What is Healthy Design? Healthy design assists the Patient and the Patient’s Carers, Supporters and Medial Staff, to remain positive and focussed on the Patient’s Medical Journey, either through recovery and rehab, or, to assist the patient and the family to transition through the medical issue as comfortably as possible. Why is Healthy Design important? The most important part of a person’s recovery ability is a patient’s own body. The patient’s body must fight off the disease, recover from the injury, recover from the surgery or treatment, adapt to the new physical situation, or adapt to any impairment; primarily it is the patient’s mindset that must retain the focus on the recovery process in order for it to be effective. Therefore, managing the patient’s experience through the medical pathway, in a way that maintains a positive mindset, will maximise the effectiveness of the treatment and provide the best chance for a return to health and recovery. A patient who understands the diagnosis, the purpose of the medical intervention, and the pathway for recovery (which can include for prescriptions and rehabilitative care), can better follow this pathway and improve their chance for a natural recovery.
The clinical process at a Hospital is vitally important to the function of the hospital. This aspect of Hospital Design is vitally important to the effective deployment of the clinical service; as such design for these components need to focus on enabling and enhancing the performance and integration of the medical teams. Staff wellness is also a critical component in hospital design; happy, well managed, satisfied and positive staff will communicate those emotions to patients and further assist with the patient’s feeling of security and positive about the medical journey about to be undertaken or already underway. Salutogenic Design Factors Psychosocially supportive design stimulates and engages people, both mentally and socially, and supports an individual’s sense of coherence. The basic function of psychosocially supportive design is to start a mental process by attracting human attention, which may reduce anxiety and promote positive psychological emotions. Health processes could be strengthened and promoted by implementing design focuses on the factors that keep us well, rather than those that make us unwell. The aim of Salutogenic Design is to create an environment that stimulates the mind in order to create pleasure, creativity, satisfaction and enjoyment. There is an important relationship between an individual’s health and the characteristics of the physical environment.
However, from the Patient Journey perspective, there seems to be a distinct lack of focus on salutogenic factors when designing modern hospitals. In fact, it would appear that these factors are almost ignored and hospital designs are delivered in spite of what we know about salutogenics, the patient experience, and contemporary psychological insights about design. Instead, modern Hospitals can be disorienting, alienating, and uncomfortable, and at times, staff can be overworked, abrupt in manner and disconnected from the patient’s medical journey. The design of the space within which these interactions occur, can set the tone for and characterise the nature, meaning and experience of those interactions. Hospitals need not take all the blame however, it seems a function of modern Architecture that wellness factors are ignored in favour of efficiency of service or of construction. An example is the modern workplace; despite it being a place whre we can spend a third or more of our waking lives, these office spaces are often unfriendly, uncomfortable, alienating, and do very little to encourage positive interaction amongst staff. For a compact, modern hospital wayfinding can become very problematic for staff, patients and visitors alike. A lack of daylight or clear orientation factors, where corridors and spaces all look more or less the same, can contribute to the feeling of disorientation and anxiety felt by patients.
Overall, Patients and patient carers who can understand and better integrate with the clinical and rehabilitative process, are going to have a better chance for recovery, and will recover more quickly.
What are some of the impacts of ignoring Salutogenic Design?
For patients where a diagnosis suggests recovery is not possible, this is an important time for that patient’s family and friends and managing this carefully and in a caring and supportive way, will assist the family and friends to transition through the loss of the person.
In the first instance, patients who feel confused or confronted may exhibit a range of emotions that make treatment and communication between patient, family and staff more difficult. Patients with heightened anxiety may not properly understand the diagnosis or treatment.
What factors contribute to Healthy Design?
Are Hospitals Healthy?
Patient management is key. The way in which the patient interacts with the Doctor, the way in which the patient comes to understand the diagnosis, the way in which the patient’s family and friends are included to the process, the way in which staff interact with the patient, all contribute to a positive psychological setting for the patient journey.
Modern hospitals do remarkably well to understand and deliver the clinical service efficiently, ensure services are appropriately clustered, provide appropriately serviced and equipped functional areas, limit chance for cross infection, integrate with loading and servicing requirements, At times, modern hospitals are beginning to provide a small village feel, or a public street, usually as part of the entry foyer accessible for visitors and staff, or patients with less acute issues.
Family and friends may not be able to provide the care and support required, and there may be issues of stress and anxiety that can turn to conflict or aggression. If this occurs, it is more than likely that it is the hospital staff who will feel the burden of this anxiety. Staff who are under duress may themselves be prone to anxiety, or be more likely to make mistakes. Mistakes in a medical setting can have very significant impacts.
Salutogenic Design Factors A frightened or anxious patient who does not understand the treatment or the recovery process, will be less likely to orient themselves towards appropriate behaviours and treatments to encourage recovery. The patient may become further alienated from the medical process, and this may induce further complications or medical issues that could be resolved in a more supportive setting. The patient’s body, in a recovery state, in a negative or adverse setting, may not operate to its maximum capability in terms of physical recovery. A patient may continue to feel disoriented and in pain following a medical intervention, and an uncomfortable and alienating setting will make the recovery more difficult. For a patient undergoing rehabilitation, a lack of positive engagement around the healing process will discourage recovery and may cause further complications to arise. How can Good Design improve the Patient Experience? Salutogenic design offers the opportunity to encourage and maximise the ability of the patient to be resilient towards their treatment and recovery. Models of Care (the Design Brief) that positively engage with and support the opportunity for Salutogenic Design, as a compliment to the clinical process, will facilitate and foster design thinking that is innovative and interpretive of opportunities for good design to contribute to patient wellness and recovery. Good design will give patient’s their best chance at health, or, the least alienating and frightening end of life experience.
The central idea is that there are three resources that combine to provide a Sense of Coherence—a forward thrust that resists the entropic forces of illness and infirmity. The sense of coherence is made up of resources that improve manageability—the capacity to maintain homeostasis and physical function; resources that improve comprehensibility—an ability to negotiate circumstances in order to maximise their benefit; and resources that enrich a sense of meaningfulness—the desires, causes and concerns that give us the need to resist illness in the first place.
When one is unable to adapt to circumstances and experiences, physical or mental health will ‘breakdown’ (Antonovsky 1972, p. 64). But by focusing on the sense of coherence and on resources, a scaffold emerges that can be readily applied to health facility design. Sense of coherencesupportive design can help liberate the resources that enable resistance to illness and reduce the disintegrative forces that cause maladaptation in the first instance.
The term ‘salutogenic’ was coined to describe a model for socioenvironmental influences on health. Substantial evidence shows aesthetic design changes in healthcare settings can improve health outcomes for patients. A number of theories have been offered to explain these effects—but most of them are limited to the specific stimulus under the microscope of the theorists. Examples include an evolutionary hypothesis to explain the influence of ‘views of nature’ (Ulrich 1991), and the ecological theory of Lawton and Nahemow (1973), which argued that there is a ‘sweet-spot’ to be found in a trade-off between designing for comfort and designing for mental and physical challenges. Others argue that the most important issues for health in design are cleanliness and pathogen control (Dancer 2004). Lighting, soundscape design and things like wall paint colour have also been considered (Hurst 1960; Vaaler, Morken, & Linaker 2005), along with seating layout in psychiatric settings (Bitterman 2013; Sloan Devlin 1992).
‘Comprehensibility’ is a person’s ability to make sense of one’s life narrative (Golembiewski 2012b). After all basic needs (manageability) are met, the desire to understand circumstances in order to make the most of them is essential.
While these theories are all important to hospital design, they ignore the elephant in the room—that architecture can be psychologically manipulative, for better or for worse. Architecture does this by providing a narrative context that affects a person’s behaviour, neural and endocrine systems, and through its influence on the brain and the body, architecture can directly influence health (Golembiewski 2016). Antonovsky’s salutogenic theory provides an accessible overarching logic for determining these effects in design (Golembiewski 2012b). The Sense of Coherence The sense of coherence is the sum of all generalised resistance resources (or GRRs—hereafter ‘resources’) minus all generalised resistance deficits (Antonovsky 1987). Resources fall into three basic (but interrelated) domains—those that enhance comprehensibility, those that enhance manageability, and those that enhance meaningfulness. Resistance deficits (GRDs), on the other hand, are the ubiquitous challenges to these resources. Resistance deficits are entropic, meaning that without a positive sense of coherence thrust, resistance deficits exert a continuous disintegrative force, allowing illness to overcome a person (Antonovsky 1996).
Resistance Resources
‘Manageability’ is a person’s ability to manage day-to-day physical realities, like paying bills, staying warm, dry, clean, rested and nourished and other maintenance of their physical lives. At a minimum, it serves the basic requirements to maintain homeostasis: to maintain body temperature, blood glucose, hydration and other critical somatic concerns (Golembiewski 2012b). ‘Meaningfulness’, according to Antonovsky (1979) and Frankl (1963), is the foundation of the desire to live. It is meaningfulness that gives life forward thrust—the will to resist the entropy of illness and death’s inevitability, and as such it is possibly the most important of the salutogenic resources. Meaningfulness is found in the intensity of personal connections, responsibilities and desires with the outside world: ‘ Biochemical Response to Design A number (if not all) of the neurotransmitters react to environmental stimuli, and therefore react to design (Golembiewski 2016). Acetylcholine, for instance, moderates balance, homeostasis, muscular tone and most of the things we associate with comfort—body warmth, the senses of touch and hunger (Changeux & Edelstein 2005). Light is thought to moderate serotonin and the hormones on the serotonergic pathway such as melatonin (Rao et al. 1992). In turn, these hormones have an influence on circadian rhythms, control of inflammation and among other things, the mobility of gallstones. The other neurotransmitter that can be highly reactive to environmental stimuli is dopamine (Koppisetti et al. 2008), and this neurotransmitter is the one that’s most closely associated with the emotions.
Architecture for Patient Manageability At its most basic, the architect’s role in improving manageability in the healthcare milieu involves improving the delivery of all the services that the hospital already considers. In hospital briefing jargon, this is ‘the functionality’ of the unit. But an architect armed with an understanding of salutogenesis can go much further; paying attention to how design can enhance the patient’s resources for recovery (Golembiewski 2010). Architecture for Patient Comprehensibility Comprehensibility is used to enhance or reinforce a person’s efficacy in their endeavours. Patients now have tools at their disposal for self-diagnosis and treatment, and this awareness has become essential for the basic maintenance of good health and for identifying illnesses early (Parker 2000). The most fundamental axioms of understanding (and therefore of comprehensibility) are structured in narrative terms: a premise, a process and a conclusion. The most important aspects of comprehensibility in healthcare settings revolve around the narratives of a patient’s sequential experience while negotiating ‘the patient journey’. The narrative sequence has the capacity to foster a sense of control and personal security. Conversely, without sufficient care, our natural inclination to perceive narratives and read the environment can also destroy confidence. Architecture for Patient Meaningfulness Because meaning in life is so important for one’s sense of coherence, it should be a pivotal concern for architects when designing for better healthcare. Meaningfulness has an intrinsic relationship with the real-world outside the facility – the world which the patient inhabits, before attending at the healthcare facility, and to which the patient will return, at the end of the medical journey. Hospitals may be considered as less than ideal places to affirm meaning, simply because patients are physically removed from most of that which gives life meaning; in fact institutional aesthetics and inconsistent care may be considered to work together to exacerbate alienation from meaningfulness for patients (Wistow 2012). Hospitals can also create social isolation by restricting the visiting hours of friends and family and by forbidding pets. Let’s discuss th Staff meaningfulness BOH function & experience for staff Routine, practise, learning by doing Mindful Purposeful Rational Meaningful
Matthew Williams
Jan Golembiewski Matthew worked as Health Sector Leader at Woods Bagot Sydney Studio. During this time, Matthew’s key responsibilities were the delivery of several Sub Acute Rehab and Mental Health Facilities in the greater Sydney Metropolitan Region. This involved developing a critical understanding of expectations, and delivery of complex, tightly coordinated and cost-efficient design solutions.
Jan is one of the world’s leading researchers in architectural design psychology. His research traces phenomenological experience back to the neurological mechanisms that cause them. This is especially relevant for design and health, because the designed environment frequently has a powerful influence on the very symptoms that need to be treated. Jan is a NSW Registered Architect, based in Surry Hills.
Matthews broad range of skills across the whole of the project process, and his detailed knowledge of technical and statutory requirements, building services and assembly, allows him to engage confidently and expertly with clients, user groups and consultants. Matthew’s flexible and robust approach to communications with the Client and User Groups supports improvement of the design as the architecture process advances.
Jan’s research experience places him at the centre of current thinking about design for health and wellbeing. He is on the editorial board of three academic journals and has guest edited a special edition on ‘Designing the Psychiatric Milieu’. In addition, Jan regularly judges the International Academy Awards for Design and Health. He has won 19 awards for his publications, conference presentations and teaching. Furthermore, Jan was the research lead on an international architectural health design competition, winning first prize.
Matthew’s strong graphical skills in hand sketching 3d concepts, and strong visual and verbal presentation techniques, allows design opportunities to be quickly explored and validated by Clients and Users. Matthew’s strong reporting skills allows for project decisions to be appropriately articulated and recorded. Within the Health architecture process, Matthew has worked at an executive level within the Architecture team in delivering: Project Bids Scope, Resource and Programme Planning, Site Utilisation Reports and Master-Planning Options (with full consultant integration), Project Business Case and Model of Care Review and Comment, Master Programme Review and Comment, User Group Review Task Scheduling and Consultation, Project Design Reporting and Sign Off at Key Gateways, Detailed Schedules of Areas linked to BIM, Detailed Room and Element Tagging in BIM, Clinical Review of Standard Rooms & Implementation to BIM, Detailed Coordination for RCPs and Room Layouts, Public Areas Concept Design and Presentations, Key Technical and Facilities Management Reviews by the Client, Budget Control and Review, Value Management, Safety in Design and Design Standard Non Compliances Scheduling and Sign Off. Example Schematic Design Report: https://issuu.com/mattwilliams65/docs/2164_schematic_design_report Example Design Intelligence Report: https://issuu.com/mattwilliams65/docs/20-2077_dida4
He is a research fellow of the Schizophrenia Research Institute and the Centre for Mental Health and Urban Design. He is a registered architect and until recently, served as Adjunct Professor in the Faculty of Creative Industries at QUT, Brisbane. He now runs his own practice - Psychological Design and teaches casually at UNSW and UTS in Sydney. Jan is internationally recognised as a popular keynote speaker and designer specialising in cultural understanding, patient-centred models of care, design psychology and all aspects of healthcare design. Jan is an author, publishing his memoir ‘Magic’ in 2018. Jan has worked as knowledge lead for UK based Architecture Firm, MAAP Architects, has completed his PHD on Psychological Design at Sydney University in 2012, graduated from a Masters in Architecture at UNSW in 2008, completed his Bachelors in Architecture at UNSW and UC Berkeley (California) in 2007, and a Bachelor of Fine Arts in 2004. An excerpt to the ‘Handbook of Salutogenisis’, published by Springer Press in 2017, is referenced here to provide insight into Jan’s research and work: https://www.ncbi.nlm.nih.gov/books/NBK435851/
Salutogenic Design Project Examples The plan of The Centre for Respite and Recovery (MAAP, Aecom and Makower Architects) has an urban street-grid like plan to enable intuitive way-finding, it is littered with gardens, has horse stables and a lunging arena to train them and an aviary also, where patients can keep and train birds. These affordances are all designed to maximise opportunities for self-empowerment and to generate the feeling there is a high probability that things will work out for the best.
The patient spaces at Khoo Teck Puat Hospital (CPG Consultants, architects and Peridian Asia and landscape architects) are environments for butterflies and other wildlife, in the hope that the abundance of nature will inspire patients and therefore enrich meaningfulness. Image courtesy of CPG Consultants.
Sculptures and bright colours to provide a sense of play and to serve as landmarks for orientation in Lady Cilento Children’s Hospital. The architects (Conrad Gargett & Lyons Architects) hope these innovations will improve the salutogenic sense of comprehensibility. Image by Christopher Fredrick Jones, courtesy of Conrad Gargett and Lyons
The ambulant area in the Royal Children’s Hospital (Bates Smart, Billard Leece and HKS) has a habitat for meercats to develop a sense of meaningfulness by keeping children engaged in enquiry about the world around them. (Photo by John Gollings, courtesy of Bates Smart).
For the Indigenous people of Australia, meaning is derived from a connection to the land and tribe. For this reason, patient rooms in Wilcannia Hospital are all on the ground floor looking out into the landscape and have a shared veranda that is big enough to accommodate large numbers of visitors. Architects: Dillon Kombumerri in Merrima, an office of the NSW Government Architect (Image: Brett Boardman).