Healing by Design: The Effects of Biophilic Design on Physical and Mental Healing
Mindy Tindall
March 20, 2019
“In the fusion of place and soul, the soul is as much of a container of place as place is a container of soul. Both are susceptible to the same forces of destruction.”
– Robert Pogue Harrison
RESEARCH QUESTION
By engaging the sensory and perceptive experiences of biophilic architectural design, can healthcare facilities enhance physical and mental healing?
INTRODUCTION
Robert Pogue Harrison’s quotation captures the essence of this research study on healing as it acknowledges the relationship between architecture and the human psyche and the vulnerability of both. For many, there are few pleasant sensorial experiences to be found when visiting hospitals or living in long-term care facilities. Healthcare facilities often conjure images of fluorescent lighting, annoying mechanical noises, dull pastel walls, and undesirable smells. Patients are often found in stretchers lining hallways or tucked away in storage closets due to a lack of available rooms or beds. Crowding and repugnant sensorial experiences can lead to increased feelings of anxiety and stress (Gifford, 2014). Prolonged or chronic exposure to the harsh sterile environments of such existing healthcare facilities can have negative impacts on cognition and mental and physical health (Gifford, 2014). This research project will elaborate on existing global research, supported by international precedent studies, and determine if biophilic design changes to healthcare environments can enhance the experience of healing.
An analysis of philosophical research surrounding phenomenology and neuroscientific research on the effects of architecture on the human brain (neuroarchitecture) suggests that architecture composed of natural design elements provides experiential qualities which aid in mental and physical healing (Dilani, 2019). This concept is called biophilic design; a design methodology used to increase connectivity between humans and nature (Slowakiewicz, 2018). It is an extension of biophilia; the inherent human need to affiliate with nature (Skyline Art, 2019). Biophilic design consists of six main principles: environmental features, natural shapes and forms, natural patterns and processes, light and space, place-based relationships, and evolutionary human-nature relationships (Skyline Art, 2019). This research proposal will investigate whether the engagement of the sensorial and perceptive experiences in healthcare facilities can improve patient healing.
The study of architecture and its relationship with humanity is complex and multidisciplinary. To examine and measure which factors initiate healing, the factors which cause illness or injury must be considered. Within the context of this research project, biophilic design, neuroarchitecture, and phenomenology relate to a broader medical term that focuses on health and well-being – salutogenesis (Lindström & Eriksson, 2005). Salutogenesis is an area of study coined by medical sociologist Aaron Antonovsky which focuses on factors that support human fitness rather than factors that cause disease – pathogenesis (Dilani, 2019 & Butler, 2019). As one of the global leaders on interdisciplinary research of the interactions between design and health, Dr. Alan Dilani states that there is a gap between salutogenic design theory and practical applications such as environmental factors, which requires the deployment of a multifaceted approach between psychology, sociology, neuroscience, architecture and design, and public health (Dilani, 2019). Dilani defines the goal of salutogenic healthcare facilities as delivering medical services in a supportive, efficient, and enjoyable environment for staff and patients, adding that proactive measures can identify disease risk factors in their early stages and ultimately reduce medical treatment costs and improve societal health (Dilani, 2019). Promoting wellness factors in healthcare facilities may lead to a decrease in medical interventions and alter patients’ perception of medical facilities and notions of unnecessary risk (Butler, 2019). To consider counterintuitive or harmful drawbacks, this research study will also explore downfalls of biophilic design such as cost, maintenance, allergies to vegetation, cultural norms, and biophobia (an aversion to nature) (Bent, 2016).
CONTEXT
Both illness and wellness factors must be considered to analyze healthcare facility design. According to the World Health Organization, air pollution, climate change, non-communicable diseases (such as heart disease and mental health disorders), and fragile and vulnerable settings are in the top 10 global threats to public health (Muscat, 2019). The time spent in North American healthcare facilities and the number of people using them has been increasing exponentially (Muscat, 2019). On average, North Americans spend approximately 90% of their lives inside buildings (United States Environmental Protection Agency, 2018). Worldwide rises in urbanization and aging populations have led to healthcare facilities exceeding capacity with increased hospitalizations and healthcare requirements (Canadian Institute for Health Information, 2019). Advanced age makes patients more susceptible to delirium, deconditioning, increased medical complications, hospital-acquired infections, and they are often unable to return home – resulting in further demands on healthcare systems (Canadian Institute for Health Information, 2019).
Biophilic design has received increasing attention in architecture and health disciplines, but research quantifying physiological and cognitive benefits of biophilic features in healthcare spaces is scarce. This is likely partially due to the topic’s subjectivity, as definitions of healthcare facilities and measurements of healing vary globally among people, and are difficult to capture. Cultural and generational norms and personal preferences or convenience often dictate where people heal after diagnosis of an injury or disorder (Gifford, 2014). Single and multigenerational homes, long-term care facilities, urgent care clinics, temporary treatment clinics, therapy offices, and shelters may provide healthcare services and accommodations for various types of healing. To successfully integrate and reap benefits from biophilic design in healthcare facilities, global health risk factors must be studied and understood to avoid the cyclical problem of treating people and returning them to the same conditions that made them sick (Borisch, 2019).
THEORETICAL BASIS
The concept of designing with nature for positive human experience and health is not new. Though the term was coined recently, elements of biophilic design in architecture were first observed in ancient Greek architecture (Mallgrave & Goodman, 2011). Using phenomenology as a philosophy and neuroarchitecture and biophilic design as methodologies which study the human experience and consciousness within the context of architecture (Mallgrave & Goodman, 2011), how do these theories elucidate how humans encounter the built environment and how do these environments impact healthcare settings and patient healing within Canada’s healthcare facilities? These ideas can be shown through connections between phenomenology, neuroarchitecture, and biophilic design principles. This research project will investigate which roles phenomenology and neuroarchitecture play in biophilic design and how these concepts influence physical and mental healing in global healthcare facilities.
This research project is based upon theories put forth by several architects and other relevant figures in the development of architectural design. Architect Albert de Pineda states that a schedule of environmental and human accommodation drives the development of healthcare facility design, suggesting that four categories constitute healthy healthcare architecture: energy (environmental sustainability initiatives and technology), ecology (landscape and context), experience (flexibility, perception, and adaptation of architecture), and empathy (human scale and physical and emotional support) (de Pineda, 2019). Dr. Alan Dilani elaborates on these ideas and suggests that characteristic conditions of coherence that determine a person’s ability to cope include the comprehensibility, manageability, and meaningfulness in the built environment (Dilani, 2019). In the context of this research study, comprehensibility suggests that the world is understandable through wayfinding signage, colors, nature, perception, and landmarks (Dilani, 2019). Environmental manageability stems from resources designed to meet situations such as natural lighting, architectural restoration, interior design, and ergonomic furniture (Dilani, 2019). Dilani suggests that humans assign meaning to their environments through music, art, physical activity, social support, physical and emotional comfort, and aesthetically pleasing views (Dilani, 2019).
Spatial typologies such as perceptual, cognitive, pragmatic, abstract, existential, and architectural gave rise to various architectural theories and applications. Theorist and architect Christian Norberg-Schulz explored the relationship between architectural and existential space, theorizing that architectural space solidifies existential space, creating a concrete visual metaphor of human life to assist with personal, cultural, and societal identification (Mallgrave & Goodman, 2011). This idea suggests the importance and universality of healthcare spaces is integral to identity. In the early 1970s, architect Ken Yeang pioneered ecology-based architecture, utilizing daylighting, natural views, and vegetation to mitigate the negative effects of architectural design (Living Architecture Monitor, 2018). The work of Swiss architects Jacques Herzog and Pierre de Meuron was groundbreaking in their awareness of materiality and sensory impact. They create illusions and allusions through material manipulation, such as suggesting height and signifi with an arrangement of panels increasing in width as they progress vertically towards the top of a building (Harvard GSD, 2011). Architect Jean Nouvel employs reflection and illusion with materials and lighting to create images of transparency and the relationships between space and material (Mallgrave & Goodman, 2011). Such visual effects can be utilized in biophilic design to alter or improve vital functional requirements of the environment to a more visually pleasing and sensorial aesthetic. Applications of these ideas in biophilic design can ease patients’ negative feelings and increase environmental legibility to ease stress.
Phenomenology as it applies to architecture has philosophical roots. The work of philosopher Jacques Derrida was particularly influential. Derrida suggested a strategy of deconstructing text to expose unintentional meanings and hierarchy as fragments of a concept’s whole through analysis of human psychology (behavior, motivation, and fulfillment), symbolism (visual and metaphorical), and pragmatism (practical and meaningful use) (Oliver, 2017). This idea was later applied in architecture by architects such as Bernard Tschumi, Rem Koolhaas, and Peter Eisenman to understand and perceive architecture through logical reasoning and sensory experience (Mallgrave & Contandriopoulous, 2008). One of the most prominent leaders in the field of architectural phenomenology is Juhani Pallasmaa, who believes that architectural perception is multisensorial to the eye, ear, nose, skin, tongue, skeleton, and muscle (Pallasmaa, 1994). Pallasmaa’s writings later in his career expressed his idea that building construction and placemaking are cultural rituals that shape connections within and to the world (Pallasmaa, 1994). He realized that we measure architectural experience in subconscious ways, that visual perception cannot be segregated from tactile feelings, and that our emotions and feelings impose positive and negative values on perception – perception is not a form of thinking but thought itself (Pallasmaa, 1994). These ideas highlight the complex interrelationship between the human psyche and the built environment and the challenges in studying them. In this research study, I will focus on Juhani Pallasmaa’s theory surrounding the emotional and visceral experience of architecture (touch, scent, sound, and feeling) and how humans interpret these elements within architecture as an anthropomorphic relationship for bodily identification and self-regulation in healthcare environments and through healing processes (Pallasmaa, 1994).
“Neuroarchitecture” is a relatively new term. It was devised to create an empirical methodology to study the intersecting fields of architecture, psychology, and neuroscience to optimize and study the experience of architecture through human consciousness (Fairley, 2018). Neurophenomenology and neuroarchitecture became more prevalent in the 1990s when brain scanning technologies became available (Mallgrave & Goodman, 2011). The field of neuroarchitecture gained traction in 2014 when John O’Keefe, May-Britt Moser, and Edvard I. Moser won the Nobel Prize for their discovery of brain cells that constitute a positioning system within the brain that makes it possible to orient ourselves in space, illustrating a cellular origin for higher cognitive function (Fairley, 2018 & The Nobel Prize Foundation, 2014). With advances in technology, researchers can monitor the heart rate, blood pressure, cortisol (stress) levels, and brain activity to better understand the human reaction and response to architecture in-situ and in virtual or augmented reality settings (Fairley, 2018). Research shows that aesthetic judgments are based upon conditions favorable to survival, such as preferring wide open spaces to confined places for an opportunity to escape (Fairley, 2018). Similarly, curves and textures are preferred to sharp angles and untextured materials, eliciting reactivity from the pleasure and reward centers of the brain (Fairley, 2018). Applications of neuroscientific findings in architecture are vast, ranging from designing for sensorial and emotional response to site attachment (Mallgrave & Goodman, 2011). Because the neurophysiological effects of healthcare environments are the most accurate clinical indicators of the body’s response to clinical environments, measurements are imperative to this research.
Current research on the effects of biophilic design on mental and physical healing is limited. This is likely due to the challenges of the topic’s subjective nature and lengthy research ethics approval processes (Nazarian, 2019). A case study which monitored the circulation of nursing staff at the Atieh Hospital in Tehran from May 26 to June 30, 2013, showed that nurses spent 49% of their time walking in corridors and 19% in patient rooms, suggesting the need for a more efficient and legible layout to increase direct care time (Nazarian, 2019). This case study also revealed that psychological distress was the greatest stressor on patients at 70% compared to medication errors, pain, and falls or accidents (Nazarian, 2019). In general, it is found that participatory co-design in healthcare facilities with the input of doctors, nurses, psychologists, and other specialists leads to salutogenic choices of user-centered design and experience of biophilic principles (Dilani, Kercher, & Nazarian, 2019).
PRECEDENT STUDIES
These international precedent studies of healthcare facilities have been chosen with the assistance of neuroscientists, researchers, and architects at the 2019 International Symposium on Salutogenic Hospital Design and Urban Health in Milan, Italy, for their use of biophilic design principles. This is a starting point for this research project and not an inclusive list – a living document for additions of biophilic structures.
The Khoo Teck Puat Hospital’s rooftop community gardens. Kishnani, 2017.
The Khoo Teck Puat Hospital in Singapore is a 1.1 million square-foot facility with 500 patient beds and deeply integrates plants within its architecture to appeal to the visual, olfactory, and auditory senses with views of water, greenery, aromatic plants, and sounds of falling water (Poe, 2019). This hospital’s green plot ratio (the relationship between the surface area of a building and the amount of plants) is 4:1, allowing the hospital to take on a rainforest-like quality by attracting butterflies, dragonflies, and birds (Poe, 2019). Its central court cascades into an open basement which gives the illusion of architecture deeply embedded in a garden (Kishnani, 2017). The hospital is arranged in a V-shaped configuration of blocks open to the north, allowing breezes and natural lighting to permeate the fenestration (Kishnani, 2017). On its roof, the Khoo Teck Puat Hospital boasts a community garden – the produce is used in the hospital’s kitchens and extras are sold to cover operating costs (Kishnani, 2017). This building opened in 2010 and won the Stephen R. Kellert Biophilic Design Award, which is an International Living Future Institute award that recognizes biophilic buildings successfully connected to natural surroundings and elements (Poe, 2019). This precedent study is ideal for this research project because of its natural surroundings (significant amount of greenery, stormwater pond, rooftop gardens, and natural ventilation).
New North Zealand Hospital. Nyt Hospital Nordsjælland, 2019.
The New North Zealand Hospital was designed by Herzog & de Meuron and Vilhelm Lauritzen Architects and was based upon social, economic, and environmental sustainability to ensure higher quality, spatial coherence, equality, safety, and expedient diagnoses and treatment for each patient (Nyt Hospital Nordsjælland, 2019). The hospital is designed at a human scale of only four floors and is closely integrated into the landscape of an organic four-leaf clover form to support healing through scenic views of natural surroundings and ample daylighting throughout the structure (Nyt Hospital Nordsjælland, 2019). The architectural concept is that of a pavilion within a forest (Nyt Hospital Nordsjælland, 2019). This hospital is valuable for this research project because of its human scale and use of organic form to enhance patient room views and daylighting (Nyt Hospital Nordsjælland, 2019).
Meyer Children’s Hospital in Florence, Italy. Archello, 2007.
The Meyer Children’s Hospital in Florence, Italy, is a combination of new additions and a restored historical building – Villa Ognissanti (Archello, 2019). The architects’ goal was to create a memory of the past and reduce the stress of typical hospital structures (Archello, 2019). It is situated in a park-like landscape and equipped with a vegetated roof, tremendous daylighting, art, and open space (Michler, 2019). Natural ventilation is provided by the vegetated roof, shading devices, and façade grills (Archello, 2019). The upper glass of the atrium has embedded solar electric panels to provide energy for the hospital and reduce glare (Michler, 2019). Its concept is that of “land art” – to appear as a natural element of the land with its vegetated roof and design replicating the contours of the surrounding Florentine hills (Archello, 2019). It is human scale at three floors, which are tapered and staggered to create overhangs with large landscaped terraces for healing gardens with views (Archello, 2019). This hospital is an ideal precedent study as it is designed specifically for children and incorporates art and creative spaces.