for patients in therapeutic environments are generally related to the inability to control the surroundings, especially in terms of physical and organisational spaces and timings of the place of care. Other stress factors include the lack of privacy, the presence of unfamiliar and often disturbing or potentially anxiogenic sounds and noises, artificial lighting with a low comfort level, and intense environmental smells, which are often familiar due to the association in the lives of most people with the experience of illness.

Design has only recently started to adopt the patients’ point of view, considering not only their physical, but also their social and psychological needs; this has prompted interventions aimed at enhancing the physical, sensory and psychological comfort, improving wayfinding systems and increasing the clarity of the meanings communicated by space design.

How to apply Biophilic Hospital Design? Case Study: Östra Hospital Psychiatric Facility, Sweden

Östra Hospital Psychiatric Facility

Full-length windows to communal courtyards let in natural light and promote natural rhythms.

To dive deeper into this theory, and understand its application, let's look at a case study. Thanks to biophilic architecture, a psychiatric hospital in Sweden named Östra Hospital Psychiatric Facility has shown that introducing natural elements to medical spaces reduces stress and aggression and increases relaxation, focus, and recovery. By mimicking natural landscapes, White Architecture has created an ideal treatment space, showing positive effects on both patients and staff alike. 

These are 3 key aspects associated with this biophilic hospital design, and how they can be implemented in the healing environment.

  1. Complexity & Order - Spatial Atmosphere
  2. Indoor & Outdoor Spaces
  3. Natural Light Promotes Natural Rhythms

1. Complexity & Order - Spatial Atmosphere

A sense of personal space and the autonomy to set boundaries is crucial to mental health and safety - especially at an in-patient treatment facility. There are three main types of spaces garnered in the Östra Psychiatric Hospital, based on environmental design. Each atmosphere mimics a natural setting, whether it be reminiscent of a cozy cave dwelling or an open savannah ripe for communication and trade.

Private Spaces

Private spaces are enclosed spaces where the individual can be alone, reflect and work as the individual sees fit. They provide a chance to recuperate from the outside world, rest easy and foster independence. Think of your bedroom, or a child's cubby, in which you feel most safe and secure.

Semi-Private Spaces

Think of your shared living spaces at home, whether it be your living room or kitchen. These spaces provide safety and familiarity while allowing for intimate socialization and creativity.

Semi-Public Spaces

Semi-public spaces are larger areas in which an individual can incorporate with their "tribe" or community, cultivating a sense of belonging and purpose. These may be more open spaces, and could be similar to a grassy plain, which foster socialization and collaboration within a community.

2. Indoor & Outdoor Spaces

Within each kind of space, a key component to fostering happiness and wellbeing, while simultaneously reducing tension, stress, and aggression is creating a visual connection with nature, both indoors and outdoors.

Views of nature

Every room in the Östra Psychiatric Hospital has at least one window with views of nature in the outside world. This is a key architectural feature as it allows for a sense of connection with the outdoors, even when one is in a more enclosed space.

 

Outdoor space Ostar

Views of green space are available in every room of the hospital.

Bringing nature indoors

Bringing elements of nature to the interior space is just as essential as views of outdoors. Whether it be a natural plant or moss wall, the use of natural building and furniture materials like wood or bamboo, or creating rooms which mimic natural landscapes, biophilic design provides a sense of tranquility and calm. These biophilic design elements increase attention and focus, and promote an overall sense of wellbeing and happiness.

3. Natural Lighting Promotes Natural Rhythms

Access "varying intensities of light and shadow that change over time to create conditions that occur in nature" are huge mind, body, and mood enhancers, Terrapin Bright Green. Exposure to natural light throughout the day from windows, skylights, and light features all contribute to great wellbeing and promote natural circadian rhythms, the regulation of sleep-wake cycles in all humans. 

As shown in the case study of White Architecture's design of Östra Psychiatric Hospital, it is important to incorporate private, semi-private, and semi-public spaces to promote feelings of safety and reduce stress. Windows with a view of and access to an outdoor natural space as well as biophilic interior design is critical to patient and staff wellbeing. Finally, a space must have dynamic and diffuse light to align circadian rhythms.

Final thoughts

The global health challenges of the 21st century require a new way of thinking and a change in the organisation of healthcare services through an approach that considers human needs in their entirety, and not in a strictly therapeutic sense. According to several studies, the humanisation of healthcare spaces and contact with nature can empower the patient and have a positive impact by reducing stress and pain and improving emotional wellbeing. However, further studies are required not just in order to deepen our understanding of the human-nature relationship and its impact on health, but also to change our approach regarding patients’ health by considering a new vision of medicine, healthcare and healing environment.

 

*Credit to Terrapin Bright Green for the Ostra Psychiatric Hospital case study and to White Architecture for designing such a unique healing space.


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