Healing Space

2011

Daniel E. Ubovich

Healing Space

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The use of natural surroundings, abundant natural light and organic shapes that influence a patient’s positive outcome.

Daniel E. Ubovich, AIA, NCARB Architect (951) 809-2035 deuaia@hotmail.com

Healing space™

A thesis submitted to partial fulfillment of the requirements of the degree of Master of Architecture

NewSchool of Architecture and Design, 2011

By Daniel E. Ubovich

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Copyright Š Daniel Edward Ubovich, 2011

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Healing space™ Though the present healthcare environment clearly provides important help to patients with serious or rare health problems, it is criticized for a number of faults, some of which are endemic to the system and others, which develop from what some, consider wrong approaches to health care. Many voice the opinion that the 'industrialized' nature of care, with constantly shifting treatments and staff, takes away the human qualities of the patient which prevents more effective quality of care. More over the architecture and setup of modern healthcare environments is often voiced as a contributing factor to the feelings of faceless treatment that many people complain about. Within the last three decades, it has become more apparent that healthcare design has been in conflict with nature. Recent trends of evidence based design have brought attention to this problem; numerous design professionals continue to overlook the inclusion of organic shapes, forms, colors and textures, into the healing environment. Therefore the main purpose of this investigation was to examine the links between abundant natural light, natural surroundings, organic shapes and a patient’s psychophysiological outcome. The participants in this study were residents of two California Veterans assisted living facilities in Southern California who were interviewed and asked to complete a series of questionnaires, detailing their attitudes, dispositions and perceptions concerning abundant natural light, organic shaped and natural surrounds which were represented by four three dimensional manifestations in the built environment. The results indicated that a majority of the participants’ perceptions of abundant natural light, natural surroundings, organic shapes, through the use of three dimensional prototypes generally coincided with the hypothesis.

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After viewing the three dimensional prototypes, most respondents adopted a belief that subsequently equated to an affirmed attitude and finally resulted in a positive opinion about them. The results of this study suggest some future direction might include investigating the relationship between abundant natural light, natural surroundings, organic shapes and a patient’s psychophysiological outcome as it relates to other venues of the healthcare built settings.

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Dedications I like to dedicate this Master of Architecture Thesis to my wife Fernanda. There is no doubt in my mind that without her continued love, support, counsel, patience and editing skills, I could not have completed this project.

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Acknowledgements I would like to offer my sincerest gratitude to all faculty and staff at the NewSchool of Architecture & Design, who made the research program possible. This program has enabled me to expand and enrich my knowledge and career as an Architect. This life changing experience has allowed me to overcome challenges and reach goals that I previously thought were impossible to surmount. In particular, I would like to acknowledge the following individuals that made it possible for me to complete this research project: Mr. Jim Engelke, Adjunct Professor for his continuous guidance throughout such a detailed project. His assistance in helping me focus my thoughts into a simplified, cohesive direction was invaluable.

Mr. Carlos, Adjunct Professor for helping me see the big picture and at the same time consider alternate views of urban planning and site planning as a relates to my project.

Mr. Howard Blackson, Adjunct Professor for providing the opportunity for an "outside the box" experience which allowed me to view architecture and urban planning in an entirely new way.

Mr. David Kopek, Professor for his guidance and support, getting me back on track after my initial struggle with the subject matter. Furthermore without his focus and experience in evidence-based design and healthcare research, I'm not sure the project would have been completed.

Ms. Maris Brancheau, Editor for her valuable time and efforts in assisting me with the editing of this project. Without professional comments, this document would have been incoherent with grammatical errors, thank you.

I like to thank my mother and my brother Milan for their continuous support and encouragement throughout the entire process. A special thank you to and my good friend Hank Spielberg for helping me with the site surveys, photographs and interviews at one of the case study sites.

I would also like to acknowledge the support and assistance given to me by the staff of the Cal Vet assisted living facilities in Ventura and West Los Angeles, CA. Especially Brenda Manke,

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Administrator at the Cal Vet assisted living site in Ventura, and Patrick Keelher, Administrator at the Cal Vet assisted living site in West Los Angeles, for their time spent coordinating the interviews and surveys. I could not have completed this effort without their assistance, tolerance, and enthusiasm.

Finally, I would like to thank my fellow cohort students, Sean Clerkin, Raymond Frank and Steve Courtenay for your support, insight and helping to make this an entertaining experience.

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Table of Contents Title page

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Copyright

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Abstract

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Dedications

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Acknowledgments

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Table of contents

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List of figures and tables

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INTRODUCTION

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REVIEW OF LITERATURE

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METHODOLOGY

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RESULTS

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DISCUSSION

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REFERENCES

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APPENDIX A

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APPENDIX B

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APPENDIX C

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APPENDIX D

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APPENDIX E

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APPENDIX F

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APPENDIX G

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APPENDIX H

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APPENDIX I

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APPENDIX J

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APPENDIX K

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List of Figures and Tables

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Figure 2

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Figure 3

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Figure 4

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Figure 5

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Figure 6

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Figure 7

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Figure 8

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Figure 9

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Figure 10

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Figure 11

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Figure 12

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Figure 13

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Figure 14

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Figure 15

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Figure 16

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Figure 17

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Figure 18

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Figure 19

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Figure 20

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Figure 21

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Figure 22

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Figure 23

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Figure 24

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Figure 25

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Figure 26

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Figure 27

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Figure 28

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Figure 30

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Figure 31

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Figure 32

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Table 1

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Table 2

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Table 3

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Table 4

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Table 5

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Healing space 1

Introduction While health environments and the use of high-tech equipment, and highly skilled staff clearly provide help to patients with serious illnesses and rare health problems, they are considered by some, as diametric to the healing process. One major criticism is the “industrialized” nature of the care, with its impersonal surroundings and constant shifting of staff and equipment. This dehumanizes the patient, and prevents more effective care. For many years, the healthcare design has been in conflict with nature; although, recent trends of Evidence Based Deign have brought attention to this problem, many architects and interior designers continue to overlook the inclusion of organic shapes, forms, colors and textures, into the healing environment. However, Biophllia is a theory that suggests that humans seek an interaction with other life, in order to feel secure, E.O. Wilson (1984), insists that life as we know it, cannot be limited to human interaction, and Erich Fromm, (1958 &1964), defines human interaction with life, to include plants and animals. Concurrently, Topophilia suggests that people form a bond with a place. Yi-Fu Tuan (1977) says that, as a person's emotional bond to a space increases, so do familiarity, comfort, and the sense of “insideness.” The healthcare environment has never been equated with a positive association with place. Del Nord (2009) asserts that the western paradigm of efficient health spaces, has lost the connection to holistic methods of healing, which may be a direct result of over sterility, and the absence of life-giving attributes.

Studies with children, demonstrate a preference for organic shapes and colors, Milbrath (1998); Willats (1997). Therefore, one can speculate that organic shapes are associated with life, living organisms, and natural phenomenon; Bartholomew (2003); Manning (2009). Rosenberg & Abelson (1960); Seigal (2005); Fontenay (1981) and L. Jussim, (1991), state that associated

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meaning (belief) can hold equal or similar behavioral results, as the actual encounter (created reality).

Many healthcare practitioners believe that, the evolution of the natural and organic healing environment is still in its infancy, and the opportunity to fully integrate natural surroundings, organic shapes, and sustainable principles into the patient’s setting, is within reach.

Therefore, the purpose of this research project is to study how the relationship between the use of natural surroundings, abundant natural light, and organic shapes, create a patient’s positive psychological outcome.

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Comparative research has indicated that there are two contradictory narratives that stretch over the contemporary healthcare environment. First, “..technology cannot care for the whole being who is [currently] in a health care crisis", (Hurlock-Chorostecki, 1999, p.20) and second, “…Humans have an innate bond with nature…. This implies that certain kinds of contact with the natural world may benefit health” (Frumkin, 2001, p. 234). While it is true that hospitals, with various specialty departments, high-tech equipment and well trained medical staff, clearly provide help to patients with serious illnesses and rare health problems, they are considered by some, as adversely affecting, and antipodal to the healing process, This research and analysis of the literature was designed to explore and identify the current status of the healthcare environment, how the recent trends of evidence-based design have impacted that built environment, the intrinsic relationship between man and nature, man's bond with a "place," and the idea that exposure to nature has an impact on a person’s attitude, which in turn leads to a positive belief, and finally, becomes a constructed reality. This study includes a particular view focusing on direct association between the use of natural surroundings, abundant natural light, natural shapes, and a patient’s positive psychophysiological outcome.

The current status of the healthcare environment Loss of natural attributes and the “industrialized nature” of the healthcare environment According to historic records, King Pandukabhaya (fourth century B.C. royalty of Sinhalese) built small laying-in homes and hospitals in various parts of Sri Lanka (Aluvihare, 1993). This is the earliest documentary evidence of institutions specifically dedicated to the care of the sick anywhere in the world. These institutions, expanded in size and complexity as building technology became more advanced. The First Council of Nicaea (in 325 A.D.), stipulated that the Christian church provide a place for healing for the poor, sick and widowed. It

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ordered the construction of a hospital in every cathedral town. Among the earliest, were those built by Saint Sampson in Constantinople, and by Basil, the Bishop of Caesarea. Medieval hospitals in Europe pursued a similar pattern where the Christian community (monks and nuns), cared for the sick and diseased. Some were attached to monasteries, while others were independent and supported by endowments from the property (McGrew & McGrew, 1985). In fact, the word “hospital” derives from the old French word for Hôtel-Dieu (“Hostel of God”), which is one of the origins of the word.

Similar to what was at hand in medieval Europe, the present modern day hospital concept of Christian care, is still used today along with secular public and private institutions. In the United States, the traditional hospital is non-profit, usually supported by religious denominations, or non-denominational community organizations (Manco, 2006). These nonprofit organizations are supplemented by large public funded hospitals, usually in major cities and in county seats. Some are affiliated with research organizations and/or medical schools. The largest of these was a public hospital system in New York City, which includes the Bellevue Psychiatric Hospital, and the New York University Hospital. The original facility opened its doors in 1680, as a poorhouse and workhouse to deal with “vagabonds and idle beggars” (Knights, 2011, p.1).

Fig. 1, Kaiser Permanente “Template” hospital recently constructed in Modesto, Antioch, Ontario, Fontana & Irvine, CA. (Irvine Medical Center shown).

In the late 20th century, for-profit hospital chains came into being around the country. In order to reduce overhead costs, some heath insurance providers, (such

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as Kaiser Permanente among others), standardized their healthcare delivery system by building “template” hospital configurations, “with the aim of delivering high-quality, efficient medical care in an increasingly competitive health care delivery environment “(Craig, Hartka, Likosky, Caplan, Litsky, & Smithey, 1999, p. 2), using standardized equipment, materials and type of personnel in each location.

Miller (2003), states that one of the major criticisms of the healthcare environment is the “industrialized” nature of care, with its unfriendly surroundings and constant shifting of staffing and equipment. This dehumanizes the patient, and prevents more effective care. In most healthcare physician groups, the doctor you see in the office is not the one that would be attending to you while in the hospital. The doctors, nurses and medical staff are being placed under more and more pressure to increase the bottom line, as hospital costs continue to soar, this leads to rushed and impersonal treatment. The architecture and arrangement of the modern hospital are often viewed as contributing to the faceless and aloof treatment that many patients complain about. Moreover, Del Nord (2009) concurs by saying that "After the western paradigm of efficient health, spaces lost the connection to a holistic methods of healing" (p.274) which dates back to Aesclepions and Hipporates, who believed that assisting nature by the use of "fresh air, good diet, purgation, …..and hydrotherapy” was the best treatment (Garrison, 1913).

Disorientation Taylor (1979) goes on to say that hospitals are commonly regarded as unpleasant places to be, and in general, the depersonalization, forces the patient to give up control over his or her daily existence. Her study suggests that some patients cope with depersonalization and loss of control by exhibiting “good patient” or "bad patient" behavior. The "good patient" may actually

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be in circumstances that exhibit anxiousness, depression, or helplessness, whereas the "bad patient" may display anger and react against "a perceived arbitrary removal of their freedom.”

The study concludes by saying that these cognitive behaviors show a pattern of health risks to the patient and staff (p.156).

Overcrowding, stress and burnout medical staff Other negative attributes associated with the current hospital environment include long waits and overcrowding, which in turn produced staff burnout, role conflict, and unconstructive job satisfaction and produced harmful psychological health risks to the medical staff and patients. Bowmen (2010) points to

Fig. 2, Relationship between nursing hours per patient and patient recovery outcome.

simultaneous hospital closings in Manhattan and Queens, back in February 2009, "resulted in 17 hour wait times at one facility in patients receiving emergency care in a hospital café". Other examples about the current healthcare paradigms describes how overloaded physicians, nursing shortages and overcrowded facilities, lead to stress in the work place, which contribute to appalling patient care, Ehrenclou (2008). Also, a study by Needleman, Buerhaus, Mattke, Stewart & Zelevinsky, (2002) confirms Ehrenclou (2008) findings: That a relationship between the number of hours nurses spend per patient, equates to superior patient care. “A higher proportion of hours of nursing care provided by registered nurses, and a greater number of hours of care by registered nurses per day are associated with better care for hospitalized patients.”

(Needleman, Buerhaus, Mattke, Stewart & Zelevinsky, 2002, p.1715), See Fig. 2.

Over crowded faculties and or poor work environment

Over crowded faculties and or poor work environment

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Over burdened staff Poor patient outcome

Stressed and Poor unhappy patient employees

Therefore, the inverse to that would be that the less Over burdened staff

nursing staff available, the poorer the patient outcome is. A similar study by Peltier, Dahl & Mulhern (2009), concluded

outcome

Fig. 3, Cycle of interdependencies between the healthcare work environment,Stressed and how andit affects the unhappy patient outcome.

that there is a relationship between the perception of healthcare providers’ work environment and poor patient

employees

care outcome: Health care is an extremely people-based industry. Much of the emphasis on the people side of health care is on procedures – the myriad of processes for handling patients including checking-in, preparing for treatment, medical procedures, food service, discharging, etc. A key take-away from this study is that, in addition to what health care workers do, emphasis needs to be placed on how the employees feel about what they do.

Patient experiences will not be good if employees are not happy.

All three paradigms create a cycle that impacts the patient’s recovery and well being (Peltier et al., 2009, p. 1)., See Fig. 3.

Recent studies have shown that, the same old model for healthcare delivery and outcomes, cannot keep pace with the current cultural and exogenous forces now impacting the healthcare industry. A new survey by the American College of Emergency Physicians reveals that despite health reform, 71 percent of emergency physicians believe that ER visits will continue to rise, and that crowding and overcrowding will intensify. Furthermore, 54 percent of the 1,800 physicians surveyed, predict that the number of specialists, such as neurosurgeons and cardiologists, who will be willing to respond to ER calls, will drop (Beaulieu, 2010). Studies on nursing performance and increased turnover have shown that the care giving environment is filled with stress, anxiety, ethical conflicts, and unrealistic work demands. Various studies have

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demonstrated that, nursing is stressful, and that the incidence of occupational stress-related burnout in the profession is evident, and is not getting any better (BĂŠgat, et al 2005). At the same time, more and more hospitals are closing due to acquisitions and lack of Medicare reimbursement. Other studies by Piko (2006) also conclude that prolonged staff related burnout, "has a special significance in healthcare where staff experienced both psychological/emotional and physical stress" which can have major behavioral and health implications to the patient. The findings of this study showed that emotional exhaustion and depersonalization scores were higher while scores on personal accomplishment was lower, as compared to other industrialized nations and U.S. samples. "Burnout, particularly emotional exhaustion, was found to be strongly related to job dissatisfaction".

Stress and burnout have also impacted the quality of the general practice, as well. The continuity of care which has always been associated with the doctor – patient relationship has been put under pressure in many places of practice and seems to be expanding due to larger teams and more registered patients, thereby threatening the likelihood of patients staying with their own general practitioner, Frederiksen, H. B. (2009). This phenomenon has led to increasing levels of distress, on the part of patients towards professionals and institutions, which in turn have led to increased levels of poor communication and conflicts, which have resulted in violent actions against healthcare professionals, in some cases, Garcia – Calvo (2009).

The relationship between the increased cost of healthcare and delivery An upward trend in the cost of healthcare has caused a financial burden on individuals and families. In agreement with a study by Yu, Dick, & Szilagyi (2008), medical costs between 2001 and 2004, a family, with children with special health care needs, has increased their risk in 2004 for having financial burden exceeding 10% of family income. Other phenomenon

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associated with the rising healthcare costs are the conglomeration, buy-outs and mergers of independent hospitals into vast healthcare systems which increase buying power for the conglomerates, but decrease completion for insurance providers, leaving the patients out in the cold.

Columbia/HCA, the largest private healthcare provider in the world (according to Wikipedia), based in Nashville, TN, has acquired over 200 IOs (Independently Owned), or NFPs (Not For Profit) hospitals, reducing the amount of providers in at least 25% of the country. Rick Scott and Richard Rainwater, co-founders of Columbia/HCA, are on a mission to turn their hospitals into the “Walmarts” of the healthcare industry, by instituting austere cost cutting measures, and re-engineering processes to use less-skilled, lower paid people (Flower, 1995).

Evidence Based Design in the Healthcare environment Philosophical underpinnings Previously I discussed the theory that, a restorative environment will be able to assist in the treatment of the physical body, as well as, support the spiritual requirements of the patient through the use of: organic environment with sustainable features, natural shapes and forms, natural patterns and processes, abundant light and space, and place-based relationships and connections to nature. The theoretical underpinnings of my topic are based on the philosophy of Hippocrates, around 450 B.C., where he saw in nature, an inherent power of healing which worked unceasingly to create bodily health: “Everything in nature tends to re-establish that perfect harmony that constitutes normal life. Every force in the individual tends to preserve a perfect equilibrium and, if it has been disturbed, to re-establish order and harmony” (Garrison, 1913; Stone, 2003, p. 2).

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Subsequently, others like Monsignor Sebastian Kneipp, Florence Nightingale, Dr. Benedict Lust, and most recently, Barbara Dossey, RN have kept the ideals of, what is now known as Naturopathic medicine applicable in the modern era (Lust, 1937; Lindlahr, 1999; Montag,, 1951; Dossey , 2009). Hippocratic medicine was humble and passive, which coincides with the concept that, a restorative environment and the healing power of nature ("vis medicatrix naturae" in Latin), can produce a positive medical outcome. This holistic philosophy of healing was gradually disregarded with the advent of the 17th Century. Hippocrates was still regarded as the source of medical wisdom, but a scientific revolution created by Newton in England and Descartes in France, changed the state of affairs. Newton taught that, mathematics was the rationale behind the celestial mechanics that explained the motions of the moon and the planets. When he published Philosophiae Naturalis Principia Mathematica (Mathematical Principles of Natural Philosophy), it gave credence to the idea first put forward by Democritus long ago, that all

Fig. 4, an example of the use of natural sculpture and ornamental elements in healthcare design, courtesy of Robert A., Pratt, A.I.A.

physical phenomena could be explained in terms of simple natural laws (Stone, 2003).

As a result, the philosophy of mechanism gained prestige,

and medical thinking began to move in the mechanistic direction, where the body is like a biological machine and doctors are in control of the healing process, no longer guided by nature.

This paradigm shift of philosophy (cultural/discursive system), from nature to logic of mathematics, not only took place in medicine, but also in architecture and the built environment of healthcare. In lieu of art and ornamentation, with natural sculptural elements (based on the values of nature), the adopted international style of the machine age, produced healthcare designs

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with glass and steel based on the ideals of simplified forms, and unadorned functionalism (Pratt, 2006; Stone, 2003), See Fig. 4.

The architect Le Corbusier called his designs

Fig. 5, Le Corbusier’s Villa Savoye, Poissy, France (1929-31).

“machines for living,” like Villa Savoye, which represented a

complete break with the past, and an expression of the political times. This philosophy of logic and mathematics (from Newton et al.), and the machine age (from Le Corbusier et al.), have been with us since the early 19th Century, but because of the work of Noble Laureate Lllya Prigogine, and the modern science of genetics, Newton’s, Einstein’s and Schrödinger’s determinism and “time symmetry” to explain everything on the basis of extensions of celestial mechanics has been shattered. I believe that, we are at a beginning of another paradigm shift in the healthcare therapeutic and built environment, back to adapting a naturopathic philosophy (Prigogine, 1996; Stone, 2003; Guiton, 1982; Frampton, 1992; Le Corbusier’s Villa Savoey, 2008, p. 1), See Fig. 5.

Positive trend The reviews of literature suggest that if the built environment was modified, it would improve the quality of life of the patient and family members. Studies from Ulrich (1984 & 2000); Rubin (1998); Fontaine (2001) and Cama (2009) purport that a change in the way healthcare facilities are designed can have the capability of fostering improved patient outcomes.

In accord with the research conducted by Ulrich et al. (1981, 1984 & 2000) manipulating

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surroundings, aesthetics and architectural features, in a healthcare setting, including noise reduction, sleep promotion, family support areas, spatial disorientation reduction, music, art, nature, light quality and air quality can produce a positive effect on a patient’s recovery.

In attune some researchers indicated that music therapy can be quite effective; It is easy to administer, relatively inexpensive, noninvasive intervention they can reduce anxiety and pain and provides patients with a sense of control and separation from the multiple environmental stressors they are experiencing. Affirming with a study by White (2000) "Patient satisfaction and outcomes clearly have improved after music therapy sessions have been implemented". In contrast to White's (2000) study, research by Silverman (2008) claim that music therapy, from clinicians and researchers, have reported a lack of evidence that music therapy is successful in reducing stress and anxiety in patients (Ornstein, 1990; Silverman, 2008).

Dunn (1995) believes that the use of aromatherapy, massage and the use of natural sounds of nature "offer a means of increasing the quality of sensory input that patients receive, at which as well as reducing levels of stress and anxiety"(p. 34). Their study tested 122 patients that were admitted to intensive care units were randomly allocated to receive either massage or aromatherapy associated with water sounds. 77% of the 122 patients tested reported "significantly greater improvement in their mood and perceive levels of anxiety, there were also felt less anxious and more positive than immediately following the therapy, although the effect was not sustained" (p. 34).

Cama (2009), one of the main proponents of the use of evidence-based design in healthcare interiors, says that "the main problem with this is delivery of the research to the field".

She goes on to say that the research is “out there�, but it is slow getting to the design studio. The cycle of innovation for the improved clinical practice models and supporting architecture, is

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offset by antiquated mindsets that see status quo as too difficult to change. On the clinical side of the equation, the research identifies a need for the improvement of nursing techniques, but misses the true role nurses play in their relationship with the patient. The issue here is one of technology versus the application of Hippocrates’s holistic healing, of “re-establish[ing] that perfect harmony" Stone (2003) with the patient; treating all aspects of the patient’s psychological, physical, social, and mental needs, not just their relationship to monitors, gages and readouts (Dossey, 2009; Marcus, 2002; Chan, 2001; White, 2000; McCarthy, 1991; and Byers, 1997).

The relationship between man and nature Man seeking nature A review of research has indicated that most of the investigations have centered around environmental health, specifically the hazardous effects of various environmental exposures, such as toxic chemicals, radiation, and biological and physical agents on the public. However, some kinds of environmental exposures may have positive health effects. According Kahn (1999), the term “Biophilia”- was coined by Edward O. Wilson in 1984, referring to what he and his colleagues hypothesize as a fundamental, generally based human need and preference to associate with nature and life. Wilson (1993), states that the biophilic instinct emerges unconsciously, through reasoning, emotions, art and ethics. It “unfolds” from early childhood, onward (Kahn, 1999, p. 2). Recent studies have shown that even a minimum connection with nature, through a window, increased productivity and health in the work-place, promotes healing of patients and reduces the frequency of sickness in prison, (Ulrich, 1981; Farley & Veitch, 2001; Frumkin, 2001). In his landmark book Biophilia, Wilson examined how our tendency to focus on life and lifelike processes might be a biologically based need, integral to our

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development as individuals and as a species, which at the time, caught the imagination of various thinkers and included the views of some of the most creative scientists of the late 20th Century, each attempting to amplify and refine the concept of biophilia. Presently authors have expanded this idea to suggest that humans have an innate bond with nature more generally, which implies that certain kinds of contact with the natural world may benefit health. Evidence supporting this hypothesis is presented from four aspects of the natural world: animals, plants, landscapes, and wilderness (Frumkin, 2001). This research, across many disciplines, has been brought together to support the hypothesis that exists a fundamental, generally based human need and propensity affiliate with life. That is biophilia. In harmony with Kahn (1999) it is important because the biophilia hypothesis could provide a unifying framework across numerous disciplines to investigate the human relationship with nature.

Kahn et al. (1999) found that "Naturalistic experiences often reduce stress, sharpened sensitivity to detail, enhance creativity, and provide intellectual stimulation and physical fitness"(p. 19). Most of research has indicated that even a minimal exposure with nature reduces the instant and long-term stress, sickness of prisoners, and calms patients before and during surgery, and promotes healing after surgery (Kahn, 1999; Kellert, 1993; Wilson 1993).

The intrinsic relationship between man and nature: A connection between living systems and perception There is considerable evidence demonstrating the connection between man and nature, Whitaker (2010) describes Humberto Maturana and Francisco Varela's theory of autopoiesis, where living systems exhibit a sort of circularity in their form and organization, which are interconnected to themselves, the environment and other organisms. All living components are interconnected so as to make a single whole structure, where no single component either starts or

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ends because the "set of structural connections" (p. 2) cannot be reasonably described as a linear series of dependencies, Instead, it is an interrelated web of interdependencies in which each component is mutually dependent on all the others in "adding up" (p. 2) to the entirety of a viable structure. There is one such "systemic" (p. 2) framework addressing living systems, phenomenology, and their cognition in terms of these essential makeup and framework.

(Maturana & Varela, 1988). In line with Maturana et al., (1988) man's "reality", of these interrelated systems, is interactive. Moreover, man's reality is mutually constructed and agreedupon view of reality is in fact, "a shared set of assumptions and perceptions� (p. 239). We see these realms simultaneously, because we have agreed that this is what is "out there." Together, we bring forth the world we experience as objective reality and an individual's "reality" is constructed from his or her (or its) perceptions, and these perceptions are interactive with the environment. This is what Maturana et al., (1988) calls "unity" (p. 239), they elaborates this by noting "Everything said is said by an observer. The qualification of all 'knowledge' with respect to a given observer is both the epistemological foundation and the explanatory focus of autopoietic theory" Whitaker (2010, p. 2).

The correlation, here, with Prigogine's world systems theory, where Prigogine (1996) speaks of a new language for the understanding of complexity of life (organism, ecosystem, and social system), Chaos, fractals, dissipative structures, self-organization, and complex adaptive systems, and the partially unknown or at least unpredictable world of multiple possibilities is significant, for it represents a salient departure from Newton’s deterministic, postempiricist, paradigm structure. Prigogine (1996) suggests that as our knowledge of natural realities expands, then emerges into more complete perspective requiring a fundamental reconstruction of both the real makeup, upon which human life is built upon, and the symbolic makeup of our rational

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schemata (Gunaratne, 2003). Thus the focus of the literature forges a connection between man and nature, whether perceived, constructed or rational.

The connection between man, plants, animals, and life An influential book by Fromm (1956) depicts the origins of human history. Though thrown out, and disconnected with the original unity with nature, man still clings to those primeval bonds and consequently "tries to identify with the world of animals and trees, in order to reconnect, unify, and remain ‘one’ with the natural world” (p. 59). However, in the 20th century, we have been overwhelmed by an almost magical ability of man to understand and control our physical environment. Has this century’s remarkable technological progress led most people to believe that what science does know about nature or it will someday know and that this knowledge will eventually lead to more control over nature (Briggs, 1992)? Simonds (1961) continues by posing additional questions: "So what is man's alternative? What is left for him to do? Is it possible that man can invent a wholly artificial environment where he can better fulfill his potential destiny? How can he better fulfill his potential destiny? “This prospect seems extremely doubtful" (p. 6). If you look back and analyze man's most successful ventures in planning it would show that his greatest improvements, to the environment, came by integrating his work with nature, by bringing nature's hills, ravines, sunlight, water, plants, and air sympathetically into the design of the landscape. Van loon & Merriman (1999) rebukes The Greeks and Romans by saying that they had never bothered about the future but instead establish their own paradise, then came the Middle Ages, men built himself a paradise beyond the highest clouds and turned the world into "a vale of tears for high and low" (Simonds, 1961, p. 7). Van loon & Merriman (1999) goes on and depicts the Renaissance, where men no longer looked towards heaven for paradise, but tried to establish their paradise on the planet through learning

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and a state of mind. "Now" (Simonds, 1961, p. 9) states that modern man, with his great knowledge and power to create, has disregarded nature's, topography, topsoil, air currents, water sheds, and the forests'. Are we tempted to believe that we can conquer nature? There are those who hold that the years from now, man will finally subject nature to his control. "Let us not delude ourselves; nature is not soon to be conquered by puny man. Conquer nature! How can we conquer nature? We are – blood, bone, fiber, and soul – a very part of nature” (p. 26). Simonds (1961) asserts that man, came from nature, is rooted in nature, and is nursed by nature. Man's every heart beat, every neutral impulse and every thought wave, are very acts and efforts are governed by nature's own bracing law. Fromm (1956) also admits that man is from the animal kingdom, from the instinctive adaptation, that he has transcended nature – although he never left it; he is still a part of it. Simonds (1961) continues by providing the following axiom: The naturalist tells us that if a fox or rabbit is snared in a field and then kept in a cage, the animal’s clear eyes will soon become dull, his coat will loses luster, and his spirit will flag. So it is with man too long or too far removed from nature. For man is first of all an animal. He is a creature of the meadow, the forest, the sea, and the plain. He is born with the love of fresh air into his lungs, dry paths under his feet, and the penetrating heat of the sun on his skin. He is born with a love for the feel and smell of rich warm Earth, the taste of sparkle of Clearwater, the refreshing coolness of foliage overhead, and a spacious blue dome of the sky. Deep down inside the soul of animal – man is a longing for those things, a desire something compelling, something quiescent sent, but always there (p. 6).

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The relationship between organic shapes and children Research has shown that children also have an inherent connection with nature.

According to Simonds (1961), children perceive images as objects in space, while the adult "with a more highly developed minds and more selective eye" (p. 139), perceived relationships: in order to comprehend a visual balance, the human eye scans, probes, explores, and wads through visual impressions at subconscious intervals in which the mind permits, or directs, from optical limbo and into conscious focus certain visual images. This creative effort of the mind, demands that the eye "compose" (p. 138) a visual image that is complete and in equilibrium. This combined joint mind – eye effort is inacceptable equilibrium when it is combined with form – balance, value – balance, color – balance, and associate – balance. The mind eye team may give less weight to a massive object that has no associative value, but more weight to one that has strong associate value or intermediate interest. For example "a ripe apple swing on a branch may thus outweigh the greatest oak tree in the forest" (p. 138). Therefore there are no to mind – eye, combinations, scanning a scene, could ever register (with the observer) identical visual images or combination of images because they seem to have no limits, and the possibilities of selective composition are endless. But, by a boundless and complicated series of instantaneous subconscious adjustments each individual "creates" their own balanced and complete optical impression. The more sensitive and perceptive the mind-eye duo has become, through instinct or training, the richer, the more delightful the visual world becomes. Additional research by Milbrath (1998), shows that young children will instinctively use a circle to represent a face or sun and a triangle to depict a roof of a house. When such shapes are used unmodified and whole, the can be thought as modular elements that a child uses symbolically with a little attempt at visual realism. The frequent use of whole "organic" shapes such a circle and triangle in a

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drawing did not statically diminish talent groups or ages of children in the cross-sectional sample. Never the less, the percentages of children by age suggest that circles were drawn more frequently by the youngest children (29%, 16%, and 8%), respectfully.

Relationship between man's bonds with place Topophilia: man’s reception, attitudes, and values of place "Space "and "Place" connote many things to many people, denoting many experiences that relate to where we work and live. Tuan (1977) suggests that place is security and space is freedom: "we are attached to the one and long for the other" (p. 3). Whether one considers sacred versus "biased" space (p. 43), mythical space and place, time in a new (or experiential) space, or cultural attachments to space, they all have a special meaning to the observer. As part of this research about city imagery, and how people perceive and bond to a certain place, Lynch (1960) describes how a good environmental image creates the feeling of security, overcomes the fear that comes with disorientation, and promotes a harmonious relationship between the possessor and the outside world. “It means that the sweet sense of home is strongest when home is not only familiar, but distinctive as well� (p. 4). The researcher goes into great detail on how environmental images are assimilated, processed and understood by the observer. Lynch (1960) explains that the perception of environmental images is a result of a two-way process between the observer and his environment. The progression involves understanding the dissimilarities and relationships of the surroundings, which the observer takes up, then with great flexibility, and within his own understanding, organizes, selects and gives meaning to what he sees. The image, now developed, has its own limits and emphasizes what is seen; meanwhile the image is continually being tested and filtered against a predetermined perception in a continuous interacting process. "Thus the image of a given reality may vary significantly between different

Healing space 20 observers" (p. 6), depending on the observers’ predisposition, attitude or outlook. The logic of the image may come about in several ways. There may be little in the image that is organized or noteworthy, but "the mental picture" (p. 6), may gain identity through familiarity. One person may discern the objects easily while others look at it and see disorder and chaos. On the other hand an object, which seen for the first time, may not be acknowledged because it looks familiar, but becomes identified because it fits a predetermined stereotype, already created by the observer (Lynch, 1960). For example; any Southern Californian teenager might recognize what an “In-NOut Burger” sign suggest, but the same sign would be indistinguishable to someone from the eastern part of the country.

Tuan (1974) talks about place, space, and environment in terms of "Topophilia": where he combines sentiment with place, which takes on many forms and creates a great range of emotion and intensity.

It is a start to describe what they are: fleeting visual pleasure; the central the life of physical contact; the fondness for place because it is familiar, because it is home and incarcerates the past, because it invokes pride of ownership or of creation; joy in things because of animal health and vitality (p. 274).

Therefore, Tuan (1974) concludes, since humans are one of the "dominate" (p. 64, 165, 193 and 219) factors in controlling the environment, it is of great importance, when considering environmental issues, to take into account mankind's bond with place.

Behavioral setting theory The research on Behavioral Setting by social scientist Roger Barker, who first developed his theoretical framework on a behavior setting, in the late 1940’s, and studies by Schoggen (1968) on ecological psychology could bridge a gap between the foundational work of Maturana

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& Varela (1988) on Autopoiesis, the insights developed in American Pragmatism, Continental Activity Theory and the relationship between man's connection with place. Consistent with Schoggen (1968), behavior settings exists at the interface between the standing patterns of behavior and the milieu (environment), wherein the behavior is happening in the "milieu"' (environment), and the "milieu" (environment), in some sense "matches" the "behavior". In technical parlance, the "behavior-milieu interface" is called the synomorph, and the "milieu" (environment) is said to be circumjacent and "synomorphic" to the "behavior". By correlating the following theories, the literature evidently indicates that man interacts and shares his perceptions, undertakes a pragmatic, systemic, functional, behavioral, and environmental relationship with space and place: 1. Autopoiesis, Maturana & Varela (1988),"a shared set of assumptions and perceptions" (p. 239).

2. The American pragmatists, Williams (1907), “It is high time to urge the use of a little imagination and philosophy. The willingness of some of our critics to read any but the silliest of possible meanings into our statements‌ is as this credible to their imagination is anything I know in recent philosophic history. Schiller says the [truth] is that which 'works'" (P. 234).

3. Activity theory and Nietzsche, Magnus & Higgins (1996),"the subject is [the] consequence to the activity, in Nietzsche view, and not the activity's originator" (p. 239).

4. Behavioral Settings theory, Schoggen (1968), "[behavioral settings theory] has made important contributions to our understanding of behavioral – environmental relationships" (p. 167).

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Restorative design with nature Nature in the healing environment In the last half of the 20th century, researchers have found that designing healing environments inspired by the biodiversity of nature (of biology, chemistry, computer science, environmental psychology and evolutionary anthropology, and neurosciences) supports the healing process. Research has shown that ancient and modern people have used the natural elements around us for healing, such as a sacred spring, reflective pond, a quite grove or magnificent mountain peaks. For centuries, men have sought these safe places for healing of the mind, soul and body (Huelat, 2008). Hippocrates believed in the “healing power of nature” (“vis medicatrix naturae” in Latin). Affirming his theory, the body’s vital essence or spirit contains within itself the power for re-balancing and healing. The word disease (“dis”, meaning apart and “ease” meaning balance), describes a loss of balance and harmony (Garrison, 1913).

Reviews of research have revealed that healing environments Inspired by "watching clouds float overhead, gazing out the window at a grove of trees, or seeing a serene sunset brings relaxation and pleasure" (Huelat, 2008, p. 3), including (Ulrich, 1981, 1984 and 2001; Del Nord, 2009; Mizan, 2004; Farley, 2001 and Kahn, 1999). Other studies by Ke-Tsung Hang (2010) and Ornstein & Sobel (1990) concur that the use of scenic beauty "openness" and "water features" connote a high correlation with preference and restoration. Similarly research by Park (2004) show that patients exposed to ornamental plants in the simulated hospital environment significantly improved female students' pain tolerance, "this was indicated by longer pain tolerance time during the cold pressure test (C PT), lower self – rating scores on the pain intensity, and lower electrodermal activities (EDA) responses of students who viewed plants as compared to ’no plants’" (p. 1). And other research by Walch (2005) present medical evidence

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that postoperative patients who are exposed increased to amounts of natural sunlight during their hospital recovery period indicated decreased stress, pain, analgesic medication use, and pain medication costs. Moreover research testing people's understanding and perception of what types of natural environments they prefer, and psychological benefits they seem to derive from wilderness experiences, and why exterior garden areas/courtyards are especially important. The Kaplan & Kaplan (1989) studies have clearly indicated that their attention restoration theory, "despite all the variations, there remains substantial consistencies. The strongest of these is the importance of nature itself‌ seems to be as close to universal as one can find." However, how can these natural manifestations be incorporated into a healing environment, so that a "nature appreciation" (Simons, 1961, p 75) becomes a part of patients' daily lives? Simons, (1961) recommends projecting colors, certain areas of interior paving, structure walls or overhead planes into the landscape whereby creating a control transition from interior to exterior, from refined to the natural. Similar to what is incorporated into the Temple of Tofukuji in Kyoto, Japan, (see Fig. 6). Chan’s (2001) research on cancer patients, bereaved wives and divorced women, treated in this type of environment �emphasizes an Eastern approach" (p.2) along with traditional Chinese medicine (which conceptualizes the body, mind, cognition, emotion and spirituality into an holistic approach) Fig. 6, Temple of Tofukuji in Kyoto, Japan. An example of incorporating natural manifestations of nature into the healing environment.

showed "significant improvements in physical health, mental health, sense of control and social support" (p.1).

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In this view, health is professed as a harmonious equilibrium that is part of the relationship of the “'yin' and 'yang': the five internal elements (metal, wood, water, fire and earth), the six environmental conditions (dry, wet, hot, cold, wind and flame)” (p.3).

Another example of incorporating the Simons et al. (1961, p 75) "nature appreciation" concept, would be to use the "seven principles of a healing environment," developed by the Danish -born , Swedish architect, Erik Asmussen. Coats (2001) provide some plausible tactics of how to create life – enhancing architecture that deals with the whole person: body, soul and spirit, as described by Asmussen's seven principles of "healing architecture" (p.243): 1). unity of form and function, 2). Polarity, 3). Metamorphosis, 4). Harmony with nature and site, 5). The living wall, 6). Color luminosity, and 7). The dynamic equilibrium of spatial experience.

Asmussen believes that architecture should be "nurturing, Fig. 7, Erik Asmussen's Rudolph Steiner seminary – cultural house, represents how a design can harmonize with its site, amassing metamorphosis of its with its surrounding green hills, be in "equilibrium" with his form, functions and "free – flowing spaces"

responsive and alive,” with “dynamically shifting spatial balances, organically expressing forms, subtly luminous colors and biologically healthy, natural materials" (p. 240).

According to Coats (2001), the Asmussen's Rudolph Steiner

seminary – cultural house, represents how a design can harmonize with its site, amassing metamorphosis with its surrounding green hills, be in "equilibrium" with his form, functions and "free – flowing spaces", See Fig. 7.

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Relationship between belief and reality Social constructivist perspective To understand the connection between the association between a belief and reality, the research must take into consideration the philosophical epistemology compositions of Étienne Bonnot de Condillac and Denise Diderot. These 18th-century philosophers contributed to our modern day understanding of belief and reality. While Condillac's philosophy considers that all knowledge was gained through the senses, Diderot's idea of self came from the understanding of materialism. Diderot believed that a man was born a certain way but society and life's problems wore away something of its original shape. Diderot's materialism was inspired by his understanding of contemporary biology and the continuity between organic and inorganic matter.

This idea was that life was merely matter organized in a particular way, and death was merely a moment in the construct passage between inert and in adamant forms (Seigal, 2005).

The researcher explains that through his writings, Condillac established that all human faculty and knowledge are transformed through sensation only, to the exclusion of any other principle, such as reflection. To prove his point on "sentationism", he imagines a statue organized inwardly like a man, animated by a soul which has never received an idea, into which no sense-impression has ever penetrated. He then unlocks its senses one by one, beginning with smell, as the sense that contributes least to human knowledge. In accordance with (Seigal, 2005), Condillac believed that the abstract signs that people came up with and believed in, were based on nature and eventually the connection between the word and nature was lost. "When the use of those signs became familiar, the origin was forgotten, and people were so weak as to believe that they were the most natural names for spiritual things. “It was even imagined that they perfectly explain the essence and nature of those things, though they only express some in imperfect

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analogies" (p. 178). Hence, Seigal (2005) concludes that knowledge is based on a normative systemic process of environment and human sensations. Furthermore Seigal (2005) explains that Diderot, in many of his works, wrote about a subject or character, which read like improvisations, and assigns associated meaning to them, such as in the book Rameau's Nephew.

Diderot engages in a spirited dialogue with an eccentric and colorful music-teacher, nephew of a well-known composer, whom he sometimes met in the garden of the Palace Royal. The participants, called I and He (Moi and Lui), disagree and agree about many things, but in reality many of the opinions expressed by Lui are those of Diderot himself, which are found in many of his other writings, as well. In other works, such as Jacques the Fatalist and his Master and his Essay on Dramatic Poetry, Diderot portrays many of his characters in contradictory terms and dualistic roles. For example, in Jacques the Fatalist and his Master, Jacques's key viewpoint is that everything that happens is "written up above" like a "great scroll" (p. 187), which is unrolled a little bit at a time, on which all events, past and future, are pre-determined, yet he still places worth on his events; he is not a passive character. In other words, Diderot described the way we are all moved to say things by unconscious associations among words and objects, concluding "Oh how much even the man who thinks the just an automation" (p. 199). The research might conceivably interpret all this as behavior of a person whose inner divisions led him away to imagine himself and others as possibly other than they were. On one hand he constructs a confined reality with materialistic principles, but at the same time, speaks to us while standing outside the universe, conclusions not too dissimilar with research previously cited (Maturana & Varela, 1988); Prigogine, 1996).

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Perceptions and aesthetics Current research has shown that most social psychologists consider belief to be about an association rather than a characteristic of a thing. Lang (1988) asserts that an attitude is a result of a combination of belief about something with a value or hypothesis connected to it. For example a building with pointed arches may be a defining characteristic of Gothic architecture; "such windows go well in ecclesiastical architecture" (p. 19) is an associate characteristic. Many such beliefs are verbalized in architectural writings and polemic theories, but many are inferred just by observing what architecture is. The same can be said about organic shapes and natural geometries. He continues by explaining his theory about belief as it relates to values, motivations, attitudes and direction whereas values are interconnected to motivations and define the attractive and repulsive elements of the world. Anything that a person desires or complements has a positive value (for that particular individual); anything that is despised therefore has a negative value. Value, therefore symbolizes a link among a person's emotions, motivations and behavior. Attitudes, on the other hand, about a specific built environment or natural surroundings have "rationalized" value, which leads to a belief" (p. 19). Although people's attitudes might have a certain direction, strength, characteristic or perceived truth about it, their attitude about something is mostly attributed to their belief. Direction of the attitude is very important in the formulation of a belief. If one, during the formation of the attitude, evaluates an object or environment and perceives its differentiations, strengths and/or weaknesses (of an object) an action takes place which either reinforces or hinders the subsequent belief. "Because one likes a particular set of symbols [it] does not necessarily mean that one will use them" (p. 19).

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Lang (1988) said the primary goal of design has always been an aesthetic one, "the creation of delightful rooms, buildings, townscapes, and landscapes" (p. 11). He promotes his argument, by referring to existing studies done by Santayana (2003), who researched aesthetic experience with a number of people and had found it useful to characterize their experience of the built environment, in three distinct categories: Sensory aesthetics, formal aesthetics and symbolic aesthetics. Sensory aesthetics involves the arousal of one's multidimensional noncognitive systems which is the product of colors, odors, sound, and textures of the environment. Moreover, Santayana, (2003) continues and says that formal aesthetics in architecture, and design, is mainly about the "appreciation of shapes, rhythms, complexities, and sequences of the visual world" (p. 11) which can also be applied to the hearing, aromatic, and touching worlds as well. In symbolic aesthetics, people gain pleasure by applying an associated meaning of their surroundings via the use of their senses and the "affect" (emotion or feeling) is the aesthetic dimension that leads us to an understanding of the positive and negative attitudes that people have about embolic meanings available in their environments.

Nasar (2008) also talks about formal and symbolic aspects of aesthetic quality in the slightly different approach. He contends that there are two ways the environment affects the assessment of aesthetic quality: formal and symbolic (or associational). A formal analysis focuses on the attributes of the object, as part of the contribution to aesthetic response which would include such properties such as size, shape, color, complexity, and balance. A symbolic analysis, of aesthetics, centers on features that come about through experience and produce an implied meaning associated with something else. Although a Ford or a Mercedes might have similar formal attributes they definitely produce a different meaning to the observer. Likewise an artificial flower (might look like a real flower) will have different meanings if the observer

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realizes it's artificial. However, a symbolic analysis centers on such things as style and context.

Other research by Berleant (1998) indicates an approach to environmental aesthetics considers the human person as an active contributor in a context that includes and is continuous with the participant. “A person is the perceptual center, both as an individual and as a member of a sociocultural group, of his or her life-world whose horizons are shaped by geographical and cultural facto” (p. 84).

Additional review on visual aesthetics indicated that one of the central issues relating to architecture and environmental planning, save for modest scientific evidence concerning the manner is in which interior environments influence human behavior. For example studies by (Locasso, 1976) have indicated problems in experimental design, measurement, and methodology, but there appears to be little solid experiential evidence that demonstrate that attractive interior spaces have any sort of beneficial influences on human functioning and behavior. Early works of Maslow and Mintz (1956) have received much exposure in environmental psychology in the environmental – design disciplines. They looked at the effects of "beautiful" and "ugly" rooms on respondents attitudes, perception, or dispositions and the amount of "energy" in "well – being" reflected in photographs of human faces. One of the renowned experiments involved two rooms, one decorated as a comfortable office and contained a mahogany desk and chair combination, a rug, drapes, paintings, sculptures and other items in the other was a plain room, painted battleship gray with single overhead bulb, suspended from the ceiling, a plain desk, and three worn-out chairs. The room was very disorganized and shuffled with papers scattered throughout, messy trash bins and papers strewn on the floor which gave the impression of a "janitors storeroom" (Maslow and Mintz, 1956, p. 248). "People who saw the so-called "comfortable office", described it as ‘attractive,’ ‘pretty,’ ‘comfortable,’ and

Healing space 30 ‘pleasant’� (Maslow and Mintz, 1956, page 247 The people who saw "janitors storeroom" described it as an "ugly", disgusting, and repulsive room (Maslow and Mintz, 1956, page 248).

The results indicated that the "beautiful room" gave significant higher ratings to those dimensions than the "ugly" room. The Maslow and Mintz (1956) study has been widely quoted and discussed in literature and in general has come to be regarded as that quote "classic" study in the area of environmental psychology.

Further research has pointed toward a number of other models for mutually supportive attitudes of people's likes, dislikes and predispositions. Studies like (Heider, 1946), Osgood and Tanenbaum (1955) and the Rosenberg, (1980) congruity model. All show that two people may have different reasons for holding the same attitude but can still agree. In addition, some attitudes are more strongly held than others and consequently are less likely to change based on the influence of other people with weaker ones as it applies to people's perception of Levittown or Las Vegas, for example (Lang, 1988).

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Methodology The Hypothesis Among skilled nursing/assistive living environments, there is a direct relationship between the use of natural surroundings, abundant natural light, organic shapes, and a patient’s positive psychophysiological outcome.

The Approach Qualitative research Positive/postpositive research adheres to a single object reality (ontology), which is established through the five senses by the use of microscopes, telescopes and sonograms, while at the same time making every attempt to separate the inquiry from the object of inquiry, so that the research will not be tainted (epistemology). The stereotype of the scientist with the white lab coat comes to mind, testing and observing. Then more tests and more observations, focusing in a single goal: to find his or her version of reality or “truth”. This quantitative way of looking at the world works well for the objective scientific paradigm, but the research and the researcher cannot get into the context and examine it. If there was a positive/postpositive research study of an atom or a rabbit, the researcher can only observe, make assumptions or deduce knowledge about what the atom or rabbit is doing, with no knowledge of its context or relationship to others, or other realities around it.

In contrast to the previous system of inquiry, the ontology of the naturalistic paradigm (to know what it is “out there”), is to look at more than one “reality”. Speaking holistically, the introduction of naturalistic systems of inquiry must utilize and be functionally interwoven with the sophisticated paradigmatic research solutions. The study must be of the “whole cloth”, where each piece of cloth is interrelated to the total. If one aspect is isolated from its context, it

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will destroy much of its meaning. The corresponding epistemological position is that, it is neither possible nor advantageous for the research to establish a value-free objectivity (Erlandson; Harris; Skipper & Allen, 1993). To a certain extent, the researcher in the naturalistic inquiry is part of the context of the research and a theoretical assumption: why would a resident or client want organic shapes, natural light and natural surroundings?, Would be very beneficial in the investigation, (See Fig. 1). Doing a naturalistic study of inquiry with qualitative information about realities (paradigms), associated with the assisted living residents, healthcare staff, and facility administrators, would give the researcher the ability to get inside (and study), the relationship between natural surroundings, abundant light and organic shapes, and a patient’s positive outcome. By learning each constructed reality, we will be able to share with the stakeholders (of each reality), and at the end, construct a new reality (or realities) that would enhance both the researcher and stakeholders, and provide a foundation for a new assisted living prototype based on holistic thinking, and a framework of multiple analysis of

Fig. 8, in this naturalistic inquiry, each respondent has its constructed reality, with its own boundaries and understating of the whole, which has a corresponding behavior.

organic shapes and sustainable principles.

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The Black Box Metaphor: Suppose this naturalistic inquiry is represented by a “Black Box” (See Fig. 2). To begin the study, the researcher climbs into the Black Box, and to his surprise, finds a light on inside.

Once inside, the researcher starts to distinguish various constructed realities of the stakeholders and respondents, then determines how they are related, and choose among the respondents for qualities interconnected to the research, or the researcher could test their own constructed realities (which are data found in other documents or records), against the constructed realities of the stakeholders. As the researcher operates and moves around inside the circle of stakeholders (the social context) of the Black Box, they bring that information into contact with each other’s constructed realities, so that they can mutually understand and expand this new shared vision that will bring empowerment, communication and positive development among the interconnected realities. During this movement inside the box, among the stakeholders, the researcher will be sharing constructed realities, and building common direction and understanding. From this process, a final outcome will emerge. Erlandson; Harris; Skipper & Allen (1993) states “From this process, the final shape of the study, and the form in which it will be reported, gradually emerges. Allowing for the emerging process is fundamental to the naturalistic design and methodology...” (p 68). In past studies, one of the major findings was called Fig. 9, the black box a naturalistic inquiry, looking at ontological assumptions of the respondents constructed realities in conjunction with their preferences, dispositions and attitudes of organic shapes, abundant natural light and natural surroundings.

“Mutual Simultaneous Shaping” (Erlandson; Harris; Skipper & Allen, 1993, p. 16). Lincoln & Guba, (1985), describe among other things, that the factors observed were also bound together in a whole pattern

like the woven pattern of a cloth, each part interconnected and dependent upon each other. Each part was both, cause and effect of every other part, “Any solution to the problem would have to be a holistic one addressing the overall pattern of the

Healing space 34 organization’s behavior and not just some one portion of it”, (Erlandson; Harris; Skipper & Allen, 1993, p. 12).

Assumptions

Reality:

Ontological Assumptions

Shared and interconnected

Epistemological Assumptions

The researcher is inside the box with an interactive link between researcher and respondents Observation, case study research, collection of existing data , documents & interviews

Methodological Assumptions

Qualitative paradigm The realities are seen by the researcher as subjective, constructive and multiple Researcher interacts with respondents inside the box Inductive process of “Mutual simultaneous shaping”

Fig. 10, Summarization chart of the Black Box study.

Case Study Another way of attaining vital information for a naturalistic inquiry is to use a case study approach, so that the researcher can investigate the phenomenon of the constructed realities in a real-life context, especially when the boundaries between phenomenon and context are not clearly evident, Yin (1981a, 1981b). In other words, the case study is relevant when you want to understand a real-life phenomenon in depth, and its relationship to its natural surroundings.

Moreover, Yin (2009) continues by saying….

The case study is preferred in examining contemporary events, but when the relevant behaviors cannot be manipulated. The case study relies on many of the same techniques as a history, but it adds two sources of evidence not usually included in the historian’s repertoire: direct observation of the events being studied and interviews of the persons involved in the events. Again, although case studies and histories can overlap, the case study’s unique strength is its ability to deal with a full variety of evidence-documents,

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artifacts, interviews, and observations-beyond what might be available in a conventional historical study (p. 11).

In order to adhere to a case study approach, five prominent characteristics should be met.

First: the study questions who, what, where, when, and why. In this particular case study, an empirical inquiry reveals why a resident or client would want organic shapes, natural light and natural surroundings, integrated into an assisted living/healthcare environment. The respondents’ perception of organic shapes, natural light and natural surroundings, in the context of an assisted living/healthcare environment, adds unambiguous methodological specifics, depth of knowledge, and the final quantities analysis.

Second: proportions-exploratory rational and the purpose of the exploration. When Christopher Columbus went to Queen Isabella to ask for support for his “Exploration” of the new world, he had to have some reasons for asking for three ships, (Why not one? or five?), and he had to have some basis for going westward, (Why not South or East?). His search began with some rationale and direction, even if his initial assumptions might later have been proved wrong (Wilford, 1992). The magnitude, rational, and purpose of this case study is, is simply to use what is accessible and available to the researcher, like Christopher Columbus, he chose the first three ships that would bring him the highest probability of success (Wilford, 1992).

In my research, the three ships will be a multiple case study of two existing assisted living projects, located in Southern California, in which I was the Architect, and had access to a large portion of the design and site information. The decision to use these two sites became evidently clear, when familiarity with personnel, logistics and site access, came into play.

Moreover, as part of the over-all design, the client, California General Services Administration, dedicated additional land at the Ventura site for a future additions. Third: what is the case or unit

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of analysis? A definition of a single case study is an individual, or clinical patterns, or derelict men. Or in a multiple-case study, it can be about decisions, attitudes, preferences, programs, the implementation process, and/or organizational changes, (Platt, 1992). Feagin; Orum; Sjoberg & Gideon (1991) describe some classic examples of single case studies in sociology and political science. Examples of multiple case study research include, church involvement, city life, gender roles, white-collar crimes, family structure, homelessness, and other types of social experiences; but within these two cases, the research is combined with qualitative and quantitative tactics, to provide a wide-range insight to the final substantiation of data, which answered why these groups were chosen. Fourth: connecting the data to the proportions, in other words, the study must have a reliance on multiple sources of evidence within the case proportions, or delimits of the cases. Yin (2009) calls it “Linking pattern matching, explanation building, time series analysis, logic models or cross-case synthesis”. And fifth, power to generalize the theory behind the study. The core of a case study is its focus on a phenomenological relationship, within a reallife setting inside the metaphorical black box, but it can lead to generalization that will be applied to a new manifesto. The findings of correlation research are universal from a representative sample to a larger population; therefore, a concept or “theory” embedded in the cases can be generalized, reproduced, and ultimately incorporated into the final prototypical design solution as well. Yin (2009), argues a similar point where a case study's strength is its capacity to generalize to a theory like an experiment can be generalized to a theory, which in turn, can be tested through other experiments.

The study of a group Another approach to the research study is to emphasize an in-depth engagement with the respondents as a group, where the aim is to learn about the relationship between symbols,

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expectations, unspoken knowledge, communication, beliefs, likes, dislikes, attitudes, and perceptions of a cluster. The premise of this exploration is to understand and analyze the individual variables predicting an event: a positive psychophysiological outcome. By using a multiple regression formula to represent how one independent variable (X) is used to predict a single dependent variable (Y). The predicted value of (Y) is a linear transformation of the (X) variables such that the sum of squared deviations of the observed and predicted (Y) is a minimum. The computations are more complex, however, because the interrelationships among all the variables must be taken into account in the weights assigned to the variables as presented by (b).

From my hypothesis, the relationship of the variables can be defined as follows: The dependent (or criterion) “Y” variable would equate to: the patients/residences positive psychological outcome. The independent (or predictor) variable “X”, would equate to: The use of natural surroundings, abundant natural light, and organic shapes, (such as a circle or curvilinear wall). The weighted vale of “b” is assigned the number 1 (the interrelationships will have the same weighted value for simplification). Therefore, the predicted outcome of the variables could be represented in the following multiple regression formula:

Y  b0  b1 X 1  b2 X 2  b3 X 3  b4 X 4  b5 X 5  e .

A positive psychophysiological outcome, associated with one’s beliefs as being positive, translates down to the cellular level, where a calming environment appears to influence improved immune responses, linked with positive mental states, Mizan (2004).

Now that the variables have been identified, the research “setting” (Grout & Wang, 2002) defined, the connection between the meaning of the variables, and the group in the natural surroundings, becomes apparent as the study unfolds. At the conclusion, the data will lead to

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explanation of unexpected or anticipated outcomes, between the rural group and the urban group.

There might be a possibility that there are obvious similarities, or no similarities, or maybe an unexpected generalization or theory that can be applicable to the research solution.

Holistically thinking, the setting comprised of two veterans assisted living facilities, located in Southern California, (see chart below). According to the VETERANS HOMES OF CALIFORNIA, an assisted living facility is an apartment-style habitat, designed to focus on providing assistance with daily living activities. They provide a higher level of service for the elderly, which can include preparing meals, housekeeping, medication assistance, laundry, and also do regular “check-ins� on the residents. Basically, they are designed to bridge the gap between independent living, and nursing home facilities. “In general, assisted living combines housing, personal services, nursing and health care, in an environment that promotes maximum independence, privacy, and the choice for people too frail to live alone, but too healthy to utilize a 24-hour nursing care." Kraditor (2001).

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Site One (Rural)

Site Two (Urban)

Beds

10900 Telephone Road, Ventura, CA. 60-bed Residential Care Facility for the Elderly (RCFE), also known as assisted living.

Completion date

2009

11500 Nimitz Avenue, Los Angeles, CA. 84-bed Residential Care Facility for the Elderly (RCFE), also known as assisted living, 252 skilled nursing beds, and 60 beds for dementia long-term care 2010

Predominate stakeholders Group

Administrator: Ms. Brenda Manke Asst. Admin.: Patrick Keleher Administrators, facility staff, nursing staff and California veterans, 62 years old and older

Administrator: Mr. Louis H. Koff, Asst. Admin.: Robin Mackey Administrators, facility staff, nursing staff and California veterans, 62 years old and older

Services

All healthcare needs, meals, transportation, and activities are provided by the Veterans Home of California–Ventura, in partnership with the VA Greater Los Angeles Healthcare System.

All healthcare needs, meals, transportation and activities are provided by the Veterans Home of California–Los Angeles, in partnership with the adjacent United States Veterans Affairs campus, Westwood CA. Four story/OSHPD -Type I-A

Location

Massing/construction Single story/OSHPD 2-Type V-A Fig. 11, Description of the group research setting

Quasi-experimental research The final approach to this study, includes a quasi-experimental of the two selected sample “case studies” assisted living groups, (Campbell & Stanley, 1966; Cook & Campbell, 1979; Shadish, Cook & Campbell, 2002), sequentially, in order to gain further insights or understanding, and the extent of meaning behind the research topic with the application of quasiexperimental techniques: Perform an explorative pilot comparative study to identify real and metaphoric representations from natural elements of wind, earth, fire, metal, sight, sound, touch and smell, using the Sensationalism and Reflection philosophy of Condilloc and Diderot (Seigel, 2008) and,

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Correlate that data with manifestations of natural elements of the built environment (three dimensional prototype representations), as it applies to George Cantor’s set theory (Dauben, 1990).

The resulting qualitative data, acquired from the pilot comparative study, the correlation study, three dimensional prototypes/questionnaires and key interviews, were plotted on an impact assessment grid for analysis, Erlandson (Harris; Skipper & Allen, 1993). What then, are the defining characteristics of a quasi-experiment? And what commonalities of previous studies, from Campbell & Stanley (1966) et al., can we draw from, and apply to this study? Specifically, there is five: First, the use of a treatment or independent variables, (symbolized as “X”), are manifested as natural elements of the built environment (three dimensional prototypes); Second, the measurement of outcome or dependent variables, (symbolized as “Y”), are tested as a positive belief that becomes reality, in association with organic shapes and natural surroundings, Social constructivist perspective, (Katz & Rothenberg, 2005) and (Snyder, 1984 ); Third, a clear unit of assignment (to the treatment); Fourth, the use of a comparison, or control group; and Fifth, focus on causality. In this study, the “unit “ are the rural and urban case studies, where the key common features, to this, and all experiments, is to deliberately vary something, so as to discover what happens to something else later, to discover the effects of presumed causes. In quasi-experiments, the cause is manipulated and measured, and occurs before the effect is measured (Shadish; Cook & Campbell, 2002).

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Methods Participants Research participants were: 25 residents, 5 residential care staff, and 1 administrator from the Ventura VA assisted living facility; and 25 residents, 5 residential care staff, and 1 administrator from the VA West Los Angeles facility. Ethnicity of participants was not evaluated. All study participants, had at least six months living or working in the facilities. The participant average profile is based partially on the U.S. Department of Health and Human Services Report (2002), and partially on statistics supplied by Cal Vet Homes, in Ventura and West Los Angeles. The residents, 65-74 years old, are 13% of the sample population. The residents, 75-84 years old, are 37% of the sample population. The residents, 85 years old or older, make up 50% of the sample population. The respondents that are white make up 91% of the sample, while only 9% are non-white. As to

Fig. 12, Example of the Effects matrix, Effects of Nature crossed referenced with LEED 2009 criteria and Effects of Nature crossed referenced with a review of literature (above), see appendix A, B & C.

gender, 75% are male and 25% are female (due to fact that the case study population is derived mainly from United States armed service personnel). Income level, 69% make less than $10,000 a year, 19% make $10,000-$20,000 a

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year, and only 12% have a yearly income of $20,000. Health-wise, 11% are in excellent or very good health, 34% are considered in good health, and the remaining 55% are in fair or poor health.

Instruments To gain an understanding of what are the positive or negative attitudes, perceptions or dispositions towards organics shapes, natural surroundings and/or sustainable principles, an 8” x 11-1/2” matrix was developed, with symbols of the basic elements of nature, which are Wind, Water, Earth, Fire and Metal located on the top row. Symbols of sight, sound, touch and smell are located on the left column, then crossed referenced. Finally, each crossed reference variable was assigned one or more adjective “descriptors” that are assigned to each description of the combination or sight/wind or touch/water. In the example (Fig. 12), the cross reference wind/smell, the associated adjective descriptor/variable is aroma. For wind/touch, the associated adjective descriptor/variable is the sensation of air movement.

Next, an 8” x 11-1/2” review of literature matrix was developed from excerpts from literature, poetry and related research were assigned to the combination of the human senses and elements of nature in order to enhance the experience of or reveal any previous knowledge of the effects of nature. For example, the correlation between sight/wind and touch/wind describes wind as “soft stirrings that rustles leaves and grasses on summer afternoons to the biting storms that threaten life and limb, wind touches us all every day of our lives” (DeBelieu, Jan, 1998) or a research study by Kline (2010) indicated that audio stimuli of natural sounds or music used in conjunction with distracting visual elements provided stronger evidence of pain reduction which points out how the combination of touch and water can produce positive effects for patients.

Other combinations revealed negative associations, such as touch and fire. In the book Fire, Wambaugh (2002) describes an October evening in South Pasadena, CA where a wave of flame

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swept through a large home improvement center, snuffing out the lives of four innocent people.

One firefighter said “The temperature near the fire reached 110° it felt like someone was firing a hairdryer in the mouth every time it took a breath”.

Subsequently an 8” x 11-1/2” matrix of sustainable principles were prepared and cross matched to reveal how past studies, literature and poetry of natural elements and the current 2009 LEED criteria (Fig. 12). For instance, the variable wind/touch was linked to a study by Toftum (2004), indicating indoor air, at a maximum temperature range and very high air velocities, up to around 1.6 m/s, has been found to be acceptable at air temperatures around 30 degrees C. However,

Fig. 13, example of how wind/water/earth and metal, combined with sight/sound/touch and smell to reveal corresponding metamorphic manifestations of natural elements (images).

the pressure on the skin and the general disturbance induced by the air movement caused the air movement to be undesirable.

But another study by Zhou, X. (2006) suggested that, dynamic air supply could reduce the velocity and still maintained

comfort and also meets LEED 2009 indoor Fig. 14, example of a three dimensional manifestation in the built environment in a built environment with simulated textures and colors.

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air quality requirements. Other combinations, such as Healing Gardens (Marcus & Barnes, 1999) match up well with LEED’s Heat Island, open space, view, habitat and storm water management criteria.

To further embody the effects of nature, the review of literature and

sustainable principles of nature were then cross referenced into a new 8” x

Fig. 15, example of a three dimensional manifestations of natural elements in a built environment cloud formations or landscape scenes, through artificial lighting, LED screen technology.

11-1/2” matrix, (Fig. 13), where each variable is assigned a corresponding image to the written adjective “descriptor” of related literature, poetry or past research to help form a language pattern that translates the abstract into physical prototypical terms, and bridged the gap between the concept word/thoughts, and the intuitive or artistic line of thought. Creativity research, illustrates how using a linguistic devise such as a list of

related words (e.g. air movement against the face, body, feels damp, dry, dusty, etc), with images of how

Fig. 16, example of a pilot exploratory correlation study in which the metaphoric images are compared and correlated with a three dimensional prototype, then documented.

wind affects people, induces the transformation of thought into physical reality, based on philosophy of sensationalism and reflection (Tyson, 1998) and (Sigel, 2005).

The evolution of wind/touch/air movement variable produces a new language pattern for design, in the form of a manifestation of natural elements of a built environment (three

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dimensional prototypes, Fig. 14), with an organic shape and/or materials, such as smooth stones, that might have good or bad implications.

For example, a curved wall of smooth stones might be acceptable, but located near higher air movement, might cause noise, and presumably fear, which is considered unacceptable. However, lowering the air velocity, using a dynamic supply register, would reduce fear, which then becomes more

acceptable. This, in turn, creates energy savings, which equates to a sustainable

Fig. 17, example of a questionnaire: Showing a three dimensional prototype of a built environment with questions relating to natural light.

principle. Other three dimensional models (Fig. 15), showing similar language patterns, such as sight/earth lead to an ultimate design with organic characteristics, depicting natural light and emulating cloud formations and/or landscape scenes, through artificial lighting and LED screen technology. Studies have shown that greater restorative effects arising from experiences in nature (Hartig; Mang & Evans, 2006), reduce stress and anxiety. Additionally, sight/earth/sound/water prototype models, referring to language patterns of abundant natural light, theorized pain and stress reduction (Malenbaum; Keefe; Williams; Ulrich & Somers, 2008), (Ulrich; Zimring; Quan & Joseph, 2006) and (Ulrich, 2008). By bringing the outdoors in, nature stimulations with both, visual and auditory distractions, can be shown as diverting and engrossing, therefore it is more effective for relieving severe pain and/or stress (Malenbaum et al., 2008 and Ulrich et al., 1993; Tse, Ng, Chung and Wong, 2002).

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From the evolution of wind/touch/air movement variables, review of literature, sustainable cross referencing and assigned images, an exploratory comparative study, where the metaphoric representations, from natural elements (images), were compared to the design with the manifestations of natural elements of a built environment (three dimensional prototypes), to determine if they were analogous. The date, time and comparative decisions were recorded on an 8 1/2” x 11” matrix for documentation purposes (Fig. 16). At the end of the exploratory study, the three dimensional prototypes with the most resemblance to the natural manifestation, were incorporated into a survey questionnaire.

Interview guidelines To design healthcare environments that captures organic shapes, natural surroundings and sustainable principles, which result in an increase of patients’ positive psychophysiological outcome, the researcher must understand environment behavior of who does what and when, in relationship, or lack of, between people’s attitudes, perceptions and dispositions of organic shapes, natural surroundings, and sustainable principles

Fig. 18, example of a body language guide, to document respondent’s perceptions during the interview.

within the context of a physical setting. By looking at how two case study environments affect people’s ability to see, hear, touch, smell and perceive their environment and each other, we were able to understand how environment can impair or improve, the residents’ and/or staffs’ positive psychophysiological outcome. Basically,

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this was done by asking questions, taking notes, performing surveys through questionnaires (Figs. 17) and performing focused interviews with residents, staff and key stakeholders, using an interview/ body language guide (Fig. 18).

Interviews with residents, staff, and administration, gained important insight and knowledge about what the respondents feel about the use of organic shapes, natural surroundings, and sustainable principles in a healthcare environment. It also helped the researcher understand how the data adapted into the larger, interpersonal, social, and cultural context of the study. The researcher went into each interview with the following objectives: Introduce and explain the reason and goals of the research project.

Lead the interviewee with a mixture of conversation and embedded questions. 

Encourage o Opinion/value questions, but start out very simple o Experience/behavior questions o Knowledge questions o Sensory questions o Background/demographic questions



Keep track of body language as the interview proceeds



Take detailed notes



Be sure to thank the interviewee The following is an example of some initial questions at an interview with a staff member

at the VA homes: Interviewer: What is your general feeling about this facility?

Staff member: I really like it Interviewer: What do you particularly like about it?

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Staff member: I really like the way it feels, open to the courtyards at the common areas and hallways.

Interviewer: What do you mean when you say “It feels open�?

Staff member: I mean that it makes me feel closer to the outside garden areas, during work Procedure 13 to 25 participants at each case study site were randomly chosen by the staff and the researcher to review each of the four questionnaires that showed a rendered three dimensional prototypes, of the built environment and three or four other questions relating to organic shapes, abundant light, and natural surroundings.

Then the participants will review the rendered three-dimensional prototype, of the built environment, and be asked to rate the image, on a Likert scale, from 1 to 5 (1 being least and 5 being very), how comfortable would you feel in a room like the one portray in the questionnaire.

During the process of answering the other question the researcher and the respondents participated in brief open-ended interview, in order to understand their perception, like or dislike of windows, natural light, views, natural surroundings, and organic shapes and materials. There is also space on the questionnaire for respondents to write about their feelings regarding the three-dimensional prototype, windows, natural light, views, natural surroundings, and organic shapes and materials.

Interviews of administrators and key stakeholders will be audio taped and take the form of an open-ended nature in which the researcher will ask the respondents for opinions about the questionnaires, natural light, natural surroundings and organic shapes and materials as it related to their assisted living environments..

Between interviews the audio tape will be played back and the data "unitized" into the smallest pieces, as possible, so that the common words, phrases and ideas emerge into

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categorical designations (Lincoln and Guba, 1985). This heuristic process will allow the emergent pieces of information to standalone and determine the respondents, preferences, likes, dislikes and attitudes about their relationship with natural light, views, natural surroundings and organic shapes and materials, which of course is associated with each interviewee's version of their constructed reality.

Design application As part of the design process, and prior to preparing the new manifesto/programs for the diagrammatic design solution, a Quality of Life questionnaire was distributed among the four administrators at the two study sites, asking them to rate five basic psychological needs as adopted by Maslow (1987). In his positive theory of motivation, Maslow identifies five basic human needs that necessitate satisfaction in order for an individual to continue to exist.

According the Maslow (1987), once the fundamental need of physical survival is fulfilled, other needs, such as: safety and security, social/belonging and self-esteem emerge, until a person reaches the need for self actualization and understands “What a man can be, he must be�

(Maslow, 1987, p. 91).

The Quality of Life questionnaire will be used to quantify the five basic human needs in a hierarchal structure in order to form criteria for design of the new diagrammatic archetype at Ventura, CA. Study site.

Implementation The results of the pilot exploratory comparative study resulted in, four- three dimensional manifestations of the built environment (prototypes) which were incorporated into the following questionnaires: 

A living ceiling

Healing space 50 

Natural light and views



Bringing the outdoors in



A living wall

The questionnaires were disseminated as part of a quasi-experimental of the two selected sample “case studies” assisted living groups in Venture and Los Angeles, California, (Campbell & Stanley, 1966; Cook & Campbell, 1979; Shadish, Cook & Campbell, 2002).

Description Prior to disseminating the questionnaires, arrangements were made with the two assisted living facilities for permission to access; however it became clear, after initial phone calls and meetings, that the availability to the sample pool would be limited to certain days, times and specific locations. Based on security requirements, the researcher was not able to wander freely and converse with residents, administrators and staff. However fifty two, out of an expected fifty surveys were realized, though research regarding sample size indicates that there are “no rules for sample size” (Erlandson; Harris; Skipper & Allen, 1993, p. 83). Hence, canvassing the Ventura and West Los Angeles case study sites at three separate occasions produced a rich purposive sample, suitable for the study.

Interviews with facility administrators, nursing staff, and other stakeholders were also limited due to availability of the person, and time constraints of the project, however the researcher was able to interact with about five to eighteen residents, and about two to four administrators at each site. Open-ended interviews were conducted with the residents and staff, while administering the questionnaires and touring the facilities. The in-depth interviews with facility administrators and major stakeholders, approximately eight, ran concurrently with the survey distribution as well. Each interview lasted about 20 to 40 minutes, even given these constraints, the researcher was able to have an interactive dialogue with the respondents that led

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to an informative reconstruction of their past, present, and future attitudes/dispositions, regarding the use of abundant natural light, organic shapes, and natural surroundings (Erlandson; Harris; Skipper & Allen, 1993).

Furthermore, it is recommended that any future attempts to interview and administer surveys at any state or privately administered assisted living facilities, should allow for additional time for greater accessibility and procurement of security clearances in order to assure a productive inquiry.

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Results The completed questionnaires were assembled, disseminated, classified, and then the respondents’ replies were analyzed three ways: as a combined total of all of the respondent’s replies, each response/per questionnaire, and a correlation between Rural vs. Urban case-study sites. The comfort scores are shown as scatter charts, as it was the clearest way to display the overall score at a glance, while the other answers are depicted in a standard text format, for more concise viewing. Finally, the correlation examination was best shown as tables, which made for a quick and easy way to compare one study site verses the other.

Questionnaires As part of A Living Ceiling questionnaire, respondents were asked to rate a three dimensional manifestations of the built environment (see Fig. 19) “On a scale of 1 to 5 (1 being least, 5 being most), how comfortable would you feel in a room like this?”The results are indicates on a scatter chart below, see (Fig. 20). The average Likert score was 3.

Fig. 19, respondents rated this three dimensional manifestations in the built environment as part of A Living Ceiling questionnaire.

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Living ceiling comfort level 6 Comfort Level

Fig. 20, indicates how the respondents scored, after they reflected on the three dimensional manifestations in the built environment.

5 4 3 2 1 0 0

2

4

6

8

10

12

14

Participants Comfort Score

Linear (Comfort Score)

The results from the rest of the questions from the A Living Ceiling questionnaire were: 1. If there were a place where you had a ceiling that looked just like clouds, would you enjoy it?

YES-76%, No-23% 2. How often would you use a room like this, if you had access to it?

Very often-7%, Often-53%, Sometimes-23%, Rarely-15%, Never-0% 3. Please describe what you would feel like if you were in a room or area like this? "not confined", "free feeling", "wide open", "lack of privacy", " too much light", "feel comfortable", "insecure", "relaxed", and "positive".

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As part of the Natura Light and Views questionnaire, respondents were asked to rate a three dimensional manifestations of the built environment (see Fig. 21) “On a scale of 1 to 5 (1 being least, 5 being most), how comfortable would you feel in a room like this?�The results are indicates on a scatter chart below, see (Fig. 22). The

average Likert score was 4.

Natural light & views comfort level 6 5 Comfort Level

Fig. 22, indicates how the respondents scored, after they reflected on the three dimensional manifestations in the built environment.

Fig. 21, respondents rated this three dimensional manifestations in the built environment as part of the Natural Light and Views questionnaire.

4 3 2 1 0 0

2

4

6

8

10

12

14

Participants Comfort Score

Linear (Comfort Score)

The results from the rest of the questions from the Natural Light & Views questionnaire were: 1. Are there windows, where you live, that allow you to look out without making an extra effort, such as opening blinds, standing, or straining?

YES-92%, No-7% 2. How often do you look out the window during the day?

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Very often-23%, Often-62%, Sometimes-15%, Rarely-0%, Never-0% 3. Please describe how you would feel while looking out to a garden or courtyard area? "very peaceful", "refreshed and calm", "looking out a window gives you a sense of freedom", "comfortable", "freedom", "scenic views of landscape is soothing and relaxing".

4. Do seasonal changes affect your mood?

Very often-0%, Often-23%, Sometimes-62%, Rarely-15%, Never-0%

As part of the Bringing the outdoors in questionnaire, respondents were asked to rate a three dimensional manifestations of the built environment (see Fig. 23) “On a scale of 1 to 5 (1 being least, 5 being most), how comfortable would you feel in a room like this?�The results are indicated on a scatter chart below, see (Fig. 24). The average Likert score was 4.1.

Fig. 23, indicates how the respondents scored, after the y reflected on the three dimensional manifestations in the built environment.

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Bringing the outdoors in comfort level score Comfort Level

Fig. 24, Respondents rated this three dimensional manifestation in the built environment as part of the bringing the outdoors in questionnaire.

6 5 4 3 2 1 0 0

2

4

6

8

10

12

Participants Comfort Score

Linear (Comfort Score)

The results from the rest of the questions from the Bringing the Outdoors In questionnaire were: 1. Are there any exterior/interior gardens or courtyards, where you live, that you enjoy?

YES-76 %, No-23 % 2. How often do you use the garden area(s) or courtyards during the day?

Very often-31%, Often- %, Sometimes-15%, Rarely-38%, Never-8% 3. Please describe what you would feel like during a visit to a garden or courtyard? “very peaceful", "serene", "quiet time for meditation and thinking", "refreshed", "too much light", give you the sense of freedom", "comfortable", "freedom" 4. Do garden areas or courtyards affect your mood, while there?

Very often-8%, Often-38%, Sometimes-38%, Rarely-8%, Never-8%

14

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As part of A Living Wall questionnaire, respondents were asked to rate a three dimensional manifestations of the built environment (see Fig.

25) “On a scale of 1 to 5 (1

Fig. 25, Respondents rated this three dimensional manifestations in the built environment as part of A Living Wall questionnaire.

being least, 5 being most), how comfortable would you feel in a room like this?� The results are indicates on a scatter chart below, see (Fig. 26). The average Likert score was 3.2.

6

Living wall comfort level score

Comfort level

5 4 3 2 1 0 0

2

4

6

8

10

12

14

Participants Comfort Score

Linear (Comfort Score)

Fig. 26, indicates how the respondents scored, after they reflected on the three dimensional manifestations in the built environment.

The results from the rest of the questions from the Living Wall questionnaire were: 1. If there were places where you had a room or space with natural materials like this, would you enjoy it?

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YES-77%, No-23% 2. How often would you use a room or space like this, if you had access to one?

Very often-7%, Often-15%, Sometimes-24%, Rarely-39%, Never-15% 3. Please describe how you would feel in a room or area like this?: "enclosed", "peaceful", "creative", "comfortable", "feels like I'm in a fish tank", "I like the materials, but not the windows", "feels like him one with nature", "positive, looks very non-institutional", "not cozy, feels like a museum" Tables 1 through 4 depict results from a correlation examination, comparing the two case study sites’ comfort level score, enjoyment, access, and moods:

Average A Living comfort Ceiling questionnaire level score

Would you enjoy a room like this?

How often would you use a room like this?

Ventura case study site: (Rural)

3.6

Yes-72% No-28%

West Los Angeles case study site: (Urban)

4.3

Yes-83 % No-17 %

Very often-15% Often- 28% Sometimes- 43 % Rarely-14% Never-0 % Very often-7 % Often-83 % Sometimes- 0 % Rarely-0 % Never-0 %

Describe what you would feel like if you were in a room or area like this?

Not confining, freedom of movement, feel comfortable, too much light.

Not feel secure, to open, very positive, open, free, relaxed, refreshed, trees, awesome.

Table 1 compares the respondents’ replies to A Living Ceiling questionnaires between the two selected case study sites.

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Natural Light and Views questionnaire

Average comfort levels score

Ventura case study site: (Rural)

4

West Los Angeles case study site: (Urban)

4

Are there windows, where you live that allow you to look out?

Yes-85 % No-15 %

How often would you look out the window during the day?

Yes-100 % No-0 %

Very often-33 % Often-50 % Sometimes 17 % Rarely-0 % Never-0 %

Very often-14 % Often-72 % Sometimes 14 % Rarely-0 % Never-0 %

Describe how you would feel while looking out to a garden or courtyard?

Comfortable, sense of freedom, positive, life, enjoyable view.

Do seasonal changes affect your mood?

Very often-0 % Often-14 % Sometimes-57 % Rarely-29 % Never-0 % Quiet time Very often-0 for % meditation, Often-3 % very creative, Sometimes-66 refreshing, % calm, too Rarely-0 % much light, Never-0 % like to see people go by.

Table 2 compares the respondents’ replies to Natural Light and Views questionnaires between the two selected case study sites.

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Bringing the outdoors in questionnair e

Average comfort level score

Ventura case study site: (Rural)

3.4

West Los Angeles case study site: (Urban)

4.8

Are there exterior/ interior gardens or courtyards, where you live, that you enjoy?

Yes-71 % No-29 %

How often do you use the garden area (s) or courtyards during the day?

Describe what you would feel like during a visit to a garden or courtyard?

Do garden areas or courtyards affect your mood, while there?

Very often-14 % Often-0 % Sometimes 14 % Rarely-57 % Never-15 %

Peaceful, comfortable, welcome, creative, very relaxing, soothing.

Very often-0 % Often-28 % Sometimes-42 % Rarely-15 % Never-15 %

Yes-83 % No-17 %

Very often-50 % Often-17 % Sometimes 60 % Rarely-17 % Never-0 %

Peaceful, relaxed, refreshed, pine trees, meditate, plants, very positive.

Very often-70 % Often-50 % Sometimes-33 % Rarely-0 % Never-0 %

Table 3 compares the respondents’ replies to Bringing the outdoors in questionnaires between the two selected case study sites.

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Average comfort level score

Ventura case study site: (Rural)

3.3

West Los Angeles case study site: (Urban)

3.3

If there were places where you had a room or space with natural materials like this, would you enjoy it?

Yes-85 % No-15 %

How often do you use the garden area (s) or courtyards during the day?

Describe how you would feel in a room or area like this?

Very often-0 % Often-28 % Sometimes44 % Rarely-14 % Never-14 %

Yes-85 % No-33 %

Very often-33 % Often-0 % Sometimes-0 % Rarely-67 % Never-33 %

Like natural surroundings, feel like in a fishbowl, comfortable, enclosed, peaceful, creative.

Feels like a museum, likes the match natural materials, not cozy, positive, noninstitutional, and feel like one with nature.

Table 4 compares the respondents’ replies to A Living Wall questionnaires between the two selected case study sites.

Interviews In order to triangulate respondent’s opinions, dispositions, attitudes about natural abundant light, organic shapes and natural surroundings against the data from the questionnaires, the researcher audio taped, then documented the open-ended interviews with administrators, staff members, and residents at each case study site, then correlated the words and phrases that they all shared, which was a part of the dialog relating to the four questionnaires. As stated in the Methods section of this study, the common words and phrases were compared using “unitized” into categorical designations based on type of interviewee (Lincoln and Guba, 1985). The table

Healing space 62 below is a tabulation of the interviewee’s common words and phrases in relationship to the case study site location (Rural vs. Urban). An analysis of the table reveals the frequent word or phrase common to all interviewees and case study sites, raked from most to lease commonly used: 1. Natural light 2. Views of natural surroundings 3. Gardening 4. Wayfinding 5. Security

Location

Ventura case study site: (Rural)

West Los Angeles case study site: (Urban)

Interviewees Administrators  Gardening  Orientation  Wayfinding  Clear and visible access  Security  Natural light everywhere  Natural light, critical to a resident’s well being.  Garden areas  Views  Exterior dining/social areas

Staff  Lots of natural light for staff and residents  Windows  Social areas  Simple wayfinding  Courtyard view everywhere  Private storage areas  Adequate space for common and garden areas  Garden and courtyard views  Need for Recreation areas

Residents  Gardening effects the mind  Views  Like natural surroundings

 Cozy areas  Non-institutional  Not enough Recreation areas  More gardens and planting  Security

Table 5 compares the type of interviewees’ frequently used words and between the two selected case study sites as shown in bold italicized.

An Interpretive-historic confirmation Nature, landscape and scenery have been around from the first days of man. Beginning with the earliest Egyptian through modern man, the depiction of natural elements in religion, art,

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literature and architecture has been a continuous stream of symbols, signs and metaphors. In Egyptian art, one finds remarkably precise elements of flora and fauna that shows the way nature affects the soul, and reveals a spiritual light deep inside all natural phenomena. By 5,000 BC, the Mesopotamia agrarian cultures around the Tigris and Euphrates Rivers emerged, focused around the symbolism of religious manifestations of their sky god An, wind god Enlil, earth god Enki (god of rivers, wells, and canals), and Ninhursaga, the goddess associated with soil, mountains, and vegetation. By the third millennia B C, the pre-Socratic philosophers, abstracted the entire phenomena as a singular "physis". To the Greeks, nature philosophically meant many things, or "all things; nature is the heavens above, the earth beneath, and the waters under the earth" (Tuan, 1974, p.132), which was exhibited in scenes of Greek tragedies, and later in the Roman theater, in pottery, and even in landscaped gardens. Later, medieval Christian thinkers (adapting that Aristotelian cosmos), did not see nature as inclusive of everything, but thought that nature had been created by God; her place lay on the earth, below the unchanging heavens and moon which was demonstrated in the Hortus conclusus, an emblematic attribute of the Virgin Mary in medieval and Renaissance poetry and art, where one could be enclosed in a private and protected cloister, for reflection n order to reflection and worship. Today, when we speak of nature, we speak of countryside and the wilderness; that pre-civil condition described as "nature, or the state of nature‌ Still unspoiled, phusis" (C.S. Lewis, 1967, p. 62) or a picturesque representation of landscape. Now nature takes on an idealized or symbolic sedimentation, which is so prominent in the urban cultures of our time. The idealization of "wild" nature as superior to "human" nature goes back to Rousseau, whose rhapsodic descriptions of the natural beauty of the Swiss countryside struck a chord in the public, and may have helped spark the subsequent nineteenth century craze for Alpine scenery. Spontaneous

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symbolic meanings are said to arise from directly perceivable analogy, between the visual surface, and the structure of the object, (such as a building), corresponding generic characteristics of organic shapes, (such as height and depth or breadth), openness, closure, outgoing, or withdrawal. Many of these empathies are said to develop from observations from the natural world, the human body, or nature itself (Lang , 1999; Arnheim , 1977).

Therefore,

respondents’ appeal, disposition, preference towards natural light, natural surroundings, garden views, security and spatial orientation, have been confirmed through an historic analysis of nature, landscape, scenery, and organic shapes.

Design application Pre-design The results of the Quality of Life questionnaires that were disseminated between the administrators at the two case study sites revealed the most important need in relationship to an assisted living environment was Shelter, food, water, followed by safety and security, followed

by Self-actualization, Independence, Interaction, Aesthetics, Belonging and finally Self-esteem.

The ranking and Liken score for each was as follows:

Ranking

Human Need

Liken score

1.

Shelter, food, water, etc.

7.1

2.

Safety and Security

7

3.

Self-Actualization

6.9

4.

Independence

6.26

5.

Interaction

6.25

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6.

Aesthetics

6.24

7.

Belonging

6

8.

Self-esteem

5.5

The quantitative findings of the quality of life questionnaire were then correlated with human senses to form design criteria as an initial step in the design process. The attributes, displayed as images and text descriptors formed a basis of understanding that was used as a programmatic mile stones in the new manifesto. Each sense and human need produced corresponding image and text descriptor which was then ranked, from top to bottom, according to importance. For example the corresponding image and text descriptor for sight and shelter created an

Fig. 27 design criteria matrix: Correlating the human senses and human needs for a basis of design.

image of comfort. Likewise, the corresponding image and text descriptor for sound and shelter created a family gathering.

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Consequently the combination of sound of a family gathering would rank higher as a design objective than the combination of smell related to self-esteem. The aim will be to incorporate each combination of the human senses and human needs, along with the natural light, natural surrounding and organic shapes into the program/manifesto.

The Program/Manifesto As part of the interview process with the Administrator of the California Veterans’ Home in Ventura, CA the researcher poised the question: What kind of proposed facility would harmonize with the adjacent assisted living complex? Many types of healthcare environments for the elderly came up during the discussion, but one common topic pointed to a configuration that is becoming more accepted, it is named: Continuing Community of Residential Care (CCRCs), which offer persons 60 years of age or older, a long term continuing care contract that provides for independent living units, residential care/assisted living services, and skilled nursing care; usually in one location, and usually for a resident’s lifetime. Specifically CCRCs provide housing, meals, transportation, activities, in addition to a continuum of care that includes assisted living and nursing home care. Increasingly, CCRCs have health clinics, wellness programs, and specialized dementia care services.

Historically, CCRCs were founded and operated by non-profit religious organizations, (e.g., Presbyterians or Episcopalian and Baptist Homes), or by fraternal organizations. Although non-profit organizations still dominate the CCRC scene (i.e., more than 80% of CCRCs in California are operated by non-profits), for-profit providers (e.g., Marriot, Hyatt, Sunrise Care), are increasingly entering this lucrative market with urban based, very upscale and expensive CCRC communities

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Based on interviews with the administrators at the two case study sites, I concluded that their primary vision would be to incorporate or encapsulate a CCRC adjacent to the existing assisted living facility, where a veteran can come into their campus, and receive multiple levels of care, and remain there the rest of his life, without going out into the community for end of life care. This arrangement of care has long term benefits for the patient and the community, by allowing a consistent level of care from pre-retirement to end of life. One of the main attractions of CCRCs is the peace of mind that comes from meeting one’s long term care needs, in a single setting. It takes away the guesswork and aggravation of arranging for future care needs, and produces a real sense of security, in knowing that one’s plans for long term care are already in place. According to the information obtained from the interviews, administrators’ state that there is also the added bonus of no longer maintaining a house. They argue that moving closer to one’s children or siblings can increase interaction, and strengthen their informal support system.

Therefore and most importantly, getting the care close to family relieves the concern of becoming a burden. Additionally, a primary value for couples is the ability to remain together, or at least be on the same campus, if one spouse requires a higher level of care. Although this is not strictly “aging in place” (i.e., living together in one’s independent unit), CCRCs offer the option of aging in a community or on a campus.

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Accordingly, the results of the research and interviews are incorporated into a new manifesto/program matrix, which specifies the programmatic requirements for a Holistic –

Fig. 28 a new archetype manifesto/program that incorporates holistic-centered care, continuing community of residential care design objectives as well as incorporating abundant natural light, natural surroundings, organic shapes and quality of life attributes

Centered Care, which embraces the geometry and functional aspects of a Continuing Community of Residential Care facility, also incorporating the use of natural surroundings, organic shapes, and quality of life attributes, to enhance the patient's positive psychophysiological outcome.

Archetype diagram Elements As part of the diagrammatic archer type plan development, the designer must consider all of the previous research data, quality of life attributes as well as each function from the innermost point of generation to the outer most point of off- site target boundaries. To start the progression, we must review and analyze how the proposed plan elements correlate to basic human senses to optimize the site-structure unity. Five basic human needs, as adopted by

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Maslow (1987) and the findings of the quality of life questionnaire were matched up against five geometric building configurations, chosen randomly, and representing five common shapes found in site planning and landscape architecture (Simonds, 1961; Coates, 2001; Grahn, 2001).

Each generic configuration was then compared to a human need to determine if that configuration embraces the characteristics or traits of that particular need. The compatibility level was than delineated as degrees of green dots to

Fig. 29 shows how generic building configurations correlate to basic human senses to optimize the sitestructure unity and the subsequent Holistic-Centered/CCRC site diagram.

degrees of red dots. For example the ovaliod configuration is very compatible with the need for shelter which received three green dots, while the buckshot configuration seems less likely to represent shelter, only receiving two red dots (Fig. 29). The conclusion of the comparative analysis reveals that the ovaliod, finger and checkerboard are best suited meet the five basic human needs, therefore a variation of this configuration should be considered as part of the HolisticCentered/CCRC archetype diagram.

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Archetype diagram The final phase of the design culminates with a Holistic-Centered/CCRC archetype diagram integrating all of the research findings based on the hypothesis: Among skilled nursing/assistive living environments, there is a direct relationship between the use of natural surroundings, abundant natural light, organic shapes, and a patient’s positive psychophysiological outcome. To this end the image below signifies a schemata where the use of natural surroundings, abundant light, organic shapes, the quality of life attributes and three levels of care (as indicated in figure 10) can be implemented as a guideline to augment any assisted living residential environment.

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Fig. 30 a new archetype design diagram that reflects the manifesto/program incorporating holistic-centered care, continuing community of residential care (CCRC) design objectives as well as abundant natural light, natural surroundings, organic shapes and quality of life attributes.

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Discussion Summary This researcher’s main objective was doing a naturalistic study of inquiry with qualitative information about realities (paradigms), associated with the assisted living residents, healthcare staff, and facility administrators, and to understand and study the relationship between natural surroundings, abundant light, and organic shapes; based on wind, water, earth, fire, metal, sight, sound, touch and smell, and a patient’s psychophysiological outcome. To know what it is “out there”, is to look at more than one reality among participants and staff's living environments, and discover if there is in fact, a direct connection.

The secondary objective incorporated the findings into the preparation and completion of a program/manifesto, and a new archetype Holistic-Centered/CCRC designthat could serve a diagrammatic outline, or road map for future endeavors.

Delimitations The study was deliberately confined to the assisted living/healthcare environment, in two case study sites located in Ventura and West Los Angeles, California based on the following criteria: 1. Feasibility: the strategies and tactics of how, what, where, to test my hypothesis, lend itself towards limited scope of an assisted living healthcare environment, rather than a more complicated acute care hospital setting.

2. Access: typically state operated facilities are easier to access due to freedom of information acts, allowing uncomplicated access to the respondents, compared to more restricted security requirements associated with acute care hospitals.

3. Familiarity: As the Architect of Record for the two projects, I had access to a large portion of the design and site information, which facilitated the development of the three dimensional prototypes, site analysis, new manifesto/program, and diagrammatic archetype design.

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Assumptions My findings indicate that some of the early assumptions attributing stress, patient disorientation, and the “industrialized” nature of healthcare, support evidence (Ulrich, 1981; Farley & Veitch, 2001; Frumkin, 2001), that a connection with nature through a window or scenic representations of natural surroundings, increased productivity and health in the workplace, promoting healing of patients and reducing the frequency of sickness and stress (Ulrich, 1981; Farley & Veitch, 2001; Frumkin, 2001). In particular Farley & Veitch (2001) states…

The most consistent finding in the literature is that people prefer natural rather than built or urban views from windows. Windows with views of nature were found to enhance work and well-being in a number of ways including increasing job satisfaction, interest value of the job, perceptions of self productivity, perceptions of physical working conditions, life satisfaction, and decreasing intention to quit and the recovery time of surgical patients.

Moreover, the results of my study also supported the findings of Mizan (2004), that point toward a connection between nature and positive psychological outcome through exposure to indoor plants, natural materials, aquatic sounds, music, abundant natural light and colors. The effect of the environment seems to “extend to a cellular level, which improves immune responses, linked with positive mental states mediated by a calming environment…”

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Interpretation The strongest examples of solidarity, included in this research study, found that the desire/use of abundant natural light, and the use of interior/exterior landscape gardens as part of an environment, scored very high in all questionnaires, by both individual respondents, and as part of a correlated analysis of the two case study sites. Close to 100% of the respondents, said windows and views are important, and four out of five respondents rated the three dimensional prototypes of "Natural light and views" and "Bringing the landscape in" as being very comfortable. Some of the respondents’ descriptions included "very peaceful", "refreshed and calm," "looking out a window gives you a sense of freedom" and "scenic views of landscape are soothing and relaxing". Conversely, the study also indicated mixed results when respondents viewed the three-dimensional prototype regarding "A living wall". 77% of the respondents indicated that they would like to be in a room with natural materials, and rounded (organic) shapes; however, only 39% indicated they would visit that same space, if they had access to it.

The descriptors similar to "enclosed", "creative", signify positive direction of the perception towards acceptability of the space, however, other descriptors approximating "not cozy, feels like a museum", indicates negative feelings or perceptions of the same spatial representation.

Strengths of the current study The methodological strengths of the study included the questionnaires, which were used to describe and/or predict the phenomenon, based on the hypothesis and the surveys, which were designed to understand and determine environment behavior of who does what and when, in relationship, or lack of, between participants, perceptions, and dispositions of organic shapes, natural surroundings, and sustainable principles within the context of a physical setting.

Particularly, the most beneficial aspect of the questionnaires and the surveys, were the use of the

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three-dimensional manifestations in the built environment, and the interaction that took place between the investigator and the respondents, while reflecting on the prototype representations, which gained the most insight.

Limitations Equally, the correlation pilot study and the open-ended interviews had its limitations as well. While the correlation pilot study was exploratory, and provided a swift approach to empirically examine the relationships between the two dimensional manifestations of the effects of nature, and the three-dimensional manifestations in the built environment, it was limited in control and sample size. Moreover, open-ended field interviews had drawbacks as well, hence they were difficult to predetermine, execute soundly, and accurately analyze, even though I believe that the "unitization" methodology was sound.

Implications The study had some unexpected findings regarding the use of the three-dimensional manifestations in the built environment, and the subsequent mixed results from the respondents; however, some possible explanations might come from the way the prototypes were interpreted.

Each observer associated their own values and sense of importance to the representation, as part of their own constructed reality; hence, each participant had a different explanation for the same image. This may be true in the light of research that has previously been done, exploring how environmental images are processed, and the relationship connecting natural scenic beauty, preference, and restoration which suggests the implication that further studies should be considered. Moreover, the current study has provided data to suggest that, patients/residents respond holistically to abundant natural light, organic shapes, and natural surroundings rather

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than in a systematic or in a heterogeneous manner, and that these conclusions imply how healthcare design can be approached.

Conclusions Can nature be incorporated as part of a universal principle, into the empirical science of healthcare design? Can the polemic design philosophies as espoused by Virtuvius, Antoine Laugier, Francesco Milizia, Charles and Henry Greene, Frank Lloyd Wright, Erik Asmussen, Lauri Baker, and John Lautner, to name a few, be included as part of a new manifesto for the patient/resident? Yes, of course. However, today we must begin to understand that “organic architecture" (Wright, 1943), equates to more than framing the view at Falling Water, the use of clinker bricks for a foundation wall, or even the use of art, ornamentation, or sculptural elements.

Moreover, we must also be cognizant that the scientific developments that followed Newton, Einstein, and SchrĂśdinger did not account for the whole relationship between man and his environment, and that the vibrant theories of Lllya Prigogine, Humberto Maturana and Francisco Varela should be reviewed, examined, and serve as a foundation for future healthcare built environments.

It is my theoretical conclusion that a large amount of the respondents’ perceptions of the variables, through the use of three dimensional manifestations in the built environments, were holistic, made up of the natural parts, reflected then associated with a value premise and belief, which subsequently equated to an affirmed attitude and finally, a positive psychophysiological outcome. As the repondents preceived and experienced abundant natural light, organic shapes and natural surroundings in the three-dimensional manifestations in the built environment they gained an holistic understanding of that particular healing space. The subsequint process as

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diagramed in (Fig. 31) produced a phenomenon: a positive psychophysiological outcome, I call this the “healing space effect”, Hence the theory of the healing space (Fig. 32) emerged.

Directions for future research The results of this study suggest some future directions for research, aimed at the understanding of the relationship between “healing space” (based on wind, water, earth, fire, metal, sight, sound, touch and smell), and the “healing space effect” in connection with other venues such as acute, intermediate or hospice care environments. Perhaps combining the dichotomized research strategies, found in evidence based design, with the holistic findings of this study could form an all-embracing umbrella of work.

Indubitably, the interpretive-historical developments commencing from the Age of Reason, points out the dangers of a priori thinking, a lesson that should never be forgotten. "The world, in fact, is still dominated by those who put the conclusions at the beginning," (NorbergSchultz, 1980).

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Healing space 92 APPENDIX A – Effects of nature correlation study

Healing space 93 APPENDIX B – Review of literature on the effects of nature correlation study

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Healing space 97 APPENDIX D –Exploratory correlation pilot study

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Healing space 101 APPENDIX E –Metaphoric images of nature correlated with the Effects of nature

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APPENDIX F-A living ceiling questionnaire

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APPENDIX G -Natural light and views questionnaire

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APPENDIX H-Bringing the outdoors in questionnaire

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APPENDIX I-A living wall questionnaire

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APPENDIX J- Philosophical underpinnings

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APPENDIX K- Natural inquire flow chart