Positive Diversions

Global Health Care 2050 Case Study, Healing Environments - Bringing Nature Nearer to the Patient's Experience


Context Founded upon clinical prerogatives the mainstream model of healthcare delivery is evidently harmful to the patient and damages staff morale. A global demand for less hostile health care has stimulated considerable debate on which kind of environment is appropriate for healing. The demand for a more patient orientated approach offers a direct challenge to established practice. This redefines the programme of patient as passive recipient to promote direct participation and appropriation of the process.

Image Problem Increasing pressure on the hospital plan, particularly in diagnostic and day care have resulted in ever deeper building volumes. Even in new-build or refurbishment, there is a preponderance of low grade spaces and cubicles for rooms, an inanimate clinical backdrop masquerading as health provision. The continuous build up of medical paraphernalia installed into industrial conditions intrinsically lead to an increasingly artificial environment The health service is dominated by excessive amounts of un-cherished utility spaces, and despite designers¹ attempts to change scenery, the resilient institutional profile stubbornly prevails. The image problem persists

When based on operational and physical functionality, the well-intended planning principles and guidance fail to recognise the user¹s perception and feelings. Hostility is further fuelled by materials that¹s antipathetic, often ecologically unsustainable and potentially hazardous. Speeded by obsession with delivery, authorities, constructors and manufacturers alike are feeding widespread urbanisation. A proliferation of the means determining the ends show clearly there are countervailing forces against delivering effective and high quality mass care. A fog has descended, blurring cultural and local distinctions, but speeding the oblivious spiral towards universality. The unprecedented global development of industrial hardware is accelerating and current procurement programmes require built forms "as is". Creative expression is pre-ordained by manufacturing at large even before the designers propose it. The health service appears destined towards still further artificiality.

Liberation from the institutional can be achieved by reducing the degree of artificiality. This will require dramatic dissolution from the footprint of a close cellular core structure in favour of an open and flexible shell. Discouraging massing accommodation along interior and dual loaded circulation at the core will allow opportunities for geometrical form and delight at the edges. Innovation flourishing at the perimeter will allow a controllable engagement with nature. To redress the balance between the artificial and nature the barriers between the artifice and the verdant must be reduced.

Evidence Based Research Over the last twenty years a more creative contribution has emerged across a wide range of health facilities. To date most emphasis has been placed on advocacy, but a significant amount of evidence base research on the benefits of humanising the hospital environment is being assembled. A recent report by the Arts Council of England includes 385 references from medical literature highlighting the importance of the arts and humanities, "inducing positive physiological and psychological changes in clinical outcomes."

Scientific research has determined that improvements in hospital accommodation will bring benefits and likely improvements in the rates of recovery. It is realised the physical surroundings are important to the morale and spiritual wellbeing of the users. The health managers and caring professionals should he made aware of the accumulating evidence. Roger Ulrich Centre for Health Systems and Design, Texas A&M University. Renowned for his well documented findings on improved recovery rates for patients with a view of a tree, believes health outcomes analysis is important, because, if sound research demonstrates that appropriate art beneficially affects the health of patients, "you have a powerful new kind of argument, a mainstream medical argument for having art in healthcare facilities."

The research indicates psychologically appropriate art can substantially affect anxiety and medicine dosage. Art which is dedicated to the clinical spaces or intervenes in the private space of the patient however has to be approached with extreme caution. What is appropriate in the evaluation dialogue is the integration of creative talents skills with the demands of the users and clinicians. It is after all the artistic process or creative phenomenon, not the artefact itself, which is our main resource. The most serious implication is the increasing lack of confidence in the very fabric of the institutions in which the patients are treated. It is rather the very process of designing hospital accommodation itself which is in question.

The notion that certain environments can embrace health and healing has inspired other international research programmes in sensory perception and therapeutic benefits.

What is significant is that existing clinical areas, according to the Centre for Healing Environments in Tokyo, have been proved to have a detrimental effect on the health of the inpatient. Uniquely comprising of medical consultants, the centre presented a report 'The Psychological and Physiological Effects of an ICU environment on Healthy Individuals'. An abstract suggests the ideal environment would be one in which patient stress and anxiety is alleviated. They hypothesise that even normal healthy individuals might experience psychological stress and rises in hormone levels known to be associated with mood and stress, when exposed to an inpatient hospital environment.

It was concluded efforts should focus on nourishing the five senses; particularly sight, sound and taste within the ICU environment. The Tokyo findings seriously undermine first principles that the hospital environment should not be harmful to the patient or carers

Nature of Health Design

The Nature of Health Design Project was initially based on a series of case studies on specific "best practice" UK facilities in preparation for exhibition at the 2002 Hospex Show. Following the Tokyo exhibition and launched during Architecture Week 2003, The Nature of Healing Art in UK & Japan exhibition see appendix is also based on a study visits to premier Japanese hospitals between 1993 and 2002. Various types of healthcare facilities developed in recent years are introduced. (Most of the Japan projects are extracted from the JIHA annual awards and the Healing Environment Forum.)

The project describes the hospital environment as highly stress-full, impacting on the quality of medical service, patient care and safety. "Evidence based design" confirms artists and designers can contribute to improved medical outcomes. As positive distracters, it is reasoned art, music and especially nature all reduce levels of stress by encouraging shifts in mood and relaxation. A blueprint for better quality care the Nature of Health Design project focuses on an integration of art, architecture and garden design to bring natural phenomena nearer to the patient's experience.,

The Nature of Healing Art exhibition presents recent key hospital projects across the UK and Japan which engage the users of healthcare with the natural context The panel presentation follows the patient journey, through the threshold, and interior pathways to the reception, ward and garden spaces. Each panel offers a potential mediation space where the building connects the patient to the rhythms and changing patterns of nature. It contains a selection of approaches and benevolent interventions, which animated by occurrences in the elements help stimulate the main senses. It offers a fresh insight to health care design where nature is fully incorporated, within reach of the patient¹s personal space.

Findings In the UK there have been a limited number of landscape successes amongst which the grounds and courtyards at St George's Tooting and the West Dorset Hospital can be included. The Exeter Health Care Arts ward garden enhancements demonstrate what can be achieved in the courtyards generated by Nucleus templates. Similarly in Japan the roof gardens at St Luke's Tokyo and the Gamagori Hospital are exceptional. The quality of light and tree planting in the main entrance concourse and the outpatients mini-lightwells at Gamagori are particularly well regarded..

Most importantly case study visits for the project revealed shortcomings in the quality of service at the care end of the patient¹s journey. The quality of departmental reception and waiting spaces is alarming. These are where care commences and where it is most appropriate to reduce levels of apprehension and tension. The Central Middlesex¹s ACAD project however offers some hope for this area. Ward accommodation and bed space provision, with the exception of the leading lights, Lambeth Community Care Centre and the Glasgow Homoeopathic Hospital, largely failed to connect the inpatient with the natural habitat or surroundings.

As a benchmark some of the best ward accommodation in Japan is presented The single room suites at the semi circular Keiyu Hospital accommodation in Yokohama with superb sea views over Tokyo Bay were selected from the new larger hospitals. It is however the smaller scale units like the Amakusa Spa Rehabilitation Clinic in Hondo City were the humanitarian criteria and nature have the most chance of merging. The Seaward Stress Care Centre by Itsuko Hasegawa promised possibilities in planning new forms of ward space. Locating the Stress Care unit next to the harbour estuary overlooking the Shiranui sea means the inpatients are able to benefit from a wash of reflected light off the tidal river. In the diaphanous building patients become subliminally orientated to the natural rhythms of the special location which have resulted in reduced length of stays. At Omuta Hasegawa was able to radically relocate the new stress care unit next to the tidal river and a great deal can be learnt from the Shiranui Hospital about how to improve the patients experience and realign the ward space to interact with the natural elements.

Observations The interface between inside and out needs attention, how do we connect the floor to the ground and the ceiling to the sky!. The immediate surroundings is the critical mediation space and requires careful landscape attention. As at Amakusa the adjoining garden can be animated for instance by pools and running water, rocks and shrubs. The water will reflect sunlight into the space and onto the ceilings. In larger ward areas introduce roof lights or even more desirable mini-light well gardens. The patient must however be empowered to control and to orientate themselves to enjoy their environment.

Generally the inpatient experience is highly restricted, isolated in artificial and controlled conditions hermetically sealed protected against the outside elements, their access, contact and interaction with nature denied. Today's ward accommodation suffers from institutional conformity, is repetitive, shabbily utilitarian and cluttered with ugly & non functional furnishings.. Although clinical functionality doesn't raise spirits, such service priorities would appear to prevail. There is a growing need to re-address the situation in favour of the comfort, perception and interaction of the inpatient. The physical surroundings of the bed space are important to the spiritual well-being and satisfaction of the patient and engaging natural phenomenon offers a solution. Maybe the 21st century will see a move away from the universal white cube to the eco-ward, a patient focused space which connects to the family, local culture, topography and natural habitation. The eco ward suggests a fundamental reappraisal of the bed space offering a fresh challenge for hospital design of the future

Healthcare will always be lacking if collective indifference to the impoverished patient and nursing care areas is allowed to continue. To establish a true Healing Environment measuring up to the challenge of the patient¹s demand is critical. Over the last twenty years more creative opportunities have been taken in the communal areas of hospitals but there has been insufficient emphasis on the care of the individual patient. The geography and emphasis of the hospital treatment regime as at the Central Middlesex ACAD and BECAD structure is about to change. There is now shift beginning from the ubiquitous clinical space to a post-modern contextual approach based on the specific needs of the patient and their particular choice of care. Clients and designers in healthcare may consider such shifting requirements away from mass public consumption to reflect on what feelings and associations the individual end-user experiences and takes away with them. Evidence-based design has established the platform, but a fusion of art, nature and healing is needed to drive innovation. Blurring the demarcation between the outside surroundings and the "interiorscape" will dissolve the barriers, increasing connectedness with nature, rendering the edifice of the institution itself invisible.

The Healing Environments Case Study prepared in Sept2004 for the GUPHA Healthcare in 2050 Report by Tokyo University for the Japanese Government.

GUPHA Global Hospitals in the year 2050 is the outcome of a three years project in a new international organization, called GUPHA (Global University Programs in Healthcare Architecture), jointly funded by the Ministry of Education, Sciences, Sports and Cultures of the Japanese government and privately funded by GUPHA members.

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