DISSERTATION ON HEALING ARCHITECTURE IN HOSPITAL DESIGN

School of Architecture Delhi Technical Campus, Greater Noida Affiliated to – Guru Govind Singh Indraprastha University Delhi

HEALING ARCHITECTURE IN HOSPITAL DESIGN Submitted by: DIPESH ANAND Enrollment no. 064181001613 Submitted to: AR.ANKUR TRIPATHI Submitted in partial fulfillment of the requirement for the Degree of Bachelor of Architecture

Batch: 2013 Date: 11/21/2016

HEALING ARCHITECTURE IN HOSPITAL DESIGN

@2016 , Dipesh anand

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ABSTRACT Winston Churchill concisely expressed the effect of architecture and our surroundings with the comment that: “We shape our buildings and later they shape us.” The intent of this dissertation is to explore how architecture can inform healing or provide spaces and events where healing can take place. We as human beings have an inner connection with our environment by physical, mental, emotional and spiritual means. Healing cannot be understood in isolation from the factors that operate in the dynamic life of an individual. These include the self, the family, the community, the environmental context within which life is carried forth, and the world of spirit or essence. Furthermore, the arts and art therapy have, over the years, been used to heal different aliments such as cancer, mental illness, aids, addiction and the elderly have been successful in doing so as it heals across all ages and race. The question I pose is can architecture do the same? Besides, can architecture play a superior role in healing? In our built environment we often interact with the buildings themselves without knowing the fact of relationship between building and surroundings. Can we create those interactions by evidence based design methods? This dissertation summarize the principals of life enhancing role of architecture and planning in the healing process. Through a theoretical approach including the history of healing architecture and the introduction of architectural and anthropological theories, the project defines four main parameters that should be included in the design of future spaces for social support: Functions that reflect the everyday life, materials & textures with a homely atmosphere, importance of daylight in hospitals and details with interior design in the human scale. The study also comprises of case studies of two hospital which lies in Delhi NCR, india (1. Medanta hospital , gurgaon 2. Fortis hospital , gurgaon ). Both the hospitals are multi specialty in nature. This study includes the innovative solution for healing environment inside and outside the hospital building through site planning , building planning , interior of the room , views, social spaces such as waiting areas, atrium , corridors, food court , healing gardens , etc.



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ACKNOWLEDGEMENT The Research Paper presented here would not have been possible but for the guidance & support of Ar. Tanya Gupta, HOD, School of Architecture for extending her support & valuable guidance whenever wherever required. DIPESH ANAND ,Guide & mentor for her/his relentless pursuit of high academic standards, the can-do attitude & imbibing professional ethics have helped this project meet high academic standards & professional working. My parents who have taught me to strive for perfection in everything I do. Any other person And also my friends & colleagues who were always around to help me. Appreciation & gratitude is owed to them. DIPESH ANAND Student (_2016_) Batch Date - 12th december 2016.

HEALING ARCHITECTURE IN HOSPITAL DESIGN TABLE OF CONTENT



PAGE NUMBER

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1. Introduction

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1.1 Preamble :- ( aim & objective , methodology and scope)

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1.2 What is healing ?

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1.3 What is healing architecture?

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1.4 Historical background

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1.5 Evidence - based design

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1.6 Present and future of healing architecture

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1.7 The future use group

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2. Space for social support

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2.1 Introduction

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2.2 Public space elements (Edward t. hall and Gehl theory)

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2.3 Homely atmosphere (sense of personalized environment)

22

2.4 Theoretical approach

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3. Salutogenic design models

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3.1 Antonovsky’s Theory of Salutogenesis

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3.2 Alan dilani - psychosocially supportive design

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3.3 Roger ulrich - theory of supportive design

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3.4 Jan goelbiewski - neurology of supportive design

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4. Precedent case studies

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4.1 Fortis hospital , gurgaon , India

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4.1.1 introduction

62

4.1.2 reason of this case study

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4.1.3 Salutogenic design method and evaluation

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A. Mapping out in relation to Antonovsky's sense

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of coherence factor B. Evaluation model in relation guidelines set through

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study of Edward t. Hall and Gehl theory.

TABLE OF CONTENT



PAGE NUMBER

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4.2 Medicity , gurgaon , India

92

4.2.1 introduction

93

4.2.2 reason of this case study

94

4.2.3 Salutogenic design method and evaluation

99

A. Mapping out in relation to Antonovsky's sense

99

of coherence factor 4.3 Analysis / interviews

110

4.3.1 interview 4.3.2 analysis

5. Conclusion

114

6. Bibliography 7. glossary



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The overall

1. INTRODUCTION 1. INTRODUCTION aim of this research is to study the life

enhancing design in hospital

1.1 Preamble :- ( aim & objective ,

architecture which increases the healing property of a building through architecture and planning guidelines. The goal of such healing spaces are they can reduce fear , stress ,

methodology and scope)

tension and give relief for some time which actually results in healing of the patient. The study has also been carried out to acknowledge the critical experience of patient , staff

1.2 What is healing ?

and visitors in hospital buildings.

1.3 What is healing architecture?

For detached spectators it seems obvious that, when building and planning hospitals, the architectural environment surrounding patents, families and sta ff , should support the

1.4 Historical background

medical treatment in friendly welcoming and accommodating environments. However, the majorities of our current hospitals are built on another foundation, and are often

1.5 Evidence - based design

considered the direct cause to stress, anxiety, frustration and generally longer

1.6 Present and future of healing

hospitalization due to the unsuited facilities and environments in today’s health care system.

architecture

This dissertation is done to have a clear and comprehensive information on how to create a healing environment in light of growing healthcare demand in India. The aim is to have

1.7 The future user group

a humanizing architecture that can positively contribute to the healing process. It should make the patient enjoy the best of bioclimatic comfort. Healthcare Design must also satisfy professional requirements. The physical environment of the healthcare facility should firstly do no harm and secondly facilitate healing process. 1.1 Preamble :-

Objective - The aim of this research paper is to obtain an in-depth understanding of the physical aspects in hospital design and how these physical aspects play important roles in creating a healing environment. Other objectives of the present paper are: • To acknowledge the critical experiences of patients, staff and visitors in hospital buildings, •Importance of daylight in hospital architecture, • To outline the physical aspects in healing environment, • To investigate the previous and current research available on the subject of health and environment, design for healing and the effect of day lighting on human beings, • To examine the elements of physical aspects of existing project brief of public hospitals, •To study the need for social support during hospitalization,



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• To promote social interactions and support , • To promote homely atmosphere, •Study the connection of building and nature.

Methodology - An extraction and assembly of the body of knowledge and on-going research of healing environment in hospital design is apprehended in this paper. It is intended to identify potential research areas on the physical aspects of healing environment in future hospital design . Methodology employed in this research is literature review, which is followed up by some architectural functional and planning design ideas. The key findings will focus on the physical and social aspects affecting the hospital environment which are the most pronounced influential physical factors affecting bedridden patients.

Scope - The scope and the intention behind the design concept healing architecture is, as described, not a new way of thinking, but is rather a continuation of earlier assumptions that the surrounding environment, daylight, nature views and access, etc., had a healing affect on patents. This research focus on recovery of the patient which reduces the rehabilitation time which in turn reduces the stay time in hospitals. The research intends to change the mind of the designer and improve the designing techniques used by the architect in designing a hospital.

1.2 what is healing ? Healing is the process of re-establishing harmony within the organism. Illness implies a loss of this balance and the need for reintegration with the body’s natural ability to heal and regenerate. Healing cannot be understood in isolation from the factors that operate in the dynamic life of an individual. These include the self, the family, the community, the environmental context within which life is carried forth, and the world of spirit or essence. Healing is dependent on reestablishing successful relationships and developing reciprocity between these factors. In fact, healing is not a process of curing or fixing, but rather a return to balance between all of these components1. Health, therefore, is understood as the presence of this balance; illness is its lack. Far from being inert containers, spaces can be understood to be fully participant in the healing experience. It is possible to conceive and create structures that heal. Although materials, structure, and equipment are part of this Endeavour, equal footing can be granted to the land, the natural world, the community, our ancestors, and the spirit in all of this.



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1.3 what is healing architecture ? modern hospital + hermitage = future hospital Hermitage - 1. Homely atmosphere 2. Connection to nature 3. Social structure institution 4.daylight factor As introduction, the project will describe and define some of those terms used when considering health care architecture, and according to the planning of future hospitals, the concept healing architecture is introduced. For detached spectators it seems obvious that, when building and planning hospitals, the architectural environment surrounding patients, families and staff, should support the medical treatment in friendly welcoming and accommodating environments. However, the majorities of our current hospitals are built on another foundation, and are often considered the direct cause to stress, anxiety, frustration and generally longer hospitalization due to the unsuited facilities and environments in today’s health care system. As a response to the current state of modern hospitals and as a weighty tool in the discussion of our future health care settings, the term healing architecture has gain ground. It is best described as a design concept, which represents the vision of encouraged human well-being and healing influenced by well-designed architectural surroundings.



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Thus we have explained an equation that says the importance of architecture in hospitalization which reduces the healing period through its various examples given below:1. Homely atmosphere or hermitage  Authentic healing modalities  Individual process  Spiritual guidance  Hermitage club spa - anti stress  Hermitage workshops  Yoga centre  Meditation centre in nature  Architecture of hermitage should be in relation to natural built environment. 2. Connection to nature  Nature window views  Garden accessible to patients  Nature art : no abstract at  Daylight factor  Internal courtyard connected to ward , patient room  Quiet in the ccu (coronary care unit)  Music during minor surgery  Air quality  Landscaped courtyard  Floor to ceiling windows  Therapeutic benefits  Landscaped setback  Front porch - (overhang may scale down the size of the building)  Entry garden  Plaza(include trees, shrubs, overall is not of green image , but of a paved urban plaza).  Roof terrace( potentials for expansive views).  Viewing/ walk in garden  Sound of water and attraction of birds to the fountain are particularly appreciated ( roof   

garden) Roof garden for mood change Wide walkways outside patient rooms provide a buffer from garden activities. A covered patio style coffee shop provide and shelter for an outdoor eating area within a garden.

3.social structure  Green lawn for social improvement in structure.  Imaginative maze for children.  Covered sitting terrace or patio within a nature surrounding.  Single occupancy vs multi occupancy patient room study.  Elements in the social dayroom.

1.4 historical background



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In the 17th and 18th centuries, the dual emergence of scientific medicine and Romanti- cism fortuitously combined to encourage the re-emergence of usable outdoor spaces in hospitals. The intention behind the concept of healing architecture seems immediately obvious and straightforward, and it seems rather strange that not all hospitals are based on these concepts of integrating the architectural environment as support for the medical treatment. However, the idea of a beneficial effect on patient’s healing process supported by well designed surroundings is not a new concept. In fact, these ideas may be traced back to thoughts and ideas evolved in the 18th century. At that time, leading doctors and nurses proposed changes in the layout and design of hospitals in order to reduce the danger of contamination by designing smaller wards and increasing ventilation. Later these theories are followed by Florence Nightingale, who in Notes on Hospital from 1859 published her philosophies and thoughts of the supporting effect of aesthetic environmental settings for the patient’s physical and psychological condition. In Denmark, the first public hospital is planned by request of king Frederik V in 1752. At that time, the medical knowledge was underdeveloped and the experience of building health care settings were naturally lacking. In the 17th and 18th centuries, the dual emergence of scientific medicine and Romanticism fortuitously combined to encourage the re-emergence of usable outdoor spaces in hospitals. The notion that infections were spread by noxious vapors spawned designs that paid special attention to hygiene, fresh air, and cross-ventilation. The so-called pavilion hospital became the predominant form throughout the 19th century. Two- and three-story buildings linked by a continuous colonnade and ventilated with large windows marked the design of the influential Royal Naval Hospital at Ply- mouth, England. Recommendations for hospital garden design written by German horticultural theorist Christian Cay Lorenz Hirschfield at the end of the 18th century uncannily foreshadow the findings of researchers such as Roger Ulrich at Texas A & M University, who documented in one study the healing benefits of a view onto vegetation for patients recovering from surgery (Ulrich, 1984).

1.5 Evidence - based design when architects , interior designer or any other firm wants to design hospitals they consults politician or decision -makers regarding the new super specialty hospitals , all the issues related to designing and physical spaces which enhance healing power of the building through appealing and sensory design solutions, the term often we use " the evidence based design'. an individual using this method makes his decision based on research papers and evidence gathered from experienced client operations. an evidence-based



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design should results in improvements to productivity , customer satisfaction and economic estimation. It was initiated on the basis of evidence-based practice and evidence-based medicine, evidence-based design is linking the physical environment with better patent outcomes by using the best current research evidence to guide design decisions, thereby moving towards a new fundamental design process. (hamilton 2003 and ulrich et al 2004). The extend of evidence-based design research is increasing. In 2003, more than 600 studies—most in top peer-reviewed journals—that establish how hospital design can impact clinical outcomes. The research team found studies that bond the physical environment to patient and staff outcomes in four areas: 1.

Reduce staff stress and fatigue and increase effectiveness in delivering care

2.

Improve patient safety

3.

Reduce stress and improve outcomes

4.

Improve overall healthcare quality

A basic requirement for the architect and the design team is to study or examine perfectly the research data to have relevant and use of EBD results in a specific building project followed by a re-contextualization before implemented in a project (Hamilton 2003 and Hamilton 2004).EBD this way not giving answer related to hospital planning it just documenting the influential factor of architectural environment ,which have a great influence on our mind. Evidence based design in healthcare architecture is not solely capable of ensuring future well-designed hospitals even architects and planners play a crucial role in evolving the process. as a requirement in current world and expectation by decision - makers , its an obvious task for designer to explore more on this field to create future healing environment for patients , staff and visitors.



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1.6 Present and future of healing architecture The idea behind the

concept

of

healing architecture not

is

a

new

concept

but

is

rather a earlier explanation more

in

advanced

techniques the

that

surrounding

environment, daylight, nature , views

and

access,.. etc. had a healing effect on

patients.

todays

in

planning

of new modern hospitals THE ARCADE AT FOTIS HOSPITAL , GURGAON

has

shifted to patientcentered

care

and

well-

being

the of

the

patients and their



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families, attempting to balance the building codes , functionality and aesthetic considerations. Today we are building upon this rational thinking , however with a broadened mind. evidence and science is no longer limited to medicine , they are also related to interior and architecture of hospitals. Developed as an extension of evidence-based medicine, research within the field of architecture and its e ffect on patent outcomes is still gaining ground, documenting the benefits of patents hospitalized in well-designed environmental settings (Ulrich et al 2008 and Hamilton 2003). today most of the hospitals are build on EBD method for increasing the healing power in our future hospitals. Through EBD, various proofs has been found, that the sensory perception patents meet during hospitalization have an impact on their experienced level of stress, and if high, this will reduce the immune system causing higher level of infection disease and delayed wound healing. This way, undue noise, interrupted sleep, lack of daylight and generally dissatisfying environments, will all be factors that a ffect the level of stress negatively. (Frandsen et al 2009, Ulrich et al 2008, Francis 2002 and Horsburgh 1995).

1.7 The future user group 1.7.1 PEOPLE AFFECTED BY CANCER When any patient is diagnosed with cancer, a range of arrangements and precaution are made, usually the treatment is done immediately after being diagnosed. these treatments are often performed while at home or hospitalized in the relevant surgical ward. suffering severe symptoms then it is shifted to oncology ward for treatment. The patients in our future hospitals are described as being more sick and weak than today’s patients - due to enhancement of ambulant treatments and a general more effective procedure, resulting in faster discharges. (Juhl et al 2008 and Kehlet 2010) According to the extrapolation of the expert panel, patents in future oncology wards, will this way only be hospitalized in 2-3 days in average – typical through their most critical period of illness. (Sundhedsstyrelsen 2010, Juhl et al 2008 and Danske Regioner 2008) with this elaboration of future patients, and the relative short period of hospitalization , it may be argued, that the patient experience in hospital is not much of importance as compared to medicinal approach . As such a logical conclusion that on the other hand would be a direct continuation of mistaken arrangements of previous hospitals from 1960`s , with layout and design not according to human scale, finally resulting in long duration of hospitalization and hospital environment without sensory elements.



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I believe that this is the time to stop counting patients as number treat them as humans and patients, like everyone else , having social attraction and basic need for encouraging social interaction. otherwise, we will simply build the same hospitals again and again. The fight against the cancer is not solely doing research in medicinal treatments , but it is required that what cancer does to a human being , its physical and psychological conditions. Especially through several course of disease it is essential to have social interaction with their closeness to feel safe and comfort in hospital environment.

1.7.2 Social relation influence on cancer Health, and persons in a partnership have this way a generally better health than singles. This may result from the positive

influence by our close relationships, or may in

some cases directly related to the social and emotional support. (Zachariae & Christensen 2004) The human is generally a social creature, and our relationship with other people – our social relations – is a central aspect of our life. The amount of social support that cancer patients is experiencing, and especially the possibilities to discuss ones disease and treatment with other cancer patients, is considered very helping in the stressful periods of the disease. (Zachariae & Christensen 2004) The diagnose of cancer generally cause depression , stress , tension , anxiety among the cancer patient and their families. the risk of developing a profound depression is increased due to isolated social spaces and lack of control over the situation. the patients are experiencing upturn process of adaption in order to accept and understand the disease, changed prospect, various treatment., etc. at that point of time social support is much more of need to conquer depression and stress.

1.7.3 Patients to patients Cancer is a very difficult disease to handle and it is very much important to have social support during these situations for comfort and support. other patient suffering from same disease regard as a useful support for them, especially for increasing hope and belief. they



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may are from different places, but they communicate in same language at that time ( Rasmussen 2003). The solidarity with other patients may range from intense intense conversation and social support to inspiration of other patient activities and actions. that's why patient don't feel left alone with their disease. particularly at time of changed treatments social support from other patient is proven useful. 1.7.4 Patients and their families A serious disease cancer not only affect the patients but solely the entire family. Partners, parents, children, close relatives are also implicated by the disease and long period of treatment. As it is important that families facing same situation get socially interacted with each other at equal status. in these forums , families can talk about the problems facing them without influencing the patients. Families to cancer patents are experiencing a tough psychical stress, but their well-being is rarely in focus. Depression, confusion, anger, sadness and other negative feelings and emotions are often unavoidable consequences for the relatives to a cancer patient, which may be overcome or reduced with increased social support to the families themselves. (Hansen & Thastum 2005) 1.7.5 Social support in future oncology ward Though we have stated that social support is very much of importance in treatment of cancer in order to satisfy their mental condition. the main focus in designing phase there will be patients themselves and the need of their families will be taken into considerations. there will be such living areas in single patient room for the social interaction of their families so that they do not feel that they are totally in medical staff .



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A current space for social support in medanta hospital , gurgaon



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2.Space for social support 2.1 public space elements 2.2 Homely atmosphere (sense of personalized environment) 2.3 Theoretical approach



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2. SPACE FOR SOCIAL SUPPORT 2.1 INTRODUCTION In chapter two of this research, hospitalized patient` requirement for social interaction and social support has been identified. Day by day patient`s general level of stress and fear increased not only due to changing pattern in disease. Also struggles to perform normal activities like low level of visits from family and friends may occur a factor of fear. the future planned single bedroom hospitals is furthermore increasing the rate of fear and stress , loneliness and the need of social support in hospitalization is playing a crucial role in future. spaces for social support interlinked with hospitalized patients is much more important which will enable knowledge sharing and diverts inspiration among the patients. Social support in future hospitals is encouraged through social interaction that may vary in different levels and variation. The social interaction can be done through informal meeting which we experienced in our daily lives such as, we experienced in trains , mall, parks , gym , city square, etc. and complete social relationships like we experienced in our homes in safe and physically well being surroundings. Through these measures social interaction will increase and knowledge sharing and inspiration with patient of equal status are potentially responsive. The physical surrounding have potential to have ideal settings where common areas are constructing

both initial contact and developed social relationships. In this

contrary the social space may seen as intersection between a public space and a homely environment. Usually our everyday activities are performed with our family and friends, while in the hospital these simple familiar activities suddenly are occurring with unknown people in a semi-public space. If we improved these social spaces then the healing power will also get increased and may even considered as an influential elements in regard to healing architecture. There are, however, not found any specific EBD research that define detailed aspects in regards to design and physical planning of these spaces. (Ulrich et al 2008) Instead, the project is stating the thesis that by introducing architectural and anthropological theories, a more thorough understanding of the human perception of space and even specific transferable architectural aspects There are, however, not found any specific EBD research that define detailed aspects in regards to design and physical planning of these spaces. (Ulrich et al 2008) Instead, the project is stating the thesis that by introducing architectural and anthropological theories, a more thorough understanding of the human perception of space



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and even specific transferable architectural aspects may be defined and incorporated when designing social spaces with inviting, attractive and sensory aspects in future hospitals.

Social support during hospitalization is experienced in various levels of intensity. The need, the promotion and finally the development of social interaction is the main essential steps towards the potential social support.

Lobby of American hospital in Dubai

Social spaces in future hospitals may be seen as an intersection between public spaces and homely environments. Elements in the social dayroom at Lund

Patent restaurant at Lund University Hospital

University Hospital



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THE PUBLIC SPACE ELEMENTS 2.2 HOW TO ENHANCE SOCIAL ATTRACTION 2.2.1 PUBLIC SPHERE ENVELOPES THE PERSONAL SPHERE In this chapter will introduce some of the general theories regarding social interaction and human behavior in the public space that architects and designers has used until now when planning and designing urban Scapes. Giving the possible privacy with some social spaces are necessary and are stated as a basic qualification of rapid recovery. But constant withdrawal and always keeping oneself to oneself so as to be spared social contacts and confrontations is often one of the symptoms of mental illness, and so care is concerned with developing the patient’s social capacity. The social element also has to be gradually stepped up, but of course depending on individual situations. The design of the physical environment, accordingly, must support the individual patient’s gradual expansion of his / her personal sphere. from patient`s own bed to open door to green or entering to another patient room and sitting down to such social well being corner to talk. Moving out to the social green area , sit on a bench near green plants , having a cup of coffee. Meeting a relative in cafe`. Going on a tour of hospital visit. All these activities get used to patient daily lives which never make them felt that they are hospitalized or progressively widening the social context. There we should shape the rooms, or shape “rooms within the room”, make small niches or seating areas of varied character where people can “take a pew”. 14Normally speaking,



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mentally ill persons have a larger bubble of personal territory. But the places created must still make people feel encompassed and secure. In pune "Mukthangan De-addiction centre" observed that patient rooms are placed near the amphitheatre

space

near

the

natural

elements

like

trees,

sunlight

and

gentle wind to heal their agitation. The language of making public activity inside the private spaces are done also in Mukthangan rehabilitation centre with the help of well lit amphitheatre space in the centre enclosed by rough wall to give those agitated people a sense of protection.  social participation and elective seclusion 

successive

expansion

personal

of

the

sphere

 parts with different degrees of seclusion

and

publicity

 secure and intimate seating areas

Mukthangan De-addiction centre, Pune by Sirish Beri, Amphitheatre Space

on the fringes of the public zone

2.2.2 Call for social contact Now I will discuss writings by architect and professor Jan Gehl and anthropologist Edward T. Hall, in their theories described in Livet Mellem Husene (Gehl 2003), Byer for Mennesker (Gehl 2010), and The Hidden Dimension (Hall 1973), respectively. The call for social contact between individuals is a concept that covers many di fferent variations, from simple unpretentious contacts to more complex and emotional conversations and intercourse. (Gehl 2003). Jan Gehl defines in Livet mellem Husene (2003), the various contacts by their intensity, where close relationships have great intensity, and the passive and casual meetings have low intensity. From this figure (below), the public space primarily represents the casual and passive kind of contacts, which compared to the more intense contacts are considered modest. However, they stll possess great quality and worthiness, as autonomous contact, or as the basis for more developed kinds of contact. For instance, as maintenance of existing relationships, and especially as inspiration of acts and activities, that other people are performing. (Gehl2003) If this basic social contact is not obtainable, the boundaries between isolation and social contact are too pronounced, and you

are

either

alone



or

in

22

binding

connection

with

others. The social contact on the low intensity scale is therefore an evident and important possibility for persons to interact with others on a casual level, and perform as transition between various kinds of contact. (Gehl 2003). The establishment of such common attractive and inviting social spaces are very much required for day meeting to interact socially patient with equal status for social support which enhances their knowledge about such situation. 2.2.3 Activities in the public zones In regards to activities in the public space, Gehl (2003) defines three types; essential activities, optional activities and social activities – all with di fferent demands to the physical environments.

The

essential

activities which are performed they

are regardless of the physical

planning of social environment ,

they are not in contact be

to such areas, this may

the

medical

treatment. The optional activities are

generally those activities which

are done when they are

desired and these activities

are only seen if the physical

environment are in proper

condition. in respect to this

optional activities are

common facilities,

relaxing walk, informal

conversations ,etc. however, if not in proper condition then only

the public or the social space is essential activities will be there.

Social contacts sorted by their intensity.



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Activities in the public space is depending on the quality of the physical environment.

2.2.4 Sociofugal and sociopetal spaces The physical environment often performs a very specific character in regards to social interaction also concerned anthropologist Edward T. Hall (1973). In the writing "The Hidden Dimension", he refers to a research study performed by doctor Humphry Osmond, who ascertained that some types of spaces, for instance waiting rooms in train stations had the ability to keep people apart, while French cafes did the opposite and made people engage interaction. He defined the arrangements that discouraged social interaction as sociofugal spaces and the spaces that encourages and enforces the development of interpersonal relationships as sociopetal. Meanwhile Osmond had observed

in his

psychiatric ward

apparently patient wee talking less to each other after such change in arrangement of furniture in such a sociopetal arrangement, the social interaction increases in that same ward. When designing future hospitals we should keep in mind the statement of Edward T.Hall

and change can be made through such small arrangements which can change



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sociofugal spaces to sociopetal spaces. Layout of furniture plays a very crucial role in enhancing the social interaction suppose if the chairs are placed back to back then the place automatically turned into sociofugal spaces. however, if the layout of the chairs are immediately changed they are face to face then the place changes to sociopetal spaces. In some occasions the sociofugal setting would be preferable, for instance when studying or reading, and what is considered sociofugal in one context might even be sociopetal in another situation depending on the occurring activity and the people involved. The challenge for the architect is consequently to design spaces with accordance between the physical space and intended function and to maintain diversity between the different spaces in order to give people the choice for social interaction or privacy depending on the circumstances and their own state of mind.

2.2.5 Detail designing Small detail of furniture arrangement can change the character of the space , if prioritized by an architect, social spaces of the future hospitals can be improved. In regards to the human interaction in public spaces, this is best unfolded on the horizontal level, where it has a rather large area of function. On this level, the social visual field is capable of intercepting other person’s features and mood in distances up tll 20 meters, and in shorter distances (1-3 meters), where we normally perform social conversations, our visual senses are supplemented with other senses in order to form a general impression of the person we are talking to. (Gehl 2003) Hall (1973) defnes very precise personal distances, where 0,45 – 1,30 meter describes the close social contact between family members, for instance around the dining table. Distances between 1,30 – 3,70 meter is defining the more public social distance between friends, colleagues, etc. and is usually seen in comfortable seating arrangements. These personal distances influence many details in the planning of social spaces, and for instance this affects the sizes of tables. If too small, two patents not knowing each other, would most likely not sit at the same table, as their intimate distance would be violated. Too large tables however, may make it difficult for patents to talk together across the table. Studies through the design phase are to consider these aspects in order to develop social spaces where patents find it natural to meet and engage contact.



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Through other studies of human behavior in public spaces, Gehl (2003) argues, that the social activities has its own self-prevailing effect, where human actions attract attention and thereby more people. These studies show an instance , that the use of benches are depending upon their orientation , where those situated where more human activities are done neither in quite green environment. (Gehl 2003) As well as the sizes of furniture the orientation and layout also have significant importance in regards to use and social interaction.



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Finally, the placement of furniture in the room is noticeable, where seating environments along with the inner facades of common open spaces or in the transition zone between two areas usually are preferred. In these places ones individual exposure is limited, and it is easier to create an overview of the surroundings and to feel comfort in these situations. (Gehl 2003)

.Piamo Sanatorium, Alvar Aalto, View of Lounge room with special

furniture

Shri. Siddhivinayak Ganapati Cancer Hospital



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Location: Miraj, Maharashtra, India Project Work Status: Completed Projects Project Completed: 1997 The main idea behind the project was to create an environment that does not convey the conventional, dull, dark, smelly and confined ambiance of a typical hospital. Good light, ventilation and a lively open interaction with nature became the paramount criteria. The hospital building is well illuminated and ventilated, incorporating plants and landscaping to bring about colorful, bright, soothing and reposeful mood. The landscaping and building have thus somewhat therapeutic value.

2.3 THE HOMELY ATMOSPHERE (SENSE OF PERSONALIZED ENVIRONMENT) HOW TO DEVELOP SOCIAL INTERACTION



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As concluded, my research is that spaces for social support in future hospital environments is defined as an intersection between the public space and physical environments with a comfortable, homely atmosphere - a social place, where patients engage meetings and social interaction, thus enabling social support. The first step towards social support is consequently for the patients to meet each other, which may include the theories of Gehl (2003 and 2010) and Hall (1973), described in the previous chapter ‘The public space - how to promote social interaction’. The next step is to develop this initial social interaction to intense level, and this process is believed to require specific demands of the physical environment. In our daily life these levels of superficial conversations are usually performed with our families or close relatives in safe and familiar surroundings. (Rasmussen 2003) When hospitalized, the family contact may be reduced (Ulrich et al 2008) and the environment today is often characterized by institutional settings – far from familiar and well-known. Hence, the two aspects that form the basis of this social interaction and support in our everyday life are apparently not present today. From architectural point of view it is very difficult to raise the visits in patients room. instead, other patient and staff can act as a family member at that point of time may be even for better social support in some health related issues. In hospitals patient are confined to such environment where the general freedom of choice, is strictly limited. However, the things concerning the social interaction and the allocated social spaces do not necessarily have to be so di fferent from the spaces we recognize from our daily life and our own homes. By changing the design of hospital dayroom of patient to an inviting , familiar and homely environment recognizable for the patients leads to better social support.

The question remaining is how this home feeling and homely environment is defined outside home?

2.3.2 Feeling at home



29

Home is by the anthropologist Mark Vacher (2006) defined as a connection between a human being and a physical object. This object is usually a building, although more primitive units also perform as homes with the same psychological characteristics. A home is personal and intimate, and not something you can buy. When we talk about houses we are capable of describing them without mentioning the people living there but when we describe a home it always belong to someone. (Vacher 2006) Houses are not only frames for people, people are framed by houses and the things they harbor, at the same time as people project their own emotions, dreams and hopes onto the things and the spaces that constitute the house. That our homes are personal is exemplified by Sjørslev (2007), who define a building as a house as soon as someone moves in, although this house is not a home until it is personalized and the resident have supplied his individual touch. Our home is therefore filled with personal objects, memories, heirlooms, etc., and even though our daily use of these objects may be of functional or aesthetic character, the sentimental value often exceeds the functional value by far. (Sjørslev 2007) kitchen and dining area in typical room

Finally, arrangement

the

details

and

of

furniture should reflect a homely environment. The size of the room, furniture orientation and the room accessories like artwork, greenery, light fittings, etc. are important aspects that should be incorporated and considered along with the design of the space, in order to design a holistic social space facilitating social interaction and support.



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2.3.3 Home outside Home Future social spaces with a familiar and homely atmosphere by implementing some fundamental characteristics derived from our homes and everyday life. One of these characteristics is the activities and potential functions of the room. Today many of the daily activities and routines in the hospital are performed without involving the patent, where for instance meals are planned in advance, cooked in large industrial kitchens and served at certain times. Another essential characteristic related to the homely atmosphere

is

believed

to

be

the

materials

and

textures

of

the dayrooms. Today these rooms are often marked as institutional and are often decorated and furnished as the bedrooms, hence the distinction between the dayroom and the rest of the hospital are often immaterial. The materials used in today’s hospitals (wood, fabrics, textiles, colors, etc.) May be the same as we use in our own home but the way they are used have very different conceptions. Textiles are for instance a material that is used rather carelessly, and does not derive the potential as we experience in our domestic environment. At homes the textiles are applied for curtains, cushions, blanket,.etc all adding a tactile perception to the material, which imply comfort and coziness to the space and experience. Today this critique may be noticed in many hospitals, as the high restriction in regards to hygienic and durability demands have excluded nearly all tactile materials, including textiles, from many applications. However, recent research and development in smart textiles is improving the potential use of textiles in new recognizable ways in future hospital environments, where the use of tactile and sensory materials, like textiles, would be possible to implement with great beneficial value. Finally, the details and arrangement of furniture should reflect a homely environment. The size of the A private space in the sun at Maggies London

room,

furniture

orientation

and

the

room

accessories like artwork, greenery, light fittings, etc. are important aspects that should be incorporated and considered along with the design of the space, in order to design a holistic social space facilitating social interaction and support.



31

Textile use in a lliving area of single patient room, fortis hospital, gurgaon

Summary The homely atmosphere in future hospitals may be difficult to define, as our home is usually very personal and individual and therefore impossible to transfer directly to a health care environment. However, it is the research of this project, that by implementing three fundamental characteristics of our home and everyday life, including functions; materials and textures and details, it is possible to create a more homely atmosphere in the social spaces, than we experience today. This atmosphere is considered beneficial for the more developed levels of social interaction and social support, as the conversations in safe, comfortable and homely environments are believed to be more outspoken and emotional than the acquaintances in the regular, standardized and clinical dayrooms we experience today.

2.4 THE THEORETICAL APPROACH HOW TO ACHIEVE SOCIAL INTERACTION AND SUPPORT Appealing and attractive spaces for social interaction and support in future hospitals are depended on the surrounding architecture and the detail of the physical design, seems easily accepted through evidence-based decision



32

maker, urban planners and anthropologists if the environment is not providing possibilities for social activities, there will not be any interaction between patients-hence no social support. The architectural effects described in the previous chapters, will in this chapter be compiled in three guiding subjects, including functions (1); materials and textures (2) and details (3), and through a translating description, their aspects are defined in regards to the context of hospitals. This theoretical approach will define the main visionary guidelines for the design phase of this project as well as form the basis of the evaluation model used in the later following case studies. The theory described by Gehl(2003) and T.Hall (1973) states that people attracts people, if the social area remains unattracted then physical environment remain empty all the time. When patents or their families have engaged social interaction, maybe through the attractive functions, they should develop these contacts, which call for spaces recognizable from their own home, partly achieved through a mix of functions – reflecting the everyday life.

Following the ideas and theories of the described

anthropologists, the materials and textures should overall assist in creating a familiar, sensory and homely atmosphere. The final aspect considered as one of the main guidelines for future social spaces are the details and interior planning in human scale, concerning scale, personal distances and sociopetal spaces. Often small details change the

way

we experience a room, and some of the main physical elements in today’s hospitals, like acoustic ceiling sheets, integrated artificial lightning, vinyl flooring, etc. are only supported by the details of for instance co ffee serving, greenery, arts and furniture, all together defining the social space as institutional, inhuman and basically unfit for social interaction.

2.4.1 FUNCTIONS REFLECTING THE EVERYDAY LIFE We often see uninspiring and unattractive spaces in hospital which is not used by the patient. Above all , patient should have choice between social and private space, ideally a gradual transition between them. Private spaces may appear in single room but a new concept is needed to get complete framework of common spaces and dayrooms in the future should appear social. This social aspect may derive



33

from inviting, attractive and socially obvious functions performed by patents and their families in the common areas of the patent ward. Accordingly, the specific programming of the common spaces in future hospitals is essentially important to design very deliberate. Firstly, the patients should engage acquaintances, through a process that may be compared to the human interaction in public spaces or the small talks with our neighbor in the front yard. In a future patent ward these informal meetings may occur in the common dayroom or even in natural flow intersections and recesses along the hallway. Secondly, the patents should develop these initial relationships, through deeper conversations and social interaction, which may cause for more recognizable and familiar settings, reflected in the patents’ everyday life. When considering functions in the common spaces, these might actually be quite parallel to the activities performed in our daily life and the planning of a patient ward may even be compared to a regular single-family house having rooms for: conversations and drinking coffee in the living room, relaxing in the lounge area; dining around the kitchen table; simple cooking in the kitchen; entertaining around the television, etc. By introducing these social activities in new-designed patent wards, and by making them optional and inviting for both patients and their families, spaces for social interaction and support are believed to have improved conditions in future hospitals.



34

2.4.2 MATERIALS & TEXTURES FAMILIAR AND HOMELY ATMOSPHERE



35

Besides reflecting the everyday life through planned activities and programming of the social spaces, materials and textures also have significant influence on the way we feel, act and interpret the room, and should reflect the familiar and homely environments we are

accustomed

to

from

our

own

house.

A deliberate choice of materials for any room, i.e. the visual surface and the tactile perception, are often under prioritized in many projects, and in health care architecture, the high demands for hygiene, cleaning and durability are usually decisive factors when considering materials in both bed rooms and common areas. Consequently, the spaces often appear clinical and institutional, with standard equipment and furniture, acoustic ceilings, white plaster walls, etc. As regards to social interaction, these spaces are predicted to limit the potential, as the patients will adapt their behavior to the institutional surroundings with no conclusive benefit for engaging social interaction and social support. Today human qualities are competing against hygienic standards and general call for durability, and the predominant challenge for the health care architect is therefore to balance between the homely expression and the rational clinical demands, keeping in mind that the close compromise may determine the success or failure of the spaces for social interaction.



36



37

2.4.3 DETAILS INTERIOR PLANNING IN HUMAN SCALE "In context of EDWARDT.HALL(1973)and GEHL(2003)" Small details may change our use and perception of any space rapidly, and if only prioritized by the architect, spaces for social support may be improved significantly in future hospitals. First of all, the overall scale of the room should be familiar in size and easy to overview if more personal conversations should take place, and even in regards to dimension of the furniture, Hall’s (1973) theories regarding social distances may be implicated. Smaller tables will for instance force patents to sit within their intimate distances (0,45 – 1,30 meter), which may be advantageous for deeper conversations and social support. However, if the patients do not know each other yet, the small table and intimate distance may be an unconscious limitation for patients to join an occupied table, and the patients will then never engage important initial contact. The design of details and furniture should therefore contemplate the intended social concept in the common areas. In this regard, Gehl (2003) is furthermore describing how the placement and orientation of furniture in public places influence the specific use. Seating environments along the perimeter of the room is usually preferred, where the individual exposure is limited, and it is possible to create a comfortable overview of the surroundings. Details in the orientation of the furniture may even define the social status of the room, where a face-to-face layout facilitates a sociopetal behavior and the back-to-back arrangement is creating a sociofugal, private space. Ideally the patent ward should provide both private spaces (sociofugal), passive observational spaces and social spaces (sociopetal) - although not necessarily in the same room. (Hall 1973). Today, details like light fittings, acoustic

regulators,

blankets,

cushions and other equipment are all details. However, by bringing focus to these significant details as well, the future design for social spaces may become a holistic design solution creating

a

homely and

inspiring

atmosphere

promoting

social

interaction and support.



38

2.4.4 THE LITERATURE STUDIES (secondary study)



39

In order to visualize the substance of the parameters (functions, materials and textures, and details), defend in the previous chapter, three various case studies will in the following chapter be described and evaluated based on the analysis form stated below. The overall thesis of this project defining the future spaces for social support as an intersection between the public space and the homely atmosphere is the overall basis for choosing three individual cases for analysis and comparison. Secondly, the cases are selected depending on the patent’s/person’s motivation for attendance, which follow the three guiding needs defined in Maslow’s hierarchy pyramid (Poston 2009). The basic needs as exemplified in a hospital (case 1), the psychological needs is exemplified in a cancer caring centre (case 2), and finally the self-fulfillment needs which is exemplified in a highend gourmet restaurant (case 3). To summarize the chapter of the wide-ranging case studies, a concluding compilation will define the common relevant guidelines for the design phase.

CASE 1 - LUND UNIVERSITY HOSPITAL



40



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2.4.4.1 CASE 1: LUND UNIVERSITY HOSPITAL KAVA SURGICAL

CASE 1 - LUND UNIVERSITY HOSPITAL

CASE 2- HEJMDAL

CASE 3 - RESTAURANT GERANIUM EMERGENCY DEPARTMENT



42

Lund University Hospital is placed in Skåne, Sweden as one of the larger regional hospital with 980 beds. The basis for this case study is the surgical emergency department (KAVA) with 24 beds and 4-500 patients per year hospitalized for 48 hours in average. Patents in this ward may be compared to oncology patients in regards to medical/surgical treatment and their general physical condition and mobilization. The ward consists primarily of multi bedrooms, where the beds are separated with curtains. When this specific ward is chosen as hospital case, it is due to the recent modernization and remodeling performed a few years ago in connection with transferring the ward. Here one of the focal points, among others, was new arrangements of social spaces. The recent buildings are constructed in 1968 and is today causing problems with the physical surroundings in regards to patient treatment and human healing condition. When the ward was chosen to move to another floor, staff was given the possibility to rethink the interior layout and organization of the ward without changing the main construction. Nurses and other members of sta ff initiated a process, where future requirements, visions and ideas were discussed and planned for the new settings. The intention of improving the social spaces was strong, and the fact that it was even a focal point in the nurse’s vision for a future ward shows appreciated awareness of its importance. The base in the new dayroom is the staff operated ward kitchen, where the meals to the entre ward are finalized (after being brought to the ward precooked from a central). Staff is consequently always present in the room performing a homely activity (in regards to cooking and not the method), and brings life and atmosphere to the space. Concurrently, the kitchen offers snacks and drinks directly from the kitchen counter, and mobilized patients can always get something to drink and eat directly from the kitchen – like in their own home. The general use of materials

and

textures indicates a clinical environment with

institutional

furniture,

vinyl

flooring and acoustic ceilings. Complimentary, there specific

are

single

Dayroom in the KAVA ward (Surgical emergency department). The social space is placed at the end of the blind corridor leading to the patent bedrooms.

elements

like a fruit basket, freshly brewed coffee, biscuits served in glass jar and blankets in the



43

lounge

area

that

attempt

to

drag

the

room

towards

a

more

homely

atmosphere. Along with the kitchen function these small details actually do support the domestic feeling of the dayroom with added features that may revive memories from the patients’ everyday life. However, the first impression and the overall experience of the dayroom as clinical and institutional is still predominantly. The intention of making the social space homely is noticeable although it lacks in completion of the commenced ideas, and a deliberate holistic approach towards creating social spaces in future health care environments are still needed for perfection.

FUNCTIONS What are the options for residence? The dayroom is considered the primary place for residence outside the bedroom, although there

are

some

smaller

furniture

arrangements in the hallway itself. These are not used during the observation, and they seem to be placed randomly in the busiest place of the hallway next to the elevator and with no seclusion from the semi-public corridor space.

What

are

the

optional

functions?

Besides reading and watching television as entertainment,

the

primary

activity

is

relaxation in the lounge area and dining at the tables. Secondly, the ward kitchen is an integrated part of the dayroom, and it offers self-provide able snacks at the ward buffet and the kitchen counter - patents have no access to the kitchen itself. Does the functions in the social space invite At

the

to time

of

participation? observation

(between



44

breakfast

and

lunch),

there were only a few people in the room, however occupied for longer

periods.

There

was

consequently only little social interaction – maybe because of different activities (snacking at the

dining

table

entertainment

in

and the

TV

lounge

area). As the functions are considerably

simply

seems

be

to

there

moderate

possibilities to join in occurring activities, although it may not be inviting as such.

MATERIALS AND TEXTURES List

and

short

description

of

used

Walls are standard white walls, floors are

grayish

vinyl

and

the ceiling of white acoustic panels with integrated lightning – the same as the rest of the ward (although change of color in floor vinyl); The kitchen is closed off for patients due

to

hygienic

demands

and

consists of steel and white laminated surfaces; Furniture in the dining area are wooden dining tables and chairs with steel frame and wooden seating; Furniture in lounge area of wooden tables and armchair and a couch with wooden frame and textile covered cushions.



45

materials,

textures,

furniture?

How is the room characterized by materials and textures? In regards to materials and textures, the room is considered quite institutional, as the vinyl floor and acoustic ceiling are predominant. The furniture in the lounge area have textile covered cushions although the dominant wooden frames and general design of these are institutional recognizable.

Are the use of materials and textures

consistent

and

deliberate? The

furniture

in

the

lounge

area,

area is varied, although it does not

accentuate

any

stories

or define a consistent use. The materials

in

the

dayroom

are not distinguished from the other areas of the hospital, and it may be different to tell the difference

between

various

rooms. In general the materials and textures seem chosen and applied haphazardly, and there is a overall lack of homogeneity and

deliberateness

in

the

hospital in this regard.

DETAILS HEALING ARCHITECTURE IN HOSPITAL DESIGN


46

kitchen

area

and

dining

Scale and partition of the room? The main dayroom is large in scale although with specifically defined partitions, and the room

is

consequently

experienced domestic in scale. The kitchen area is by a counter closed off towards the patent zone and is physically separating the room in two. The patient area are sub organized in a lounge area and a dining area of two tables. Furniture and distances? The lounge area is furnished with a 3-person couch and two armchairs surrounding an oblong coffee table. In scale it is recognizable from private homes and the multiple seating options provide alternatively choice regarding social distances; The dining area consist of two tables with 4 and 6 chairs respectively. The 6 person table is placed in the perimeter of the room in front of the window. The table for 4 persons is placed in the middle of the room and is not used during observation.

Other details? Specific details are worth mentioning as room accessories including a fruit basket and containers with biscuits in the kitchen area, as well as the blankets in the lounge. The intention of making a homely



47

environment is remarkable, although not quite succeeded. The overall impression of the room is due to the general use of materials still significantly institutional and it takes more than just small details to define attractive and welcoming social spaces.

CONCLUSIVE REMARKS Lund University Hospital is a case

illustrating

the

good

intention of improving the social spaces in the existing hospital wards. It is a significant progress just to call attention to the problem of unfulfilled common areas, and with the enhanced focus from the staff, some hospitals are taking the lead – and in Lund with various success. The fact that a fair amount of square meters are dedicated to the dayroom is positive, and the room even has some small elements, where the intersection between the homely atmosphere and the public space is combined - although not convincingly enough.

The

room

is

still

experienced

quite

institutional, especially expressed by the overall materials like vinyl flooring and acoustic ceiling sheets, and the lack of tactile and sensory elements. The idea of letting the kitchen be a central part of the room is in general good and even recognizable from our own home, but the fact that it is closed off from the patients may instead work as an amplified reminder of hospitalization? The kitchen table towards the patent area, is however a self-service are, which share familiar elements, although the freshly brewed coffee, which is chosen for its homely character, instantly turn institutional when being served in 3 liter coffee pot with stacked industry cups. The small details could easily have been better thought through, and why should the patients not have access to a smaller part of the real kitchen themselves?

In general the dayroom in Lund meets many of these adversative examples, where the intention lacks completion due to small details that easily could have been improved if they were only in focus. The room is therefore experienced as institutional even though



48

some positive elements do exist, and the future design of these spaces needs a more holistic approach towards material use and the general perception of space. Compared to the other dayrooms experienced in Lund University Hospital, the KAVA ward is indeed a consolation. On the floor below the dayroom is a 15 m2 room in the middle of the building envelope with no windows and natural lightning, and consequently it seems to be empty most of the day. The spaces for social support in future hospitals should, in regards to design and planning, be more holistic and well considered, than it is experienced in Lund.

3. SALUTOGENIC DESIGN MODELS 3.1 Antonovsky’s Theory of Salutogenesis 3.2 Alan dilani - psychosocially supportive design 3.3 Roger ulrich - theory of supportive design 3.4 Jan goelbiewski - neurology of supportive design



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3.1 ANTONOVSKY’S THEORY OF SALUTOGENESIS In contrast to the traditional study of the sources of disease, known as pathogenesis, Salutogenesis is an approach to medical treatment and healthcare that focuses on the origins of health. It was developed in the late 1970s by Aaron Antonovsky, a professor, researcher and medical sociologist who was interested in answering the question of how most people manage to live relatively healthy lives despite being faced with disease, emotional and physical stress, social struggles and other challenges: “Given the ubiquity of pathogens—microbiological, chemical, physical, psychosocial, social and cultural—it seems to me self-evident that everyone should succumb to this bombardment and constantly be dying” (Health Stress and Coping ). He wrote: “the question then becomes not how some concentration camp survivors or poor people manage to stay healthy, but how any of us manage to stay healthy—the question of Salutogenesis” . By shifting his focus from disease to health, Antonovsky began to develop a systematic research methodology with a focus on what promotes health, as opposed to what causes disease. Finally, Antonovsky was concerned that the pathogenic approach implies a dichotomous relationship between health and disease; that is, a patient is healthy in the absence of disease. This idea precludes the possibility of disease and health being interrelated, simultaneous and multi-dimensional conditions. In the 1990s, architect Alan Dilani suggested that Antonovsky Salutogenic approach be applied not only to medical treatment and research, but also, to the physical design of healthcare facilities as a means to promote health. He suggested the use of Antonovsky theory to create Psychosocially Supportive Design, a theory and framework that promote health through the design of the physical environment. In order to understand how Salutogenesis can be applied to design, it is necessary to identify some key concepts of Salutogenesis, the most notable being the disease/ease spectrum, the relationship between stress and tension, the role of personal and social resources that one has available—or as Antonovsky calls these, Generalized Resistance Resources—and sense of coherence. Antonovsky placed health and disease, or ease and dis-ease, together on each end of a continuum. He defined the health ease/dis-ease continuum as a: “multi-faceted state or condition of the human organism” . He emphasizes that Salutogenesis is not about making a sick person well, rather it is about identifying their location on the continuum, and mitigating the stress that may move them towards the dis-ease side . One of the key defining characteristics of the Salutogenic model is what Antonovsky refers to as a sense of coherence. He defined sense of coherence as: “a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that (1) the stimuli derived from one’s internal and external environments in the course of living are structured, predictable and explicable; (2) the resources are available to meet the demands posed by the stimuli; and (3) these demands are challenges, worthy of investment and engagement”



50

According to Antonovsky the strength of one’s sense of coherence is determined by three key factors: comprehensibility, manageability and meaningfulness (Table 1)



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3.2 ALAN DILANI - PSYCHOSOCIALLY SUPPORTIVE DESIGN In the 1990s, architect Alan Dilani, proposed that Antonovsky’s principles be applied to the built environment, specifically to the design of healthcare facilities. Since then, Dilani and many other architects, designers and theorists have begun to further explore Antonovsky’s theory and to approach architecture, interior and urban design through a Salutogenic lens,. Alan Dilani conceived this idea to promote health “The Psychosocially Supportive Design approach is offered as a useful theory and framework to guide healthcare designers and planners who consider how the physical environment impacts wellness factors in order to promote health”. According to him Salutogenic design not only identifies the cause of stress it can also introduce the wellness factor that can strengthens health. “The theory suggests that we not only design for stress reduction, but focus on salutary rather than risk factors”. Based on his vast research he created a list of design qualities that he argues strengthen an individual`s sense of coherence. (Table 2) lists these attributes and categorizes them based on Antonovsky’s sense of coherence factors.

This includes the designers and developers, as well as the doctors, staff and possibly the patients and their families. If the entire team understands the impact that design has on a sense of coherence and in turn on the success of a project, they may be more likely to support the design process and to encourage the upkeep of the facilities. “The organization should measure the sense of coherence; the staff should comprehend it and act on it”

3.2.1 Psychosocially supportive design The quality and character of the designed environment should be considered to be a powerful instrument capable of improving and strengthening health processes. The question how health care environments could promote the patient’s health should be a major issue for designers and planners. Since the new care philosophies (Salutogenic based perspective) involve both the human body and its psychosocial context the interaction between the nursing staff and the patients will become increasingly important in the future.



52

One of the conditions for health promotion in hospitals is to create an organization that provides the major parts of care services as close to the patient as possible, within the patient’s familiar environment. An emphasis on patient-focused care presupposes a different building structure, as it requires a decentralization organization. Instead of the traditional grouping structure the new model for RIT 2000 (University Hospital in Trondheim), in Norway, has been organized around the patient and his/her disease. The planning for RIT 2000 has broken important new ground by integrating and extending concepts such as a patient-centered care philosophy and environmental design, and multi disciplinary care teams.

Traditional wards where the staff is based somewhere in a room far away from patient rooms will disappear. In modern wards, there will no longer be a nurse station but a centrally placed workstation, which is easy to reach, and where the staff is always available. From there, the staff should be able to survey and watch a group of patients within a very short walking distance. This arrangement is called a “cluster”. A ward can consist of two or three clusters which can easily be coordinated and flexibly used depending on the patients’ demand for care. Communication and contact between staff and patients is made easier in this way, creating a feeling of security for both staff and patients. Research has shown that access to nature, daylight and other wellness factors like art and music can result in the patient using fewer drugs and spending less time in the hospital. Nature can affect our emotions positively. It can easily catch a person’s attention or interest and in turn can stop or reduce anxiety while bringing about desirable psychological changes. It can reduce blood pressure, ease pain and stimulate our senses positively. An increase in the consideration of wellness factors within design could have beneficial effects on well being and health processes and thereby creates environments that are not only functionally efficient but also highly psychosocially supportive.



53



54



55

3.3 ROGER ULRICH - THEORY OF SUPPORTIVE DESIGN Although Roger Ulrich’s Theory of Supportive Design does not specifically follow Antonovsky’s Salutogenic approach, it does support the physical characteristics of Salutogenic design. The Theory of Supportive Design is a stress-based model that is a marriage of semi scientific and scientific research. It looks at how design affects healthcare outcomes in a traditional design setting, using stress as a starting-point. According to Ulrich, manifestations of stress can be psychological, physiological and behavioral. Ulrich states that instead of working to mitigate these negative manifestations, the design of traditional healthcare facilities actually worsens them. Noise, lack of privacy, and visually un-stimulating design elements can undermine a patient’s sense of personal control or autonomy, whereas, supportive design can aid in coping with stress and foster improved medical conditions. Ulrich focuses on three supportive design guidelines :1. Design that fosters a sense of control with respect to physical surroundings; 2. Design that facilitates access to social support; 3. Design that provides access to positive distractions Some of the scientific research done by Ulrich on the :A. influence of gardens and plants in hospital and in other healthcare settings. B. view through the window may influence recovery from the surgery. C. new spaces where patents through social interaction and support may reduce their experience of loneliness and fear in the hospital environment. He identifies general guidelines intended to help inform the designer’s creativity and point the designer in a direction that will lead to stress-reducing design and that can be tailored to meet specific needs and goals. Although Ulrich’s model may have helped inform Salutogenic design and provides some key design characteristics that will alleviate stress, it lacks the integrative and holistic approach that is key to Salutogenesis. Ulrich’s model is much more specific than Salutogenesis and does not look at the bigger picture of health promotion through design and how designers can achieve this goal, from conception to completion. It is still, however, valuable to recognize Ulrich’s theory, as it is a significant contributor to current Salutogenic design models.



56

CURRENT EXAMPLE:The Khoo Teck Puat Hospital (KTPH) in the city / state of Singapore is setting new standards for incorporating nature into the design and layout of the health facility. Tim Beatley in UVA Design describes it as “arguably the greenest, most biophiliac hospital in the world”. Using the principles of biophilic design, and incorporating nature’s influence into the design of healthcare facilities has numerous positive benefits.

With this in mind,

Interface’s Essence range has been designed using natural patterns and hues to create spaces that echo nature; helping hospitals become places of rejuvenation and healing rather than decline and sickness.



57

3.4 JAN GOELBIEWSKI - NEUROLOGY OF SUPPORTIVE DESIGN Jan Golembiewski, a leading researcher of the relationship between the built environment and mental wellbeing, states that: “Salutogenic theory is a particularly useful tool as it is specific and easily applied to an architectural application” Similarly to Dilani, he maintains that comprehensibility, manageability and meaningfulness— which support a strong sense of coherence and foster a natural healing process—have clear architectural ramifications. He studies the architecture and design of psychiatric healthcare facilities through the lens of comprehensibility, manageability and meaningfulness. 1.Comprehensibility- he says, is making sure that perceptual cues are present to assist perceptual processes. These include attention to texture and materiality, controlling the size of spaces and the numbers of patients and normalizing environmental features. 2.Manageability- making provisions for patients to exercise control of their environment. Features such as operable windows or access to sporting facilities can make a significant difference in the level of manageability a patient may feel. Meaningfulness refers to a personal or cultural connection and can be enhanced by aesthetics or by consideration of spatial organization, such as providing spaces for visitors or for special personal belongings. it is the most special ingredient of sense of coherence. Golembiewski states that: “Under normal circumstances people have a great deal of ability to adapt to new surroundings—even in stressful situations… However, when environmental factors start to erode a general sense of coherence—when meaning, control and comprehensibility are lost—resistance to disease weakens and perceptual difficulties are exacerbated, often creating a vicious circle of increased vulnerability and anxiety”. In his research he found that manageability, comprehension and meaning have significant architectural ramifications and they are central to Salutogenic design. As well, his studies that show how environmental factors may erode a sense of coherence and, in turn, will weaken resistance to disease and perpetuate anxiety



58

4. Precedent case studies 5

4.1 Fortis hospital , gurgaon , India 4.2 Medicity , gurgaon , India 4.3 Analysis / interviews



59

5.1 FORTIS HOSPITAL, GURGAON , INDIA 5.1.1 INTRODUCTION 5.1.2 REASON OF THIS CASE STUDY 5.1.3 SALUTOGENIC DESIGN METHOD AND EVALUATION A. Mapping out in relation to Antonovsky`s sense of coherence factor B. Evaluation model in relation guidelines set through study of Edward T. hall and Gehl theory. 5.1.4 CONCLUSION



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4.1.1 INTRODUCTION Location : sector 44, Gurgaon Site area : 43,303 sq. m. Built – up area : 65,961 sq.m. FAR : 1.52 Principal Architect : Ar. Rajinder kumar, Rajinder Kumar Associates, New Delhi 

Fortis Memorial Research Institute, Gurgaon (FMRI) is a flagship hospital of the Fortis Healthcare Limited.



FMRI is a multi super-speciality, hospital.



FMRI is a set on an 11 –acre campus.



It has 430 functional beds, with a further planned increase in beds to 1000.



FMRI is accessible easily by road, It can also be reached using Delhi Metro, as the hospital is located opposite to the HUDA city metro station

DEPARTMENTS 

Minimal Access, Bariatric & GI Surgery



Plastic Surgery



Ophthalmology



Pulmonology



Plastic Surgery



Dental Sciences



Internal Medicine



Cosmetic & Plastic Surgery



Invasive Cardiology



Paediatrics



Minimal Assess Surgery (Gynae)



C-DOC



Neonatology



Liver Transplant, GI & Hepato Pancreato Biliary Surgery



Mental Health & Behavioural Science



Radiation Oncology



Radiology



Rheumatology



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

ENT



Gastroenterology & Hepatobiliary Sciences

LOCATION :-



62

NIEGHBORHOOD CONTEXT :-



63



64



65

4.1.2 REASON OF THIS STUDY



66

There are tremendous reason for choosing this hospital , main aim to create an environment which should not give a sense of boring hospital. The design philosophy behind this hospital to provide the health and well being of the people they serve through integrated, innovative, and compassionate care, also creates spaces that allow for privacy, rejuvenation, choice, humanistic scale, feel and experience, communication, and collaboration. The Hospital should incorporate new trends like wellness, technology and creates a Gen Next Medical Center which sets new standards for healthcare focusing on healing & nurturing robust health. At the south corner is a quiet & sun-filled healing garden for patient, recuperation & areas of respite for staff and families. All major areas in the hospital will have natural light for healthy and sustainable environment. The architecture of this hospital considered the healing source, although factors like daylight, room atmosphere, sound, music, art and optional privacy, altogether are believed to assist in creating carefully designed environments that affects and supports the psychological and physical healing of the patients. With acceptance of the architectural influence on human healing aspects, it is even more obvious that healing architecture should be incorporated in the planning of future hospitals.

4.1.3 SALUTOGENIC DESIGN METHOD AND EVALUATION



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A. Mapping out in relation to Antonovsky`s sense of coherence factor Based on research done by Alan Dilani on theory of Salutogenic by Antonovsky , he created a list of design qualities which enhance the sense of coherence . In case of Fortis Hospital there are some design qualities which enhances coherence factor of the building. Although , in hospital some patients are in stress , anxiety , fear , loneliness , insecurity , frustration and generally longer hospitalization due to the unsuited facilities but in case of Fortis Hospital there are no such situation which demoralize the patient. The design of this hospital suggest that we not only design for stress reduction , but focus on salutary rather than risk factors. There are several design features which shift the pathogenic approach to Salutogenic approach manifests in the built environment. According to Antonovsky the strength

of

one’s

sense

of

coherence

is

determined

by

three

key

factors:

comprehensibility, manageability and meaningfulness.

A.1 COMPREHENSIBILITY - It means when faced with stressful situation or challenge , a person will have the ability to seek meaning in it, and will do his or her best to overcome it. There are some design characteristics which help in enhancing the sense of coherence among the patient , staff and visitors , discussed below;-

1. WAY FINDING  Modular planning of clinical floors to optimizes flexibility and improves way finding.  Clear organization and simple circulation system within medical areas eases patient and staff use.  Flexible floor plates provide shared practice space, systems, and amenities for various clinical modules and sub-specialties.  Ward layouts in older hospitals generally provide long corridors organized around a central nursing station, where medication and charts are located. Research has shown that nurses spend much of their time walking up and down halls increasing fatigue and stress and sharply cutting the time available for observing patients and delivering direct 

care. Common console for cathlabs , MRI, X-RAY , AND ICT decreases the circulation pattern proves efficient for patient and staff.



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DIRECTION SIGAGE BOARDS EASE

SIMPLE CIRCULATION SYSTEM

PATIENT USE.

ESCELATORS FOR EASE AND FAST MOVEMENT FOR BOTH VISITORS AND STAFF.



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70

PLAN OF THE NIGHTINGALE WARD



71

VIEW OF THE NIGHTINGALE WARD. ( LESS CORRIDOR SPACE USED IN PLANNING OF WARD MAKE IT EFFICIENT FOR STAFF AND PATIENCE).

2. PERCEPTION The experience already starts when guest or patient enters the lobby area , where an welcoming fountain sculpture and reception welcomes the visitor with a holistic experience. In a beautiful designed combination between the functional space and interior decoration , the holistic experience make you feel forget where you really are. When focusing on the lowest levels of Maslow’s pyramid of needs, the physical and psychological, respectively, the high-end hospital

like Fortis is primarily addressing the self-fulfillment needs of

the visitors, and Fortis is accordingly providing a holistic experience, where design and atmosphere is united in a multiple sensory expression.



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REFRESHING & CONGENIAL ENVIRONMENT FOR PATIENTS BY CREATING A MODERN, UP MARKET & PLUSH INTERIORS.

3. LANDMARK While entering the central courtyard we see a white sculpture titled Loveable Curious Child – a baby with a stethoscope plugged into the ground, creates a landmark of the hospital building. Around this sculpture many people take selfie and sit together, seems to be an vital part of the hospital social space.



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VIEW OF A CENTRAL COURTYARD

4. PLEASURE It also accommodate a small cinema name as " FORTIPLEX", for visitors it is a recreational hall where visitors can watch a cinema for several time, so that they will get some relaxation and stress free time



74

A.2 MANAGEABILITY- A person can sense of the situation , problems or challenges that they face. it also mean making provision for the patients to exercise control over their environment. Features such as operable windows or access to sporting facilities can make a significant difference in the level of manageability a patient may feel. “The feeling that a



75

person is in control of his or her environment and life circumstances is very fortifying… the feeling that you are totally out of control is absolutely disempowering” 1. AESTHETIC ELEMENTS

2. NATURAL LIGTH

Perception of sunshine contribution study done for the fortis hospital ( included both patient and staff interviews)

Survey question Considered sunlight to be a nuisance Considered sunlight to be pleasurable Considered sunlight to be calming Considered sunlight to be unfavorable

Patient

Staff

2%

55%

91%

33%

95% 1%

37% 18%

The study found that these patients subsequently required less narcotic pain medication, experienced a shorter hospital stay, and had fewer negative evaluative comments in nurses’ notes.



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SECTION SHOWING NATURAL LIGTH PENETRATION IN THE ATRIUM



77

All major areas in the hospital will have natural light for healthy and sustainable environment. Skylight at the roof transmitting natural light into the most common & waiting areas.

DOUBLE OCCUPANCY ROOM

SINGLE OCCUPANCY ROOM

The integration of natural physical environments into treatment for human sufferers has always proven to be an effective course of action. Elements in nature emulate qualities of calmness and serenity that are necessary for a healing environment. There are two benefits of windows: one is daylight and the other is view.

3. GREEN ENVIRONMENT

VIEW OF THE EXTERIOR LANDSCAPING AT THE ENTRANCE PORCH Landscaping in order at the entrance give visitor and patient a sense of order , decreases the stress and anxiety among the patient , ultimately arouses a level of coherence factor



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among themselves. it also provide a sense of supportive design for patient as plants represents

life

,

growth

and

hope.

they

can

provide

interest

and

diversion.

A.3 MEANINGFULNESS- In the face of a challenge or stressful situation, a person has adequate their disposal and that they trust , which can help them cope.

1. SOCIAL SUPPORT

ARRANGEMENT OF FURNITURE IN MAIN ATRIUM SPACE increases the social support among the visitors as they talk to each other about the disease or experience without knowing the patient, these kind of seating arrangement make these spaces as sociopetal. The fact that it is only space adds a social unifying value, even though it is still possible for different groups to sit privately at the same sofa at one time. The ground floor is the center for social interaction, where people arrange meetings or just engage on informal basis.



79

ARRANGEMENT MATERNITY

OF

FURNITURE

WAITING

AREA

IN FOR

MOTHER is designed in such a homely attmosphere which reduces stress level among the patient. The detail with the false cieling and sofa shows the intention making the waitinf area comfortable , homely space but the specific choice of curtain make it seem clinical in some respect.

2. MUSIC AND ART Studies have shown across a variety of patient groups that pleasant music, especially when controllable, often can reduce anxiety or stress and helps some patients cope with pain.



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Wallpaper at pediatric centre

Wallpaper at oncology department

Patient Based Art Programs include artwork that is selected based on the unique needs of each patient groups (such as Cancer, Pediatric, Geriatric, Women, Heart, ICU, Rehab and Psychiatric). Patient Based Art helps to deinstitutionalize the clinical setting while illustrating a sensitivity to location and patient demographics. Patient based artwork can also aid in way finding by helping to visually identify areas. A successful healthcare art program consists of a coordinated series of visual elements placed in public and private spaces throughout the facility. The selection of these elements, as well as their size and placement, is crucial to the success of the program. If photographs and slides of nature are viewed positively and reduce stress, it is probable that artwork that replicates nature would also have this effect. Research on adult patients suggests that by infusing art into the healthcare setting, patient-focused design may foster improved moods or reduce stress that would impact the negative thoughts that could impede the healing process.



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ALL

PHOTOGRAPHS

ARE

CLICKED

BY

DIFFERENT DOCTORS ACCORDING TO THIER EXPERIENCE AND ALIGNED IN THE HOSPITAL CORRDIOR.



82

3. VIEWS

VIEW OF THE GARDEN AND THE CITY FROM SINGLE OCCUPANCY SUITE ROOM IN NORTH DIRECTION. Views of vegetation, and especially water, appear to sustain interest and attention more effectively than urban views of equivalent information rate . Because most natural views apparently elicit positive feelings, reduce fear in stressed subjects, hold interest, and may block or reduce stressful thoughts, they might also foster restoration from anxiety or stress. in comparison with the wall-view group, the patients with the tree view had shorter postoperative hospital VIEW OF THE GREEN AREA FROM DOUBLE

stays,

had

OCCUPANCY ROOM IN SOUTH - EAST

comments from nurses, took fewer moderate

DIRECTION.

and strong analgesic doses, and had slightly lower

fewer

scores

for

negative

minor

complications

.

comparatively

therapeutic

evaluative

postsurgical

natural

scene

had

influences,

it

should be recognized that the "built’ view in this study was a comparatively monotonous one,



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a

largely

featureless

brick

wall.

B. EVALUATION MODEL IN RELATION GUIDELINES SET THROUGH STUDY OF EDWARD T. HALL AND GEHL THEORY.

B.1 FUNCTIONS What are the options of residence ? The living area in suit room considered as primary place for visitors , where visitors always remain close to the patient. Although looking at the furniture arrangements in the living room looks almost like you are in such a homely atmosphere, which ultimately increases the sense of coherence among the patient. The lighting in the room sets a relax mood of patient and visitors both , which changes the pathogenic place to Salutogenic place.

seating arrangements in the suite room for visitors.



84

What are the optional functions ? You

can

watch

television

as

entertainment , the primary activity is relaxation on the lounge. Other than this there are no such optional activities like kitchen counter for selfprovide able snacks in the room.

Does the function in the space in the social space invite the participation? When you arrive in the center staff is

welcoming

the

guest

accommodatingly

and

friendly

describing the various possibility in house. This behavior enhances the homely atmosphere , arouses a sense of coherence among the staff and visitors. The arrangement of furniture also allows different visitors

seating arrangements in the cafe area for visitors.

to sit together and talk to each other.

B.2 MATERIAL AND TEXTURE seating arrangements in the central courtyard



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area for visitors.

List

and short description of used material, textures, furniture?

The

red color broad strip dominating the central courtyard is a sound absorbing material

which

reduces the bad noise , enhances the healing

power

of hospital. Furniture are consists of couches

and

armchairs in white upholstery with colorful accessory cushions and small wooden tables

aside.

The red color strip dominating interior of atrium

How is

the

room characterized by materials and texture? In regards to material and textures , the space

is

not seems to be very attractive and luxury, as

the

travertine stone flooring and designed false ceiling generally predominant. The furniture used in lounge area have leather covered cushions ,recliners and general design of these are luxury.

Recliners in NICU waiting areas

Are the use of materials and textures consistent and deliberate? The furniture in the ward area seem to be institutional , although it does not define a consistent design as compared to single occupancy room . The material in the ward

are

distinguished from the other areas of the hospital. There is some lack of luxury in these common ward as compared to other areas.



Not that much luxury in common ward areas

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B.3 DETAILS Scale and partition of the room ? The main suit room is large in scale through with specially defined partition with door accessibility and the room is experienced personalized in scale. The living area in this category divide the room into two. The patient area is kept quiet institutional and a living area is non institutional.

Furniture and distances ?

The room is divided in patient and visitors use in presidential suite.

The living area is luxury designed with a 6 - person dining table and one armchair with a coffee table. In scale it is recognizable from private homes and

the

multiple

seating

options

provide alternative choice . The lshape

sofa

is

placed

along

the

perimeter of the room and is not used during observation. There is one dining table and couch for seating.

Other details ? Specific details such as flower pot at the window bay as well as lamp in the living area arouses a feeling that a patient is in his/her home. t is done to define attractive and welcoming social space.

Small details gives a feeling of home.



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4.2 MEDANTA HOSPITAL, GURGAON , INDIA 5.2.1 INTRODUCTION 5.2.2 REASON OF THIS CASE STUDY 5.2.3 SALUTOGENIC DESIGN METHOD AND EVALUATION A. Mapping out in relation to Antonovsky`s sense of coherence factor



88

4.2.1 INTRODUCTION Medicity will be a world class 1,200 bed hospital with 10 super specialties, 40 high-tech, air-conditioned surgical amphitheatres equipped to perform robotic surgery, and much more. On its campus, there will be a medical college and a paramedical college, as well as a diagnostics and research and development facility. Area: 43 Acres Built Up Area: 15, 00,000sq ft Client: Global Health Pvt. Ltd. (The Institute of Integrated Medical Sciences & Holistic Therapies) Architect: cardinal hardy architects / jodoin lamarre pratte architects / group arcop Cost: 900 Crores Rs. (Approx) Status: Design Development Departments : Division of Endocrinology and Diabetes

Division of Endocrinology and Diabetes Division of ENT & Head Neck Surgery Department of Internal Medicine Department of Ophthalmology Division of Plastic, Aesthetic & Reconstructive Surgery Department of Pathology & Laboratory Medicine Department of Physiotherapy & Rehabilitation Division of Radiology & Nuclear Medicine Department of Transfusion Medicine (Blood Bank) Emergency & Trauma Care Pharmacy

4.2.2 REASON OF THIS STUDY



89

There are enormous reason for choosing this hospital , The prestigious Medicity project, a state-of-the-art institute of integrated medical sciences and holistic therapy, will, for the first time in the history of medicine, combine different

streams

of

medical

science

such

as

allopathy, Ayurveda,

homeopathy, naturopathy and unani, to find a holistic treatment for modern ailments and diseases. The design philosophy behind this hospital to provide the health and well being of the people they serve through integrated, innovative, and compassionate care, also creates spaces that allow for privacy, rejuvenation, choice,

humanistic

scale,

feel

and

experience,

communication,

and

collaboration. The architecture of this hospital considered the healing source, although factors like daylight, room atmosphere, sound, music, art and optional privacy, altogether are believed to assist in creating carefully designed environments that affects and supports the psychological and physical healing of the patients. This is a project that is very close to our heart. The Trehan family, who formulated the vision and encouraged a detail-oriented execution of the project, were wonderful people to work with. We wanted to create an uplifting and happy space far removed from how we generally see hospitals. It was a tremendous opportunity to create a difference, especially amongst people who were unwell and recuperating.



90

MEDANTA HOSPITAL

NIEGHBORHOOD CONTEXT:SITE PLAN :-



91

5th floor level plan :- Green color represent healing garden , as it is enclosed between the buildings, which acts as a central green court or we can say a healing garden for the patient to increase common activity aoruses the sense of coherence among the patientand the staff.

N



92

10th floor level plan :-

N



93

4.2.3 SALUTOGENIC DESIGN METHOD AND EVALUATION A. Mapping out in relation to Antonovsky's sense of coherence factor A.1 COMPREHENSIBILITY 1. Way finding Clear organization and simple circulation system within medical areas eases patient and staff use. In case of medanta there is no such common ward arrangements which arouses a problem related circulation of staff and visitors. Ample amount of daylight is penetrating in the corridor areas so that there will no dark spots in the corridor, proper signage boards and welcoming staff helps visitors in way finding to their destination.

Daylight in corridor ,but does,nt have soft edges

lift lobby showing rectangular dead end

The language of forms in architecture also has a correlation to the feeling one obtains from the space. For example the natural environment has soft edges, but no right angles (Red stone). However, the right angles in our everyday life are endless in the built environment. The architecture of a healing environment can take on the qualities of natural conditions through imitation in form. While one might feel constrained and boxed in rectilinear spaces, the fluidity of an organic space creates no such feeling. Without right angles, the spaces become seemingly less harmful and comforting to the human eye. "It is not the rectangle which is the problem, but its life-sapping characteristics. Where materials, textures, colors, light, living line and



94

human activity can reinvest such forms and spaces with life, the ly None the less, in general, one feels on much safer ground with non-rectangular, or shape-moderated spaces.”-RogerUlrich

2. Colors As the color of the ceiling and walls are mainly white , slightly change in bedrooms but although it is kept as

institutional look. The ceiling is cement plastered incorporating

various HVAC or piping with adequate cove lighting.

View showing the texture and colors of waiting areas and private rooms



95

3. Nature Medanta come up with the design solution to give natural views to visitors waiting area and lounge area through floor to ceiling windows. It is evidence that visitors having a view of nature remain calm and peace. Outside the building there is also an assembly area for the visitors where visitors walk and talk with each other, in term increase the social support among them.

Stepped terrace landscaping in front of window.

visitors having view of terrace landscaping through window.

Green lawn in front of the hospital entrance for social gathering Green entrance and landscaping in a systematic pattern arouses a sense of control among the patient and visitors, which realizes the patient a sense of security ultimately increases the coherence factor among the staff and patient.



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Systematic arrangement of shrubs and trees

4. Pleasure

There is a provision of lounge area for visitors with a capacity of 20 recliners and 15 sofa set with center table, so that visitors find relax when they are tired or in stress. They can also watch television and read magazine, it is 24 hrs open for the visitors. The furniture used in lounge area have leather covered cushions ,recliners and general design of these are luxury.

View of the lounge area for the visitors for night stay.

A.2 MANAGEABILITY 1.Natural light

Perception of sunshine contribution study done for the medanta hospital ( included both patient and staff interviews)

Survey question Considered sunlight to be a nuisance Considered sunlight to be pleasurable Considered sunlight to be calming Considered sunlight to be unfavorable



97

Patient

Staff

2%

45%

89%

35%

91% 1%

32% 12%

As the orientation of the building is north -south oriented, building has two big bed tower which is interconnected with one central arm. The two bed tower enclosed an green area in between which is having shaded area due to south-east block. While talking about the interior space of bedroom , The bedroom on outer side of south-east block get ample amount of daylight while the inner face is in shaded region , on the other side north-west block getting the west sun in the inner side while the outer side is in shaded region. Other areas like food court and waiting lounges are getting ample amount of daylight. Some areas like waiting areas in OPD section on above floors are not getting daylight , seems to pathogenic in that case , which increases the stress level among the patient and visitors.

Day light penetrating in the food court through double

Waiting areas at each floor situated at perimeter of

height glazing , refreshes the mood of visitors.

building connected through window.



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Healing garden enclosed between the building block not

Some waiting areas are not getting ample

getting direct sunlight from east direction.

amount of daylight makes them boring .

Bedroom facing south-east direction , ample amount

Bedroom facing north-west direction, deficient of

of daylight through window.

daylight.

2. Green environment Healing landscapes have long been an important aspect of human life. When people first began erecting dwellings, healing places could be found within nature through sacred groves, special rocks and caves . With same approach of Roger ulrich , medanta also accommodates a healing garden or we can say a therapeutic garden on the fifth floor level for the patient use only.



HEALING GARDEN

99

Healing gardens foster`s the following elements: a. Sense of control Patients/residents must know a garden exists, be able to find it easily and be able to access and use the space in an active or passive way. It should also have areas for privacy that are shielded from window views. A variety of types of spaces can aid in allowing users to make choices. Feelings of control can also be enhanced by involving users in the design of the garden. b. Social support Spatially enclosed settings that allow for socializing are often preferred by users. Designing for small as well as the occasional large group (associated with hospital initiated programs and large extended family visits) is important. However, all considerations for social support should not deny access to privacy (which undermines patient control) c. Physical movement and exercise Mild exercise can be encouraged by designs that allow for patient accessibility and independence and provide features such as walking loops. d. Access to nature and other positive distractions Medicinal and edible plant species and those that engage all of the senses are often a good choice for the design’s plant palette, as are plants that encourage wildlife.

e. Sense of personalized environment Schematic diagram showing the interaction of bedrooms and healing garden adjacent to each other on 5th floor



100

Above figure shows the spatial assessment of Medicity based on the green approach, shows the arrangement of bedrooms along the healing garden which increases the physical interaction between the nature and patient helps in reducing the stress level among the patient , ultimately enhances the coherence factor, makes Medicity as a Salutogenic model. There has been provide such access control for the visitors , only patient are allowed in healing garden with nurse in daytime. There is a department name as "PANCHKARMA" based on Indian therapeutic surgeries, utilizes healing garden for the rehabilitation or healing of patient in some case.

A.3 MEANINGFULNESS 1. Art When I was in hospital, the photographs on the corridor walls kept my mind off thermometers and at Gurgaon’s multi-specialty hospital Medanta, the sculpture at the entrance is very soothing to relatives of patients. Titled the Trees of Life or the Mannat (wish fulfilling) Trees and made by Rajasthani artist Ruchur Tiwari, the sandstone structures are 21 feet each in height and stand tall, inviting visitors across religions. On the base of the tree is a beautiful cluster of mauli, the sacred red thread that relatives tie while praying for recovery of their loved ones. Not only is the artwork helpful for the patients but it also touches on the work life of doctors and technicians who work in the stressful environment. “If I go to a room with a painting, I do look at it and appreciate it. It’s not only aesthetic but also has an impact on your behavior and provides an environment that is not sterile in terms of thought,” says Dr Randhir Sud, chairman of the Medanta Institute of Digestive and Hepatobiliary Sciences. Anything that helps any patient

remove emphasis from her or his

illness is a

huge help.



101

The Trees of Life installation at the Medanta hospital, Gurgaon, created by Rajasthani artist Ruchit Tiwari.

2. Views While visiting the inner wing of bedroom tower , view from the transparent glass window seems to be pleasant and green. For persons experiencing anxiety or stress, studies indicate that certain types of nature scenes rather quickly foster more positive feelings, and promote beneficial changes in physiological systems – for instance, lower blood pressure. Those patients assigned a landscape with trees and water experienced less anxiety, and required fewer strong pain doses, than control groups assigned no pictures. Positive distractions are a small subset of environmental-social phenomena that are distinguished by their capacity to quickly and effectively promote restoration from stress (Ulrich, 1999).



102

View of the nature through different room

increases the coherence factor among the patient.

3. Positive distraction There are lots of positive attraction in the hospital which make

it look like a non

institutional place such as food court , healing garden , luxury lounge area , small cafeteria , green lawn at the entrance of hospital, etc. Such positive attraction distract the mind of patient and visitors to a relax mode , thus reduce stress n anxiety among them. The great majority of patients prefer representational art depicting serene, spatially open natural environments having scattered trees and/or no turbulent water features--but consistently dislike abstract art. Although designers, artists, and some healthcare staff react positively to abstract images, or to art having a sense of "challenge" or ambiguity, there is evidence that such properties in pictures can negatively affect patient stress and worsen other outcomes.



103

Art work in bedroom distract patient mind.

Lavish food court give variety to visitors.

Temple and green areas outside the building.

Television in patient bedroom distract patient mind.

4. Patient experience



104

5.3 ANALYSIS / INTERVIEWS



105

4.3.1 interviews ( Therapist interview)



106

4.3.1.2 Psychologist interview



107

4.3.1.3 Consoler interview



108

4.3.2 Analysis



109

5. CONCLUSION The ability of architecture to heal the mental and physical illness with the different planning parameters and the elements that can enhance healing has been explored. Without compromising on the need, the ability of all patients to be outdoors in a good environment is, in my view, the absolutely greatest strength in the design of this caring environment. The spontaneous process of making architecture, it’s almost as if we formulate our own “abstract” ideas of what we envisage a space to be, through special images from memory we assemble architecture to be a part of the real world. It not only seems that art is inherent in all of us, it is also possible that architecture is inherent in all of us. As an act of healing it is symbolic of our perseverance as a species to live a fulfilled existence. In exploring art as healing, architecture as an art and lastly, architecture as a healing space, I can deduce that the common bond between them is that art does have healing qualities and it can be said that such healing qualities provide therapeutic harmony in all of us. I believe its effects may be limitless in measuring the benefits to the Self. The journey of healing through art seems to be a process of retrospection, Self growth and Self discovery. This investigation has brought about key design objectives that may be crucial in space making concepts for my healing architecture in healthcare design. The purpose of creating a green oasis which patients can retreat to unescorted by staff, in my opinion, has to be achieved. Even in a number of problems where the outdoor environments are concerned, everyone agrees that the existence of the gardens and light courts is something absolutely positive and something that is very good for the patients. It is also clear that being allowed out in the gardens is perceived as conferring an opportunity of greater sovereignty. In this way I think the aim of increasing normalcy has been achieved. Patients often experience different needs from time to time, and so the architect should consciously design the place or the environment so as to facilitate the process which recovery. In the design process, the architects should consciously reduce the institutional ambience and create such Salutogenic design which will shift the pathogenic approach . As I see it, there is scope for the patients to use different parts of the environment, both indoors and outdoors depending on the stage of the recovery process they have come to. Outdoor spaces are always with lusting green and the sound of water to heal their agitation. Indoor is more towards the sunlight that enhance the healing and the ventilation to give the patient high level of conformability.



110

With the aid of my detail study and the precedents I have concluded four connections that has to be consciously addressed while designing.

1. The connection with the personalized environment - Healing begins when one is in a space of Homely atmosphere. The physical space however is one that must be comfortable and a reflection of oneself. The physical environments have great influence on our social behavior and the possibilities for patents to engage social activities promoting social support. The common spaces should provide more than just the possibility for patents to form this basic contact. 2. The connection to sensory experience : The integration of all the senses helps complete the highest potential of an environment to allow for healing to emerge. As, Human beings cannot live without natural surroundings. The symbiotic relationship that exists between the two is one that has to be nurtured. A physical and visual link with nature has positive beneficial qualities that help in healing and health in general. 3. The connection with Light: Natural sunlight kills harmful bacteria and cleans air. Apart from these obvious natural benefits of sunlight, natural light - when controlled - gives a space character that is sensual so giving a space an emotive quality which can be felt by the end-user. Light is also a symbol of growth and life as it benefits the natural world in that way. 4. The connection with the City: The city environment is harsh and busy and tends not to offer many places or spaces of retrospection and contemplation. The site should be a part of the city but detached from the fast pace. The end user should be able to arrive conveniently with public transport to the site to allow a large catchment of people seeking a place for healing. The site should also be in a place that is not difficult to navigate and find.



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8. BIBLIOGRAPHY www.hindustantimes.com/brunch/art-is-finding-an-unusual-home-in-indian-hospitals/storyyk6GAHLQvEFfJYd46rWCVN.html timesofindia.indiatimes.com/life-style/health-fitness/de-stress/music-therapy-to-heal-cancerpatients/articleshow/51921616.cms?from=mdr kgd-architecture.com/portfolio_page/fortis-hospital-gurgaon-i-healthcare-4/ soundofarchitecture.com/blog/architectural-healing-how-the-built-form-changes-lives archinect.com/firms/project/14168405/medicity-medanta/60103380 Salutogenic Places: Designed to Thrive. Farrow Partnership Architects. YouTube Golembiewski, Jan A. "Start Making Sense Applying a Salutogenic Model to Architectural Design for Psychiatric Care." Facilities Golembiewski, Jan A. "Salutogenic Design: The Neurological Basis for Healthcare Design" World Health Design Journal. Dilani, Alan. "Psychosocially Supportive Design." World Health Design Journal Dilani, Alan. “A new paradigm of design and health in hospital planning. World Hospitals and Health Services, 41.4 “About Maggie’s.” Maggie’s Centres. The Maggie Keswick Jencks Cancer Caring Centres Ulrich, R. S. (2000). Environmental research and critical care. In D. K. Hamilton (Ed.), ICU 2010: Design for the Future. Houston: Center for Innovation in Health Facilities, 195-207. Ulrich R S (2004) The role of the physical environment in the hospital of the 21st century: a once-in-a lifetime opportunity. New York: Robert Wood Johnson Foundation. Ulrich, R. S., LundÈn, O., and J. L. Eltinge (1993). Effects of exposure to nature and abstract pictureson patients recovering from heart surgery. Paper presented at the Thirty-Third Meetings of the Society for Psychophysiological Research, Rottach-Egern, Germany. Abstract published in Psychophysiology, 30 (Supplement 1, 1993): 7. Ulrich, R. S., Simons, R. F., Losito, B. D., Fiorito, E., Miles, M. A. and M. Zelson (1991). Stress recovery during exposure to natural and urban environments. Journal of Environmental Psychology 11: 201-230. Ulrich R, Zimring C, Quan X et al (2006) The environment’s impact on stress. In S Marberry (Ed.), Improving healthcare with better building design. Chicago: Health Administration Press, 37-61.



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GLOSSARY Environment: that which environs or surrounds; surrounding conditions, influence, or forces, by which living forms are influence and modified in their growth and development. Heal: to restore or be restored to health Health: the general condition of the body or mind with reference to soundness and vigor Well-being: a good or satisfactory condition of exis tence; a state characterized by health, happiness, and prosperity Psychology: the scientific study of the human mind and its functions, esp. those affecting behavior in a given context. Flexibility: responsive to change; adaptable Meditation: a stylized mental technique... repetitively practiced for the purpose of attaining a subjective experience that is frequently described as very restful, silent, and of heightened alertness, often characterized as blissful Urban: Characteristic of the city or city life. Evidence-based: entails making decisions about how to promote health or provide care by integrating the best available evidence. Therapeutic: having or exhibiting healing powers. Spirit: the principle of conscious life; the vital principle in humans, animating the body or mediating between body and soul. Body: the physical part of a person Mind: the element of a person that enables them to be aware of the world and their experiences, to think, and to feel; the faculty of consciousness and thought. Habitat: the natural home or environment of an ani mal, plant, or other organism. Sequence: a set of related events, movements, or things that follow each other in a particular order. Sequence: a set of related events, movements, or things that follow each other in a particular order. salutogenis -Salutogenesis is a term coined by Aaron Antonovsky, a professor of medical sociology. The term describes an approach focusing on factors that support human health and well-being, rather than on factors that cause disease (pathogenesis). pathogenesis -The pathogenesis of a disease is the biological mechanism (or mechanisms) that leads to the diseased state. The term can also describe the origin and development of the disease, and whether it is acute, chronic, or recurrent.



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DISSERTATION ON HEALING ARCHITECTURE IN HOSPITAL DESIGN

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