Ros cheong thesis 2013 theory by Ros Cheong

CARE IN PLACE:

A PARADIGM SHIFT OF THE LOCAL HOSPI+AL

THESIS THEORY COMPONENT _pg 1 - 173

Care in Place

CARE IN PLACE:

A PARADIGM SHIFT OF THE LOCAL HOSPI+AL A Thesis presented to the School of Graduate Studies at the University of Auckland In Partial Fulfillment of the Requirements for the Professional Degree Master of Architecture (M.Prof) By Ros Cheong July 2013

Care in Place

ABSTRACT Public buildings habitually reveal valuable interrelationships in culture and place and how society treats its citizens, as Winston Churchill once remarked: “We shape our buildings; thereafter they shape us.” Likewise in the field of healthcare, medical architecture ought to reflect development of care, relative to medico-technological innovation, shape-shifting insights in psychiatry, and attitudes held by the city and its inhabitants. And where would be more appropriate to witness these key developments, than on the grounds of the local hospital? Such a thought seems peculiar, for the hospital is a curious and fascinating architectural assignment, but often because of its lack of capacity to mirror the demands and desires of the city. There is no greater irony or absurdity in architecture than a civic building purposefully erected as an icon of health and care, that has a general disposition to create unliveable, uncaring spaces; moreover, it tends to be a place avoided by the majority at best and patronized with an air of reluctance, let alone be compared to other conventional public buildings in terms of the architectural delight elicited. This thesis has been inspired by the growing conviction of the need to look for fundamentally fresh approaches to hospital typology, driven by the idea of returning the hospital to society as a milieu of care and good health. Doing so would not only herald the reinstatement of a caring stance, but an architecturally moving and empowering place to redeem the delight of its visitors. Approaching from the evolution of care, and the values of the city, the thesis examines key generalisations made about the architecture of hospitals which has largely incapacitated its ability to provide a perceivably caring setting within contemporary contexts. A suggestion of trends hospital design could adopt to complement adjacent societal trends in relation to healthcare is made, which culminates in a postulation of approaches to re-evaluate what a healthy, caring place should be like, by attaching symbolic meaning and local sense of place. A design-proposal, implementing the findings of the thesis’s for a large community hospital in the suburbs of Auckland, New Zealand, is presented as a test-bed for architectural speculation for a future generation of hospital design that delivers care and exuberance on all levels. This thesis takes a generic-specific approach and is in no way prescriptive, but rather it balances a grounded approach inherently imperative in the rationale of healthcare systems with an inventive, optimistic attitude. An extensive range of both architectural and interdisciplinary literature is therefore drawn from global best practices – particularly in Western Europe and Scandinavia where the practice of contextual design is superior – to general design aspects that embody the image of care and general wellbeing.

Care in Place

DEDICATION To God, To Humanity, To the betterment of healthcare.

ACKNOWLEDGEMENTS I want to thank the following individuals: My mum, who has been my pillar of support and encouragement throughout the duration of my degree. My supervisor Ross Jenner for his unstinting guidance during the making of this thesis. My friends in studio who have offered a wealth of critique and knowledge that have shaped my line of creativity. Kudos to Yun Kong Sung and Jenni Qin for lending a hand in compiling this document. My best friends outside of studio whom i share my ups and downs with. And last but never least, I thank God for granting me journey mercies throughout my years in architecture school.

TABLE OF CONTENTS ABSTRACT

ACKNOWLEDGEMENTS

INTRODUCTION 1.1. 1.2.

A Curious Typology Definitions

15 21

PART ONE

Care in Place

2. DEBUNKING CHRONIC SYMPTOMS

2.1. A Misunderstood Typology 2.2. Specific Typology, Specific Generalization 2.3. Complexity 2.4. Monumentality 2.5. Hermetically Sealed 2.5. Evidence-Based Design

33 35 37 43 51 59

PART TWO 3.

HOSPITAL AND CITY, HOSPITAL IN CITY

3.1. Hospital and City 3.2. De-institutionalization 3.3. The emergence of Specialist, Comprehensive Care 3.4. Communal Settings in Public Buildings

71 73 81 89 93

A TYPOLOGY OF TYPOLOGIES

4.1. 4.2. 4.3.

Just a Hospital Performance-Oriented Design Towards Possibilities - Marketable Spaces - Wellness and Community Centres - Accommodation - Care Processes in Place

107 112 119

THE AESTHETICS IN PLACE-MAKING

135

5.1. An Architecture of Immediate, Intimate Care 5.2. Views 5.3. Natural Landscape 5.4. Way-finding

105

PART THREE

165

6.1. 6.2.

The Australasian Context Proposal: North Shore Hospital

167 175

CONCLUSIONS AND REFLECTIONS

278

BIBLIOGRAPHY

282

LIST OF FIGURES

287

10.

APPENDICES

137 141 149 157

Care in Place

FIGURE 2. Interior spaces of the Denver General Hospital, Colorado, USA

Care in Place

LAMENTATIONS Why are hospitals either so boring, or so ugly? I wondered this all the time. Before I embarked on this project, I couldn’t quite summon to mind a single hospital design that I knew in detail, let alone one that has claimed my enthusiasm, even after all these years studying a stupid number of buildings. In fact, all I know of if that I’ve had the displeasure of being in hospitals – and I know just how much I hated being in them. I tried to pinpoint as to why I hated them. Was it because of the people? I didn’t think so; on the contrary, it was the presence of people and of their movement that made me feel more comforted, less alone, less anonymous. And sometimes they were so fun to talk to. And I then realized how – unexciting – the design of hospitals were. There was a boringness that ran deeper than the boring walls and corridors that extend to infinity and all the furnishings they slap on to disguise the joylessness of space. It’s quite sad when that was about the only thing that could circle in my mind. Aside from some prescriptive guide they were designed to, hospitals don’t feel like they have to care about making people feel good - let alone care about exciting architecture. But then I also realize how no one really cares about hospital design either - and they are only in it because they just have to. Architects design them as if they are doing civic homework. You just don’t hear anyone exclaim how awesome hospitals are, with the same enthusiasm as they might have for other buildings. It’s quite sad isn’t it?

Care in Place

INTRODUCTION TO A CURIOUS TYPOLOGY It is duly noted that the city and its architecture are inextricably central to man’s environment and he creates it for himself. Buildings not only provide immediate solutions for his needs, but also emulate his culture and aspirations.1 Every architectural type transcends forms and functions in a long, dynamic evolution of this time-hallowed discipline as the designer of culture, in relation to its position of context and design.2 Within the same vein of thought, a society’s self-image in care and the enhancement of wellbeing is expressed not least in how its local hospital cares for those in need. Since their evolution began 250 years ago, hospitals have been deliberately distinguished in their function to contribute to care, with architecture deployed as an instrument to make that process possible.3 The perennial schism between architecture and the design of hospitals is however revealed in its incredibly conflicting role in several emergent issues that have become endemic.4 Within the city mosaic they are the place for care, and constitute the security bedrock of a stable community. The experience of the general public, however, is ambivalent if not negative, often associated with monumentality, soulless mazes and spaces, harsh lighting and waiting areas that create the wrong kind of anonymity.5 Florence Nightingale’s observation of hospitals still stands where she remarked that people can feel ill; or even more ill; it seems like a mockery and heterodoxy that this omnipotence is so deceptive, and a strange principle to enunciate as its primary requirement is to do the sick no harm.6 Like most civic settings today, local hospitals are considered public spaces; we have all visited them at least once in our lifetime, be it to get cured, or to visit a loved one. Yet, hospitals have been consistently regarded as background buildings, hardly exciting passions within mainstream architectural culture, often sidelined by other civic buildings. Most of all, one often feels that a hospital is not publicly accessible, for it is often found perching at the periphery of the rest of functioning society. Apparently, no one would voluntarily hang out in a hospital.7

FIGURE 3. All-in-one: The archetypal largeness, standardization, complexity and isolation often found in hospital places: Arcbitectenbureau Swinkels en Salemans, in Vijverdal Maastricht, the Netherlands, built between 1968-1973.

1 2 3 4 5 6 7

Alex Anthony Baker, Richard llewelyn-Davies, and Paul Sivadon, Psychiatric Services and Architecture (Geneva: World Health Organization, 1959), 9. Noor Mens and Cor Wagenaar, Health care Architecture in the Netherlands (Rotterdam: Nai Publishers, 2010), 7. Health care Architecture in the Netherlands (Rotterdam: Nai Publishers, 2010), 277. Sunand Prasad, “Typology Diagrams and Introduction,” in Changing Hospital Architecture, ed. Sunand Prasad (London: RIBA Publishing, 2008), 1. “Typology Diagrams and Introduction,” in Changing Hospital Architecture, ed. Sunand Prasad (London: RIBA Publishing, 2008), 11. Philipp Meuser and Christoph Schirmer, “From ‘House for the Sick’ to Hospital,” in In Hospital Architecture Volume 1: General Hospitals and Health Centres, ed. Philipp Meuser and Christoph Schirmer (Singapore: Page One, 2007), 1. Prasad, “Typology Diagrams and Introduction,” 7.

Care in Place

Healthcare is an ever-changing scene; there is no type of building in which the relationship between function and design is so intense. The experience of care has evolved beyond the mere dependence on medical treatment to recognise the spatial qualities and facilitation of interaction in place. Yet, hospital architecture often overlooks current demands for comprehensive, patient-centred healthcare. Quite often, the medicalisation and advances in technology tethered to efficiency is of utmost priority while design is an afterthought; this industrialised delivery of care dehumanises and depersonalises the inhabitant.8 Context has become a prerequisite with many other typologies. Yet, hospitals tend to depend on the analysis of design precedents. This cookie-cutting process makes many hospital models of an outdated paradigm, and continues to fuel its disconnection with the city and its ineffectiveness in delivering care. The socio-cultural values of architecture exceed the cultural implications of the function it is intended to accommodate. Whereas many hospitals demonstrate clever solutions to complex problems, solutions are hardly representative of cultural values. Hospital spaces determine behaviour and tolerance and interference with cultural codes. Failure to respect such codes is a reason why hospitals are perceived as inhospitable places.9 Since its raison d’etre as a specific typology, hospitals have become outdated. They often lag behind the development of other typologies, such as offices and shopping centres, where 30 years ago, complaints against both healthcare and office design were similar, including a lack of attention to user needs, inflexible outdated planning, poor coordination of management premises issues, little architectural ambition and integration with city.10 The need to redefine attitudes towards it is overdue.

8 9 10

Care in Place

Mens and Wagenaar, Health care Architecture in the Netherlands, 25. Cor Wagenaar, “The Culture of Hospitals,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 11. Prasad, “Typology Diagrams and Introduction,” 3.

THESIS PROPOSAL Critical question: How can design attitudes towards the hospital evolve to reclaim its role in local place? The hospital is a dramatic failure and an architectural graveyard, and eventually this tension necessitates fundamental changes to redeem their well-intended nature. The primary intention of this thesis is to refresh attitudes towards hospitals, reclaim the original purpose of hospitals to care in place, and to seek to contribute towards its paradigm shift. The thesis is structured in three parts: -

In Part One, Chapter Two: Debunking Chronic Symptoms debunks key historical assumptions of the hospital, which has limited and still is limiting its potential to deliver.

In Part Two, the project unveils itself as an exploration of ways a hospital can create an integral place of care. Moving on from there, Chapter Three: Hospital and City, Hospital and City, examines the current situation of the city and healthcare practices, and how it produces key trends and arrangements that a hospital should take into consideration in its master-planning and architecture. Chapter Four: A Typology of Typologies turns to other geographies of care for inspiration. Chapter Five: Aesthetics in Place-making examines several aesthetics of place which contribute towards a caring, health-enhancing environment.

In Part Three, Chapter Six summarizes the Australasian context as an extension of the findings in the previous chapters. The accumulation of findings in the written component of the thesis is applied to a design proposal for North Shore Hospital in Auckland.

Care in Place

A couple of notes:

11 12 13 14

Care in Place

The evolution of hospitals is best guided by ‘the primacy of design’, and one of the emergent departures in design attitudes towards achieving this is the need to analyse how a complex of factors can converge in the creation of healing places.11

Researchers have also noted that what is perceived to be salutary must be seen in the context of social and economic conditions, and that everyday geographies of care must be studied as well as places with a reputation for healing.12 In the search for best practice in the arena of care, enhancement of wellbeing and place, I have chosen angles that best fit the notion of care in place from an extensive range of literature (from evidence-based to the general concept of care and place).

The phenomenon of the production and delivery of care and of place involves factors that are fundamentally multifaceted and interlinked, to address the ‘wicked’ issues in hospitals – problems that can never be fully described, seldom made explicit and do not have optimal solutions.13 Although the thesis proceeds in a sequence which is as logical as possible, the elements of care and place can never be isolated; inevitably, there will be some overlap and repetition between chapters.

Likewise, if one looks for laws determining a genetic code that enables designers to predict the preceding phases of hospital evolution, one would look in vain, for this thesis was written with an open-minded approach.14

Lawrence Nield, “Changing Hospital Design in Australia,” in Changing Hospital Architecture, ed. Sunand Prasad (London: RIBA Publishing, 2008), 223. S Curtis et al., “Therapeutic Landscapes in Hospital Design: A Qualitative Assessment by Staff and Service Users of the Design of a New Mental Health Inpatient Unit,” Environment & Planning C: Government & Policy 25, no. 4 (2007): 592. Bryan Lawson, “Healing Architecture,” Arts & Health: An International Journal for Research, Policy and Practice 2, no. 2 (2010): 98. Wagenaar, “The Culture of Hospitals,” 24.

PAST

PRESENT

Chapter One: Debunking chronic symptoms of hospitals Attitudes towards hospital design over the years have limited and debilitated the sense of care and place - and care in place - felt in hospitals. These issues must be

FUTURE

Chapter Two: Current trends in Place Hospital design should be aligned to the attitude shifts within the current context of care and place. Several of these can be found within the city and its inhabitants.

Chapter Three: A typology of typologies? typology that specializes in a certain type of spaces that is geared towards the provision of holistic care.

Chapter Four: The human-centred place Hospitals should be designed to the natural aesthetics of place in its ambition to elicit a sense of care and place.

Chapter Five: Case Study An overview of current Australasian hospital architecture is provided, followed by a design proposal for orth Sho re Hospital, Auc land, e w ealand.

FIGURE 4. Summary of thesis structure

Care in Place

DEFINITIONS KEY WORDS USED IN THE BODY OF LITERATURE “The Art of Medicine is incomplete without health-care settings, a factor in the healing process.” Hippocrates

Care in Place

Care - /ke(ə)r/ According to classic dictionaries of philogy, care comes from the Latin cura. The word was used within the context of relations of love and friendship, and expressed the attitude of devotion and concern for a loved one. This is consistent with the old English noun caru, ‘burdens of mind’, and the verb carian, ‘to feel concern or interest’.1 The attitude of care has led to preoccupation and a feeling of responsibility for the overall wellbeing of people.2 With good reason, the Latin poet Horace (65-8 BCE) could observe that “care was the permanent companion of the human being, in devotion and concern … out of love”.3 Today, the modern meaning of care has expanded to cover the necessary provisions of wellbeing. Wellbeing refers to the health, welfare, maintenance, and protection of someone or something; physically, emotionally and spiritually; recovery and healing are no longer solely attained through medicine but are significantly influenced by its place. The entirety of wellbeing refers to both the sick and the well, both the individual and the community, beyond human physiology to the natural or ordinary processes of human life.4 Just as the duty of care involves the recuperation and recovery of the unwell, care also involves the enhancement of health, as the World Health Organization, in 1946, defined health as “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity”.5 Care is needed for the healing process, for to heal is to restore to health and cause an undesirable condition to be overcome. Likewise, a healing environment cares for its inhabitants by supporting them through negative impacts of life.6 Comfort is also a way of care for one to ‘soothe in grief’. Likewise, care as a noun provides comfort, describes a state of freedom from pain or constraint.7 It is also through the notion of enhancing one’s health that the term therapeutic has also gained currency. ‘Therapeutic’ derives from the word therapeuetin, or ‘to take care of’. Conversely, a therapeutic environment indicates a location where healing takes place, or in the more ambitious meaning of a setting that is itself therapeutic.8

FIGURE 5. An image of care. “Miss Nightingale in the Hospital of Scutari,” in Sick-Nursing and Health-Nursing (1893). FIGURE 6: (opposite) An image of care in place. Helsingor Psychiatric Hospital by Bjarke Ingels Group and JDS (2009).

1 2 3 4 5 6 7 8

Leonardo Boff, Essential Care: An Ethics of Human Nature (Texas: Baylor University Press, 2007), 57. Essential Care: An Ethics of Human Nature (Texas: Baylor University Press, 2007), 58. Essential Care: An Ethics of Human Nature, 59. Philipp Meuser and Christoph Schirmer, “From ‘House for the Sick’ to Hospital,” in In Hospital Architecture Volume 1: General Hospitals and Health Centres, ed. Philipp Meuser and Christoph Schirmer (Singapore: Page One, 2007), 11. Peter Scher, “Lessons in Humanizing Health Care Architecture,” in The Culture for the Future of Healthcare Architecture: Proceedings of 28th International Public Health Seminar, ed. Romano. Del Nord (Firenze: Alinea Editrice, 2009), 110. David Canter and Sandra Canter, “Building For Therapy,” in Designing for Therapeutic Environments: A Review of Research, ed. David Canter and Sandra Canter (Great Britain: John Wiley & Sons, Ltd, 1979), 3. Liz Haggard and Sarah Hosking, Healing the Hospital Environment: Design, Maintenance, and Management of Healthcare Premises (London: Taylor & Francis, 1999), 1. Canter and Canter, “Building For Therapy,” 3.

Care in Place

In the contemporary era, care is also connected with empowerment; empowerment being an enabling process whereby one takes control of one’s own life and environment, in a process of helping people to assert control over factors that affect their health and wellbeing. The presence of care is also important in the process of normalising, which is to bring individuals from a state of abnormality and return them to their place in functioning society.9

Place: /plās/ In its most basic sense, place is the setting of the events of human life; it is the locus of action of intention and is present in all consciousness and perceptual experience. This human focus is what distinguishes place from the surrounding space or from simple location. It is not a location or state of mind, but the engagement of the conscious body with the conditions of the specific location. It provides an organising principle for a person’s engagement or immersion in the world around him or her.10 Some places create a physical identity through certain qualities, where they can be conveyed through topographical features or conferred by central reference points.11 To Heidegger, place gathers the meaning of a situation that poetically binds architecture and landscape into a cumulative and cultivated whole. By fusing an edifice, its site and environments into habitats, place-making establishes a phenomenological linkage that experientially combines them into an evolving organic entity and capitalises upon the potential of their attributes. Place extends from the human-centred environment to the local context. It is both a communal designation and an experiential event, and thus its referent is a contextual human situation centred in personal experience. 12 The making of place is simultaneously a material construct and a construct of the mind. Place is a space of emotional and personal significance or, as Yi-Fu Tuan opines, of humanised space.13 An authentic sense of place, expressed in Heideggerian language, involves feeling a sense of belonging to a place, knowing this without reflecting on it.14

Care in Place

9 10 11 12 13 14

DH Lau, “Patient Empowerment: A Patient-centred Approach to Improve Care,” Hong Kong Med J 8, no. 5 Oct (2002): 372. Arnold Berleant, “The Aesthetic in Place,” in Constructing Place: Mind and Matter, ed. Sarah Menin (New York: Routledge, 2003), 42. “The Aesthetic in Place,” in Constructing Place: Mind and Matter, ed. Sarah Menin (New York: Routledge, 2003), 43. Max Robinson, “Place-making: The Notion of Centre,” in Constructing Place: Mind and Matter, ed. Sarah Menin (New York: Routledge, 2003), 144. Sarah Menin, “Introduction: Place, Progress and Evolution,” in Constructing Place: Mind and Matter, ed. Sarah Menin (New York: Routledge, 2003), 1. Berleant, “The Aesthetic in Place,” 46.

Place is subjective to individual experience; one’s place is another’s non-place. The psychological reality of being ‘in-place’ sees the environment as isomorphic with one’s life. Confidence in place is the opposite of atopos (no-place), a characteristic of an emotional, mental and physical nothingness that can accompany depression or homesickness – that inner place of desolation extrapolated onto the environment.15 To define place, it is important to acknowledge complex specificities of human engagement with innumerable settings, and that the commonest of everyday locations may become an experience of something new.16 Simon Richards believes that it is as much a process of creating selves as it is creating place.17 Behind the idea of a relationship between the self and context is the premise that before an engagement there is a self that needs to engage; being must come before doing.18 Place-making is not the same as space-making. Heidegger determined that space is something which stems out of a place and, in a sense, something which is created before it is experienced. For him, space presupposes place. He determined that one’s capacity to ‘dwell’ in the phenomenological sense is an essentially architectural experience; the very being of being is linked to one’s situatedness in the world. He favoured the notion of place over that of space, because to him, place described more accurately the situation of human existence and could remain bound with actions and routines of individuals who dwell in them. Place is more descriptively powerful, and participates in rituals of human interrelationships. It reports the presence of life by accommodating and revealing necessities of subsistence, and manifesting thoughtful experience. As an extension of that idea, buildings and dwellings are rooted in places of inhabitation. 19 Likewise, Henri Lefebvre expounds: “If space has an air of neutrality and indifference with regard to its contents and thus seems to be ‘purely’ formal, the epitome of rational abstraction, it is precisely because it has already been the focus of past processes whose traces are not always evident on the landscape. Space has been shaped and molded from historical and natural elements, but this has been a political process. Space is political and ideological. It is a product literally filled with ideology.” 15 16 17 18 19

Menin, “Introduction: Place, Progress and Evolution,” 2. “Introduction: Place, Progress and Evolution,” 5. “Introduction: Place, Progress and Evolution,” 6. “Introduction: Place, Progress and Evolution,” 5. Adam Sharr, “The Professor’s House,” in Constructing Place: Mind and Matter, ed. Sarah Menin (New York: Routledge, 2003), 132.

Care in Place

(Lefebvre, 1976:31) He contends that there are different modes of production of space - spatialisation – from natural space, or ‘absolute space’, to more complex spatialities whose significance is socially produced. Each historical mode is a three-part dialectic between everyday practices and perceptions (le perçu), representations or theories of space (le conçu) and the spatial imaginary of the time (le vécu).20

1.0.3: Hospital: Hos.pi.tal : /häspitl/ Every piece of architecture possesses this common denominator that ties building to context – a set of circumstances in time and place. Thus, the comprehension of place is integral to an understanding of architecture, and for it to discern its essence and create meaningful places.21 Ultimately, as in the past, the architecture of hospitals, their location, content and built form will be determined by the wealth, culture and ethics of the society that commissions them.22 Conceiving or building enclosures that mediate between human life and the realities of nature aims to address place-making.23 Architecture’s most fundamental quality is that of being a vehicle to convey meaningful messages and going beyond redefining functions to socialising them to address people in immediate ways, deepening their sense of reality.24 At first glance, it may seem presumptuous to suggest that architecture can contribute to revolutionising healthcare.25 Medically, architecture cannot restore a patient’s command over the world inside the healthcare institution. However, Charles Jencks claims that a caring design attitude shown by an institution makes a difference, especially if perceived through an architectural form. Design can increasingly help to counter the inevitable feeling of helplessness that accompanies unwellness. In an ambitious sense, hospitals can convey the ethos of care and of a competent health organisation, and feel welcoming, therapeutic, modern and efficient; an appropriate design solution can transform healthcare facilities into extraordinary places in which to get well and stay well.26 The hospital only took on its modern meaning as an institution providing medical and surgical treatment and nursing care for sick or injured people during the sixteenth century. Its history can be

20 21 22 23 24 25 26

Care in Place

Lindsay Prior, “The Architecture of the Hospital: A Study of Spatial Organization and Medical Knowledge,” The British Journal of Sociology 39, no. 1 Mar (1988): 94. Robinson, “Place-making: The Notion of Centre,” 143. Derek Stow, “Transformation in Healthcare Architecture: From the Hospital to a Healthcare Organism,” in Changing Hospital Architecture, ed. Sunand Prasad (London: RIBA Publishing, 2008), 30. Menin, “Introduction: Place, Progress and Evolution,” 3. Cor Wagenaar, “The Culture of Hospitals,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 25. Stephen Verderber, “Hospital Futures: Humanism Versus the Machine,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 78. Shakti Gupta and Sunil Kant, “Trends and Dimensions in Hospital Architecture: A Hospital Administrator’s Perspective,” Hospital Notes 7, no. 2 April/June (2005): 61.

FIGURE 7. Two supporting images of a community-oriented care hospitals aspire towards today. Masterplanning Proposal for Cincinnati Children’s Hospital Medical Center to create a new children’s square and for a growth strategy by Skidmore, Owings and Merrill.

traced back to time immemorial; by limiting its definition to a typology that specialises in healthcare, we can determine its origin from the Middle Ages from the Latin hospes which refers to either a guest or the host who receives the guest, and from hospes the Latin adjective hospitalia - an apartment for strangers or guests, from which the medieval Latin hospitale derived.27 The German word spital meant a poorhouse or home for the aged.28 The hospital, hostel and hotel all derive their name from hospitium – a guesthouse – and have common origins in the dwellings that monks kept for passing travellers.29 The origins of the modern hospital, like medicine itself, are rooted in the fusion of religion and healing. The old great hospitals of Europe, characterised by cloisters and squares, atria and gardens, emphasised space, light, tranquility and the need for rest and relaxation.30 Hospitals originated from ancient Greece, where the hospitals of antiquity emulated the model of the classical temple, which is hardly surprising since the concept of healing was closely linked to religious rites and rituals. They are comparable to the monastic hospitals of the Middle Ages, which naturally resembled monasteries, and were often connected to ecclesiastical institutions and military grounds. Subsequent hospitals became civic buildings commissioned by the municipality.31 Generally, healing environments are places that heal the mind, body and soul; where respect and dignity are woven into everything; where life, death, illness and healing define the moment. The hospital is almost synonymous with a healing environment, for it supports those events or situations that a healing environment facilitates.32 An attractive facet that emerged in the mid-twentieth century was that the hospital was a communal amenity open to all, implying that healthcare architecture is pre-eminently a social task. 33 Care and place are embedded in the foreground of community values and vice versa, and hospitals are to be designed as living communities for patients with a sense of safety, comfort, dignity and repose, whereby the patient is fundamental to the successful working of the whole. On a communal scale, hospitals should enhance existing place and existing notions of care, which in turn creates a better place for care.34

FIGURE 8. A physician visiting the sick in a hospital. Source from a German engraving dating back to 1682.

27 28 29 30 31 32 33 34

Wagenaar, “The Culture of Hospitals,” 26. Meuser and Schirmer, “From ‘House for the Sick’ to Hospital,” 11. Abram de Swaan, “Constraints and Challenges in Designing Hospitals: the Sociological View,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 92. Haggard and Hosking, Healing the Hospital Environment: Design, Maintenance, and Management of Healthcare Premises, 1. Clare Cooper Marcus, “Healing Gardens in Hospitals,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 26. Barbara Dellinger, “Healing Environments,” in Evidence-Based Design for Healthcare Facilities, ed. Cynthia McCullough (Indianapolis: Sigma Theta Tau International, 2010), 45. Noor Mens and Cor Wagenaar, Health care Architecture in the Netherlands (Rotterdam: Nai Publishers, 2010), 84. Gupta and Kant, “Trends and Dimensions in Hospital Architecture: A Hospital Administrator’s Perspective,” 61.

Care in Place

RENDER

Care in Place

A hospital is a place for expression and reaffirmation of identity, autonomy, and consumer choice;35 one that cares for the needs of people is one that also empowers.36 Balanced against the emphasis on the need to treat illness and protect patients and other people, is the desire to enable them to live autonomously in the community and to take part in decisions about their own treatment. For in infirmity, loss of control is usually felt by people; it engenders much stress and adversely affects health outcomes from bodily function to things such as unavoidable procedures, chronic pain, or even impending death. These goals require that hospitals should be places where a patient’s identity can be revealed and expressed. Hospitals, then, need to provide settings which respect the individuality and diversity of the patients and staff, including their cultural practices and personal choices. Links with their family and community and the spiritual support derived from faith and worship need to be encouraged. Hospitals should give all building occupants environmental comfort and, most importantly, control over that comfort. An architecture that contributes to the normalisation of the ill, not only provides a place for cure but helps patients feel like people again.37 It is through their merging, that we come to understand that the role of the hospital is concerned with the overall wellbeing of people, which we also conveniently refer to as ‘health’ - for healthcare’s mission is to provide the full continuum of care and cover the spectrum of life from ‘cradle to grave’, and is multi-faceted in the big picture of wellbeing and the restoration of health.

FIGURE 9. An image of care in place, in the thesis proposal for North Shore Hospital, Auckland, New Zealand.

35 36 37

Aysu Baskaya, Yusuk Z Ozcan, and Christopher Wilson, “Wayfinding in an Unfamiliar Environment: Different Spatial Settings of Two Polyclinics,” Environment and Behaviour 32, no. 6 Nov (2000): 595. Clare Cooper Marcus and Marni Barnes, “Historic and Cultural Overview,” in Healing: Therapeutic Benefits and Design Recommendations, ed. Clare Cooper Marcus and Marni Barnes (New York: John Wiley & Sons, 1999), 38. Bryan Lawson, “Healing Architecture,” Arts & Health: An International Journal for Research, Policy and Practice 2, no. 2 (2010): 102.

Care in Place

CHAPTER TWO: DEBUNKING CHRONIC SYMPTOMS FIRST OF ALL, THE EVOLUTION OF DESIGN ATTITUDES TOWARDS CARE AND PLACE BEGINS FROM THE SHIFT AWAY FROM THE GENERALIZATIONS OF HOSPITAL ARCHITECTURE.

Care in Place

2.1

A MISUNDERSTOOD TYPOLOGY

‘No art is more widely misunderstood than the art of architecture, and no building illustrates the misunderstanding more clearly than the hospital – so precisely adapted to the uses of science that it’s hard for people to imagine any relationship between such a building and that great tradition whose flowers are the Parthenon and the Cathedral of Chartres.’1 J. Hudnut, Harvard GSD, 2006

FUTURE?

One could argue that the neglect of humane features in hospitals had roots in the rather insensitive nature of modernist science.2 The symbolic triumph of medical science made modern hospitals a profound legacy of the twentieth century. Yet despite their manifest importance, their preservation as emblems of the ideals of care is far from secure.3 It is hardly surprising that hospitals, confronted with a concentration of bureaucratic power, regulatory impetus and the advancement in exigencies in (institutionalised) medicine, would be completely absorbed by it and slowly lose their inherently critical design attitude.4 This stagnancy has contributed towards the uniform look across many hospitals that make for a certain blandness and pareto-optimal kind of style – designed according to an architectural standard that is compliant and non-controversial – and the makings of a depressing generalisation.5 Such an attitude is far-flung from a relationship with religious notions made in antiquity, when temples arose where the sick could gather to work on healing.6 Care of the ill and the decrepit was appended to ecclesial architecture; the spatial proximity of ecclesial messages of charity to the treatment of illness elicited the drive towards community feeling combined with a comforting, spiritual care.7

FIGURE 10. A brief evolution of hospitals, and most notably from the arena of hospitality and placefulness to a building that lack of those two aspects in healthcare systems.

1 2 3 4 5 6 7

Franz Jaspers, “Preface,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 32. Marek H Dominiczak, “The Art of Medicine: Of Wandering Doctors, Cities, and Humane Hospitals,” The Lancet 377, no. 9759 Jan (2011): 23. Philip Goad, Cameron Logan, and Julie Willis, “Modern Hospitals as Historic Places,” The Journal of Architecture 15, no. 5 (2010): 601. Cor Wagenaar, “The Architecture of Hospitals,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 14. Abram de Swaan, “Constraints and Challenges in Designing Hospitals: the Sociological View,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 90. Noor Mens and Cor Wagenaar, Health care Architecture in the Netherlands (Rotterdam: Nai Publishers, 2010), 13. Philipp Meuser and Christoph Schirmer, “From ‘House for the Sick’ to Hospital,” in In Hospital Architecture Volume 1: General Hospitals and Health Centres, ed. Philipp Meuser and Christoph Schirmer (Singapore: Page One, 2007), 13.

Care in Place

FIGURE 11. Development of the hallmarks or â&#x20AC;&#x2DC;symptomsâ&#x20AC;&#x2122; of hospital architecture from past to present times.

Care in Place

2.2 SPECIFIC TYPOLOGY, SPECIFIC GENERALIZATION It is only since the Age of Enlightenment around the 18th century that function has become the imperative for social organisation, and architecture has become a tool to manifest the rational society; such change was connected with the emergence of new insights into the arena of care marked by science and technology, while relations with tradition and convention were severed.8 The double emancipation of care from the limitations of religion and superstition ushered in a revolution of hospitals becoming the very first modern typology, as rational islands in a sea of religion.9 10 The principles of a specific typology and social agenda conceived particular functions, organisation and form. Hospitals became healing machines, principally with a modular layout and clear separation of functions, exemplifying belief in the healing powers of nature and rationality through structured access to fresh air and greenery.11 Medical technology however made atmosphere redundant, and man became more an object on the scene than the focus of design, increasingly alienated and anonymous in a dehumanised and intimidating environment. Hospitals were also built to deal with the expectation of growth (an attitude that increasingly turned into a liability), mass, standardisation and universality.12 While clean air, light and space were still key concepts, production of such were replaced by compact, mechanised forms. At the core of modernism were purity and sobriety and the designation of function as the essence of design and planning, and eventually they became the built equivalent of the lab coat: closed, hermetic and unexpressive skins hiding processes no one wants to understand.13 Lewis Mumford laments the scientist’s pompous ignorance of human values: “From the standpoint of the physical scientist, life is non-existent and the values of life are, if anything, merely accessory to the triumphs of physical science.”14 The architecture of hospitals and the attitudes of designers have been so deeply entrenched in universal generalisations that it is difficult to suggest opportunities for a forward-thinking strategy without debunking some of these assumptions. Before we can define what hospital architecture could – or should – be like today, one must first overcome the chronic symptoms of hospital architecture.

8 9 10 11 12 13 14

Mens and Wagenaar, Health care Architecture in the Netherlands, 9. Jaspers, “Preface,” 30. Mens and Wagenaar, Health care Architecture in the Netherlands, 9. Cor Wagenaar, “IV Berlage Institute,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 202. Liz Haggard and Sarah Hosking, Healing the Hospital Environment: Design, Maintenance, and Management of Healthcare Premises (London: Taylor & Francis, 1999), 1. Mens and Wagenaar, Health care Architecture in the Netherlands, 48. Jaspers, “Preface,” 32.

Care in Place

FIGURE 12. A set of several plans and an axonometry of the main building in North Shore Hospital, Auckland, in a masterplanning exercise put together by Jasmax Architects in their 2030 Strategy. Illustrative of the common complexity of a hospital plan anywhere around the world.

Care in Place

2.3 COMPLEXITY Mens & Wagenaar suggest that while architecture extends beyond an accommodation of processes, it is determined above all by the theme of the internal logistical organisation that dominates all else. In extreme cases, hospital design appears daunting because hospitals are perceived as systems, rather than buildings.15 16 Architects regard it as a field where architectural ambitions come a poor second and it is too difficult to include in a design curriculum, so it becomes an isolated field lagging behind the most progressive developments in the art and science of architecture, and indeed losing the commitment and skill required in the making of places that mean something to people.17 Hospitals therefore became structures rather than buildings, and solutions not to formal architectural problems but to brakes on the inevitable process and future expansion.18 Complex system design during the 1900s was the result of the conduct of systematic research and mechanisation, and the full implication of the epistemic shift of Enlightenment.19 As more complex medical procedures developed, specific settings were required in which to perform them.20 Hospitals were thus faced with the need to juggle the programmatic complexity of hygienic space and the evolution of professional medicine; it was no longer enough to provide salubrious environments for care, but they needed to be an expression of organised knowledge.21 The focus on the accommodation of processes over the making of places meant that innovation was concentrated in the pursuit of generic models with high adaptability and indeterminacy to respond to the specifics of clinical models and operational policies. This led to the miserable doctrine of significant currency: they are so extraordinarily complex that the creative freedom that occurs in other building typologies must inevitably be suppressed, and architecture is secondary to the implacable demands of optimising clinical adjacency.22 This is well articulated in a 1929 issue of the English journal Architecture, where Edward F. Stevens, an influential American hospital architect, noted that “the success of the hospital lies chiefly in its planning, not in its elevation”. The complicated demands of planning hospitals became the basis of his claim to specialised knowledge, and he – like many of his peers around the world - was primarily concerned with 15 16 17 18 19 20 21 22

Mens and Wagenaar, Health care Architecture in the Netherlands, 7. Goad, Logan, and Willis, “Modern Hospitals as Historic Places,” 604. Sunand Prasad, “Typology Diagrams and Introduction,” in Changing Hospital Architecture, ed. Sunand Prasad (London: RIBA Publishing, 2008), 3. Mens and Wagenaar, Health care Architecture in the Netherlands, 198. Health care Architecture in the Netherlands, 82. Dominiczak, “The Art of Medicine: Of Wandering Doctors, Cities, and Humane Hospitals,” 22. Goad, Logan, and Willis, “Modern Hospitals as Historic Places,” 603,04. Prasad, “Typology Diagrams and Introduction,” 3.

Care in Place

configuring hospital elements in the most efficient and practical way possible, to the degree that the care of the patient was about enabling all the elements of the institution to work in concert. Discussing rational planning in his treatise on the modern hospital, Stevens clearly revealed the influence of ‘scientific management’ on his thinking and drew inspiration from the manufacturing processes which informed his hospital work.23 Whether or not this revealed any fault in the way the process of care was conceived, the conundrum was that care in most cases was perceived as too dynamic, unpredictable and uncoordinated for the established architectural forms to bear, and original architectural form crumbles in the interest of the evolving facility.24 Despite the belief that these processes could be welded into an architectural unity of distinctly aesthetic possibilities in the hands of competent architects, the expansion in underlying architectural order has not been the norm, and it has tended to develop in a somewhat ad hoc fashion.25 Though lavish decoration and a sometimes exuberant architectural finish paid lip service to the status of their clientele, hospitals were moulded to the needs of the medical machine.26

23 24 25 26

Care in Place

Cameron Logan, “The Modern Hospital as Dream and Machine - Modernism, Publicity and Transformation of Hospitals, 1932-1952,” Fabrications 19, no. 1 (2009): 71. Goad, Logan, and Willis, “Modern Hospitals as Historic Places,” 605. Ibid. Jaspers, “Preface,” 32.

FIGURE 13. The dominance of plan drawings: A typical hospital plan by Edward F. Stevens. FIGURE 14. (opposite) The common mentality of care in interior spaces, with its efficient and engineered appearance.

THE CASE AGAINST COMPLEXITY Overdesigned design can dehumanise people, making them feel lost and inept for not understanding or relating to their setting. The ‘medical model’ is geared towards treatment and pathology; such a model prevents intervention before symptoms occur, treats illnesses and not the whole person, and places the onus on professionals and technology to ‘fix’ society rather than on the individual or wider community.27 Designing off it appears to stimulate a highly fractionated and diverse set of group goals and consequent group requirements. Therefore, hospitals often emerge as incoherent communities without common goals for human-centred care. They seem to be industrial complexes housing a number of separate processes, each with its own evaluation criteria.28 The patient, sometimes literally, is moved from department to department to be subjected to the relevant technology. An undiluted functionality often creates rather sinister structures which, as the architect Markus Schaefer remarked, “stripped the patient of her privacy and individuality, the healing machine of her body”. Hospital space became increasingly perceived as overwhelming, incomprehensible and even threatening.29 Retrospectively, it demonstrates an astonishing lack of cultural balance. Subsequent coercion led to feelings of disempowerment and ineffectiveness in treatment, especially for chronic patients and for those who are ambivalent about making changes or lack the confidence to do so.30 Technology is also changing profoundly; it is moving from being concentrated at the point of care in the hospital to being in the hands of patients and caregivers. For the last century, technology has been geared toward replacing the dialogue between the patient and the physician, and designed to reveal the ‘truth’ about medical conditions that most consumers can barely comprehend.31 The genuine increase in complexity of treatment is often confused with the need for a machined architecture; even when healthcare processes are complex, the processes of architectural evolution are in no way mechanical but rather are guided by the way the present situation is interpreted.32

27 28 29 30 31 32

David Canter and Cheryl Kenny, “Evaluating Acute General Hospitals,” in Understanding and Evaluating Therapeutic Environments for Children, ed. David Canter and Sandra Canter (Great Britain: John Wiley & Sons, Ltd, 1979), 310. “Evaluating Acute General Hospitals,” in Understanding and Evaluating Therapeutic Environments for Children, ed. David Canter and Sandra Canter (Great Britain: John Wiley & Sons, Ltd, 1979), 315. Dominiczak, “The Art of Medicine: Of Wandering Doctors, Cities, and Humane Hospitals,” 23. DH Lau, “Patient Empowerment: A Patient-centred Approach to Improve Care,” Hong Kong Med J 8, no. 5 Oct (2002): 372. Jean Mah, “For the Future of Health Care Design, Look Beyond the Hospital,” http://www.fastcodesign.com/1663450/for-the-future-ofhealth-care-design-look-beyond-the-hospital. Wagenaar, “The Architecture of Hospitals,” 12.

Care in Place

In a culture where every building detail is regulated, defined and assessed, hospitals are the most scrutinised of all. Too often any good intentions are stretched by complexities, leading to inscrutable outcomes.33 In between and around, there has grown a helter-skelter arrangement of other facilities, with a lack of clarity of form. They are anonymous boxes linked by a system of invisible mechanical connections and visible walkways, ramps and garages. It is experienced as insanely complex; architecture dissolves into its own innards and becomes atomised within larger structures.34 The hospital therefore becomes a traffic machine where the emphasis is not on functions but on routing and clustering. This ‘introvert functionalism’, where linear forms articulate unobstructed maximal external flexibility, organises, but also degenerates hospitals so they exist as pure structure subsequently fleshed out in corridors, atria and entrance halls. While it is difficult to achieve strong architectural design on ground floors when the ragged edges convey sloppy, unfinished impressions, development continues to happen irrespective of its context.35 The supposed elasticity within an overcomplicated design fails to keep up with the more difficult issues of dynamic care development. An irony in all of this was that an underlying motive for achieving greater efficiency in hospital operations was the highly specific nature of functional planning and technical servicing, proving a great practical challenge for older hospitals to adapt with the medico-technological field today. Complexity also means that it is harder to improve a current hospital around newer care models. Hospital construction is driven by conservative building committees. The overall environment of a hospital suffers as the building grows from a single building to an addition on an addition, and it seems that nearly every addition tries to establish a new logic.36 This open-end structured flexibility tends to occupy a lot of room and increase walking distances; it is also too often a pretext to design in a chaotic way and to camouflage conceptual imperfections, leading to designs that were nothing but feeble and imprecise responses to a deliberately badly formulated problem.37

33 34 35 36 37

Care in Place

“IV Berlage Institute,” 202. Aaron Betsky, “Framing the Hospital: the Failure of Architecture in the Realm of Medicine,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 70. Mens and Wagenaar, Health care Architecture in the Netherlands, 230. Goad, Logan, and Willis, “Modern Hospitals as Historic Places,” 612. Mens and Wagenaar, Health care Architecture in the Netherlands, 227.

Conventional thinking

While a ‘high-tech’ image also continues to instill public confidence in a hospital’s ability to provide the best treatment, people remain attracted to environments that are reassuringly familiar in the overall process of care. Technology, once a convenient justification for complexity, is today no longer a complicating factor; technology has become more streamlined and portable, and information technology can be wireless. Likewise, the healthcare and treatment process has become easier to understand and dispense. Whatever medical treatment is needed is generally nothing really special and, when it is, can be usually solved by both medical and technological industries.38 In fact, technology now enables architects to loosen their grip on complexity, and at the same time make hospitals less specialised structures. If anything, a case for a less complex architecture for care to neutralise intense specialisations in medical treatment is stronger, and one should no longer accept that hospital architecture is too complicated to constitute a general debate on its architectural values and its functions.39

Liberation with the possibilities of technology

FIGURE 15. From complex to simple buildings: The unnecessary complex aesthetics and built construction in hospital architecture can now be limited within the area of smaller, more portable and wireless technology and equipment.

Contrary to common belief, hospitals can be relatively simple buildings, for all they need to do is create a place where patients can receive treatment and support. Often a minority of specific facilities such as operating rooms and emergency centres require added complexity or be completely sterile, but only for a few specific patients. For example, the design requirements of patients staying overnight is shown to be hardly more difficult than hotel accommodation, and specific needs can be handled by the tech industry. The practice of medicine and technology does not supplant the staff-patient relationship; the irony is that as technology accelerates, the need for human contact seems to accelerate as well. Technology is best applied when it supports, but it does not direct, human life – rather it provides the tools for accomplishing more with less.40 Hence, it has lost grounds for requiring exceptionally high levels of complexity.41 One can only wonder if modernism’s obsessive commitment to medicoarchitectural functionalism and efficiency could ever have constituted anything more than a flawed attempt to achieve the goal of a truly curative architecture, its ultimate powerlessness effectively repressed beneath said declamatory functionalism.42

38 39 40 41 42

Allison B Arneill and Ann Sloan Devlin, “Health Care Environments and Patient Outcomes: A Review of the Literature,” Environment and Behavior 35, no. 5 (2003): 671. Jaspers, “Preface,” 41. Joan Whaley Gallup, Wellness Centers: A Guide for the Design Professional (New York: John Wiley & Sons, Inc, 1999), 16. Wagenaar, “The Architecture of Hospitals,” 12. Jonathan Hughes, “Hospital-City,” Architectural History 40(1997): 269.

Care in Place

2.4 MONUMENTALITY The evolution of the hospital scale began in the late eighteenth century, where pavilion forms were adopted to allow for the amelioration of contagion and the circulation of fresh air.43 Staggered and stacked buildings, terraced buildings, and pavilions were considered parameters of a human architecture.44 The advent of pavilion planning in the late eighteenth century, and its universal acceptance in the nineteenth — due largely to the influence of Florence Nightingale — pointed to the role architecture might play in the abatement of ill-health.45 Michel Foucault’s reason for scepticism about the ability of a hospital to express itself as architecture is mainly economic, for the ideal city, according to Vitruvius, was the military camp based on a rational, well-ventilated grid.46 The pavilion’s ties to military camp arrangements proved a double-edged sword, resulting in dynamic competing and complementary ideas of a hospital as a machine for delivering treatment and a hospital as a place for respite.47 48 Secular hospitals in the seventeenth and eighteenth centuries, triggered by the wake of mercantilism, took shape as large halls like religious and civic buildings and were often heavily fortified.49 Just as the Romans associated worship with monumental architecture,50 an association between clinical and civic architecture has long been implied and occasionally explicitly invoked:51 institution is the counterpart of specialisation and the result of professionalisation in specific fields of knowledge and expertise. Institutionalisation is often viewed in a distinctively positive light due to links with science, technology and societal progress.52 The Renaissance’s finest achievement in medicine laid the foundation for the belief that medical knowledge would enable a deeper understanding of the body.53 Many cultures also tend to provide large, imposing buildings to showcase their prowess and ability – for example in academia and congress halls.54 The pavilion plan, within that same public attitude, was not an idea that demanded great architectural expertise.55 Moreover, one of its early criticisms was that it might encourage hospitals to be constructed FIGURE 16. (opposite) Largeness in the city context: Medical Centre, Presbyterian Hospital, New York, in 1930. FIGURE 17. A classic image of monumentality in scale in hospitals when juxtaposed with a domestic urban grain.

43 44 45 46 47 48 49 50 51 52 53 54

Goad, Logan, and Willis, “Modern Hospitals as Historic Places,” 603. Meuser and Schirmer, “From ‘House for the Sick’ to Hospital,” 15. Cameron Logan and Julie Willis, “International Travel as Medical Research: Architecture and the Modern Hospital,” Health and History 12, no. 2 (2010): 117. Wagenaar, “The Architecture of Hospitals,” 71. Gordon C Cook, “Henry Currey FRIBA (1820–1900): leading Victorian, hospital architect, and early exponent of the “pavilion principle,” Postgrad Med J 78(2002): 352. Prasad, “Typology Diagrams and Introduction,” 1. Wagenaar, “The Architecture of Hospitals,” 28. Dominiczak, “The Art of Medicine: Of Wandering Doctors, Cities, and Humane Hospitals,” 22. Hughes, “Hospital-City,” 266. Wagenaar, “The Architecture of Hospitals,” 14. Haggard and Hosking, Healing the Hospital Environment: Design, Maintenance, and Management of Healthcare Premises, 7. Alex Anthony Baker, Richard llewelyn-Davies, and Paul Sivadon, Psychiatric Services and Architecture (Geneva: World Health Organization, 1959), 12.

Care in Place

in a rough and temporary manner.56 People tended to favour representationally public and monumental complexes over pavilions,57 but it is nevertheless very clear that they valued the advanced architectural program and modernist expression for what it could communicate about the hospital to the public.58 For example, large scale constructions with high-quality materials give users the feeling that they matter and will sustain themselves longer.59 The pavilion system and its variants were also deemed to be inefficient; walking distances were too long and somewhat uncontrollable in development.60 The late eighteenth century fueled the idea of the hospital as a single flexible facility governed by formal rules of composition:61 people in the 1900s became convinced that all the important institutions for treatment should be centralised, with large areas occupied by symmetrically designed spaces for acute uses.62 Whereas pavilions posited strict separation of functions and the specific character of each building, corridor systems were chosen to reduce walking distances to a minimum.63 In the eyes of the public, there was no better way to express simplification, honesty and clarity than to employ the International Style, the Americanised representation of the new social welfare-oriented capitalism of western democracies.64 The expression of volume rather than mass and the expulsion of applied ornament created a new health machine of three functionally very distinct parts – patient wards, concentrated treatment facilities, and outpatient wards, all expressed clearly in standard forms – that were brought together under a single building. High density had also surged in popularity after Le Corbusier’s Unite d’Habitation in Marseille; as a result, mega-hospitals became a compact and economical solution, part of the trend of centralisation in the 1960s where giant buildings without precedent were constructed, and the abandonment of horizontality in favour for a more economical vertical built form.65 While oversized structures promised an immediate spacious atmosphere,66 the interstitialism that emerged within hospitals was also conceived as a way of responding to the hyper-accelerated rate of change in the healthcare landscape. The confluence of the aforementioned factors resulted in the promotion of an ‘infinite’ internal flexibility and universality of stacking patient floors and supporting floors to prevent traffic flows from crossing one another; hospitals became anticipatory, no longer 55 56 57 58 60 61 62 63 64 65 66

Care in Place

Logan and Willis, “International Travel as Medical Research: Architecture and the Modern Hospital,” 117. Cook, “Henry Currey FRIBA (1820–1900): leading Victorian, hospital architect, and early exponent of the “pavilion principle,” 358. Jaspers, “Preface,” 31. Logan, “The Modern Hospital as Dream and Machine - Modernism, Publicity and Transformation of Hospitals, 1932-1952,” 72. 59 Mens and Wagenaar, Health care Architecture in the Netherlands, 7. Health care Architecture in the Netherlands, 48. Goad, Logan, and Willis, “Modern Hospitals as Historic Places,” 603. Mens and Wagenaar, Health care Architecture in the Netherlands, 50. Health care Architecture in the Netherlands, 88. Jaspers, “Preface,” 37. Meuser and Schirmer, “From ‘House for the Sick’ to Hospital,” 15. Mens and Wagenaar, Health care Architecture in the Netherlands, 8.

FIGURE 18. The Americanized International style: the expression of volume rather than mass, the emphasis on balance rather than preconceived symmetry, and the expulsion of applied ornament - the same ambition towards simplification, honesty and clarity. While it reflected the slogan ‘light, air and space’ and was referential to nature by favouring spacious locations and gardens, healthcare architecture became a synthesis of standardised forms (e.g. T-Type, K-Type et cetera). Sketch of Charité - Universitätsmedizin Berlin, Germany.

solely reactive to external determinants and delimited by architecture,67 and often encapsulated a strange dichotomy between an austere exterior and deliberate cosiness of interior spaces.68 The paragon of modernity and hard monumentality was tethered to the need for standardisation, which presupposes the ability to mass-produce components – and even whole buildings – using prefabricated elements combined with a fixed system of dimensions. Basic units became nearly identical; form became pronounced; wards became exceptionally compact. While hospitals were not entirely identical, they do illustrate the ideals of the universal hospital building package and of the hospital that paid as little heed as possible to its surroundings and could be placed in any arbitrary location.69 Monumentality also contributed towards the facelessness of hospitals. Mies van der Rohe’s ‘Less is more’ ideology liberated architectural vocabulary from stylistic exercises through consistent elimination of excess ornament and redundant form. The tabula rasa where pure concepts and spaces could emerge gradually degenerated towards the starvation of the imagination, turning freedom from style into a stylistic straitjacket, with relentless repetition of anonymous boxes.70 Hospital aesthetics were sometimes relegated to secondary significance; to the extent that the appearance of the place was considered at all it was usually its ‘newness value’ that was prized by owners or institutional leaders, and was compensatory with effective medical regime.71 72 Consequently, a large hospital seemed to have no face, identity, clear centre or periphery, and easily became recognised as the palimpsest of the city and the materialisation of the morbid nature of human existence.73 Paradoxically, a non-expressive architecture that merely disguised the hospital’s functions seemed to underscore its machine-like qualities.74

FIGURE 19. Interstitialism: an intermediate space located between regular-use floors, commonly located in hospitals and laboratory-type buildings to allow space for the mechanical systems of the building. By providing this space, laboratory and hospital rooms may be easily rearranged throughout their lifecycles and therefore reduce lifecycle cost. The product was a matchbox in a muffin (pillar-on-podium) form which posited the flexibility to redesign and rebuild to the dynamics of technology, allowing change to occur where it is most frequently needed without disturbing inpatient wards. Axonometry of Diaconessenhuis, Eindhoven, the Netherlands (1956-66) by W.F Lughart.

Many hospital designers were primarily oriented to their clients and the professional and technical discussion surrounding their specialisation. The broader development of the expressive potential of architecture in the aesthetically radical gestures, philosophical speculation and manifestoes of the European avant-garde was not an obvious priority. In their extensive published work on hospitals, much of which was concerned with design in the broadest sense, hospital experts almost never commented on the external appearance of hospitals. While confidently progressive and perhaps even modernist in their attitude toward the role of the hospital in society, they were also self-consciously practical in outlook and spent little time worrying about hospital elevations. This was consistent with a great majority of hospitals built in North America and Great Britain prior to World War II.75 67 68 69 70 71 72 73 74 75

Stephen Verderber, “Hospital Futures: Humanism Versus the Machine,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 78. Jaspers, “Preface,” 37. Mens and Wagenaar, Health care Architecture in the Netherlands, 155. Bjarke Ingels, Yes is More: An Archicomic on Architectural Evolution (Köln: Evergreen, 2009), 1. Goad, Logan, and Willis, “Modern Hospitals as Historic Places,” 608. Logan, “The Modern Hospital as Dream and Machine - Modernism, Publicity and Transformation of Hospitals, 1932-1952,” 72. Betsky, “Framing the Hospital: the Failure of Architecture in the Realm of Medicine,” 76. Wagenaar, “The Culture of Hospitals,” 40. Logan, “The Modern Hospital as Dream and Machine - Modernism, Publicity and Transformation of Hospitals, 1932-1952,” 72.

Care in Place

From left to right: Consistently big: FIGURE 20. Centre Hospitalier, Lille, 2009. FIGURE 21. L’Hopital Beaujon, Clichy, Paris, 1937. FIGURE 22. Diaconessenhuis, Eindhoven, the Netherlands 1956-66.

From left to right: Monumentality can lead to long, endless corridors where when not designed well, can lead to a feeling anonymity and placelessness. FIGURE 23. Sint Jozefziekenhuis, 1904 FIGURE 24. Hôtel-Dieu de Paris, 1877 FIGURE 25. A commonplace hospital corridor today. 46

Care in Place

FIGURE 26. Standardization: The employment of Industrial, Flexible and Demountable (IFD): uniform building blocks, faรงade panels and system walls, prefab pipes and cables, allowing outpatient units to be suitable for different specializations.It encourages maximal free divisibility of spaces due to the need for technology and its infrastructural demands, and are manifested in system of partitions that is easy to move, making functions movable and rooms interchangeable. Structural Diagrams of a hospital merger, developed towards opportunities for expansion of built form.

Care in Place

THE CASE AGAINST MONUMENTALITY If institutions constituted the lifeblood of all professional and specialised activities, then why are they so often distrusted, and why is quality always blamed on its institutional character?76 Larger hospitals of the period, and those on prominent urban sites, tended to contest the size of civic and educational architecture.77 While a grand scale is beneficial to many civic buildings, excessive size is perceived negatively in hospital buildings.78 Despite this identifiable direction in acting as conventional markers of civic beneficence, there was no overt justification for the choice of this expressive language, neither necessitated by functional requirements nor something architects would come up with. Monumentality does not convey a recognisable visual rhetoric of wellbeing and did not give any obvious support to salubrious patient care. Rather, impressive sizes simply reflected the rapidity in the growth of demand for treatment in more than a fundamental break with the institutions of the past.79 Economist and welfare theorist Tibor Scitovsky predicted that an excess of standard goods would lead to increasing social dissatisfaction, because they were devoid of real sensory stimulation for human beings, leading to a cheerless and tasteless economy.80 This resonates strongly with Rem Koolhaas’s theory of Dirty Realism, where ‘more is more’ – where accumulation and addition has replaced higher forms of organisation such as hierarchy and composition.81 Once a pillar of civic culture, the hospital had severed its roots with society and contemporary design. As it became symptomatic for its loss of control, self-regulating and self-referential qualities, criticisms came from the erosion of the level of amenities with pre-existing districts, and the destruction of the human dimension, trapped in the immateriality and immortality of space in time. The more monumental hospitals became, the further they diverged from the ambition of creating healing environments that emulated nature, as they accommodated and subordinated themselves to science in efficient, costeffective ways.82

76 77 78 79 80 81 82 83

Care in Place

Wagenaar, “The Architecture of Hospitals,” 13. Logan, “The Modern Hospital as Dream and Machine - Modernism, Publicity and Transformation of Hospitals, 1932-1952,” 75. Wagenaar, “The Culture of Hospitals,” 23. Logan, “The Modern Hospital as Dream and Machine - Modernism, Publicity and Transformation of Hospitals, 1932-1952,” 75. Francine Houben, “Mobility: A Room With a View,” in Mobility: A Room With a View, ed. Luisa Maria Calabrese and Francine Houben (Rotterdam: Nai Publishers, 2003), 1. Ingels, Yes is More: An Archicomic on Architectural Evolution, 4. Olivia Van der Bogt, “Architectural Models for Decentralized Hospital Buildings,” in The Urban Project: Architectural Intervention in Urban Areas, ed. Roberto Cavallo, et al. (Rotterdam: Delft University Press, 2010), 59. Goad, Logan, and Willis, “Modern Hospitals as Historic Places,” 604.

To date, hospital design continues to initiate and encourage a progressive stance, but continues to undermine established spatial relationships within, contributing towards a more rapid rate of obsolescence of spaces within.83 Koolhaas continues to assert that the only argument in favour of gigantism was the promotion of interdisciplinary work, and for such purposes gigantism may only apply to teaching hospitals. For communal settings, however, size hardly ever improves hospitals, let alone facilitates care, which takes place on more intimate levels.84 Rather, the largeness of hard-to-solve logistical conundrums denies the hospital clarity of form, personal privacy and wellbeing. The more complex designing gets, the further it diverges from reasons for complex logistics, and a hospital’s spatial frame of reference, of place.85 It was only in the 1980s that this idea of big buildings was realised as cumbersome and excessive.86 Increasing evidence reveals the logistical issues from having an entire spectrum of medical ability under one roof, for it generates large masses of traffic and, in striving to achieve multidisciplinary settings, and combines things with hardly any functional relation to one another. While the classic institution implied close proximity of a concentration of different specialisations in the past and accessibility of information, in a world where information can now be exchanged wirelessly, physical distances become less relevant, and sharpened distinctions between ‘hot floors’, offices and recovery facilities (and awareness that some facilities have little functional relation with one another) are suggestive towards the unravelling of the program.87

FIGURE 27. Lack of reference to surrounding place. Medical Centre, Presbyterian Hospital, New York, 1930.

It was during the 1920s that rising costs coincided with the idea that the hospital was now the only place in which to obtain medical service of the highest standard, prompting an exploration of ways to meet the almost unlimited demand for services with minimisation of (finite) materials and costs, combined with extremely heavy use. This has led to rapid ageing and the requirement for the continual replacement of materials, systems and services.88 Rigid forms in hospitals have therefore constrained the continuous evolution of medicine.89 If gigantism leads to unnecessary complications for hospitals, then nothing would be more natural than to call for their dismantling.90 84 85 86 87 88 89 90

Wagenaar, “The Architecture of Hospitals,” 13. “IV Berlage Institute,” 202. Meuser and Schirmer, “From ‘House for the Sick’ to Hospital,” 15. Mens and Wagenaar, Health care Architecture in the Netherlands, 280. Goad, Logan, and Willis, “Modern Hospitals as Historic Places,” 614. “Modern Hospitals as Historic Places,” 604. Wagenaar, “The Architecture of Hospitals,” 16.

Care in Place

2.5 HERMETICALLY SEALED ‘Today people live in rooms that have never been touched by death, dry dwellers of eternity, and when their end approaches they are stowed away in sanatoria or hospitals of their heirs.’91 Walter Benjamin, 1920 The idea of healing people in beautiful landscapes strongly influenced an entire architectural epoch, in the process of transforming the hospital city into a garden city.92 It was believed that the mechanical operation of civilisation drove people mad, and in a protest against the hassles of modern mass society, the subsequent life reform movement emphasised the need to get out of customary living conditions.93 As a result, hospitals moved out to suburban locations for the well-intended purposes of discovering the perfect humanitarian spirit and sanitary installations through isolation, and to partake of the luxury of space and gardened spaces, and become sprawling developments where light, air and nature could enter once again.94 At the basis of hospital foundation lay the understanding that separation of the sick from everyday life was necessary, due to fear of contagion; hospitals were founded at the entrances to towns, in areas unsuitable for settlement, on the sidelines of a town’s business and social centre.95 The pavilion design was abandoned with the diffusion of germ theory in the latter quarter of the nineteenth century; windows that were once so central to the flow of fresh air were sealed, and the operation of a new and revolutionary theory of disease was reflected in the construction and use of the isolation cubicle to minimise cross-infection.96 97 Hospitals sealed themselves to the exterior, but remained open to an interior court. Religious amenities provided focal points but were gradually replaced by operating rooms where science replaced faith. This new division of space which rapidly fragmented the broad vision intrinsic to the construction of the Nightingale ward was quickly adopted throughout Western Europe.98 Until the 1940s, hospitals still welcomed the importance of light, ventilation, and rural surroundings, but belief in the infectious properties of miasma and the medical technology that took over the system, not only meant that the new status of the building was reflected in an often pronouncedly representative look, but depended increasingly on mechanical production of light and air.99 FIGURE 28. (opposite) The New York Presbyterian/Columbia Medical Center, erected in the 1920’s, now engulfs the entire site that used to be an old park. FIGURE 29. (above) A classic image of isolation from place. FIGURE 30. Out in the rural: E.G. Wentink, Design for Veldwijk, Ermelo, 1884.

91 92 93 94 95 96 97 98 99

Helene Frichot and Rochus Urban Hinkel, “A Visit to the Hospital,” Artichoke 25(2007): 92. Meuser and Schirmer, “From ‘House for the Sick’ to Hospital,” 15. Ibid. Ibid. Miri Rubin, “Development and change in English hospitals, 1100-1500,” in The Hospital in History, ed. Lindsay Granshaw and Roy Porter (London: Routledge, 1990), 43. Lindsay Prior, “The Architecture of the Hospital: A Study of Spatial Organization and Medical Knowledge,” The British Journal of Sociology 39, no. 1 Mar (1988): 95. Wagenaar, “The Culture of Hospitals,” 31. Betsky, “Framing the Hospital: the Failure of Architecture in the Realm of Medicine,” 95. Mens and Wagenaar, Health care Architecture in the Netherlands, 47.

Care in Place

Often it was believed that privacy was a completely self-evident desire that needs no explanation, but the growing anxiety of being exposed in unsightly situations derived from the greater equality now among human beings, meant that the sick were shielded out of shame in front of the healthy. Special visiting rooms became built like sluices between two worlds to avoid confrontations with the unpresentable.100 Increasingly sophisticated techniques of separation and categorisation have also been developed to minimise the risk of contamination and to maximise control in the battle against illness. Classificatory rubrics have been deployed since the eighteenth century to categorise patients by medical or surgical specialty. Equally, isolation wards have long sought to control disease through physical separation and containment, the equivalent of the tuberculosis or mental colonies of yester-year, while latterly the adoption of intensive care units (for immediate post-operative care) has centralised this form of acute care in a single department, as opposed to providing it individually in general wards. Yet, there is a lingering undercurrent of miserable inadequacy to such an obsessive preoccupation with order, efficiency and correctitude, especially within an institution essentially devoted to fending off illness, disease and bodily malfunctioning.101 Control and segregation were not, however, the only functions of disciplinary spacing; in some ways it reflected a culture in which the body and its functions are closely regulated. Such a division of space and time according to bodily function and the principles of privacy are perhaps some of the most striking features of hospital plans. In fact, one sees a history of the body as well as of illness and disease, for the buildings represented by these plans constitutes the modern image of bodily care and organisation.102 Appropriately enough, awareness of the circulation of bodily fluids has provided a corporeal analogy for urban circulation since the mid-sixteenth century, given that wellbeing has long been equated with vitality and movement and illness characterised by torpor and lassitude. The spatial dimension of the conception of health and wellbeing at both individual and master-planning levels has routinely been aligned along an axis of circulatory efficiency and facility of movement. And, tellingly, a reassessment 100 101 102

Care in Place

Swaan, “Constraints and Challenges in Designing Hospitals: the Sociological View,” 93. Hughes, “Hospital-City,” 269. Prior, “The Architecture of the Hospital: A Study of Spatial Organization and Medical Knowledge,” 105.

FIGURE 31. The Department of Veterans Affairs (DVA), USA, contructed in a number of gargantuan facilities during the 1960s and early 1990s, such as a 900-bed replacement hospital. FIGURE 32. Cite Hospitaliere, Lille, 1935-1953,

of the relationship between patient ambulation and post-operative recovery has constituted a major feature of post-War clinical practice, resulting in an emphasis on the early post-operative ambulation of patients. No longer would confinement in bed be viewed as the surest route to recovery; the mobility of patients was now actively encouraged. In spite of, or because of, this emphasis on movement and circulation, order and rationality have retained positions of fundamental importance in the modem hospital, providing a framework of control within which efficiency might be guaranteed. With patients free to roam the ward, the problems of clinical supervision and surveillance of patients demanded new and more elaborate solutions.103

103

Hughes, â&#x20AC;&#x153;Hospital-City,â&#x20AC;? 268.

Care in Place

Closed from exterior environments, opening up interiorly in the form of courtyards.

FIGURE 33. Hotel-Dieu, Paris. FIGURE 34. J. Gerl, Allgemeines Krankenhaus (General Hospital), Vienna, 1783.

FIGURE 35. One of the most notable hospitals in the world by Sir Christopher Wren, The hospital was created on the instructions of Mary II, who had been inspired by the sight of wounded sailors returning from the Battle of La Hogue in 1692. Royal Naval Hospital, Greenwich. 1694.

Care in Place

THE CASE AGAINST HERMITAGE People’s minds and bodies are private affairs, and so are the diseases and injuries that afflict the mind and body. The ill may wish to rely on their inner circle of friends and family, and ideally, medical expertise is provided at home by visiting doctors. This was until technology changed the hospital from an almshouse into an institution providing the best medicine has to offer. This depersonalises what people experience as very personal; as soon as a patient checks in, having to say goodbye to his loved ones, giving up the privileges of managing his time to his wishes – to the regulatory hospital clock, and limited nutrition.104 An architectural contribution to the civic realm had clearly not been on the agenda. The way hospitals are located in the urban tissue reflects the way they relate to society; if they are isolated complexes, this is indicative of their severance from everyday life,105 and the last five decades showed marked preference for siting hospitals on greenfield sites away from town centres to give freedom for layout design.106 However, cloistered hospitals have difficulty returning patients back to normal life, and a selfcontained hospital city runs a risk of becoming detached.107 In extreme cases, it manifests a hospital culture, where members share a collective system of values, traditions and expectations, and standards of conduct exclusive to the rest of the community.108 Closed urban islands tend to become self-centred and large-scale; as more functional spaces are added to the outside, the outer envelope begins to close physically. This phenomenon has similarly occurred in suburban housing developments with pedestrianised cores, in the design of retail-loaded infrastructure hubs with auxiliary spaces such as car-parking located at the periphery where they function intentionally or unintentionally as barriers, with decreasing vestiges of accessibility to the outside world and its social network. The outcome is a reclusive and introverted atmosphere that feels inhospitable to outsiders – and in the greater context, an unsociable and uncaring place.109 All the abject business of the body, every mortal threat to our corporeal lot is sequestered within healthcare environments, usually made-over anodyne so as to distract one from the resilience and precariousness of the human condition. Given the levity of fundamental life events, still architecture, FIGURE 36. The process of creating closed - and even more closed - urban islands.

104 105 106 107 108 109

Wagenaar, “The Architecture of Hospitals,” 15. “The Architecture of Hospitals,” 18. Prasad, “Typology Diagrams and Introduction,” 8. Baker, llewelyn-Davies, and Sivadon, Psychiatric Services and Architecture, 24. Lau, “Patient Empowerment: A Patient-centred Approach to Improve Care,” 216. Christian Salewski, “Spaces for Coexistence,” in Open City: Designing Coexistence, ed. Kees Christiaanse, Tim Rieniets, and Jennifer Sigler (Amsterdam: SUN Publisher, 2009), 153.

Care in Place

as it is meted out in healthcare, takes every opportunity to hide the mess of lives cut short. For the dying, it is the discovery of oneself in a foreign territory, anaesthetised, atemporal, under palliative care, lingering, while nurses absently guide death through its inevitable denouement.110 Once inside the hospital, it is as though the external world and culture never existed and time unfolds at an excruciatingly slow pace. The medical gaze needs to penetrate the entire infrastructure: architecture and body alike are kept under keen observation, every peculiarity has to be pathologised, apprehended through medical discourse and articulated through standard procedures of intervention.111 What is emphasised within hospital spaces is the functional compartmentalisation and arcane hierarchy that necessarily disciplines the body and organises it according to particular pathologies under the watchful gaze of elaborately organised teams and bio-political means. Distinct wards isolate different conditions, doctors wander from bed to bed with their ‘objects’ under investigation located in bed confinements observing with blinking, non-comprehending eyes. The one apparent concession made to the consumer is the ubiquitous placement of TVs, allowing hours of sick time to be whiled away with the nothing-information of televisual media.112 For Foucault, the construction of asylums occurred during the era of the Great Confinement in which new disciplinary techniques emerged; this was represented by a physical enclosure that converted humans into docile bodies, where the control and division of space and time became a vital means for their discipline and surveillance.113 The symbol of security and control, in places such as prisons, is Jeremy Bentham’s late-eighteenth-century `Panopticon’, a design featuring corridors radiating from a central observation point from which inmates can be continually inspected.114 According to Foucault, its emergence marks the beginning of an era in which the hidden control encapsulated and expressed in the darkness of the dungeon is reversed in the light and visibility of the central tower, and where the expanse of such visibility is nothing more nor less than ‘a trap’. For, in such visibility is hidden a new technology of surveillance which is ubiquitous and all consuming. In fact, the common denominator of hospital arrangements as Foucault contended, is no longer the technology 110 111 112 113 114

Care in Place

Frichot and Hinkel, “A Visit to the Hospital,” 92. “A Visit to the Hospital,” 93. “A Visit to the Hospital,” 92. Prior, “The Architecture of the Hospital: A Study of Spatial Organization and Medical Knowledge,” 101. Ufuk Dogu and Feyzan Erkip, “Spatial Factors Affecting Wayfinding and Orientation,” Environment and Behaviour 32, no. 6 Nov (2000): 593.

of visibility, but the technology of individualisation and physical control, in the increasing focus on the individual as an object of control more than on a disease amenable to therapy.115 It is therefore amusing to note that while hospitals make so much effort to hide themselves away from the city, their inhabitants have to put up with total strangers in the shared spaces of waiting rooms and bedrooms. If anything demonstrates the fact that the hospital is actually a collective building, the lack of care for privacy does – something that is unnecessary for any procedures.116 The concept of confined environments also feels almost utopian, where a confinement of space and segregation aimed at risk-minimisation through control of time and space in a way that is anti-urban and aesthetically boring. This non-place and non-time, synchronic adhesion to a particular section of time, and consequently remaining isolated in space and time, meant the hospitals need not evolve, came into being and is not subject to any transformational external dynamic. Hospital boundaries achieve a displacement and de-temporalising through codes and behaviour. For target markets, it suggests constancy and stable values at the expense of long-term development. However, the city cannot deny those who would cut themselves out of the urban economy through segregation as that impact on the outflow of investment of development and change.117 Therefore this suggests a trend towards openness rather than closure.118

FIGURE 37. (opposite) Design for the Hotel-Dieu, Paris, 1785, highly similar to the Panoptican (opposite and above).

115 116 117 118

Prior, “The Architecture of the Hospital: A Study of Spatial Organization and Medical Knowledge,” 103. Wagenaar, “The Architecture of Hospitals,” 15. Mark Michaeli, “Utopia Re-Read,” in Open City: Designing Coexistence, ed. Kees Christiaanse, Tim Rieniets, and Jennifer Sigler (Amsterdam: SUN Publisher, 2009), 103.04. Salewski, “Spaces for Coexistence,” 147.

Care in Place

FIGURE 38. EBM (above) spawned the development of EBD (left). IThere are several processes involved how EBD actually becomes an evidence for a building to use it, such as: - Scientific Evidence: This includes group design studies, research groups, target population sample, consistency of training, symptom and long–term outcomes. - Clinical Utility: Degree of feasibility of implementing the practice. - Cultural Competence: Degree of fit with needs of community. However, EBD is also often used as a ‘checklist’ without justifying it in the project in detail, especially in architectural qualities in care.

Care in Place

2.6 EVIDENCE-BASED DESIGN The architecture of hospitals and care is gradually evolving from a traditional reliance on historical precedent to a position informed by critical analysis and scientific method,119 subject to the straitjackets of accountancy and accountability.120 The twentieth century’s healthcare building boom ended with an increasing emphasis on the contextualisation of medicine. These ideas influenced the design of a new generation of hospital spaces within the context of consumer culture and aesthetics. This coincided with an application of scientific method to hospital architecture that emerged in the form of Evidence-based Design (EBD). A substantial body of evidence now relates aspects of design to medical outcomes.121 While no universal definition exists for EBD, ‘evidence-based’ is often used to demonstrate effectiveness of research and science programs, with a methodology thoroughly devoted to the program itself sans extraneous events.122 EBD’s hallmark is the use of research in decision-making that, according to Cyndi McCullough, “should result in demonstrated improvements in the organization’s utilizations of resources”. 123 124 It is along the same line of thought with Evidence-based Medicine (EBM) from which EBD is derived, which is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.125 While historically there appear to be indications of EBM-like practices in antiquity, most pertinent to this discussion was its emergence in 1972 with the seminal work of Sir Archie Cochrane in the seminar compendium Effectiveness and Efficiency: Random Reflections on Health Services. He stressed the importance of using randomised controlled trials (RCT) as a basis for determining the efficacy of various medical treatments. It was considered then, and essentially is still today, best practice for making healthcare decisions based on the principles of epidemiology. The findings that even the most commonly used procedures and therapies are not necessarily those shown by studies to be most efficacious, and that a non-substantial amount of practice has not been particularly well-evaluated, has led to pressures for medicine to become ‘evidence-based’. To overcome opinions by consensus formed in poorly understood ways by ‘experts’, the idea is to shift the centre of gravity of healthcare decision119 120 121 122 123 124 125

Verderber, “Hospital Futures: Humanism Versus the Machine,” 78. Haggard and Hosking, Healing the Hospital Environment: Design, Maintenance, and Management of Healthcare Premises, 1. Dominiczak, “The Art of Medicine: Of Wandering Doctors, Cities, and Humane Hospitals,” 23. Research Review, Evidence-Based Programs and Practices What Does It All Mean? (Florida: Children’s Services Council, 2007), 1,2. Edward J Mullen and David L Streiner, “The Evidence For and Against Evidence-Based Practice,” Brief Treatment and Crisis Intervention 4, no. 2 (2004): 112. Cynthia McCullough, “Evidence-based Design,” in Evidence-Based Design for Healthcare Facilities, ed. Cynthia McCullough (Indianapolis: Sigma Theta Tau International, 2010), 91. F Becker and J Carthey, “Evidence-based Healthcare Facility Design: Key Issues in a Collaborative Process,” in W092: Interdisciplinarity in the Built Environment Procurement Conference (Newcastle, Australia2007), 2.

Care in Place

making towards an explicit consideration and incorporation of research evidence. To many, EBM has been rightfully described as a spectrum of health research from the lab to hospital. 126 In his essay Knowledge without Authority in 1985, Karl Popper argued that “all observation involves interpretation in light of our theoretical knowledge, or that pure observational knowledge, unadulterated by theory, would, if at all possible, be utterly barren and futile”.127 Conversely, as the new field of EBD was embedded in a knowledge base that can hardly provide any explanatory theory and therefore could not be used to understand why some design solutions work and others do not, advocates of EBD promote the adoption of the broad tenets of EBM.128 Initially regarded as ‘soft’, architectural factors postulate hard consequences and direct connection with the core function of hospitals, and EBD has convincingly demonstrated that at least some of these consequences are identified and construed in measurable ways.129 Today, EBD is a limited methodology and polemic to justify what is ‘right’ or ‘wrong’. The traditional, institutionally designed healthcare facility has bearing on the wellness of its patients as long as the level of care is superb. Likewise, healthcare professionals are finding that sensitive design can enhance recovery and shorten hospital stays. At the same time, the role of the physical environment and facilities themselves are not universally included in routine patient satisfaction assessments, even when patients mention the importance of such aspects within their environment.130 EBM is described as a holistic approach; in fact proponents of the field suggest the need to involve the more thoughtful identification and compassionate use of individual predicaments, rights and preferences in making clinical decisions about care. But it is contradictory to ‘research-based’ methods. As a recently established way of working, it will eventually mature and gain wisdom and judgment should it consider the influences of its surroundings.131 EBD however has limitations and is consistently lukewarm towards the notion of place-making,132 and needs ways to be more malleable around the quality of care in context, such as the ability to combine scientific knowledge with artistic knowledge and being more imaginative. While design research is relatively new to academic knowledge, it is now more rigorous with better understanding.133

Care in Place

126 127 128 129 130 131 132 133

“Evidence-based Healthcare Facility Design: Key Issues in a Collaborative Process,” in W092: Interdisciplinarity in the Built Environment Procurement Conference (Newcastle, Australia2007), 3. “Evidence-based Healthcare Facility Design: Key Issues in a Collaborative Process,” 5. Ruchi Choudhary et al., The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity (New Jersey: Robert Wood Johnson Foundation, 2004), 3. Mens and Wagenaar, Health care Architecture in the Netherlands, 7. Arneill and Devlin, “Health Care Environments and Patient Outcomes: A Review of the Literature,” 666. Mullen and Streiner, “The Evidence For and Against Evidence-Based Practice,” 117-19. Mah, “For the Future of Health Care Design, Look Beyond the Hospital”. Bryan Lawson, “Healing Architecture,” Arts & Health: An International Journal for Research, Policy and Practice 2, no. 2 (2010): 97.

FIGURE 39. EBD: The competing forces of Art and Science.

THE LIMITATIONS OF EVIDENCE-BASED DESIGN 1. The lack of research in a new area of design, with relatively few studies spread across the myriad factors involved in the design of the healthcare physical environment134 has culminated in a reiterative ‘cook-book’ design process that creates generically ‘safe’, context-less space.135 Architecture becomes rich where artistic processes and ways of knowing are combined with technique. Theory and science are not new to architecture; in fact designers have rightly increased our empirical and theoretical knowledge about how to design them to be more sustainable. However, EBD, which seeks to exploit empirical knowledge about human behaviour, becomes problematic in application when dealing with the fundamental organisation and creation of places that lie at the heart of the architectural design process. A collision of artistic and scientific ways of knowing, or rather, the solutionfocused approach based on episodic knowledge.136 To date, limited rigorous studies address the link between the physical environment and health outcomes, in the widening spectrum of interactions and situations affecting hospital design, and clearly cannot constitute a critical mass of knowledge for evaluation.137 However, EBD follows EBM’s way of developing and refining interventions to administer it very faithfully to the procedure through the accumulation of knowledge.138 The combined limitation of available evidence thus reduces the use of EBD down to a functional explanation that cannot be used to explain actual causal relationships between design and outcomes that can lead to meaningful predictions in healthcare design.139 Applying a ‘one size fits all’ solution often results in a lack of invention and richness, in a world where boundary conditions always change, and spaces need to be connected to surrounding places.140 Another important realisation about EBD is that it will never be either broad or deep enough to address or answer every conceivable question about how physical design influences healthcare quality that arises in planning and designing a health facility;141 finding data to validate everything is difficult for healthcare issues are systemic and ‘wicked’.142 Extensive writings have been done concerning extant knowledge and other factors impacting on the simplest of design decisions. Research is not a substitute for experience, preference and values; it guides decisions but does not make them. However, values of place make research relevant to specific projects.143 134 135 136 137 138 139 140 141 142 143

Becker and Carthey, “Evidence-based Healthcare Facility Design: Key Issues in a Collaborative Process,” 2. Mullen and Streiner, “The Evidence For and Against Evidence-Based Practice,” 115. Lawson, “Healing Architecture,” 97. Becker and Carthey, “Evidence-based Healthcare Facility Design: Key Issues in a Collaborative Process,” 5. Lau, “Patient Empowerment: A Patient-centred Approach to Improve Care,” 221. Becker and Carthey, “Evidence-based Healthcare Facility Design: Key Issues in a Collaborative Process,” 6. McCullough, “Evidence-based Design,” 10. Becker and Carthey, “Evidence-based Healthcare Facility Design: Key Issues in a Collaborative Process,” 5. McCullough, “Evidence-based Design,” 17. Becker and Carthey, “Evidence-based Healthcare Facility Design: Key Issues in a Collaborative Process,” 2.

Care in Place

For example, aesthetics, a subjective component of EBD, does not have any research supporting a certain colour scheme because of its non-quantifiable aspect.144 Yet, healthcare civic structure has its specific shade of hospital green, linoleum scented with disinfectant, long and echoing corridors, crowded wards and flimsy curtains that divide one life from the next. Solutions most frequently employed to the very specific, functional constraints are to create a cheery veneer of bright colour and pattern. Alternatively, design is neglected altogether for an administrative choice of kitsch floral or benign beige to remind one of home.145 The challenge for architects is to transform various forms of evidence into useful information, specific to the particular context and institution, through a collective problem-solving process. 146An understanding of context and of community expectations, discovered through a structured and collective discourse, stimulates new insights about what one could do in our situation that might not have been possible in other projects. 147

144 145 146 147

Care in Place

Marcia Vanden Brink and Steve LaHood, “Aesthetics and New Product Development,” in Evidence-Based Design for Healthcare Facilities, ed. Cynthia McCullough (Indianapolis: Sigma Theta Tau International, 2010), 20. Frichot and Hinkel, “A Visit to the Hospital,” 92. Becker and Carthey, “Evidence-based Healthcare Facility Design: Key Issues in a Collaborative Process,” 5. Susan Francis, “European Hospital Design,” in Changing Hospital Architecture, ed. Sunand Prasad (London: RIBA Publishing, 2008), 153.

FIGURE 40. The process of EBD involves the need to validate all design decisions in the end, which often excludes design qualities that have the possibility to facilitate care, even if it is not so obvious.

EBD does not exist to include all identified needs or for all target populations148

If place-making was about, in general architectural terms, capitalising on a local community’s assets, inspiration, and potential, then one can see how EBD does not utilise the full potential of placemaking as much as it readily solves many of the space-making issues in hospitals. The more overtly architectural concerns of place-making and of design as response to feelings as much as function have usually been neglected in hospital design.149 Sometimes the interiors of buildings, size and relationships of buildings are ostensibly designed as an afterthought and need attention as they contribute heavily to the therapeutic nature of place.150 Observations in isolated studies are insufficient to advocate replication of architectural aspects. To be effective, any design process must intentionally be, from the beginning, a redesign process;151 moving a program to a community setting from a research setting does not simply entail a change in location. For example, an issue concerning adapting programs to fit community characteristics shows that designers may not take into consideration dissemination issues; and implementers may not consider issues such as generalisability and fidelity (or adherence to the program) concerns.152 This often leads to design revolving around sickness rather than wellbeing, and often ignores values and preferences held by the public.153 A dynamic tension emerges between the strict, standardised nomothetic top-down approach, and the idiographic case-wise bottom-up approach that demands individual sensitivity and responsiveness – as it lacks relevance to the socio-cultural needs of a specific culture.154 Place-making is still limited in EBD when it creates an island of place familiar to a person’s experience of place, but may have little connection to its immediate periphery, for example, building patient hotels in the countryside. Links between everyday surroundings and the rest of society within the recovery pathway to create social inclusiveness is hazy in the clinical setting. To a certain extent it is also inaccurate to say that hospitals are healing spaces when they can make completely healthy people from the community feel uncomfortable and awful.155 Roger Ulrich himself contended that unfamiliar environments can produce psychological stress that can negatively affect healing and wellness, even if they were designed to be therapeutic. 156

148 149 150 151 152 153 154 155 156

Review, Evidence-Based Programs and Practices What Does It All Mean?, 8. Francis, “European Hospital Design,” 153. David Canter and Sandra Canter, “Creating Therapeutic Environments,” in Understanding and Evaluating Therapeutic Environments for Children, ed. David Canter and Sandra Canter (Great Britain: John Wiley & Sons, Ltd, 1979), 342. Review, Evidence-Based Programs and Practices What Does It All Mean?, 10. Ibid. Mullen and Streiner, “The Evidence For and Against Evidence-Based Practice,” 114. Lau, “Patient Empowerment: A Patient-centred Approach to Improve Care,” 215. Mens and Wagenaar, Health care Architecture in the Netherlands, 280. Arneill and Devlin, “Health Care Environments and Patient Outcomes: A Review of the Literature,” 666.

Care in Place

Design processes are inherently different from medical diagnosis.

As evident from architectural plans, a building is a domain of knowledge in so far as it embodies spatial ordering of categories and a domain of control in so far as it involves an ordering of boundaries. In Foucaultian language, buildings are mechanisms in which different forms of power-knowledge masquerade, and one task confronting the sociology of space is to disassemble the components of whatever technology is concealed within. Spatial organisation however, shows the intertwining of both space and society in a single order of existence. Therefore, a sociology of space demonstrates how spatial constructs co-vary and sustain human practice, and is best understood in relation to the discursive practices disclosed in their interiors.157 In a similar vein it can be demonstrated that hospital plans are essentially archaeological records encapsulating and inextricably imprisoning within themselves a genealogy of medical knowledge. The study of alterations in hospital facilities can thus reveal changing objects of medical attention, or disclose innumerable principles concerning the conceptualisation of disease and illness; the construction of children’s wards, for example, correlates with the rise of the child as a focus of medical practice; the birth of the asylum with the invention of madness; and the emergence of the pavilion hospital with the diffusion of miasmic theories of disease. And thus the architectural plan lays bare the spatial expressions in which medical knowledge and therapeutic practices are constituted.158 As the process of EBD development mirrors the development of EBM, the potency of the medical model determines whether a hospital leans towards the aesthetics of the surgical ward, or therapeutic settings. Where medically-oriented aspects do occur, there is a strong likelihood that other dehumanising aspects of a medical model surfaces – beginning with the treatment of people as patients rather than people. The high level of cleanliness of very specific routines or presence of staff and control of movement is potentially counter-therapeutic.159

157 158 159

Care in Place

Prior, “The Architecture of the Hospital: A Study of Spatial Organization and Medical Knowledge,” 92. “The Architecture of the Hospital: A Study of Spatial Organization and Medical Knowledge,” 93. Canter and Canter, “Creating Therapeutic Environments,” 340.

There are large volumes of patients with relatively similar complaints and physiology, while in design, every project is unique and invariable assembled in different ways, in spite of several components sharing similar aspects. It is contentious to refer to EBD as naturally analogous to EBM; EBM’s theoretical base and methodology cannot be ‘borrowed’ by the design field. Clearly, the new movement of EBD seeks to create for health care design a kind of evidential backbone that goes beyond anecdotal evidence.160 There are differences between how ‘evidence’ is being used in architecture and in medical care. EBM is developed in carefully controlled studies that form a body of information from which predictive theories can be developed. To date, no widely accepted protocols have been established for developing evidence for design and no recognised bodies have established themselves as capable of dispassionately reviewing and drawing conclusions from research studies. Without the ability to create predictive theories, EBD is reduced to the application of anecdotal conclusions about how one would like the environment to be rather than how one can expect the environment to be.161 This, in a nutshell, is the subject of EBD; designers seemingly want evidence for everything from successes, failures, progresses, and what will most likely work. This also ambitiously includes evidence of design configurations used in the past resulting from precedent work towards similar problems to accumulate knowledge to ‘fit’ problems with the most likely solutions that will work again: so-called ‘collective intelligence’. Effectively, EBD reduces design processes down to a formula or template.162 The quality of basic scientific research on healthcare environments that links design interventions to its outcome within a relevant population is problematic because the primary ambition of EBD focuses on the ‘does it work?’ question; measuring the effectiveness of an intervention becomes a critical factor in the causal explanation of any design intervention. However, so far the causal powers of studies in healthcare design have been disappointing. Even in the seminal works in this field, the recommendations for design intervention are rarely derived from causal explanations.163

160 161 162 163

Becker and Carthey, “Evidence-based Healthcare Facility Design: Key Issues in a Collaborative Process,” 1,3. “Evidence-based Healthcare Facility Design: Key Issues in a Collaborative Process,” 2. Nikos A. Salingaros and Michael Mehaffy, “Evidence-based Design,” http://www.biourbanism.org/evidence-based-design/. Becker and Carthey, “Evidence-based Healthcare Facility Design: Key Issues in a Collaborative Process,” 6.

Care in Place

Today, two sets of theories are commonly discussed in the design field: Positive (analytic, predictive) theories and normative (creative) theories. The former is analogous to scientific theories that deal with how the world is and not how it might be, while the latter consists of statements about what ought to be. As elucidated by Lang in 1987, “the scientific method provides rules for description and explanation, not for creation … design may be derived from scientifically formulated positive theory, but this does not make it scientific. Normative theory is based on an ideology or world view even if this is not explicitly stated.”164 In the realm of hospital design, positive theory aims to enable designers to derive a large number of descriptive statements from a single explanatory statement in order for them to base their design on a sound theoretical foundation. Proponents of EBD argue that it provides the evidence for building hospitals in a certain manner. However, it is dangerous to assume that a simple accumulation of facts about the world provide profound understandings of how the world is. While EBD makes for great guidelines, the evidence that this knowledge is based on does not guarantee better outcomes in care.165 Bill Hillier in 1996 described two logical ways in which an architect can make predictions: 1) from known precedents, and 2) from theoretical principles, stating that prediction based on precedent can never be duplicated exactly and must involve the use of interpretation because the new synthesis of precedent re-contextualises it. Most precedents in design, however, are weakly analytical and strongly normative, and are probably better defined as proactive in addressing a particular design issue, rather than predictive of specific outcomes.166

164 165 166

Care in Place

“Evidence-based Healthcare Facility Design: Key Issues in a Collaborative Process,” 8. “Evidence-based Healthcare Facility Design: Key Issues in a Collaborative Process,” 9. Ibid.

Hillier also advises that a design theory’s predictive value is intrinsically dependent on the strength and appropriateness of a theory’s analytical foundation: the normative theoretical concepts steering the generation of design also take the form of analytical concepts which indicate that if the designs follow the precepts of the theory, then it is to be expected that the design will work the way the architect intended. However, these advantages only exist to the extent that the theory’s analytical foundations are not illusory; if they do not offer a realistic picture of how the world works, then it is likely that the designer’s predictions will refer only to an illusory reality. A poorly founded analytical theory will not inhibit architects in the creative phase of design, but it will lead him or her to look in the wrong place, and will also mean that their predictions are unlikely to be supported by events when the building is built. This is a reason why bad theories are potentially dangerous in architecture.167 Therefore, EBD should be used carefully in healthcare design, and caution should be used in the generalisation of evidence from a limited number of credible research studies. This is why a basic systematic metaanalysis of the existing and future studies is essential for designers to choose the appropriate type of evidence from research to improve the accuracy of predictions in environmental design.

167

“Evidence-based Healthcare Facility Design: Key Issues in a Collaborative Process,” 10.

Care in Place

CONCLUSIONS Hospitals are built expressions of the good intentions of the city, but often technocracy gets in the way of the modest idea of achieving care, and other architectural concerns of care in place-making are neglected or remain an oversight.168 Consequently, they are often manifested as the standalone, cold, territorial and/or isolating bulwark;169 therapeutic functions, in a continuation of modernist zeal, had unqualified priority, while the respite function withered.170 Additionally, the heavy dependence on EBD has shown that we start off with good ideas that become too prescriptive, presenting a limited and strictly utilitarian view of possibilities with a standardised design mentality.171 There is now an urgency for architecture to make sense out of the medical mess and create fine spaces of solace within frightening spaces.172 On the other hand, excellent architecture can parallel function, connections with locality, anticipating future changes and satisfy emotional needs. As designers of the community, it is important to realise that hospitals are communities in and of themselves. Yet, few hospitals are designed to celebrate connections with place, or build on the healing benefits of creative communities. In most of them, the mental good-will achieved by relating to and finding comfort in your neighbours is not always a priority.173 With the clarification of the main assumptions, one can begin to see the hospital as a potential architecture of care and place.

168 169 170 171 172 173

Mens and Wagenaar, Health care Architecture in the Netherlands, 163. Health care Architecture in the Netherlands, 280. Dominiczak, “The Art of Medicine: Of Wandering Doctors, Cities, and Humane Hospitals,” 23. Haggard and Hosking, Healing the Hospital Environment: Design, Maintenance, and Management of Healthcare Premises, 15. Betsky, “Framing the Hospital: the Failure of Architecture in the Realm of Medicine,” 76. Prasad, “Typology Diagrams and Introduction,” 4.

Care in Place

CHAPTER THREE: HOSPITAL AND CITY, HOSPITAL IN CITY DESIGN ATTITUDES TOWARDS HOSPITALS CAN EVOLVE WITH CONTEMPORARY ATTITUDES TOWARDS PLACE AND CARE.

Care in Place

FIGURE 1. The inextricably linked relationship between the hospital and the city, and the need for the hospital to be perceived as a part of its place.

Care in Place

3.1

HOSPITAL AND CITY

“In a way, every architectural project is an urban project. Without knowledge of the context, design becomes a hopeless task doomed to irreparable failures. The proposition that hospitals be implanted in urban settings, recognized as small towns in themselves. The hospital is a large house, which is conversely, a small city. A house, a hospital, a city – what’s the difference?” John Cole, 20061 In his seminal L’Architettura della Citta in 1966, Aldo Rossi expounded his views on the identity of the city, linking its unique personality to its built environment. While most of a city’s building stock is replaceable, its identity is not, as long as changes respect the ‘genetic code’ inherent in the scale and structure of its urban tissue, and that identity and change are very compatible.2 A city’s identity is described by Thomas More as the link between space and constitution, thus an entity in space and a representation of a community, the basis of a societal order and its product.3

FIGURE 2. In Aldo Rossi et al., ‘The City Analogous,’ (1976). This table is conceived as analogous City "collective work" in which several figures belonging to the repertoire of production and memory accumulate towards the overlapping of the fabric of the historic city and its monuments, it reproduces an urban landscape that lies in the practice of the additive mounting their own construction logic. Important aspects of the table include: the emphasis on the fact that urban structures are constituted of parts itself autonomous and concluded; the other aspect addressed is that the city suffered similar fits within a range of urban models, which in turn have continuously characterized the thinking about architecture and the city in history.

Rossi implies that a city can therefore absorb almost any function and be modernised without being destroyed. The city’s capacity to adapt to new and challenging circumstances is further supported in Lewis Mumford’s The Culture of Cities (1938) and The City in History (1961). However, destruction usually results from deliberate attempts to ignore the existing urban-scape; whenever this occurs, intrusive buildings set themselves apart from their place.4 In this context, hospitals are often compared to intruders because they destroy urban tissue and create their own world in total disregard of context, just as a patient might find a doctor who uses nothing but scientific tests inhumane and self-limiting to a relationship.5 Rossi however further expounded the existence of a collective memory where archetypal buildings play a key role. Although originally derived from its function, typology is, in his view, an alternative for simple functionalism that contains memory, creates freedom to evolve, and is open to new interpretations. Urbanising a hospital can therefore contribute towards its functional integration with local place.6

1 2 3 4 5 6

John Cole, “Strategic Planning for Healthcare Facilities,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 107. Cor Wagenaar, “The Architecture of Hospitals,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 17. Mark Michaeli, “Utopia Re-Read,” in Open City: Designing Coexistence, ed. Kees Christiaanse, Tim Rieniets, and Jennifer Sigler (Amsterdam: SUN Publisher, 2009), 103. Cor Wagenaar, “The Culture of Hospitals,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 24. “The Architecture of Hospitals,” 17. Ibid.

Care in Place

Mumford’s aforementioned publications also apply remarkably well to hospital architecture. Hospitals too reflect life and are representative of the city and society because of the way they seemingly emulate the neighbourhood composition of streets and squares. He deduces that architects tend to endow their projects with the fundamental characteristics of well-designed cities: their capacity to form and sustain living communities is a means of integration on all platforms.7 Gordon Friesen takes it further by saying that the hospital is the exemplary intermediary between the body and the city - standing not only as the site of health interventions, but also itself linked to the city through its rehearsal of planning techniques akin to those of modernist urbanism. Like modernist town-planning, Friesen’s hospital planning privileged the building’s circulatory systems with the aim of rationalising and accelerating the delivery of clinical care; indeed, the increasing proportion of hospital buildings given over to circulatory systems and engineering distribution routes must surely stand as a characteristic of twentieth-century hospital design.8 FIGURE 3. The shift towards a idea of a hospital-city rather than a hospital at the periphery of the city instigates the paradigm shift towards an architectural model of care within its place. FIGURE 4. (opposite) A town’s qualification as a city is not predicated on its size but, as Lewis Mumford wrote, is a ‘point of maximum concentration for the power and culture of a community.’ Thus this place of concentration for expression as an embodiment of our collective aspirations must be immediately visible and definable, and must be made visible in an architeture that acts as an exclusive framework. In his book The Culture of Cities, Mumford used Lakeview Terrace (in an artist conception) as an example of a plan that was well adapted to site, noting the placement of the buildings at right angles to the road, the abandonment of costly streets, and the ample interior playground.

Mumford explains that there are no laws governing their cycles of growth and decline, and so in order to understand their ‘biography’ one must delve deeply into that history. Fragments of culture endure long after the society originally sustaining them has ceased to be a rational response to a situation of expression of need. For as Geert Driesen declares, the city represents more than just a metaphor for the relation between buildings and history, it represents the manifold processes moulding current society. A hospital, as an urban project, should therefore resonate with the processes of evolution in place.9 Therefore, if it is also appropriate for hospitals to bridge the gap between medical establishment and everyday life, and for those private concerns that are eventually part of everybody’s life, then this would call for strategies to reintegrate the hospital into the urban tissue. Most importantly, such reintegration links design to the culture that produces them and rectifies what seems to have become a medical monopoly over people’s most private experiences: the need to overcome illness and injury. Ideally, hospital architecture would demonstrate how modern culture reconciles function in respect to the integrity of people and place.10 This chapter takes a progressive stance on how hospitals can evolve according to the key components of current society that are relevant to care. 7 8 9 10

“The Architecture of Hospitals,” 24. Jonathan Hughes, “Hospital-City,” Architectural History 40(1997): 268. Cole, “Strategic Planning for Healthcare Facilities,” 24. Ibid.

Care in Place

FIGURE 5. The shift towards a idea of a hospital-city involves an extension of access in the process of connecting hospital to place.

Care in Place

ENABLEMENT OF ACCESSIBILITY “The street is a room by agreement … a community room dedicated to the city for common use … its ceiling is the sky.” Louis Kahn, 1959 11 Networks have been largely anonymous and marginalised, and the expertise of designers seldom utilised. Yet, they are public spaces in which most of us spend a great part of time, and when oriented to local place, should be brimming with opportunities for encounter and exchange.12 Mobility and the development of infrastructural corridors are part of modern society and a daily pursuit where people derive a sensory experience from their everyday mobility.13 Over the last 20 years hospitals have remained conservative in terms of major circulation and strict zoning, in a similar way to present day urbanism, except that hospitals became rigid institutionalised cities of disciplines and beds where streets only served as traffic arteries.14 This mirrors modernist projects and their powerful conceptual polemic that forced the nineteenth-century correspondence between boulevard/city into the one highway/metropolis and impositions of anti-distinctive elements on existing urban structures and by doing so, killed off the character of traditional streets.15 The use of a neutral and universal grid only allows room for constrained planning, and can hardly be described as an agent for incremental change when the development of hierarchies through ‘streets and local streets’ have seldom led to structured extension or alteration.16 Both in manifesto and in practice, modernist urbanism has obsessively promoted the efficiency and velocity of circulation through processes of geographical specialisation and separation. Sanitation and health may be proffered as worthy mitigating factors but the invisible hand of capital may also be sensed in the re-organisation of the spatial logic of the city to facilitate the functioning of circulation and, ultimately, production.17

11 12 13 14 15 16 17

Luisa Maria Calabrese, “Overture,” in Mobility: A Room With a View, ed. Luisa Maria Calabrese and Francine Houben (Rotterdam: Nai Publishers, 2003), 78. “Overture,” in Mobility: A Room With a View, ed. Luisa Maria Calabrese and Francine Houben (Rotterdam: Nai Publishers, 2003), 88. Francine Houben, “Mobility: A Room With a View,” in Mobility: A Room With a View, ed. Luisa Maria Calabrese and Francine Houben (Rotterdam: Nai Publishers, 2003), 2. Lawrence Nield, “Postscript: Reinventing the Hospital,” in Changing Hospital Architecture, ed. Sunand Prasad (London: RIBA Publishing, 2008), 258. Calabrese, “Overture,” 87. Lawrence Nield, “Postscript: Reinventing the Hospital,” 255. Hughes, “Hospital-City,” 268.

Care in Place

Cities on the other hand, began as an urban grid with groups of continuous buildings in outwardfacing, quite regular clumps, among which is a defined continuous system of intersecting spaces, and slightly deformed regularity as a mechanism for generating contact.18 Current attempts to desegregate the road into specialised devices are illustrative of the importance of street presence. Roads can be interpreted as privileged points of views for determining how landscapes can be shaped.19 A task is to fully develop the environment in the right balance; where the landscape angle is combined with an awareness that mobility routes are public spaces with a culture, code of conduct and aesthetics of their own.20 It has since been suggested that hospitals should assimilate into the city by effectively becoming a node connected to other cities in networks, leading to deconstruction of care as a physical, tangible entity, accessible by remote diagnostics and surgery and community.21 It is also interesting to note that Modernist architecture had been associated with the internalisation of structure, an inevitably abstract and rectilinear exterior, and the eschewing of decorative ornamentation.22 It has been constantly attacked for being a manifestation of mere rationalism, with the aim of arriving at a unitary and generally valid world view and being reduced to function and economy, thus considered by many as authoritarian or even totalitarian.23 In recent years, contemporary architecture has gone through periods of detachment from its public and become less than popular; strangely, this arguably started with Modernism which was really inspired by an essentially social programme and human agenda. It is very misunderstood, because protagonists saw equally true an architecture of poetic quality alongside reason and technology.24 Le Corbusier in his term ‘plan libre’ does not mean arbitrary freedom, but a space that flows between elements of varying definition of stability. Thus the free plan may be understood as a system of interacting places.25

FIGURE 6 & 7. The analogy drawn between the basic circulation principles in a hospital and the road by Sir Colin Buchanan, in an investigation of traffic architecture in his report Traffic in Towns, 1963.

18 19 20 21 22 23 24 25

Lawrence Nield, “Postscript: Reinventing the Hospital,” 258. Calabrese, “Overture,” 87. Houben, “Mobility: A Room With a View,” 30. Paul Hyett and John Jenner, “Rebuilding Britain’s Health Service,” in Changing Hospital Architecture, ed. Sunand Prasad (London: RIBA Publishing, 2008), 102. Liz Haggard and Sarah Hosking, Healing the Hospital Environment: Design, Maintenance, and Management of Healthcare Premises (London: Taylor & Francis, 1999), 3. Christian Norberg-Schulz, “The Return to Modernism,” in An Architecture of Poetic Movement : Altered Perceptions, ed. Peter Pran (England: Andreas Papadakis Publisher, 1998), 6. Bryan Lawson, “Healing Architecture,” Arts & Health: An International Journal for Research, Policy and Practice 2, no. 2 (2010): 107. Norberg-Schulz, “The Return to Modernism,” 7.

Care in Place

3.2 DE-INSTITUTIONALIZATION Local context and human-centered care Humanist Alberti concluded his holistic vision of cause and effect in a healthy place with an apposite picture in which he depicts the town as a large house and the house as a tiny town; knowledge was gained by taking a panoramic view of things and was further enhanced by referring back to ancient sources.26 Relations between cities and buildings are based on complimentary principles of ‘continuity and simultaneity’.27 Health and architecture are intimately connected in advanced cultures, where the right ambient temperature and atmosphere are part of corporate image and brand development.28 Contours are slowly emerging of a trend that recognises their public character, no longer separate from social and physical context of the city but integral, so they become public amenities directly benefitting urban life.29

FIGURE 8. (opposite) The Modern and Humane Hospital: An investigative study drawing depicting the integration of built form into the city’s urban fabric. Best size and form usually depends on how big a city should be in order to meet the needs of its inhabitants and fulfill functional requirements. It supports the idea of using the scale of plots, zoning structure, neighbourhood streets, and such an approach as prerequisite parameters in the process of giving hospitals back to cities. FIGURE 9. A hospital that conforms with the built aesthetics in place, such as the pitched roofs of the surrounding houses. George Dodd (1856), Pictorial History of the Russian War 18545-6.

The physical form of infrastructure and its surroundings are bound to their use, culture and geography,30 and one can speculate as to how large typologies can weave themselves into the local fabric to create social interaction and acceptance as opposed to continually reinforcing barriers. The emerging discipline of landscape urbanism – which treats infrastructural assemblages as dominant features of both architecture and landscape of contemporary cities – offers real possibilities for building an urban politics for subtending the fracturing and bunkering processes associated with splintering urbanism.31

The case against institutionalization Oliver Van Der Bogt claims that in the wake of organisational expansion, it would seem that spatial concentration should be feasible. However the existing urban structure usually lacks the space required to effectively assimilate large complexes32 – hence sited on the city edge, close to transport hubs, generally oriented on an internal system of passages, pathways and spaces which have little relationship to public place, and become unsatisfactory to accommodate flexible and sustainable aspects.33 Conventionally, the illegitimate reduction of society’s complexity to the level of simple, reclusive organisational schemes failed to deliver liveable environments because of their failure to reflect real problems, which over time were realised as unsolvable ‘wicked’ problems. Within the city, attention 26 27 28 29 30 31 32 33

Philipp Meuser, “Architecture as a Quality Factor,” in Construction and Design Manual: Medical Practices, ed. Philipp Meuser (Berlin: DOM Publishers, 2009), 12. Cole, “Strategic Planning for Healthcare Facilities,” 111. Meuser, “Architecture as a Quality Factor,” 12. Noor Mens and Cor Wagenaar, Health care Architecture in the Netherlands (Rotterdam: Nai Publishers, 2010), 8. Calabrese, “Overture,” 82. Stephen Graham, “Networked Infrastructure and the Urban Condition,” in Open City: Designing Coexistence, ed. Kees Christiaanse, Tim Rieniets, and Jennifer Sigler (Amsterdam: SUN Publisher, 2009), 157. Olivia Van der Bogt, “Architectural Models for Decentralized Hospital Buildings,” in The Urban Project: Architectural Intervention in Urban Areas, ed. Roberto Cavallo, et al. (Rotterdam: Delft University Press, 2010), 59. “Architectural Models for Decentralized Hospital Buildings,” in The Urban Project: Architectural Intervention in Urban Areas, ed. Roberto Cavallo, et al. (Rotterdam: Delft University Press, 2010), 60.

Care in Place

(above, left to right) The (slow) rectification of the large hospital grain in alignment with city grid. FIGURE 10. Hopital Bichat, plan and present. FIGURE 11. Hopital Saint-Louis, Past and Present (1611, 1943, today) FIGURE 12. Hotel Dieu, Paris, 1750 and 1878. FIGURE 13. (opposite page) Developmental Plan for the Academisch Ziekenhuisa Groningen, 1976, where in the plan, the built form reflects the dimensions of the surrounding buildings.

Care in Place

turned pragmatically from controlling to coping, whereby in theory de-institutionalisation would result in dynamic and endlessly interconnected places.34 While this ‘open’ urban condition implies greater difficulty to maintain than confined communities, it remains ambiguously located between control and laissez-faire, so that a city will be in a position to meet challenges as they arise, and that the uniqueness of hospitals emerges through a societal practice of complex, permanent, mutually stimulating and conditioning interaction.35 Where the sovereignty of the patient is revived and the process of reassemblage of healthcare services guided by the interests of care, de-territorialisation of hospital boundaries becomes a realistic possibility.36

A call for smaller urban grain of recognizable units We may realise place in a town that possesses a high degree of coherence relative to its scale; it is the interaction of human sensibility with an appropriate physical location that place acquires its distinctive meaning, and locations acquire ‘associations’.37 This doesn’t mean it is necessary to scale things to the human body; it is a question of framing a relationship to invasive medicine and situates the act of healing.38 Creating buildings that repeat city form and acknowledge its capacity to change require the acceptance of a certain degree of fragmentation; buildings that respect context hardly ever take the form of monolithic blocks, rather involving a combination of emulating the scale of parcels surrounding them surrounded by ‘infill’ space. If scale is not derived from function but rather from institutional considerations, a series of smaller units for hospital facilities is favourable.39 A scale down from the hierarchical overall control tied to institutions,40 and enlargement of design control, would mean that smaller and relatively low-rise, lower-than-treetops architecture is less likely to develop its own autonomy,41 tends to have more transparent logistical planning,42 is a relief to look at, establishes continuous and cohesive dialogue with setting, and makes them more pleasant. By maintaining the middle scale, the overall complexity of the city is reduced to a seemingly controllable level so as to guarantee a specific identity. The connection the buildings have to the overall scheme and their immediate surroundings, and the notion of designing communities rather than space, are secondary for their successes.43 34 35 36 37 38 39 40 41 42 43

Christian Salewski, “Spaces for Coexistence,” in Open City: Designing Coexistence, ed. Kees Christiaanse, Tim Rieniets, and Jennifer Sigler (Amsterdam: SUN Publisher, 2009), 150. Michaeli, “Utopia Re-Read,” 102. “Utopia Re-Read,” 106. Sarah Menin, “Introduction: Place, Progress and Evolution,” in Constructing Place: Mind and Matter, ed. Sarah Menin (New York: Routledge, 2003), 5. Aaron Betsky, “Framing the Hospital: the Failure of Architecture in the Realm of Medicine,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 76. Wagenaar, “The Architecture of Hospitals,” 17. Salewski, “Spaces for Coexistence,” 150. David Canter and Sandra Canter, “Creating Therapeutic Environments,” in Understanding and Evaluating Therapeutic Environments for Children, ed. David Canter and Sandra Canter (Great Britain: John Wiley & Sons, Ltd, 1979), 337. Mens and Wagenaar, Health care Architecture in the Netherlands, 280,84. Salewski, “Spaces for Coexistence,” 152.

Care in Place

FIGURE 14. The decentralised, lower-rise hospital is one that is divided into departments and combined with traffic arteries. It begins its evolution from the care-institution as a city, towards the city as a care-institution. This is shown through European trends, where the arrangement of compact, multiple volumes interwoven into urban fabric, along with the pre-eminence of light and logical networks for internal (public) organization, generates an inviting interface between city and hospital. In this instance, this also enables the emergence of public areas between medical, paramedical and supplementary non-medical functions and vice-versa. For example, the coupling of outpatient units and specialized medical facilities, found in close proximity to hospitals, could still take advantage of hospital infrastructure.

Care in Place

Decentralisation This concept of decentralisation offers opportunities for dividing hospital services into separate components.44 Small-scale specialist clinics and care provision could increase the approachability of healthcare and feels ‘closer’ to people. Even creating wider accommodation in different but tightly networked locations can deliver empowerment when people believe they can make choices which needn’t feel dictated by others.45 Emulating an infrastructural network designed to deliver predictable, dependable services across the metropolis as infrastructural grids is democratically accessible and homogenous.46 Gradually, the dispersal of infrastructure made distances seem less of a hindrance to interaction and mobility. Furthermore, modern communication technologies make it much easier to decentralise existing institutions and create a system of satellite clinics.47 Verderber & Fine (2000) called this reduction of the forbidding tradition ‘functional deconstruction’, which began in the mid-1980s as a plea to attend to regional characteristics. The health village emerged as a residentialist solution to the conflict between modernism and postmodernism. A horizontal appearance - as opposed to vertical emphasis - created the possibilities for courtyards, and the lowrise approach with irregularly shaped space permits future expansion and a regionalist appearance. The village emphasis gives the patient greater choice, reduces stress, and decentralises patient services (or centralises them, from the patient’s perspective). Support for this strategy is backed by evidence presented by McLaughlin (1976), who found many problems with the matchbox-and-muffin scheme of patient towers arising from supporting services, which limited its ability to evolve with the evolution of care.48 On top of an ease with effectively integrating form into their social and physical surroundings, decentralisation allows hospitals to be built in urban settings rather than in isolation, working with the belief that patients benefit from close contact with normal society, which, in turn, benefits from the presence of its debilitated members.49

FIGURE 15. Opportunities: As a result of technology, a smaller, high tech core hospital is envisioned, whereupon patients can be transferred to other provisions, and municipal and regional treatment centres would be set up for outpatient assistance and day treatment. It demonstrates the possibilities of smallscale and light forms of hospital-related care that can be delivered through the division of the hospital. Scenario planning and experiment of the division of facilities in a hospital in the Netherlands, EGM architecten, design submission Stagg jubilee, motto ‘Overstagg’, in 1997.

44 45 46 47 48 49

Bogt, “Architectural Models for Decentralized Hospital Buildings,” 58. Mens and Wagenaar, Health care Architecture in the Netherlands, 281. Graham, “Networked Infrastructure and the Urban Condition,” 157. Wagenaar, “The Architecture of Hospitals,” 17. Allison B Arneill and Ann Sloan Devlin, “Health Care Environments and Patient Outcomes: A Review of the Literature,” Environment and Behavior 35, no. 5 (2003): 670, 73. Wagenaar, “The Architecture of Hospitals,” 16.

Care in Place

Decentralization heralds the return of the pavilion, and the hospital leaves the pedestal (opposite page) FIGURE 16. Hopital Lariboisiere, Paris, 1839-1854 by M.P Gautheir: The Origin of the Pavilion, with wide spacings to avoid contagion. It is credited with being the first pavilion hospital to be built. FIGURE 17. A Nuffield Hospital Design Study maintained until 1937 – Pavilions for infectious diseases with key arrangements. FIGURE 18. The old St Thomas Hospital, dating back to the twelfth century. It featured decentralized sanitary facilities, the facility that was the key to public health. A long range of pavilions filled a long narrow site, with all services and administration built in separate blocks.

The village emphasis, and a loose functional zoning for flexibility and openness is noticeably similar to the once-prevalent pavilion developments,50 which proved popular for their lack of monumentality, opting instead for relatively small structures spread out on spacious green plots, usually divided by gender by a central axis.51 While its ideals were embraced more easily in the psychiatric world than in the then-more conservative medical echelons,52 it later provided the framework for the separate housing of emerging medical specialties. It was a historical shift from the temple typology towards an almshouse with integrated healthcare, where access and the need to make places as normal as possible were priorities.53 Pavilions had originated in eighteenth-century France primarily through Henry Currey (1820-1900), leading exponent of pavilion design, and Florence Nightingale, leading advocate for hospital reform – originally for sanitary and cross-ventilation benefits, but by the turn of the twentieth-century the beneficial effects of sunshine entered the equation.54 The Pavilion hospital was closely connected with the expression of the miasmic theory of disease, and accordingly focused on the flow of air through wards and patterns of ventilation between them, and is full of light.55 Nightingale’s Notes on Hospitals (1859) describes four basic defects in hospital design. They were, in her opinion: (i) the “agglomeration of a large number of sick under the same roof”, (ii) a deficiency of space (which correlated closely with deficiency of ventilation), (iii) deficiency of ventilation, and (iv) inadequate light. The key of Pavilion design was to introduce the element of separation which would address those defects. At that time, patients were still housed in open halls, but decentralisation allows for smaller built form. For example, the use of verandas, to which patients can be expelled during the hours of daylight, facilitates the circulation of air, and staircases in multi-storey blocks are often placed on the outside rather than the inside of buildings for the same reason.56 57

50 51 52 53 54 55 56 57

Salewski, “Spaces for Coexistence,” 154. Wagenaar, “The Culture of Hospitals,” 28. “The Architecture of Hospitals,” 17. Marek H Dominiczak, “The Art of Medicine: Of Wandering Doctors, Cities, and Humane Hospitals,” The Lancet 377, no. 9759 Jan (2011): 22. Gordon C Cook, “Henry Currey FRIBA (1820–1900): leading Victorian, hospital architect, and early exponent of the “pavilion principle,” Postgrad Med J 78(2002): 352. Lindsay Prior, “The Architecture of the Hospital: A Study of Spatial Organization and Medical Knowledge,” The British Journal of Sociology 39, no. 1 Mar (1988): 94. Cook, “Henry Currey FRIBA (1820–1900): leading Victorian, hospital architect, and early exponent of the “pavilion principle,” 354. “Henry Currey FRIBA (1820–1900): leading Victorian, hospital architect, and early exponent of the “pavilion principle,” 355.

Care in Place

FIGURE 19. A comprehensive range of built personalities for an increasing range of specific groups offer a series of separate entrances for different patient experiences for different circumstances. In The Custom City, based on The Architecture of Mass Production , page 312.

Care in Place

3.3 THE EMERGENCE OF SPECIALIST, COMPREHENSIVE CARE An increase in specific health issues now means that there is a trend from generalist hospitals, to specialist care. As soon as the hospitals developed into the pinnacle of science, services became out of reach for the poor. While first-world healthcare systems are more egalitarian and democratic today, their duty of care is still out-of-touch with most of the population.58 No longer can a generalist hospital meet the demands for care. Within the context of developed countries there are broadening aspirations to cater to an ever-increasing diversity of health issues – an aging population, non-communicable diseases, chronic illnesses and mental health to name a few. For this reason alone, there are always more people who require care and assistance, and this destabilises traditional healthcare systems.59 Awareness of personal health, preventive care and the quest for knowledge of how the body works have long been preoccupations of advanced cultures; this specialisation and privatisation of certain departments go hand in hand with greater distribution and reduction of scale.60 While the definitions of care models around the world are imprecise and often have different denotations, they have in common a clear concern for a rationalised blueprint and delivery of services across the three chief sectors of primary, secondary and tertiary care,61 around a holistic social and human-centred model of health where wellbeing is given high priority in terms of design.62 They also share the need for a continuum of care, where acute, ambulatory and rehabilitative care are coordinated whether in the same or different healthcare facilities.63 An integrated healthcare model means that medicine develops ever more ways of providing noninvasive care and cure in a transitional phase away from nursing units, resulting in precipitous drops in hospitalisation demand.64 While it is necessary to keep inpatient services, ambulatory services - forecast to become the centrepiece of healthcare - are developed to provide more reassuring environments for patients.65 Another notable trend in the health care field is the coupling of ambulatory care centres and outpatient care facilities for they share overlapping or similar care processes. Because of the notable

FIGURE 20 & 21. Prevention and education of health is currently more dominant than the process of treatment. The expansion in the types of care needed means the need to expand the diversity of care settings, or ‘care landscapes’.

58 59 60 61 62 63 64 65

Wagenaar, “The Culture of Hospitals,” 31. Joachim Fischer and Philipp Meuser, “Goodbye to the Wheelchair Ramp,” in Construction and Design Manual: Accessible Architecture, ed. Joachim Fischer and Philipp Meuser (Berlin: DOM publishers, 2010), 13. Bogt, “Architectural Models for Decentralized Hospital Buildings,” 60. Lawrence Nield, “Changing Hospital Design in Australia,” 248. Hyett and Jenner, “Rebuilding Britain’s Health Service,” 108. Shakti Gupta and Sunil Kant, “Trends and Dimensions in Hospital Architecture: A Hospital Administrator’s Perspective,” Hospital Notes 7, no. 2 April/June (2005): 62. Wagenaar, “The Culture of Hospitals,” 75. Franz Labryga, “Principles of Planning,” in Construction and Design Manual: Medical Practices, ed. Philipp Meuser (Berlin: DOM Publishers, 2009), 263.

Care in Place

differences in the strictness of building codes in acute care hospitals, such facilities also become an opportunity for more progressive and sensitive design.66 The emergence of pavilions reflected rising specialisations in the medical world, each harbouring individual disciplines around overlapping shared facilities, and is the preferred form for places of long-term care and specialisation rather than invasive cure.67 ‘General’ hospitals were also forced to open specialist departments in the late nineteenth century.68

Compactness and specificity One can thereby observe that while hospitals are responding to the urban place over time, there is also a simultaneous centralisation and standardisation of certain facilities while others are devolved to a more local place, each setting created according to their suitability and convenience for care.69 Concentration and de-concentration become concurrent and complementary processes, where scale of healthcare provision is reduced through a network of individual clinic groups around one small core hospital.70 A fundamental aspect is the decentralisation of care around specialised departments that addresses problems that over-compartmentalise, and rely on only one operating approach for all.71 Different groupings of such facilities are therefore out of a human-focused interest and not just geographically-oriented.72

A combination of unique environments for each care setting Standardisation presupposes the ability for mass production, but its Achilles heel is in taking local peculiarities and personal preferences into account.73 The real requirement is therefore to design a building that will not only facilitate the indeterminacy of care but also personalise it.74 On the other hand, flexibility is increased by detaching non-specific parts, and assumes that all generic functions that have no need to be located in a hospital can be accommodated better elsewhere; as a result, the 66 67 68 69 70 71 72 73 74

Care in Place

Arneill and Devlin, “Health Care Environments and Patient Outcomes: A Review of the Literature,” 671. Wagenaar, “The Culture of Hospitals,” 29. Cook, “Henry Currey FRIBA (1820–1900): leading Victorian, hospital architect, and early exponent of the “pavilion principle,” 355. Susan Francis, “European Hospital Design,” in Changing Hospital Architecture, ed. Sunand Prasad (London: RIBA Publishing, 2008), 161. Bogt, “Architectural Models for Decentralized Hospital Buildings,” 60. Arneill and Devlin, “Health Care Environments and Patient Outcomes: A Review of the Literature,” 674. Lawrence Nield, “Postscript: Reinventing the Hospital,” 263. Mens and Wagenaar, Health care Architecture in the Netherlands, 156. Gupta and Kant, “Trends and Dimensions in Hospital Architecture: A Hospital Administrator’s Perspective,” 62.

FIGURE 22. The European model of care: Shows the movement towards smaller centres or departments of specific care is deeply rooted, that still encourages a level of proximity for collaborative work between departments as well as to infuse community participation on more intimate scales.

hospital proper loses a lot of the spatial ballast that only gets in the way when changes are necessary.75 Subsequently, uniformity, monotony and negation of individual preferences are avoided, while mass production and possibilities of individual expressions are reconciled with one another.76 The current progression of care recommends that with decentralisation goes an ability to design a succession of distinctive care settings. Perception and experience of the evolving hospital can be radically seen as a differentiated network of specialised clinics designed around treatment process.77 Different categories of people follow personalised courses of treatment, resulting in identification of specific groups. Medical specialisations are ideally distributed among these groups so that the hospital becomes divided into specialised clusters.78 For example, an emergency centre may require a standard, efficiency-oriented space where every second could be the difference between life and death, while an ambulatory centre can be designed as close as possible to the home situation, where the provision of care is least urgent and its inhabitants in a more relaxed state of mind.79 In terms of adaptability, the accommodation of functions in separate, low and compact volumes, along with a strategy of building the complex in stages, allows each part to be expandable and adaptable without disturbing total structure and enables aesthetic design, thus converting all functional hard requirements into matter AND with form, materials and colour: each function fits and has a place of its own.80

FIGURE 23. A series of diagrams showing that while certain parts of the hospital remains standardised, the indeterminacy of care can be facilitated through the process of decentralisation, whereby ‘soft spaces’ in between buildings enable adaptability to changing circumstances and requirements. Together with Figure 22, they have been identified as benchmarks for the thesis design proposal.

75 76 77 78 79 80

Mens and Wagenaar, Health care Architecture in the Netherlands, 230. Health care Architecture in the Netherlands, 156. Health care Architecture in the Netherlands, 277. Health care Architecture in the Netherlands, 236. Sunand Prasad, “Typology Diagrams and Introduction,” in Changing Hospital Architecture, ed. Sunand Prasad (London: RIBA Publishing, 2008), 8. Mens and Wagenaar, Health care Architecture in the Netherlands, 125.

Care in Place

ENLIGHTENMENT

MODERNITY

BIO-MEDICAL MODEL

Care in Place

POST-MODERNITY

PUBLIC HEALTHCARE MODEL

INTEGRATION

3.4 COMMUNAL SETTINGS IN PUBLIC BUILDINGS Why is the community needed in care? Health services are not the only or even the most important determinants of health; as observed, numerous social factors probably influence health more fundamentally than health services. Community is considered a social rather than a spatial phenomenon. Peer groups do not necessarily have to be cohesive and tightly knit because the purpose is to provide all members with the opportunity for displaying, expressing and acting out their individuality, revealing differences in background and behaviour that preclude friendship. That way, every community is recognised as a fragile subculture with its own values and behavioural patterns.81 There is a strong link between the concepts of empowerment and development of the community. The World Health Organization (WHO) health promotion glossary distinguishes between individual and community empowerment; individual empowerment refers primarily to the individual’s ability to make decisions and have control over his or her personal life; community empowerment involves individuals acting collectively to gain greater influence and control over the determinants of health and the quality of life in their community, an integral element to individual empowerment. In empowerment models, patients and community can choose, or resist, where they want to go to without judgment. Being able to choose makes people feel that they are listened to. 82 Many hospitals site themselves away from society for reasons such as safety, minimal disruption and for room for expansion with less spatial compromise.83 This, coupled with the overdependence on medicine and staff to care and treat patients, eventuates in out-of-town campuses dislocated from city centres. Conventionally, hospitals were solely built exclusively for its cyclical transient and permanent populations; those to be cured, and those to be cared for; while remaining sealed and uninviting to the rest of the public.84 For the city is a superimposition of interrelated and independent fields and networks that cannot be instantly imposed, constantly fixed or easily reproduced; theming environments out of context is destined to fail to reflect the complexity of society and give places a lasting sustainable meaning of a real community.85 FIGURE 24 & 25. (opposite) Evolving relationships between the hospital and city run parallel with the shift from a medical to public healthcare model. Where large, cancerous growth has excluded hospital from place in the past, the crumbling of its unnecessary monumentality, complexity and hermitage now opens a window of opportunity to be integral with surrounding context and community. This parallels the shift in healthcare, from one where an ill or debilitated person is segregated from society and placed in solitary confinement, dependent on medical treatment, to one where the ill and injured receive care and support from the community in the healing process.

81 82 83 84 85

Simon Richards, “Communities of Dread,” in Constructing Place: Mind and Matter, ed. Sarah Menin (New York: Routledge, 2003), 115. DH Lau, “Patient Empowerment: A Patient-centred Approach to Improve Care,” Hong Kong Med J 8, no. 5 Oct (2002): 373. Francis, “European Hospital Design,” 157. David Canter and Cheryl Kenny, “Evaluating Acute General Hospitals,” in Understanding and Evaluating Therapeutic Environments for Children, ed. David Canter and Sandra Canter (Great Britain: John Wiley & Sons, Ltd, 1979), 310. Salewski, “Spaces for Coexistence,” 153.

Care in Place

Technically perfected medical science also excluded the idea that while elements of modern society may make people sick and be a psychic burden, their presence can also contribute to the recovery process.86 Today, public image is just as critical as medical competence, and the community becomes the therapeutic environment with the aim of prevention top priority.87 This is supported in a study conducted by Van Klingeren and Muller, who concluded that healthy people could learn a lot from their unhealthy neighbours; the healthy who adapt themselves to a dysfunctional, sick society, and the ill, who behave like explorers, wandering through space and reaching higher levels of creativity.88 Conversely, the presence of the wider functioning community, and a design that considers community needs, avoids the making of a ‘hospital culture’ and remains culturally congruent with the rest of society.89

Designing community-oriented hospital architecture As agents of regeneration, community-focused hospitals elicit benefits through the regeneration of public place in and around hospitals, and through offering users a richer set of public places. The shift towards community care demands a move towards a community-oriented architecture, with emphasis on the domesticity of settings and community orientation of organised care.90 No longer can a hospital regard itself as a transcendental entity unaffected by exterior events, but as a self continually affected by its environment in both its built fabric and social dynamics.91 Clearly, while location alone will not determine wellbeing, locations continuous with community place are less likely to be institutionalised.92 City renewal from a broader planning perspective moves the hospital towards the city with a broader emphasis on urban revitalisation.93 The desire for social interaction, linked with goals for social reintegration of people with illness, calls for hospitals to be well-connected to the community setting beyond the hospital. Design features that are important in this respect include whether the building fits in with its surroundings, conveys a sense of civic pride and is located within a community.94 86 87 88 89 90 91 92 93 94

Care in Place

Philipp Meuser and Christoph Schirmer, “From ‘House for the Sick’ to Hospital,” in In Hospital Architecture Volume 1: General Hospitals and Health Centres, ed. Philipp Meuser and Christoph Schirmer (Singapore: Page One, 2007), 11. Canter and Kenny, “Evaluating Acute General Hospitals,” 310. Wagenaar, “The Architecture of Hospitals,” 16. Lau, “Patient Empowerment: A Patient-centred Approach to Improve Care,” 225,30. Prior, “The Architecture of the Hospital: A Study of Spatial Organization and Medical Knowledge,” 109. Richards, “Communities of Dread,” 115. Canter and Canter, “Creating Therapeutic Environments,” 337. Francis, “European Hospital Design,” 157. Ufuk Dogu and Feyzan Erkip, “Spatial Factors Affecting Wayfinding and Orientation,” Environment and Behaviour 32, no. 6 Nov (2000): 595.

FIGURE 26. Building in urban fabric: the public area of city continues virtually uninterrupted on the site of the hospital, so that services offered would also be available to local residents. Each pavilion had its own entrance, if extension outside hospital grounds were to prove necessary in the future, small-scale structure would avoid the presence of hard contrasts 97/168. The movement towards these smaller residentialist care centres is also deeply rooted in the need to break down the scale of large hospitals, while still enabling clear access. 10/83 Rohmer, Residential Care Center, Nijmegen in 2009

Community access and scale If holistic care is accessible in the neighbourhood, the hospital can become settled in the local community.95 Architecturally, keeping with the community’s housing and culture would prevent the development of unnecessary fears of hospital care which the monstrous prison-like buildings of the past have helped to produce.96 The emphasis is no longer on segregation but on the preservation of continuity of the personal relationships the patient has developed in the community.97 The benefits of scale also work well for hospital staff, who often wish for smaller units to obtain a closer interaction with patients. Another suggestion is for buildings to appear smaller, more pluriform and more ordinary,98 with volumes broken down to correspond to and acknowledge the texture of the local neighbourhood.99 Human-scale institutions are unhindered by monumentality and are more approachable, and could form the potential bridge between specialised care and the rest of the community, which creates social inclusiveness and is communally enlightening.100 FIGURE 27. Openness at the edge: The design proposal for North Shore Hospital includes attractive and inviting pedestrian routes from main access paths into the heart of the hospital.

It is not the island condition per se that leads to the closed or open city, but the scale and nature of islands; the open edge creates permeability and accessibility determined by physical, locational and social factors.101 The avoidance of urban sprawl, or dispersed, irregular, auto-dependent developments almost pertinent to cheap, monotonous buildings aesthetic dullness can also be resolved by creating different environments to serve the needs and interest of people moving at different speeds through environments. For example, good streets offer much to notice when walking at a regular pace whereas walking on suburban arterials is highly monotonous and inhospitable due to the lack of aesthetic detail.102 Offering a range of supporting services for an open set of network spaces encourages heterogeneous mixing.103

95 96 97 98 99 100 101 102 103

Wagenaar, “The Architecture of Hospitals,” 17. Alex Anthony Baker, Richard llewelyn-Davies, and Paul Sivadon, Psychiatric Services and Architecture (Geneva: World Health Organization, 1959), 12. Prior, “The Architecture of the Hospital: A Study of Spatial Organization and Medical Knowledge,” 107. Canter and Canter, “Creating Therapeutic Environments,” 337. Francis, “European Hospital Design,” 157. Mens and Wagenaar, Health care Architecture in the Netherlands, 281. Salewski, “Spaces for Coexistence,” 153. Lawrence Frank, Howard Frumkin, and Richard Jackson, Urban Sprawl and Public Health: Designing, Planning, and Building for Healthy Communities (Washington D.C: Island Press, 2004), 2,18. Graham, “Networked Infrastructure and the Urban Condition,” 157.

Care in Place

I AM A GAP SITE

I LIKE MY NEIGHBOURS

I LOVE MY NEIGHBOURS

I LOVE MYSELF

FIGURE 28. Development and Context in conformity with place and community, where Tom Turner observed that there are logically only four possible relationships between any proposed development and its place: identity, similarity, difference and coalition. Based in Development and Context by T. Turner, in City as Landscape.

Care in Place

Smaller clusters of buildings Verderber and Fine also debated the balance between compactness and linearity;104 the categorisation of different therapies and patients leads to a large number of small communities.105 The hospital can be a therapeutic community where a group of people reside – thus a collective unit analogous to a village.106 Social centres are therefore necessary and be of lasting public retention because it potentially overcomes the exclusionary experiences one often encounters.107 Equitable care comes from the non-hierarchy in communal places, allowing all to play active and responsible roles in the healing process as well as strengthening community spirit.108 Decentralising less specialised activities away from acute centres for community health is intended for outpatient appointments instead of going through an acute care hospital where waiting times are considerable, and people needn’t be exposed to its stressful atmosphere. Greater focus on personal responsibility has emphasised the importance of non-health specific interventions dealing with education and community-based support.109 110

Aesthetically, hospitals should have a face and an identity. Location generates tradition and both are reinforced by the external appearance of the hospital. In the recent history of public building architecture there has been a plethora of discussion about the value of designing buildings from the inside out,111 making external forms reflect interior requirements, and making visible community-oriented spaces.112 This also mitigates the harsh confrontations with cold new buildings and spares natural features and historical buildings as much as possible.113

104 105 106 107 108 109 110 111 112 113

Leanne Rivlin and Maxine Wolfe, “Understanding and Evaluating Therapeutic Environments for Children,” in Understanding and Evaluating Therapeutic Environments for Children, ed. David Canter and Sandra Canter (Great Britain: John Wiley & Sons, Ltd, 1979), 669. Mens and Wagenaar, Health care Architecture in the Netherlands, 170. Baker, llewelyn-Davies, and Sivadon, Psychiatric Services and Architecture, 29. Graham, “Networked Infrastructure and the Urban Condition,” 157. Hyett and Jenner, “Rebuilding Britain’s Health Service,” 108. Cole, “Strategic Planning for Healthcare Facilities,” 359. Hyett and Jenner, “Rebuilding Britain’s Health Service,” 108. David Canter and Sandra Canter, “Building For Therapy,” in Designing for Therapeutic Environments: A Review of Research, ed. David Canter and Sandra Canter (Great Britain: John Wiley & Sons, Ltd, 1979), 17. Peter Scher, “Lessons in Humanizing Health Care Architecture,” in The Culture for the Future of Healthcare Architecture: Proceedings of 28th International Public Health Seminar, ed. Romano. Del Nord (Firenze: Alinea Editrice, 2009), 110. Mens and Wagenaar, Health care Architecture in the Netherlands, 170.

Care in Place

Case: Hospital in Venice, by Le Corbusier (1964-5), unbuilt. Le Corbusier’s city grids, domestic layouts and the Modular are generally considered to be expressive of the spatial innovations of the new sciences, formulating a code that is capable of articulating dynamic, generative architecture, and therefore providing a homogenous, quantitative, and infinitely extensible continuum of surrounding place. Jack H. Williamson (1986) christens this alleged dematerialisation as the ‘anti-object paradigm’, parallel to the loss of autonomous individuality under the new collectivist and determinist social and psychological sciences, while Andrew McNamara (1992) similarly reads it as an evidence of a desire to collapse all boundaries – natural, spatial, social and aesthetic – into an undifferentiated field. In his Venice Hospital proposal, the Modular programmes of numerous modernist urban projects made clear the conjunction of notions of circulation, efficiency and health; Le Corbusier’s Urbanisme in 1924 drew that explicit analogy between the act of surgery and urban improvement schemes. By zoning away industry and by separating out traffic flows into specialized, 98 Care in Place

pedestrian-free transportation networks, health and efficiency of circulation could be assured for all. concerns which must surely mirror the development of modern life in a mobile, capitalist society 120/267 The hospital is the uncontested epitome of the ‘mat’, or carpet, building type - a low sprawling structure developed in the late fifties and sixties that is making a strong comeback in contemporary architecture. Planned in 1965 for the arsenal area at the edge of the city, the hospital was designed to extend the city’s roads and canal networks, while simultanously turning in on itself to create flexible, quasi- urban interior environments in the form of endlessly repeating courtyards. The point of departure for the hospital was the room or Cellule, created at the human scale, which is part of a care unit that houses 28 patients. The unit is organized around a central space, Campiello and four circulation paths, Calle which are intended for both circulation and and inhabitation by patients. The frame work yields a horizontal hospital. The hospital stops being a static

organism and acquires the flexibility to follow both the evolution of medical innovation and to accommodate the possibility of future growth. The hospitals departments are interchangeable and can be used in accordance with the hospitals needs. In the hospital the patient finds the condition of city life when entering the “Calle”, the “Campiello” and hanging gardens. “Opening the ground floor directly onto the city, allows for a cityhospital encounter, and facilitated the transmission of medicine to the outside world.” FIGURES: 30.1. Plan view of the model of the Venice Hospital. 30.2 The colour-coded version of the plan, which further highlights the mat development. 30.3. The low-rise built form allows for patients to be continuously connected to sky and natural light. 30.4. An artist perspective of what the hospital could look like in elevation, merging with the other low-rise buildings.

Two cases that exhibit design to local place: Isala Clinics, Zwolle, the Netherlands, by Alberts & Van Huut and a/d amstel architecten, early 2000-ongoing. The organic, nearly whimsical character of the buildings, combined with a green landscape, give a small scale character, via a progression of smaller built forms, despite it being the largest hospital in the Netherlands. Facade design is based on the division of space and above all on the right proportion between space and use of materials, while bearing similarities to the facades of its surrounding buildings. Within the plan, several units (called butterflies) are grouped together and interconnected, each different from the rest and specially adapted to specific functions, with the new criteria being age category and nature of therapy. FIGURES: 31.1. Elevations of a large volume made up of many smaller buildings - Note how the windows still match one anotherâ&#x20AC;&#x2122;s facades. 31.2. The view of the hospital in the city backdrop. 31.3. Plan view of the hospital, revealing its organic nature. St. Olavs Hospital, Norway, 2009, by Narud Stokke Wiig Architects. As the main objective has been to integrate the university and the teaching hospital to produce an effective patient-oriented processing facility for health and welfare services, the architectus were explicitly concerned with urban integration, where the hospital was envisaged as a typologically indistinguishable quarter of the city, its departments occupying an extension of Trondheimâ&#x20AC;&#x2122;s general street grid. The location of the university hospital within the grid based city structure imposes a design discipline for the development of the various clinics, buildings and facility centres. Six clinical centres are built around a central square and have their own landscaped central areas. These centres are linked below ground with technical and service culverts with bridges on the first floor for patients and staff, maximizing the openness of the ground floor. FIGURES: 32.1. the composition of hospital grounds around suburbia. 32.2. Well-designed shared spaces on the ground floor, making it easily accessible from the city. Care in Place 99

Hospital - the perceived large mass

100

Care in Place

Modularity, scalability, adaptability, flxexibility and universal capabilities - through corridors and particularization of mass

Increasing surface area of building through embedding greenspaces and atriums within building

Linear Strategy for wayfinding

Buildings surrounded by greenscapes

D b

Adaptability and elasticity

Designing a series of unique buildings.

Designing a series of unique access paths while retaining access points from the city.

FIGURE 33. Summary of a process towards designing a hospital in place, bearing in mind that there is no surefire process towards designing a hospital.

Hospital evolution is almost entirely determined by insights into its functioning, often resulting in onedimensional buildings perfectly able to accommodate a particular vision, but completely outdated as soon as new insights appear. A corollary of the classic functional approach is the need to keep adapting or replacing buildings, thus hospitals appear in their own guise for brief periods, followed by the process of renovation, extension or demolition.114 There is now a keener search for the essential, generic and versatile rather than specific and tightly fitted to immediate needs, and the slogan ‘long life, loose fit, low energy’, overlaid with technologically sophisticated and high-performing structure and fabric.115 Aside from the heavy dependence on the use of an adaptable infrastructure, the perimeter placement of utilities improves access for repairs and upgrades, keeping occupied space in operation as long as possible, allows systems to evolve separately from building itself, and have the capacity to anticipate change without force-fitting. One of those alternatives is the use of soft spaces: easily relocated areas sited adjacent to treatment rooms to allow expansion with minimal refurbishment, to permit expansion without the need to construct separate footprints or execute refurbishments causing major disruptions.116 In essence, it evolves and revolves around the preservation of sociable and liveable spaces.

114 115 116

Health care Architecture in the Netherlands, 9. Prasad, “Typology Diagrams and Introduction,” 7. Douglas Olsen, “Changing Hospital Design in the USA,” in Changing Hospital Architecture, ed. Sunand Prasad (London: RIBA Publishing, 2008), 194.

Care in Place

101

102

Care in Place

CONCLUSIONS The relationship between healthcare and renewal could not be more obvious. Civic typologies assume institutional habits with reason; on the contrary, the hospital redeems its civic function and relevance in care through the lack of institutionalisation, by courageously moulding itself on the city. Their reweaving back into local place should recognise the full plurality of voices within the contemporary context, and overcome the disconnecting logics of superimposed modernistic planning and mega-structures, and its socially purified secession.117 Deinstitutionalisation through an initial decentralisation comes with the reduction of the urban grain.118 This decentralisation of form parallels the specialisation of healthcare services, including an increasing emphasis towards primary healthcare and wellbeing, and the need for community inclusion and participation in the treatment process. That is bearing in mind that decisions are ultimately made with regard to the desired degree of concentration, distribution pattern and siting of new amenities, the result of autonomous deliberations on the part of the healthcare organisation. The emphasis now seems to be on satellite feeders, where these outpatient facilities and medical office buildings are argued to provide not only greater convenience for patients but also easier staff flow. The clustering of units potentially makes people more comfortable with the idea of the whole hospital broken down into more manageable parts.119 In essence, designing a hospital in relation to local place and values returns it to the people, initiating a return to basic principles of patient empowerment and re-integration.120 New combinations of facilities are now feasible, topical and appropriate in the current arena of care, as a refreshed strategy of urban renewal that focuses on the creation a new public domain, but this has yet to fully permeate into practice.121 The next chapter within this thesis continues to address this paradigm shift.

117 118 119 120 121

Graham, “Networked Infrastructure and the Urban Condition,” 157. Bogt, “Architectural Models for Decentralized Hospital Buildings,” 58. Arneill and Devlin, “Health Care Environments and Patient Outcomes: A Review of the Literature,” 690. Wagenaar, “The Culture of Hospitals,” 40. Bogt, “Architectural Models for Decentralized Hospital Buildings,” 58.

Care in Place

103

104

Care in Place

CHAPTER FOUR: A TYPOLOGY OF TYPOLOGIES WITH THE OPPORTUNITY TO CREATE PLACES FAMILIAR TO AN OVERALL WELLBEING, ONLY CAN DESIGN ATTITUDES EVOLVE TO CREATE CARE IN PLACE.

Care in Place

105

FIGURE 1. Cover ofArchitectural Review in June 1965 featuring Gordon Friesenâ&#x20AC;&#x2122;s circulatory and hardline utilitarian logic of the modern hospital.

106

Care in Place

4.1

JUST A HOSPITAL

“Hospital planning demands the same careful thought that is the foundation of any modern successful business enterprise. It is essential in the shoe factory, the paper mill or the business establishment to so plan that the raw materials may be assembled and finished product delivered with the fewest possible intervening motions…. In the factory the saving of time in any of the processes adds to the annual product, and in the hospital, likewise, careful scientific nursing, freedom from disturbing elements and everything that can help early convalescence, add to the efficiency of the institution…”1 Edward F. Stevens, 1918 For Heidegger, identification belongs primarily in the mind of the beholder, and space is bundled into places by people through various identifications of places involved in their daily lives; space only comes into being if those places can be identified. Chapter One and Two postulate that the overall disestablishment of institutionalized design attitudes and the conformity of design to local place initiate progressive shifts away from the image of a medical bulwark. Yet, people identify hospitals as an incredibly exclusive typology for the debilitated minority, for the notion of care within the medical realm still translates to limited choices when it still considers the dialectics of arts and desire and leisure at once articulate and mystical as well as desirable and irrational.2 A hospital, to most, is still just a hospital.3

Comparisons A hospital complex is in the first place a utilitarian building, however if it fails to rise above that level, it becomes a health factory.4 Any attempts to associate hospitals with other public buildings have consistently been in a harsh light, as the struggle continues to shed its cumulative built manifesto as a machine a guerir, or a ‘curing machine’. A hospital is historically understood as a place where one succumbs to an edifice of control and confinement in the throes of their vulnerability;5 the traversing and organising of subjects, 1 2 3 4 5

Cameron Logan, “The Modern Hospital as Dream and Machine - Modernism, Publicity and Transformation of Hospitals, 1932-1952,” Fabrications 19, no. 1 (2009): 72. Luisa Maria Calabrese, “Overture,” in Mobility: A Room With a View, ed. Luisa Maria Calabrese and Francine Houben (Rotterdam: Nai Publishers, 2003), 89. Cor Wagenaar, “The Culture of Hospitals,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 74. Marek H Dominiczak, “The Art of Medicine: Of Wandering Doctors, Cities, and Humane Hospitals,” The Lancet 377, no. 9759 Jan (2011): 23. Aaron Betsky, “Framing the Hospital: the Failure of Architecture in the Realm of Medicine,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 68.

Care in Place

107

both individual and collective, at micro and macro scales makes them exemplary in disciplining the wayward body. Design-wise, it is an emblem of ameliorative design with a continual tension between its tendency to grow cancerously into giant labyrinth machines, or to dissolve into anonymous parts spreading throughout the city.6 Modern society, fully planned and controlled, appears to limit personal life by subordinating institutions, and humans are treated as a collection of possible diseases, all of which are the exclusive domain of medical specialists.7 The correlation between cleanliness and health seems fairly obvious when considered today. Foucault introduces a shift in the role of the hospital in the eighteenth century that marks the beginning of modernity in many texts he wrote, from a place to die to a place to be cured. In his interpretation, this shift was based on a paradigm that was not the civic hospital, but rather the maritime or military hospitals, both of them more an instrument of prevention than one of curing, where in war the army could not afford to lose manpower in its hospital and was therefore attempting to bring its patients back to an operable status with the shortest delay. Additionally, the maritime hospital forbids its patients in quarantine to exit it, while the military one applied continuous surveillance on its patients to prevent them from deserting, or faking diseases. 8 According to Foucault, those two examples which constituted the new paradigm of a medicalised hospital transmitted their disciplinary characteristics to the civil institution. For him, discipline is indeed the new key word of this society that starts to constructs itself at the end of the eighteenth century and space has therefore to be thought through this filter, “Discipline is, above all, analysis of space; it is individualization through space, the placing of bodies in an individualized space that permits classification and combinations. Discipline is a technique of power, which contains a constant and perpetual surveillance of individuals. “9 Therefore, it was convenient to determine that hospitals either housed a fate shared either with highly industrial buildings like factories, laboratories and other nuclei of logistical operations, symptomatic for their self-regulating and self-referential qualities; or with disciplinary systems such as the penitentiary producing docile and obedient bodies pliable to the governmental insistence on ‘normalisation’.10 However, what people tend to forget is that the hospital clearly distinguishes itself from other industrial buildings as it plays crucial roles in all our lives.11 6 7 8 9 10 11

108

Care in Place

Helene Frichot and Rochus Urban Hinkel, “A Visit to the Hospital,” Artichoke 25(2007): 93. Wagenaar, “The Culture of Hospitals,” 37. Léopold Lambert, “Architecture and Discipline: The Hospital,” http://thefunambulist.net/2012/06/29/foucaultepisode-6-architecture-and-discipline-the-hospital/. Ibid. Cor Wagenaar, “The Architecture of Hospitals,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 14. Ibid.

The outdated paradigm While technological progress also forced a lot of renovation, medical progress correlated with increasing specialisation so new disciplines called for rooms that must satisfy certain requirements, while being expandable and flexible.12 The problem was that hospitals consist of units with very different functions and are thus not amenable to a uniform design that would deny differences in use.13 The strategy to achieve all this was through the emergence of Synthetic Modernism, as brought up earlier in Chapter Two, where the trinities of facilities that time – outpatient, inpatient and acute treatment centres – became segregated from each other and were at liberty to develop their own dynamics without each other’s interference. The eventual standardisation of particular features, functions, dimensions and physical implementation was the precedent to the perfection of the ‘stereotyped’ H-, K-, and T-letter hospital forms et cetera.14 Urban hospitals also became increasingly determined by a limited economy, and the minimalist skyscraper from the United States eventually became commonplace. This emerged in a ‘tower-onpodium’ arrangement, accommodating support units often concentrated in a broad low-rise podium for ease in adapting to changing technology; topped by a ward tower where the need for continuous renovation is less urgent.15 The flaw does not lie entirely with the standardisation of hospitals, but also in the combined employment of design methods to improve them. As seen in Synthetic Modernism, architects tend to use what is generally described as a solution-focused approach to their work along with most designers in similar areas, through a process where they evaluate, then abandon, modify, re-combine and generally progress towards an idea that seems to marry problem and solution together. They tend to steer away from working from some deep analysis of a problem through some theoretical procedure towards a solution and are often thought of as ‘lowest-cost culture’.16

12 13 14 15 16

Noor Mens and Cor Wagenaar, Health care Architecture in the Netherlands (Rotterdam: Nai Publishers, 2010), 122. Health care Architecture in the Netherlands (Rotterdam: Nai Publishers, 2010), 86. Health care Architecture in the Netherlands, 86, 122. Dominiczak, “The Art of Medicine: Of Wandering Doctors, Cities, and Humane Hospitals,” 23. Bryan Lawson, “Healing Architecture,” Arts & Health: An International Journal for Research, Policy and Practice 2, no. 2 (2010): 98.

Care in Place

109

110

Care in Place

Using history to unravel decision-making processes makes for an unpredictable future that is the prolongation of an unrepeatable past,17 and the danger of the nostalgic preservation of a tired template is when the modern facility is a cookie-cut improvement of an artifact.18 Coupled with a lack of studies pre-1970s – with little architectural discourse toward hospital design issues since Nightingale’s Notes on Hospitals – designers routinely rely on what are called post-occupancy evaluations in their work,19 or the evaluation of the impact of finished projects to design new ones. 20 Of all building types this century, general hospitals have been the one project which has grown most directly out of a design methodology of reiteration that evolves with rapid medical changes.21 However, this episodic knowledge becomes ‘precedent’ where design is based on past experience over new theory,22 leading to an inherent conservatism and the lying-in paradigm to improve existing models, not question it.23 Evidently, despite being largely rebuilt in the last two decades, the architecture of Australasian hospitals – and many others around the world! – looked almost identical to those in other western countries, dealing in importation of forms without indigenous processes of brief, context-setting, functional order or architectural response.24 This suppresses the potential opportunities to create inclusive places for all in the burgeoning field of public health.25

FIGURE 2. A current evolutionary pathway of hospitals, based on investigative studies by the Berlage Institute, and Sunand Prasad. It is noted that certain hospital forms are more commonplace than others.

17 18 19 20 21 22 23 24 25

Wagenaar, “The Architecture of Hospitals,” 16. Philip Goad, Cameron Logan, and Julie Willis, “Modern Hospitals as Historic Places,” The Journal of Architecture 15, no. 5 (2010): 608. David Canter and Sandra Canter, “Creating Therapeutic Environments,” in Understanding and Evaluating Therapeutic Environments for Children, ed. David Canter and Sandra Canter (Great Britain: John Wiley & Sons, Ltd, 1979), 309. Allison B Arneill and Ann Sloan Devlin, “Health Care Environments and Patient Outcomes: A Review of the Literature,” Environment and Behavior 35, no. 5 (2003): 667. David Canter and Cheryl Kenny, “Evaluating Acute General Hospitals,” in Understanding and Evaluating Therapeutic Environments for Children, ed. David Canter and Sandra Canter (Great Britain: John Wiley & Sons, Ltd, 1979), 309. Lawson, “Healing Architecture,” 98. Lawrence Nield, “Postscript: Reinventing the Hospital,” in Changing Hospital Architecture, ed. Sunand Prasad (London: RIBA Publishing, 2008), 255. “Changing Hospital Design in Australia,” in Changing Hospital Architecture, ed. Sunand Prasad (London: RIBA Publishing, 2008), 23. Lawrence Frank, Howard Frumkin, and Richard Jackson, Urban Sprawl and Public Health: Designing, Planning, and Building for Healthy Communities (Washington D.C: Island Press, 2004), 91.

Care in Place

111

4.2 PERFORMANCE-ORIENTED DESIGN FOR A HOLISTIC MODEL OF CARE IN PLACE The idea that a hospital is itself representative of an earlier phase of historical development is usually undesirable. Thus, in addition to the almost inevitable programmatic changes that create new patterns of circulation and changing uses, there is also a tendency to make symbolic and cosmetic changes to update the image of the buildings; hence multiple additions around originally constructed forms can detract from the aesthetic impact of the architecture.26 It was only at the close of the twentieth century that the relationship between function and typology was questioned, with the aim of emancipating hospitals away from their functionalist shackles.27 Developments in the last two decades seem to chip away at the image of a specialist facility, through the guidance of ‘the primacy of design’,28 signalling a paradigm shift in thinking from typology-oriented to performance-oriented. This can be abridged in three historical postulations:29 1) Abbe Laugier: the origin of architecture was to be found in the model of the primitive hut, 2) Le Corbusier: design should be founded in the production process itself and in this way correspond to the new spirit of the times, 3) Aldo Rossi: Architecture is an autonomous language with collective memory of forms that are embedded and exemplified in the built city. A design that is performance-oriented evolves, interbreeds and produces new spectrums of scales and dimensions of spaces and definitions, and affects the way one produces space in place. It calls for a constant feed of raw innovation relevant to local place and culture, and contributes to the quality and enhancement of care.30

5 FIGURE 3. Five general models of care, in regards to the gradual shift of the patient being chronically dependent, to independent and normal again. 1) Custodial: imprisonment, 2) Medical: drugs 3) Prosthetic: dependence on others to do things for them These lack the connection to place and community care, and are now regarded as outdated care models.

26 27 28 29 30

Goad, Logan, and Willis, “Modern Hospitals as Historic Places,” 608. Mens and Wagenaar, Health care Architecture in the Netherlands, 9. Lawrence Nield, “Changing Hospital Design in Australia,” 223. Wagenaar, “IV Berlage Institute,” 203. Lawson, “Healing Architecture,” 98.

4) Normalization: provide people with the support and training for them to overcome their difficulties and become normal again. Often there are attempts to go beyond normalization to enhance surrounding place and counteract other aspects generated by the institution. 5) Individual Growth Model: If a place and its architecture allows for the greater interaction between staff and patient, and community and patient, then there is growth potential for patients not only towards normalcy, but general wellbeing. A study by David and Sandra Canter in Designing for Therapeutic Environements, 1979.

112

Care in Place

An evolution into ‘campus’ hospitals The public assumption of care is that the places are separate and identifiable from the rest of society, and designed for the specific purpose of therapy. However, from the perspective of the setting as therapeutic it may not be readily so – for why is the provision of care needlessly confined to those places, and only to specific people?31 If performance-oriented design executes care, and the most recent model of care underscores the need to normalise and enhance humans towards individual growth, then this implies the need to cover a broad spectrum of care identifiable to the community and share common architectural moments with an everyday environments to make ill people like others in the community.32 It is recognised that patients may at first require continuous supervision and individual care for they possess different degrees of frailness, either constitutionally or as a result of life experiences, but no longer is it necessary for them to remain chronically dependent. Every effort should be made to enable a transition from isolation to community life, from complete dependence to independence, via a gradually increasing complexity of arrangements within a therapeutic community to meet the normal stresses of an ordinary community.33 As hospitals evolve physically as components of a disaggregated whole, so does their ability to dislocate and disperse in network systems. Pavilion systems, as detailed in Chapter 2, have successfully allowed patients to be grouped accordingly, while natural settings allow the enjoyment of nature believed to improve their mental wellbeing. Today, the advanced version is realised in a conglomerate of customised facilities. A larger, contemporary version of the pavilion is the campus, derived from the Latin word for field; it has since expanded to describe a collection of buildings that belong to a given institution, persisting in hospitals and large workplaces. 34 Campuses function metaphorically as cities in development and underscoring the theme of open space as a carrier for city’s organisation. This makes it clear that structure, shape and terrain, alongside character and cohesion of public spaces in between buildings should determine the future of the site, not just the buildings.35

FIGURE 4. Campus model - a series of different buildings.

FIGURE 5. Campus models have inspired many other typologies - for example, the Microsoft Campus in Redmond, Washington, USA.

32 33 34 35

David Canter and Sandra Canter, “Building For Therapy,” in Designing for Therapeutic Environments: A Review of Research, ed. David Canter and Sandra Canter (Great Britain: John Wiley & Sons, Ltd, 1979), 4. Ibid. Alex Anthony Baker, Richard llewelyn-Davies, and Paul Sivadon, Psychiatric Services and Architecture (Geneva: World Health Organization, 1959), 11. Paul Hyett and John Jenner, “Rebuilding Britain’s Health Service,” in Changing Hospital Architecture, ed. Sunand Prasad (London: RIBA Publishing, 2008), 104. Geert Driesen, “A Strategy for Re-Urbanizing Hospitals,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 107.

Care in Place

113

114

Care in Place

Architecture of care and place beyond the hospital The hospital is no longer labeled as a typology for it is more appropriate to reposition its image as a series of care-oriented spaces. Furthermore, regardless of the organisational theme a hospital is geared to, bridging the gap between health processes and everyday life necessitates a degree of familiarity indigenous to local place and society.36 Analysis of actual uses has shown that only a minority of what goes on in hospitals is really different from what goes on in other types of buildings, to the point that within the continuum of care they are almost homogenous in appearance.37 Two ways to change the traditional patient role and to increase patients’ sense of control in the hospital environment are to increase their freedom of choice of daily rituals and allow them access to education and information.38 It is also now increasingly common for a clinic or specialist centre to merge with complementary typologies or organisations.39 One could then treat the evolved hospital as a mixeduse development that hybridises medical care with other service industries to make it as fashionable as other local places in the city.40 Studies show that the informality of such a concept creates a welcoming atmosphere that encourages the patient to play an active role in place,41 for example, having an outpatient unit conceived as a normal form of provision of services.42 Architects can specify amenities, but not how well those amenities are maintained or how they might translate into qualities for the folks that end up using hospitals. While it is now considered dubious to cluster highly diverse medical functions, often bearing hardly any relation to one another in large complexes, researchers have noted that what is perceived to be therapeutic must be seen in the context of social and economic conditions and that everyday geographies of care must be studied as well as places with well-known reputations for healing.43 If care constitutes the overall wellbeing of an individual, then there are many other buildings that currently outperform the hospital in care provision. 44 Before venturing on in this chapter, it must be highlighted that the idea of introducing different amenities in place appears somewhat contradictory with other literature in regards to place; for are

FIGURE 6. What could the hospital be like? Looking for qualities of care and place beyond the hospital leads to many more exciting possibilities in how to infuse care and a sense of place into hospital design: A series of studies conducted by Dutch Health Architects in the Netherlands into other typologies.

36 37 38 39 40 41 42 43 44

Wagenaar, “The Architecture of Hospitals,” 96. Mens and Wagenaar, Health care Architecture in the Netherlands, 9. Arneill and Devlin, “Health Care Environments and Patient Outcomes: A Review of the Literature,” 673. Mens and Wagenaar, Health care Architecture in the Netherlands, 10. Christian Salewski, “Spaces for Coexistence,” in Open City: Designing Coexistence, ed. Kees Christiaanse, Tim Rieniets, and Jennifer Sigler (Amsterdam: SUN Publisher, 2009), 151. Canter and Kenny, “Evaluating Acute General Hospitals,” 315. Mens and Wagenaar, Health care Architecture in the Netherlands, 7. Health care Architecture in the Netherlands, 9. S Curtis et al., “Therapeutic Landscapes in Hospital Design: A Qualitative Assessment by Staff and Service Users of the Design of a New Mental Health Inpatient Unit,” Environment & Planning C: Government & Policy 25, no. 4 (2007): 592.

Care in Place

115

those amenities really a form of place in the end? To be modern is to give up the ‘sense of place’ associated with the late medieval hierarchical world in favour of a space and time conceived to be populated by infinite numbers of entirely exchangeable loci. In Getting Back into Place, Edward Casey contends that the concept of place is intended to belong within the tradition of place studies as rejection of modernity. Consistent with this understanding is the treatment of ontological understandings, with Aristotle’s definition of place as a ‘container’ for things and as a kind of being, not just as a being or thing.45 To Casey, non-place is to be feared, and explains the object obsession so important to the development of Western science and technology. As he writes about ontomania: “In philosophy the threat of atopia calls forth a veritable ontomania, an irrational desire to have and to know as much determinate presence as possible; in short, put Being before Place … the aim remains the same: to fill up, to populate, the empty field with as much determinate Being as possible.”46 Hegel elaborates that while indeterminate being lacks all quality, but in itself the character of indeterminateness attaches to it only in contrast to what is determinate or qualitative, determinate being stands in contrast to being in general, so that the very indeterminateness of the latter constitutes its quality.47 The common argument across Casey’s study was that designers have subordinated place to space and time when place is in fact primary,48 as he distinguishes the abstractness of space from the lived concreteness of place, and that it is the place that one navigates via the use of local knowledge and embodiment and one aches for when homeless, that Casey desires to get back into. This material is in line with the work of Marc Augé who coined the phrase ‘non-place’ in reference to homogenised places of transience that do not hold enough significance, in his opinion, to be regarded as places within the super-modern times. Non-places, to him, include motorways, hotels, airports and supermarkets, where the anodyne and anonymous solitude experienced offers the illusion of being part of a grand globalised scheme: a fugitive glimpse of a utopian city-world. These are also amenities that the design component of the thesis would ‘ironically’ employ.49

45 46 47 48 49

116

Care in Place

Edward Casey, “Getting Back into Place: Toward a Renewed Understanding of the Place-World,” (Indiana: Indiana University Press, 1993). Ibid. G. W. F Hegel, The Science of Logic, Two vols., vol. One (Cambridge: Cambridge University Press, 2010), 131. David Morris, “Review Essay of Edward S. Casey: Getting Back into Place: Toward a Renewed Understanding of the Place-World and Edward S. Casey: The Fate of Place: A Philosophical History,” Continental Philosophy Review 32, no. 1 (1999): 38. Marc Auge, Non-Places: Introduction to an Anthropology of Supermodernity (London: Verso, 1995).

The limit of these arguments however comes in the way it performatively ‘spatialises’ place itself in relationship to places as a traditional essence or form.50 Should one treat the hospital as an extension of existing city space, bearing in mind that hospital spaces are not highly branded and value above all the spirit of care through the connectivity to familiar and comfortable existing places - this prevails over the arguments of what place ‘should’ or ‘should not’ be. Additionally, the potential in improving the spatial qualities in hospitals would also include the ability for said hospital spaces to connect with the experience of care and place more meaningfully than it does in their current state. That aside, this chapter draws comparisons and inspiration from a range of facilities that contribute to care in hospitals, and explores opportunities for hospitals to normalise through socially-accessible approaches without stigma.

Thomas Brockelman, “Lost in Place? On the Virtues and Vices of Edward Casey’s Anti-Modernism,” Humanitas 16, no. 1 (2003).

Care in Place

117

FIGURE 7. The idea of a â&#x20AC;&#x2DC;Care Boulevardâ&#x20AC;&#x2122; in many European countries: characteristic of a boulevard, but based on malls, supplemented by businesses, care hotels, maternity hotel and polyclinics. Particularly in Germany, business models tend to aim to earn the most money through retail, and medicine almost becomes a business. The idea is that the provision of extensive public spaces through shopping and entertainment, buildings become more permeable when assimilated with other amenities and offers civic convergence points to be enjoyed by locals.

118

Care in Place

4.3 TOWARDS POSSIBILITIES Marketable Space One approach to designing places for care is towards replacing institutional networks with healthcare systems that are shaped by the local market economy. Whether or not this trend will help to improve the quality of healthcare is not a primary concern – but rather, it is more interesting to see how hospitals are liberated from their institutional character and new opportunities created to re-conceptualise them, a precondition for designing better, more functional buildings that once again express the main tendencies within contemporary architectural culture.51 In any project, design takes into account the gradual transition to a system where market mechanisms are given a prominent role. The magical formula constantly repeated is the replacement of supply by demand regulation. In a liberalised market, demand determines supply, and expenses are not cut by limiting supply, but by competition, and that competition will only increase as the market acquires an increasingly open character.52 Often, any existing retail spaces like drug stores and pharmacies are typically no-frills, bright, clean and orderly, failing to realise that they are physical extensions of caring practice.53 One can only wonder why people put up with this unjustifiable unpleasantness, for in a typical retail sector such is usually not tolerated.54 Part of the reason for patients’ acquiescence in hospitals may be the indirect way medical treatment is usually paid for, and that in their moment of need, treatment appears both involuntary and consensual in a system that ‘takes care of everything’. There are hardly any direct relations between consumption and payment when the individual plays no role in adjusting supply and demand nor in negotiations.55 In a consumer model, individuals are the health variants of customers; the better informed consumers are the healthier populations, leading to the concept of the ‘expert patient’ who manages their own health through preventive measures.56 If the hospital was like a city, and modern life revolves around shopping, then the best way to integrate hospital and city is to link it up with shopping. While most complicated medical procedures cannot be FIGURE 8. Images of commercialism and consumerism in care. Bumrungrad International Hospital, Bangkok, Thailand. The hospital also has a lobby said to be reminiscent of a five-star hotel providing concierge-style services.

51 52 53 54 55 56

Wagenaar, “The Architecture of Hospitals,” 15. Mens and Wagenaar, Health care Architecture in the Netherlands, 277. Roger Yee, Healthcare Spaces 5: Are you Feeling Better? (New York: Visual Reference Publications Inc, 2002), 10. Wagenaar, “The Architecture of Hospitals,” 15. Abram de Swaan, “Constraints and Challenges in Designing Hospitals: the Sociological View,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 89. Sunand Prasad, “Typology Diagrams and Introduction,” in Changing Hospital Architecture, ed. Sunand Prasad (London: RIBA Publishing, 2008), 4.

Care in Place

119

advertised as consumer commodities, many less intrusive interventions can, and if a hospital succeeds in attracting business, it may surround itself with the client-oriented atmosphere typical of shopping centres.57 The need for a corporate architecture has high relevance in enhancing service provision, effecting quality and identity over the long term.58 General health centres can be complemented by a number of commercial facilities that are thematically appropriate, resulting in multi-layered programs where various components strengthen each other and give extra significance to the location, with significant overlaps between neighbourhood provisions, and catering for diverse target user groups.59 As outpatient-related facilities tend to attract a constant flow of revenue because of their customer-oriented form of service provision, architectural interventions could merge health spaces with retail to turn the recuperative process into a shopping experience, thus contributing to the transition towards normalisation.60 Paradoxically, healthcare itself is usually not the commodity that causes hospitals to resemble malls. It is hard to see medical treatment as a commodity that can be marketed in the usual way as it would presuppose patients who are physically and mentally able to operate individually. Shopping implies possibilities of choosing between different products, and assumes that customers possess a basic level of medical knowledge to compare medicine and make informed decisions about their health. Finally, shopping also presupposes having fun – hardly imaginable with the rituals of purchasing treatment.61 The evolution from a bureaucratic setting to a group of private enterprises operating in a free and competitive market may be prompted by commercial motives, but adds value to the hospital experience, earning them a reputation for the empowerment of the individual by inviting them to exercise choices as a rational and self-interested agent.62 Studies suggest that greater empowerment generates higher satisfaction and greater involvement in care, through demonstrating their needs, wants and demands in the marketplace. Other studies have also shown the appreciation of a retailer’s presence in a time of emotional need. As a result, hospitals welcome shops that offer almost everything addressing ordinary needs to feed on a constantly refreshed supply of individuals. 63 57 58 59 60 61 62 63

120

Care in Place

Wagenaar, “The Architecture of Hospitals,” 16. Philipp Meuser, “Architecture as a Quality Factor,” in Construction and Design Manual: Medical Practices, ed. Philipp Meuser (Berlin: DOM Publishers, 2009), 12. Olivia Van der Bogt, “Architectural Models for Decentralized Hospital Buildings,” in The Urban Project: Architectural Intervention in Urban Areas, ed. Roberto Cavallo, et al. (Rotterdam: Delft University Press, 2010), 62. Mens and Wagenaar, Health care Architecture in the Netherlands, 282. Wagenaar, “The Architecture of Hospitals,” 18. “The Culture of Hospitals,” 40,41. “The Architecture of Hospitals,” 18.

Hospitals – like many institutions that used to rely on the structures of welfare state planning – are starting to emulate shopping centres since shopping is the biggest economic activity in the new, global economy that became the universal standard since the 1980s, after the definitive failure of socialism. This trend is elaborated in the monumental Harvard Design School Design Guide to Shopping with Koolhaas, where he observes that “not only is shopping melting into everything, but everything is melting into shopping”.64 Shopping’s overwhelming success is due to it being a naturally appealing and liberating activity for most, because of the shift to an approach that stresses the positive aspects of a patient’s overall health rather than solely on what is wrong.65 Instead of being a healing machine in times of urgent need, it becomes a pleasure zone where health is enhanced. 66 Whereas the traditional hospital is usually associated with interventions that are necessary, unpleasant and risky, it is now endowed with an atmosphere that allays anxiety, and is comfortable, safe, varied, interesting and appealing. The divide between the realm of medicine and the world of sports and relaxation would gradually disappear, almost naturally ridding hospitals of the straitjacket of controlled movement and actions.67 FIGURE 9. Shopping strips extend between different places. Shopping becomes not a space to visit while on route, but the route.

FIGURE 10. Elevation: Shopping strips on the ground levels of hospitals and highly permeable to human traffic, with more private and intimate care in the upper floors.

Proponents of healthcare design evolution have also cited the shopping mall as an inspirational building type for health care that makes patients comfortable because of its familiarity.68 The tendency to associate the hospital with a relatable experience not only normalises the everyday hospital visit, but attracts the general public.69

64 65 66 67 68 69

“The Architecture of Hospitals,” 17. Ibid. “The Culture of Hospitals,” 41. “The Architecture of Hospitals,” 18. Arneill and Devlin, “Health Care Environments and Patient Outcomes: A Review of the Literature,” 669. Goad, Logan, and Willis, “Modern Hospitals as Historic Places,” 609.

Care in Place

121

Wellness and Community Centres Centres for wellness are centres for life. The incorporation of wellness centres is a marked shift away from the ownership of consumables and discretionary spending, to the growing concern for the quality of life, reflected in the interest of health, education and outdoor pursuits.70 Wellness centres were already found in antiquity in Athens, Rome, when doctors broke away from religious mystical teachings in favour of rational-natural knowledge and worked preventively for the enhancement of health. Although they were not medical institutions, they inspired a succession of amenities towards wellbeing by offering compensatory strategies for the less healthy effects of modern life, notably the lack of exercise, increase in chronic issues and increase in stress. What a hospital does under less pleasant circumstances and in response to medical necessity, these places invite people to partake in voluntarily and bestow an aura of medical approval on the benefits they offer people.71 Hospitals in turn could benefit from a wellness centre’s positive image and appealing qualities. People who may not have been served by hospitals previously now have easy access to programs in which they have been interested and therapies they may want to try.72 Since the 1980s, hospital design has started to centre itself around large halls and streets, emulating the public spaces of the city, and bringing the public in. Therefore, the creation of amenities mimetic – and in reference – to a local community plan regenerates and enriches the hospital program as a place for dispensing knowledge and empowering humans.73 While wellness centres typically create places for alternative medicine and allied health in the evolution towards an outpatient-oriented program, they lend an increasing space to the wider community. Exposing healthy individuals to the availability of services that may not be immediately health-related is a way of educating the public on how the hospital can serve the greater public interest. Services are located in line with what is characteristic of community (care) centres, and will vary in relation to the frame of reference. Although its principal characteristic has to remain that of the structure with a strong socio-health character, it forms a hinge between the acute hospital, and the local health and social services.74 70 71 72

73 74

122

Care in Place

John Worthington, “Managing Hospital Change: Lessons from Workplace Design,” in Changing Hospital Architecture, ed. Sunand Prasad (London: RIBA Publishing, 2008), 50. Philipp Meuser and Christoph Schirmer, “From ‘House for the Sick’ to Hospital,” in In Hospital Architecture Volume 1: General Hospitals and Health Centres, ed. Philipp Meuser and Christoph Schirmer (Singapore: Page One, 2007), 21. Peter Scher, “Lessons in Humanizing Health Care Architecture,” in The Culture for the Future of Healthcare Architecture: Proceedings of 28th International Public Health Seminar, ed. Romano. Del Nord (Firenze: Alinea Editrice, 2009), 246. Wagenaar, “The Culture of Hospitals,” 40. Scher, “Lessons in Humanizing Health Care Architecture,” 253.

FIGURE 11. Baths of Caracalla. FIGURE 12. An experimental exercise conducted in the development of Erasmus MC University Medical Center, in Rotterdam, inspired by the therapeutic qualities of gardens. Health centres became the combination and assimilation of both programs, making the hospital feel like a tourist attraction.

If a hospital is located in the heart of its community it will be visited by its inhabitants often, without them needing to enter it for healthcare or to visit a loved one, for it exudes a genuine sense of community; it could very well become the multipurpose, multifunctional place capable of materially running the totality of primary and preventive care that not only guarantees continuity in the treatment process, but retains community values enabled by a knowing participation of locals that will see those spaces used for the generation of other gratifying community itineraries.75 Designated communal space raises opportunities for the development of individual competencies, through the participation in group activity sessions, classes, community meetings and lunches; all of these increase community ownership within hospitals, an essential precursor to citizens feeling that this service belongs to them.76

FIGURE 13. A proposal for Denmark Hill centre, a mental health centre, that intends to house teaching and learning facilities, a café and exhibition spaces. The aim of the project is to destigmatise preconceptions of mental health and wellbeing within the wider community, in an integrated centre for doctors, nurses, teachers, patients and carers.

75 76

“Lessons in Humanizing Health Care Architecture,” 109. Ivo Cristante, “Creating an Artificial Impression of a Realistic Healthcare Setting: How Designers Might Avoid Institutional and Predictable Designs,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 96.

Care in Place

123

Accommodation Even today, progressive patient care and the relationship between the ward and hospital remain significant, for it has to be a balance between efficiency in layout in supplies and surveillance, and for comfort, companionship and recreation.77 The ward is considered a critical setting where the patient is the primary focus. That advantage allows it to exist as a place of security and privacy within the hospital. However this becomes counter-productive if the ward is so removed as to produce a sense of isolation and encourage highly dependent and passive behaviour.78 As an elementary egospheric form, the apartment is the built equivalent where the symbiosis of family members is cancelled in favour of the symbiosis of the solitary individual with itself and its environment. To a certain extent it is narcissistic, in the sense of partnerlessness and the lack of a human complement.79 It is often stressed that hospitals should be made as ‘ordinary’ as possible. With all due respect however, one must remember that a hospital is not a home, and it is not very desirable to disguise it to make it look like something that it is not.80 However under these circumstances, home is also an informal version of the ordered relations with place which orientates individuals in space, time and society. Also, not everyone needs to be in acute wards. In line with treating patients with proper dignity and respect and in a manner that is up-to-date with the modern consumer world, the evolution of the hospital insists on the emulation of the home setting.81 No one ever feels completely at home in a hospital, but best practice indicates they are the closest thing towards normalisation, where spaces resemble the voluntary aspects of gracious living where visitors are admitted and where families stage their selfpresentations. This is opposed to people being stowed away wherever they can fit.82 One’s own home can be important as a place of privacy permitting uninhibited self-expression and behaviour, especially for people with chronic illnesses whose bodily appearance and behaviour are not always well accepted by others in public places. Thus, a theme running through hospital design literature concerns the possibility of extending a homelike atmosphere and reference is often made to features such as lighting and soft furnishings which enhance a homely atmosphere,83 that, to make people whole, one should create places similar to normal environments.84

77 78 79 80 81 82 83 84

124

Care in Place

Canter and Kenny, “Evaluating Acute General Hospitals,” 326. “Evaluating Acute General Hospitals,” 316,21. Mark Michaeli, “Utopia Re-Read,” in Open City: Designing Coexistence, ed. Kees Christiaanse, Tim Rieniets, and Jennifer Sigler (Amsterdam: SUN Publisher, 2009), 106. Baker, llewelyn-Davies, and Sivadon, Psychiatric Services and Architecture, 29. Adam Sharr, “The Professor’s House,” in Constructing Place: Mind and Matter, ed. Sarah Menin (New York: Routledge, 2003), 140. Betsky, “Framing the Hospital: the Failure of Architecture in the Realm of Medicine,” 91. Sarah Waller and Hedley Finn, Enhancing the Healing Environment: A Guide for NHS Trusts (London: King’s Fund, 2004). Ufuk Dogu and Feyzan Erkip, “Spatial Factors Affecting Wayfinding and Orientation,” Environment and Behaviour 32, no. 6 Nov (2000): 594.

FIGURE 14. Interethnisches Wohnen in Vienna, 1991, by architect Peter Scheifinger, featuring integrated living for senior people.

By the mid-1900s, ease of supervision and economy of attendance had overtaken the exuberance of ward design.85 Accommodation in hospitals has often been criticised for its lack of variation, and the greatest number of complaints focus on the lack of control patients have of their environment.86 However, John Hunt counter-argues that particularisation cannot be helped; due to the necessary standardisation and repetition in ward planning, even the most inventive of designs will reveal a cellular characteristic.87 This however introduces opportunities to embed design ‘inflections’ – and that pandering towards care and place – into the basic schema of the building, such as a generous lobby space, subtle deflections in line of view and movement,88 and well-lit public waiting rooms with multiple choices of comfortable seating in family clusters.89 Accommodation in hospitals takes two positions: Integrated living The concept of integrated communal living is also closest to the multi-generational demographic seen in wards. Living in an alliance of generations is actually completely natural, and the most human way to live for it encourages understanding and tolerance. It is important to note that not all patients are bedridden, and many of them would want to survey their surroundings out of restlessness and curiosity. The community-oriented scale, with a lower patient-to-ward ratio is a pre-requisite for mutual participation in space, facilitating mutual support, alleviating handicaps given for each specific group and combating tendencies towards isolation and anonymity. In its final consequence it also means reflecting on and reducing the complexity of society and those barriers constraining different groups.90 Hectically laying down action plans based on statistical forecasts has never been worthwhile and here, the use of multi-generational housing above all shows that the key to living together on equal terms, independent of differences in physical constitution, is human interaction. It is a greater sense of family and community which is needed rather than a conscious way of life, for without a willingness to interact with understanding and demonstrate tolerance towards others’ needs or lifestyles, even the best barrier-free architecture is useless.91 FIGURE 15. The geriatric ward features the use of park-like spaces that connects to surrounding landscape, in the thesis proposal for North Shore Hospital.

85 86 87 88 89 90 91

Canter and Kenny, “Evaluating Acute General Hospitals,” 316. “Evaluating Acute General Hospitals,” 319. John Hunt, “Critical Care - Auckland City Hospital,” Architecture New Zealand no. Nov/Dec (2003): 34. “Critical Care - Auckland City Hospital,” Architecture New Zealand no. Nov/Dec (2003): 35. Kirk Hamilton, “Evidence Based Design and the Art of Healing,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 275. Peter Ebner, “Integrated Living,” in Housing for People of All Ages: Flexible, Unrestricted, Senior-friendly, ed. Christian Schittich (Basel: Birkhauser, 2007), 11,12. Joachim Fischer and Philipp Meuser, “Goodbye to the Wheelchair Ramp,” in Construction and Design Manual: Accessible Architecture, ed. Joachim Fischer and Philipp Meuser (Berlin: DOM publishers, 2010), 17.

Care in Place

125

Hotels A more pampered and private comparison is the hotel, where healing processes can be continued as a holiday.92 Roger Yee depicts it a Shangri-La where consumers exercise the power of choice in settings reminiscent of luxury resorts, a distraction away from the troubling realities of healthcare provision while they ponder aesthetics.93

FIGURE 16. Images of Phoenix Weymouth Hospital, London in 2010: Resembles a luxury hotel or a classy bedroom rather than a hospital. The idea was simple: patients can become ‘guests’ in specially designed hotels, recuperating with the support of patients, nurses and family and friends. The model is based on a system widely used in Scandinavia, with patient hotels situated in the grounds of hospitals, staffed by nurses and afford quick access to specialist consultants should patients need urgent treatment. Patients recovering from operations, cancer treatment, stroke victims and new mothers are among those placed in the special hotels.

92 93

126

Care in Place

Swaan, “Constraints and Challenges in Designing Hospitals: the Sociological View,” 91. Yee, Healthcare Spaces 5: Are you Feeling Better? , 6.

Case: Maggie’s Cancer Caring Centres, Great Britain A network of drop-in centres and ‘homes from home’ which aim to help anyone who has been affected by cancer and provide a less clinical and more caring and humane environment that the hospital setting tends to lack. Founded by Maggie and Charles Jencks, who believed in the ability of buildings to uplift people, and of beautiful spaces needed in which to digest even the worst

of news, “Each one is like an experiment in a petri dish,” says Charles Jencks. While each building is designed by different architects, many of which are more known for far larger and more ambitious works, they all share the common ground of being incredibly quiet, modest interventions on site - generating the kind of convival atmosphere clearly designed around domesticity and embrace, encouraging visitors to walk in, make their own tea and converse with staff.

FIGURE 17 (clockwise and chronologically) - moments of ‘conversations’ with place. 17.1 Edinburgh, 1996, by Richard Murphy Architects 17.2 Dundee, 2002, by Frank Gehry 17.3 Fife, 2006, by Zaha Hadid 17.4 London, 2008, by Sir Richard Rogers 17.5 Glasgow, 2011, by Rem Koolhaas 17.6 South West Wales, 2011, by Kisho Kurokawa Care in Place

127

FIGURE 18. A circulation diagram of Kansai Airport by Renzo Piano Building, used by Lawrence Nield in his comparison of airports and offices to hospitals. FIGURE 19 & 20. Deventer Hospital in the Netherlands, by Dutch Health Architects. The design is reminiscent of an airport, consisting of a ‘backbone building’ combined with a hall. The backbone houses the specific treatment of the hospital and the wards, while the ‘hall’ houses become flexible appendages combining the outpatients department on the ground floor with the (back)offices on the first floor.

128

Care in Place

Care processes in place: Airports and Offices Thirty years ago, complaints about hospitals, airports and offices were similar. Like hospitals, offices and airports deal with a series of events rather than static functions, and are considered people buildings.94 Yet, they were designed as a national infrastructure rather than architecture, with a lack of attention to human needs, poor process coordination, little architectural ambition and integration with city. Today, it is useful to look at offices and airports as inspirations towards the breakdown in impersonal institutionalism and hierarchy in the process of care, an area where hospitals continue to struggle.95 Both facilities have also been actively re-establishing the beneficial aspects of urbanism considering the impersonal opposition between the everyday and strategic whole.96 Hospitals are often organised in a cellular tree structure, which becomes problematic when places where expansion is necessary are not situated at the tips of branches. The over-particularisation makes people become anonymous and reduces the dynamics of a movement economy. On the contrary while airports and offices usually have large-span flexible halls, those halls merely provide an open envelope for accommodating different small-scale activities and differentiated groups of people along different pathways.97 Workplaces have changed radically from Taylorism since the 1980s – an unhealthy method of organising offices into hierarchical assembly process similar to mass production. It became understood that offices work collaboratively towards an increased productivity and improvement of work attitudes.98 Should hospitals shift towards shared settings with individuals moving between settings, this could lead to a variety of work settings available and enable greater collaborations in care. The overlapping clinical spaces that are produced provide flexible forms of space briefing, focusing on adaptable shells, and specific settings designed as demands emerge and change, and liberate organisational thinking over time.99 Like airports, hospitals facilitate chains of care processes daily within extensive traffic systems, especially when today an average two-thirds of hospital activity relates to patients visiting for just the day.100 Airports use a combined suite of programs for processing linked to an exciting architecture of excursion. Outpatient facilities are similar to the series of waiting spaces in airports.101 FIGURE 21. A comparison between the airport and the hospital in terms of processes by Nield. He goes on to iterate that the facilitation of care process could find inspiration in the clear workflows of offices and airports, as well as their integration of retail and commercial activity between public and work spaces for a exuberant atmosphere.

94 95 96 97 98 99 100 101

Worthington, “Managing Hospital Change: Lessons from Workplace Design,” 49. Lawrence Nield, “Postscript: Reinventing the Hospital,” 252. Worthington, “Managing Hospital Change: Lessons from Workplace Design,” 255,58. Mens and Wagenaar, Health care Architecture in the Netherlands, 236. Lawrence Nield, “Postscript: Reinventing the Hospital,” 252. Worthington, “Managing Hospital Change: Lessons from Workplace Design,” 59. Lawrence Nield, “Postscript: Reinventing the Hospital,” 252. Betsky, “Framing the Hospital: the Failure of Architecture in the Realm of Medicine,” 75.

Care in Place

129

The next stage in its evolution consists of the fundamental appraisal of relations between function and building, presenting designers with challenges in which crucial episodes from evolution prove to have lost none of their topicality. Thinking on this score currently oscillates between two extremes:102 -

The experience of space, ambience, succession of rooms, encounters determined by logistical organisation, colour material and context. Architecture manifests here as the art of manipulating spatial effects – apart from the effectiveness of this strategy which at first is explicitly regarded as an essential component of the therapy offered in hospitals, this approach does justice at any rate to the fact that the patient’s experience forms the ultimate criterion anyway.

The need to facilitate processes, different flows of traffic, internal logistics, and thus expenses. In the ideal situation the two approaches are mutually complementary rather than exclusive. 103

FIGURE 22. The use of large atrium-like spaces like those of offices, and airports (and shopping malls to a degree) to connect different departments together enables for a pooling effect of different groups of people. Academisch Medisch Centrum (AMC), Amsterdam, built between 1981-1985. FIGURE 23. Possibilities: From open plan offices to open plan surgery theatres? The removal of walls could become a great communication platform to accomodate the capacity for events and consultation between surgeons. Wilheim Schulthess Klink, Zurich. 102 103

130

Care in Place

Mens and Wagenaar, Health care Architecture in the Netherlands, 9. Lawrence Nield, “Postscript: Reinventing the Hospital,” 254.

CONCLUSIONS Architects do not traditionally give high priority to the beauty of hospitals compared to other public buildings, which has unfortunately impeded the opportunities to instil a greater degree of care and place, as performed successfully in other typologies. Therefore, this chapter is all about changing attitudes, and being spoilt for choice in hospital design by drawing inspiration from more architecturally exciting programs more often than prisons and factories. What has emerged as a priority in care is providing the patient with choice—a concept fundamental to environmental psychology and the belief that giving patients control may influence their medical outcomes by increasing the patient’s control over his or her environment, making them more resistant to life’s hassles.104 Providing a range of environments reflects a model of enhancement in care. 105 Universal applications that overlap cultural differences in healthcare stem from place and local traditions, such as a scale of environments and activities which leads to a range of expressions for choice, the ability to be occupied with things to do to distract oneself from illness, and the development of an environment that passively facilitates inter-personal relationships and the active participation of all patients in the process of ‘re-socialization’.106 Architecture has the ability to redefine hospital programs and introduce relevant expert knowledge from typologies from hotels to offices as part of a re-integration strategy back into the heart of the city and the lives of people. Such aspects, further underpinned by the ensuing discipline of human-centred care, have a direct impact on human perceptions of hospitals, and clearer understanding of how they affect health outcomes.107 This shift in thinking has led to the concept of the monolithic hospital now being replaced by a variety of buildings types constituting the majority of new construction, argued to enhance the culturally relevant image of care and place and attract economy.

104 105 106 107

Arneill and Devlin, “Health Care Environments and Patient Outcomes: A Review of the Literature,” 672. Canter and Canter, “Creating Therapeutic Environments,” 344. Baker, llewelyn-Davies, and Sivadon, Psychiatric Services and Architecture, 27. Ibid.

Care in Place

131

132

Care in Place

If a hospital now needs to attract people, one argument around it is that it should then become less like a hospital – by inference, a place no one wants to be in – and more like a city where all are happy to inhabit. Simultaneously, new destination cultures are emerging, bringing with them new programs such as the wellness centre and the hotel, all of which arguably display roots in antiquity and widely embraced. Likewise, the current appearance of a hospital in the form of skeletal drips and white walls feel increasingly alien and incomprehensible.108 Just as hospitals are shifting away from utilitarian stylings these new concepts could potentially see shifts in architectural sensibilities towards care in place. Perhaps the issues in designing hospitals for care and place lie in the complexity and range of functions, processes, emotions, tragedies and delights with which it is expected to cope; therefore a future contemporary hospital carries in it the echoes and memories of the mall, the airport lounge, the living room, the city, and more. It is surely impossible for any singular building to attempt to embody all of even many of these characteristics without deteriorating into a mess, and in attempting to do so architecture has the potential to descend into the sterility and bland offensiveness which renders it what Marc Auge has christened a ‘non-place’.109 Getting these multi-faceted forms back into place and creating a more accessible and comprehensible form of place and care through nature and the natural instincts of people are thus examined in the next chapter.

108 109

Edwin Heathcote, “Architecture and Health,” in The Architecture of Hope: Maggie’s Cancer Caring Centres, ed. Edwin Heathcote Charles Jencks (London: Frances Lincoln Ltd, 2010), 89. “Architecture and Health,” in The Architecture of Hope: Maggie’s Cancer Caring Centres, ed. Edwin Heathcote Charles Jencks (London: Frances Lincoln Ltd, 2010), 88.

Care in Place

133

134

Care in Place

CHAPTER FIVE: THE AESTHETICS IN PLACE-MAKING THE RESTORATION OF ARCHITECTURAL PLACE-MAKING QUALITIES WITHIN THE PROCESS OF CARE ENABLES THE CREATION OF CARE IN PLACE.

Care in Place

135

136

Care in Place

5.1

AN ARCHITECTURE OF IMMEDIATE, INTIMATE CARE

In traditional hospital design, humans were considered more as objects on the scene rather than its focus, thus were delineated from the hospital architectural planning. Added to this was the conventional medical dimension, a ‘special’ orientation of building towards the goal of treatment. In the evolving care model, sensitivity towards individuals’ feelings and their need for sensory input impels hospital architecture to focus on improving the quality of place-making for care providers and recipients of health care.1

FIGURE 1. A hospital interior. Barrack Hospital, Scutari, 1854. FIGURE 2. (opposite) A patient receives care from both staff and from her immersion in a caring environment. Based on the thesis proposal for North Shore Hospital, Auckland.

Hospitals are places where tragedies and miracles are part of everyday life; for that reason it resonates with the psychological state of mind of the patients, especially those going through those profound experiences. Place-making occurs where design is a product of the public realm and its requirements, and full of stories and meanings, whereby a hospital means different things to different people. It can mean the place where someone recovered from illness, or where a child was born, or where a family member died. It also has different meanings to the doctor, to the cleaner, to the nurse and to the administrator.2 Medical treatment remains invasive no matter how much designers try to disguise it, and sometimes the complexity of hospital spaces cannot be helped.3 An architecture of care is not synonymous with cure but it is therapeutic, restorative, and aids people in making essential connections. It provides opportunities to make choices, seek privacy, experience a sense of control and create positive distractions. It immerses the individual in a totality of experience.4 Likewise, medicine has little to offer chronic stress and unhappiness, but a convivial setting for convalescence has proved beneficial.5

1 2

3 4 5

Philipp Meuser and Christoph Schirmer, “From ‘House for the Sick’ to Hospital,” in In Hospital Architecture Volume 1: General Hospitals and Health Centres, ed. Philipp Meuser and Christoph Schirmer (Singapore: Page One, 2007), 11. Ivo Cristante, “Creating an Artificial Impression of a Realistic Healthcare Setting: How Designers Might Avoid Institutional and Predictable Designs,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 97. Aaron Betsky, “Framing the Hospital: the Failure of Architecture in the Realm of Medicine,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 74. Clare Cooper Marcus, “Healing Gardens in Hospitals,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 315. Simon Bell, “Challenges for Research in Landscape and Health,” in Innovative Approaches to Researching Landscape and Health: Open Space: People Space 2, ed. Peter J. Aspinall, Simon Bell, and Catharine Ward Thompson (London: Routledge, 2010), 260.

Care in Place

137

The aesthetics of place Since the 1980s, the human-centred approach has gradually built a trust relationship in healthcare delivery in an area once dominated by consideration of process,6 as architects become partphysiologists in working the way the whole body system works together.7 We understand the setting of human life as an integration of person and environment and the constant exchange between them. In the most basic sense of existence, there is no separation but rather a fusion of rather discrete entities, like body, consciousness, culture, organism, thoughts and external world.8 Architecture is rightfully described as of the senses; the five senses allow the experience of context, and as we experience we overlay feelings on to the information that our senses supply. It is also easy to assume that people who are critically ill are less aware of their surroundings when they lack communication. But when caring for people, one should assume that their senses are as acute as a functioning individual, if not accentuated, because their world becomes contracted and focused through illness.9 Our visual senses are, for most and in the context of this chapter, the most important ones for it gives humans 80 percent of the information around them and is invaluable for establishing a sense of place.10 For most, it sets first impressions of a place.11 There is something more to the quality of place that is not so much a physical or cultural layer, but its largely overlooked aesthetic dimension.12 Vitruvius concluded that while the durability and convenience of buildings are integral to the Modern Movement, aesthetics is only apparent in highly intellectualised forms, for aesthetics is the appreciation of surroundings beyond sensory matter, and is only understood by our higher sense spiritually, psychologically, intellectually and physically.13 A poetics of place must put the aesthetic in place; in grasping the aesthetic character of place, we are not merely identifying another aspect of this complex idea but rather are probing its very centre.14 The experience acquired is called perception. However, perception in environmental experience is

6 7 8 9 10 11 12 13 14

138

Care in Place

Sunand Prasad, “Typology Diagrams and Introduction,” in Changing Hospital Architecture, ed. Sunand Prasad (London: RIBA Publishing, 2008), 4. Liz Haggard and Sarah Hosking, Healing the Hospital Environment: Design, Maintenance, and Management of Healthcare Premises (London: Taylor & Francis, 1999), 116. Arnold Berleant, “The Aesthetic in Place,” in Constructing Place: Mind and Matter, ed. Sarah Menin (New York: Routledge, 2003), 45. Haggard and Hosking, Healing the Hospital Environment: Design, Maintenance, and Management of Healthcare Premises, 162. Bell, “Challenges for Research in Landscape and Health,” 261. Barbara Dellinger, “Healing Environments,” in Evidence-Based Design for Healthcare Facilities, ed. Cynthia McCullough (Indianapolis: Sigma Theta Tau International, 2010), 51. Berleant, “The Aesthetic in Place,” 44. Haggard and Hosking, Healing the Hospital Environment: Design, Maintenance, and Management of Healthcare Premises, 2. Berleant, “The Aesthetic in Place,” 42.

synesthetic, since all senses are engaged in a homogenous fashion in an interpenetration of body and context. By introducing the aesthetic dimension, place becomes demarcated by the range of perception, and restricts its scope in any instance to the particular context of perceptual experience. It is critical in confining aesthetics of place to contexts, and separates ‘place’ from the whole environment. Just as aesthetics denote enriching and ennobling experiences, they can also be offensive and harmful.15

The making of place Place-making is an integrated approach; one should therefore not focus on the spaces of rooms and corridors, but rather on the construction of virtual, physical and mental environments to foster new mentalities and types of behavior.16 This is done through the provision of care-oriented spaces which are imbued with the cultural concerns of the community and value the individual over technology.17 The ability to design a humanising architecture that positively contributes towards the healing process gives spaces a humane character without being over-personalised for an increasingly over-personalised society,18 and over time, familiarity by adopting an aesthetic of care that is rooted in the culture of the hospital.19 Manipulating the environment is undoubtedly the common way of improving health standards in the city, where the damaging effects of mass and monumentality in the past led to boredom, loneliness and stress; stress, Ulrich says, exacerbates every known clinical condition.20 In essence this recalls the old enlightenment ideal of transforming hospitals through design into a healing machine. Much of hospital design relies heavily on a man-made environment.21 It is of fundamental importance however that, 1) humans have not evolved in this millennium as much as design, medicine and attitudes have, 22 and 2) the site is more than another conundrum in the genesis of a structure as it is capable of molding experience.23 FIGURE 3. The making of places, and the balance between manipulating the environment to make it conform to built form, or allowing the environment to have an aesthetic input in built form.

15 16 17 18 19 20 21 22 23

“The Aesthetic in Place,” 46. Bart Van Schaik and Erik Veldhoen, “A Hospital for the Twenty-first Century,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 382. Shakti Gupta and Sunil Kant, “Trends and Dimensions in Hospital Architecture: A Hospital Administrator’s Perspective,” Hospital Notes 7, no. 2 April/June (2005): 61. Simon Richards, “Communities of Dread,” in Constructing Place: Mind and Matter, ed. Sarah Menin (New York: Routledge, 2003). Marcus, “Healing Gardens in Hospitals,” 319. Kirk Hamilton, “Evidence Based Design and the Art of Healing,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 275. Noor Mens and Cor Wagenaar, Health care Architecture in the Netherlands (Rotterdam: Nai Publishers, 2010), 327. Bell, “Challenges for Research in Landscape and Health,” 260. Max Robinson, “Place-making: The Notion of Centre,” in Constructing Place: Mind and Matter, ed. Sarah Menin (New York: Routledge, 2003), 143.

Care in Place

139

The late Sir Peter Shepherd suggested that as humans react instinctively to natural settings, the first rule is to preserve – and enhance – the natural features in which the character of the place resides, character as in an emergent property related to how places function in some way.24 Reformers derived healing qualities not from medicine but from a purified, natural environment.25 Out of an exhaustive number of incorporating, interlinking factors, making it hard to isolate the impact of single factors, this chapter focuses on three key areas of architectural aesthetics derived from place that give hospitals their sense of place, and consequently, their identity as caring places.

24 25

140

Care in Place

Ian Thompson, “What Use Is the Genius Loci?,” in Constructing Place: Mind and Matter, ed. Sarah Menin (New York: Routledge, 2003), 68. Cor Wagenaar, “The Culture of Hospitals,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 29.

5.2 VIEWS The principle of creating views out of buildings has previously been in conflict architecturally with a principle of clinical adjacency towards seclusion. However, it is understood today that the ability to design to give views out of buildings capitalises on one of the most accessible forms of a natural resource, and helps an individual gain a sense of place and its impact on wellbeing in the shortest space of time.26 From an evolutionary perspective, a view satisfies the physiological need for the adaptation and re-adaptation of the eye to distance, providing a visual rest centre.27 By instinct, it distracts people from focusing on their immediate circumstances. For these reasons any view is better than no view, and where a view is available it should be exploited, although clearly the quality of the exterior view will depend upon the surroundings of the building.28 Man has an innate desire for variety and change in his environment. Perception reacts to a degree of change; it is the natural order of things that the appearance of interior spaces alters with time and this gives confidence in a continuing reality. This change, wrought by the changes in the seasons, the weather and the time of day, is achieved with little success by artificial means. 29 People often experience considerable stress and anxiety, and hospital confinement limits a patient’s access to outdoor environments almost entirely to views. Exterior views are therefore especially important to individuals with unvarying schedules and in confinement, which could influence a patient’s emotional state and might accordingly affect recovery. Views of surroundings sustain interest and attention, and reduce stress.30 Viewing content is clearly of importance, and it is the information it provides which will determine its success. Ulrich rightfully postulates an evolutionary theory predisposing humans to find scenes of nature restorative. Investigations of aesthetic and affective responses to outdoor visual environments have shown a strong preference for natural scenes over urban views that lack natural elements. Views of vegetation, and especially water, appear to sustain interest and attention more effectively than urban views of equivalent information rate.31 Because most natural views apparently elicit positive feelings, induce relaxation, and may block or reduce stressful thoughts, they might also foster restoration from anxiety or stress and promote recovery.32 33 Common sense suggests that patients FIGURE 4. Views from a stationery point - e.g. in bed or in a waiting room. FIGURE 5. Views of natural environment and everyday life when moving from place to place (compared to a blank corridor space)

26 27 28 29 30 31 32 33

Bryan Lawson, “Healing Architecture,” Arts & Health: An International Journal for Research, Policy and Practice 2, no. 2 (2010): 102-03. Derek Phillips, Daylighting: Natural Light in Architecture (Oxford: Architectural Press, 2004), 11. Dellinger, “Healing Environments,” 56. Phillips, Daylighting: Natural Light in Architecture, 6,9. Roger Ulrich, “View through a window may influence recovery from surgery,” Science: New Series 224, no. 4647 (1984): 420. ibid. “Health Benefits of Gardens in Hospitals,” in Science: New Series (Plants for People. International Exhibition Floriade 2002), 3. Haggard and Hosking, Healing the Hospital Environment: Design, Maintenance, and Management of Healthcare Premises, 26.

Care in Place

141

Case: Paimio Tuberculosis Sanatorium, in Finland by Alvar Aalto, completed 1932. Paimio Tuberculosis Sanatorium: While it followed many of the tenets of Le Corbusier’s pioneering ideas for modernist, rationalizing architecture, the result was of an extraordinary healing space implementing the principles of light, air and of design becoming a contributor towards the healing process, and described as one of the most humane hospitals built during its time. Featuring streamlined balconies stripped of fenestration and abstracted stuccoed and cream brick facades, the emphasis on access to natural light and to surrounding nature became the hallmark of modernism— neutralising to an extent the effects of stern functionality. Within healthcare, this was particularly applicable to tuberculosis sanatoria built in the early 20th century, to allow patients ample access to fresh air, which was at that time regarded as a therapeutic measure. Aalto’s building was integrated with the surrounding forest but in addition he applied the concept of total design that included the building, the interiors, and even small utensils. This building, along with the hospitals and sanatoria in Scandinavia and Germany became a key inspiration for Australasian architecture. (119/23) FIGURES 6.1 Thin building plan on site to maximize accessibility to natural atmosphere. 6.2 Aalto’s concept of total design, from furnishings to the view out. 142

Care in Place

waiting at a clinic where they may be concerned about some test results might benefit most from a calming view. On the other hand patients in more long-term care may benefit more from views that are interesting and stimulating.34 Perhaps to a chronically under-stimulated patient, a lively city street might be more stimulating and hence more therapeutic than many natural views.35 Another aspect of orientation and one where the mere presence of day-lighting is reassuring, is the subconscious desire of people when inside a building to keep in touch with the outside world, whether to know the time of day or the nature of the weather.36

Day-lighting The history of day-lighting dates from the beginning of time starting with natural light entering the mouths of caves, and the first civilised use was the Roman patio house, where holes were left in the roof admitting light. After 1900, daylight competed with the various forms of artificial light, to the point day-lighting appeared to be irrelevant, having as its nadir the development of Burolandschaft when buildings could be of infinite depth, and when hospitals were built without any windows at all.37 The luminous environment comes inextricably linked with views and enhances the quality of views. It plays an important role and an integral part of place. There are numerous reasons for the renewed interest in day-lighting that has been examined in an evidence-based way.38 Studies have indicated that daylight has significant effects on circadian rhythm, and is the most important environmental input in controlling bodily function after food.39 The presence of daylight in indoor environments influences physiological responses, such as the reduction of depression and agitation.40 It is of utmost importance, however, to pay homage to the less tangible aspects of day-lighting which relate more to the human spirit, and the quality of life, such as the experience of natural colour of daylight;41 for whilst the physical colour of our world as experienced in daylight changes from morning FIGURE 7. Views as a positive distraction from immediate negative circumstances.

34 35 36 37 38 39 40 41

Lawson, “Healing Architecture,” 102. Ulrich, “View through a window may influence recovery from surgery,” 421. Phillips, Daylighting: Natural Light in Architecture, 11. “Day and Light: Natural Light in Architecture,” (The Chartered Institution of Building Services Engineers, 2007), 1. “Day and Light: Natural Light in Architecture,” (The Chartered Institution of Building Services Engineers, 2007), 2. S S Campbell et al., “Exposure to light in healthy elderly subjects and alzheimer’s patients,” Physiology Behavior 42, no. 2 (1988): 144. M Schweitzer, L Gilpin, and S Frampton, “Healing Spaces: Elements of Environmental Design That Make an Impact on Health,” The Journal of Alternative and Complementary Medicine 10, no. 1 (2004): 75. Ruchi Choudhary et al., The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity (New Jersey: Robert Wood Johnson Foundation, 2004), 20.

Care in Place

143

Case: REHAB, Centre for Spinal Cord and Brain Injuries, Basel, Switzerland, by Herzog and de Meuron, 1999-2002 The client’s express wish from the beginning was not to have the new REHAB centre look or feel like a hospital. The result is an open, breathable building conceived from inside out: instead of an arrangement of structures, courtyards are placed in a large rectangle, serving as orientation devices and allowing daylight to penetrate the entire interior. Because the patients are so restricted to the centre’s grounds for long periods of time as part of the rehabilitation process, the architects set themselves the task of designing a multifunctional, diversified building, almost like a small town with streets, plazas, gardens, public facilities, and more secluded residential quarters where people take different paths to move within places - surroundings that allow the patients as much autonomy as possible. The landscape is the feature of the design; one enters the building right into the centre of which is a cultivated field. As a wayfinding strategy, all courtyards are made to be unique; one is filled with water, another clad entirely in wood and etc. Likewise, all “houses” vary considerably, where places like the gym and patients’ rooms are defined by large windowpanes and views of the landscape, while other rooms such as the bathhouse are entirely inwards in orientation; The diversified design offers patients and their relatives a building that does justice to the complexity of their needs, providing places where one can retreat and be alone and others in which to enjoy company, and non-territorial and non-specific places for the times in between treatments, for conversation with relatives, or for staff members during their breaks. FIGURES 8.1 Moments of permeability between exterior and interior spaces. 8.2, 8.3 & 8.4 A courtyard filled with water, a courtyard of open spaces and delicate structures of wooden rods, and a courtyard that closes in on itself and opens up towards the sky - some of the several courtyards used in the navigation system.

144

Care in Place

to night, the changes are a part of our experience; we compensate automatically, a white wall appears as a white wall even if in the evening it may be warmer, or is coloured by sunlight, or altered by cloud formations; it is the colour we regard as natural.42 Sunlight adds to daylight another dimension of therapy and other place-making factors such as variety and change, modeling and general creation of delight.43 The direction of natural light providing shadow patterns informs the appearance of objects and surfaces and gives them the appearance that we associate with the natural world.44 Its importance during the day is most noticeable when it is denied. Sunlight, along with the shifting changes in amounts of light during the day, creates the natural and unambiguous appearance of a space, where the overall experience and its objects and surfaces are modeled. Change in their lit appearance allows people to continue an exploration of spaces in time; an entirely different measure of experience to the static qualities of spaces lit artificially during the day; or where there is no access to the daylight outside.45

Orientation The less tangible aspects of views and daylight become paramount when combined, essential in providing a pleasant visual environment and contributing to a feeling of wellbeing.46 The experience of the world outside through views and daylight constitute the centre of architectural strategy primarily through the orientation of the building on site, and the nature of apertures. They will subsequently influence the framing of content and the quality of its components. The experience of the world beyond the building informs building orientation with the added aspect of content and the experience of something at a distance as a rest centre for the eye.47 The external siting of buildings maximises the influence of diurnal change and enables those within a building to establish themselves in relation to the world outside.48 This orientation comes with the 42 43 44 45 46 47 48

Phillips, Daylighting: Natural Light in Architecture, 6. Daylighting: Natural Light in Architecture, 12. “Day and Light: Natural Light in Architecture,” 1. Daylighting: Natural Light in Architecture, 6,9,12. “Day and Light: Natural Light in Architecture,” 3. Daylighting: Natural Light in Architecture, 6,7. “Day and Light: Natural Light in Architecture,” 1.

Care in Place

145

146

Care in Place

knowledge of a person’s whereabouts in relation to the outside world. In a totally artificial environment, a person has difficulty in finding his way inside a building, a problem which was evident in hospitals where people became disoriented.49 Footprints on large floor plates mean less natural light, and using fluorescent tubes and mechanical ventilation. Natural light and engagement with the outside world and landscape helps patients to recover more quickly, use fewer analgesics and have lower blood pressure and conserve energy.50 Likewise, there will be instances in large building complexes where internal views from one part of the interior to another may be had; these will provide enough visual rest centres to satisfy the physiological requirement, but without views to day-lit areas they will lack the amenities of change, variety and modeling which inform the natural scene outdoors.51

Apertures

FIGURE 9. Apertures in the form of light-wells creates a point of intense penetration of place into buildings with a deeper plan, such as the operating theatre units shown here, as part of the thesis proposal for North Shore Hospital, Auckland. FIGURE 10. A view of nature during the treatment process. Hitoshi Abe: Matuda Dental Clinic

Windows provide views to the world and are the vehicle for admitting daylight; providing access to outside views through windows would provide humans with a sense of orientation and connection to the external environment. For ease of control, windows could be in the form of electronic windows adjusting the amount of light coming in.52 53 Constructional elements need to take into account clarity, with minimal construction and continuity so people can look without obstructions through continuous strip windows.54 Light-wells also introduce daylight deep into the interior of larger buildings. This development had the important effect of increasing the “daylight effective depth” and has its modern equivalent in the atriums we see today, the word atrium being derived from the original Roman patio house.55 While vertical windows were clearly of highest importance, and continue to be so today, it is interesting that this method of introducing daylight to the centre of buildings still provides the mere assurance of contact with the changing world.56 49 50 51 52 53 54 55 56

Daylighting: Natural Light in Architecture, 6. Lawrence Nield, “Postscript: Reinventing the Hospital,” in Changing Hospital Architecture, ed. Sunand Prasad (London: RIBA Publishing, 2008), 255. Phillips, Daylighting: Natural Light in Architecture, 11. Daylighting: Natural Light in Architecture, 15. Allison B Arneill and Ann Sloan Devlin, “Health Care Environments and Patient Outcomes: A Review of the Literature,” Environment and Behavior 35, no. 5 (2003): 681. Betsky, “Framing the Hospital: the Failure of Architecture in the Realm of Medicine,” 70. Phillips, “Day and Light: Natural Light in Architecture,” 2. Daylighting: Natural Light in Architecture, 4.

Care in Place

147

148

Care in Place

5.3 NATURAL LANDSCAPE We can trace a continuum in landscape architecture; at one pole, those works in which the primary purpose has been to blend seamlessly with nature or the vernacular landscape of cultivation; at the other, works in which the conscious imposition of cultural forms upon nature provided the raison d’etre for the design. We often prefer the conservative approach, which makes new development similar to its surroundings.57 Excellent urban space makes sense and relates to users at both conscious and subconscious levels. Space and form are the products of their contemporary culture but so are users and their culture the product of their social and physical environment. Thus, the reconnection of the primeval forces of nature in landscape to inhabitants at both physical and theoretical levels is necessary.58 The benefits of having direct exposure to nature have been acknowledged as a possibility of an optimal embedding in landscapes,59 60 and allows for physical non-hierarchical separation on different categories of people with a large degree of transparency. The aesthetics of nature naturally create a beautiful verdant place that serves as an enticement to go outdoors.61 By perceiving the environment from within, as it were, looking not at it but being in it, nature is transformed into a realm in which we live as participants, not as observers.62 In Botany of Desire, Michael Pollan described the mutual interdependence of man and nature, seen from the perspective of plant life, and subordinating them to his own successful evolution. To him, nature stands as a symbol for the primeval habitat of mankind: paradise. Trees and landscape become a comforting metaphor for solidarity, strength and permanence,63 while flora symbolises bloom and transformation.64 Together they show the enduring nature of life and that such things can survive the turbulence of time and history.65 FIGURE 11. A bedridden patient enjoys a ‘walk’ in the park. In the Healing Garden at Good Samaritan Hospital, Portland, Oregon, where the connection to nature gradually changes garden space into recovery places.

57 58 59 60 61 62 63 64 65

Thompson, “What Use Is the Genius Loci?,” 69-70. Luisa Maria Calabrese, “Overture,” in Mobility: A Room With a View, ed. Luisa Maria Calabrese and Francine Houben (Rotterdam: Nai Publishers, 2003), 78. Mens and Wagenaar, Health care Architecture in the Netherlands, 13. Lawson, “Healing Architecture,” 102. Clare Cooper Marcus and Marni Barnes, “Historic and Cultural Overview,” in Healing: Therapeutic Benefits and Design Recommendations, ed. Clare Cooper Marcus and Marni Barnes (New York: John Wiley & Sons, 1999), 4. Sjerp de Vries, “Nearby Nature and Human Health,” in Innovative Approaches to Researching Landscape and Health: Open Space: People Space 2, ed. Peter J. Aspinall, Simon Bell, and Catharine Ward Thompson (London: Routledge, 2010), 29. Haggard and Hosking, Healing the Hospital Environment: Design, Maintenance, and Management of Healthcare Premises, 19. Marcus, “Healing Gardens in Hospitals,” 319. Ibid.

Care in Place

149

Few studies have been done to show a correlation between natural landscape and health outcomes for its healing value has been hard to quantify or prove; yet this bond with nature is expressed almost instinctively.66 Humans have evolved to have strong aesthetic preferences for natural landscapes and the colours blue and green, and elements of the plant world have been essential aspects that attract the eyes.67 When asked to ‘imagine’ a healing environment, an overwhelming majority of people have some reference to nature even when seeking medical treatment.68 Society has emerged from a culture whose basic values include a close connection to nature; nature does not constitute surrounding space, but rather, humanity is part of nature and vice-versa.69 In an era where built environments are often taxing and excessively stimulating, a natural setting has lower levels of complexity and becomes a relief.70 Study responses suggested that gardens represented a complete contrast to the experience of being inside a hospital: domestic versus institutional scale, natural versus man-made; organic versus geometric. The belief that plants and gardens alongside views and daylight as essential components in healthcare environments is more than a millennium old. During the Middle Ages in Europe, for example, monasteries created elaborate gardens as pleasant, soothing distractions to the ill, which followed through to prominent contained gardens commonly found in western hospitals in the 1800s.71 Interest in connecting healing and nature was gradually superseded by medical science over the centuries, causing architects to concentrate on reducing infection risk and functional efficiency; in essence the art of terracing succumbed to the likes of buildings that were starkly institutional and unacceptably stressful.72 There existed a puritanical streak which suggested that money spent on landscaping was money wasted,73 and landscaping became mere decoration to offset the monumentality of the building or to impress the public. Even when a garden did exist, it rarely appeared on a hospital map.74 Today there is a resurgence in the provision of gardens, for the presence of nature largely accounts for

66 67 68 69 70 71 72 73 74

150

Care in Place

Marcus and Barnes, “Historic and Cultural Overview,” 17. “Historic and Cultural Overview,” 5. “Historic and Cultural Overview,” 8. “Historic and Cultural Overview,” 9. Roger Ulrich, “Effects of Gardens on Health Outcomes: Theory and Research,” in Healing: Therapeutic Benefits and Design Recommendations, ed. Clare Cooper Marcus and Marni Barnes (New York: John Wiley & Sons, 1999), 51. “Health Benefits of Gardens in Hospitals,” 2. Ibid. Haggard and Hosking, Healing the Hospital Environment: Design, Maintenance, and Management of Healthcare Premises, 83. Marcus and Barnes, “Historic and Cultural Overview,” 1.

FIGURE 12. A design that weaves its way through the site through the careful scupting of the existing topography. Images of the Therapeutic Garden of the Institute for Child and Adolescent Development, Wellesley, Massachusetts.

calming experiences.75 There have been clear positive relationships between gardens and health; the proximity of green-space has an effect on levels of physical activity in all age groups.76 As suggested by research of varying capacities, the basic underlying premise is that gardens facilitate stress-coping and restoration, by far the most important benefit reported. Overall, this enhances the ability for individuals to cope, and thus improves health outcomes.77 The impact of green views on mental health and wellbeing is expressed through increased rates of restoration. Health is improved by using green-space as a point of social contact and integration. The experience of being outdoors with access to fresh air and green-space can contribute to a general sense of wellbeing and a richer engagement with place; this arose out of a growing interest in salutogenic environments that promote healthier lifestyles. The quality of landscape and its associated features in which we lead our lives makes a difference to the quality of the lived experience.78 The mere presence of outdoor parks et cetera gives people the sense that they could if necessary escape – work stress, interpersonal conflicts, monotony, stress.79 Several studies also show that gardens and nature in hospitals can significantly heighten satisfaction with the overall quality of care, both by access and through views.80

FIGURE 13. A piece of local landscape in interior spaces. Hitoshi Abe: Sekii Maternity Clinic.

75 76 77 78 79 80

Ulrich, “Health Benefits of Gardens in Hospitals,” 2. Bell, “Challenges for Research in Landscape and Health,” 260. Ulrich, “Effects of Gardens on Health Outcomes: Theory and Research,” 36. Bell, “Challenges for Research in Landscape and Health,” 261. Ulrich, “Effects of Gardens on Health Outcomes: Theory and Research,” 40. “Health Benefits of Gardens in Hospitals,” 6.

Care in Place

151

Case: Butaro Hospital, Rwanda, by MASS Architects. Opened in 2011. In this grassroots project, the architecture takes advantage of the temperate climate to create a network of outdoor spaces and a ventilation strategy that changes the air in the ward at least a dozen times an hour using a simple stack principle. The hilltop campus is a series of terraced gardens, open courtyards and covered verandahs, that serve the dual purpose of creating gathering areas and preventing infection by eliminating enclosed spaces where possible. A series of unique buildings enable navigation around the veranda system, with secluded patients wards around courtyards, 152 Care in Place

Designed to the Virunga Mountain chain, it also involves a combination of locally sourced materials that embedx built form into its existing topography. The sloped site is contoured with a network of walkways, ramps and stairs, while allowing views of the Northern Rwandan landscape. The open structure of individual buildings connected by loggias and open spaces appears like a small village inhabited by different families. Breaking with the default anonymity and seclusion normally associated with hospital architecture, Butaro has an inviting atmosphere more typical of a holiday park. Overall, MASS saw this project not simply as a medical infrastructure, but also as civic infrastructure, as hospitals in these areas become anchors for new communities.

FIGURE 14. 14.1. The framing of the landscape via apertures 14.2. Likewise, interior spaces are framed, and windows are positioned so that patients have a view out towards courtyards. 14.3. Use of stonework and local materials 14.4. Low walls in outdoor courtyards double as seating areas, turning them into gathering spaces 14.5. In place: breathtaking views out towards the mountains 14.6. Minimal impact on the topology: buildings and pathways glide and sculpt themselves around land gradients.

Opportunities to design to local place Landscapes need not be fancy, but should have some element of maturity and perspective.81 The idea of a healing landscape is linked to the idea of ‘place identity’, the concept of landscape taken from cultural geography with the aim of exploring the characteristics of place. Hospitals often tend to embed nature in gardens, presupposing that the presence of nature itself sufficiently identifies itself with human desires.82 However, on a larger scale it is also recognised that the community identifies strongly with their local landscape. What is troubling is the homogenisation of landscape through the insidious processes of globalised capitalism these days.83 Landscape character comes from being locally distinctive, and any attitude towards a site which ignores whatever natural value has already accumulated is going against contemporary consensus.84 To date, public institutions have a tradition of formal gardens, suggestive of the glory of management.85 However, the average public expectation of a garden is stuck in this time warp. Often, emotional congruence – or the ambiguity in the emotional perception of something based on an individual’s emotional state, which could amplify happiness in the happy, or sadness in the sad – also happens with something that is man-made, or out-of-place.86 Any alteration of the natural landscape could begin by consulting its inherent ‘symbolic’ values and making the most of its readily available features.87 88

FIGURE 15. A care boulevard in Rijnland Ziekenhuis (Hospital Rhine), where the building is constructed around existing bodies of water. By Rothuizen Van Doorn’t Hooft architecten en stedenbouwkundigen, in Alphen aan den Rijn, the Netherlands, 2008. FIGURE 16. Taniyama Hospital, Nikken Sekkei. Japan.

81 82 83 84 85 86 87 88

Haggard and Hosking, Healing the Hospital Environment: Design, Maintenance, and Management of Healthcare Premises, 26. S Curtis et al., “Therapeutic Landscapes in Hospital Design: A Qualitative Assessment by Staff and Service Users of the Design of a New Mental Health Inpatient Unit,” Environment & Planning C: Government & Policy 25, no. 4 (2007): 200. Thompson, “What Use Is the Genius Loci?,” 73. “What Use Is the Genius Loci?,” 72. Haggard and Hosking, Healing the Hospital Environment: Design, Maintenance, and Management of Healthcare Premises, 26. Ulrich, “Effects of Gardens on Health Outcomes: Theory and Research,” 66. Thompson, “What Use Is the Genius Loci?,” 72. Ulrich, “Effects of Gardens on Health Outcomes: Theory and Research,” 88.

Care in Place

153

FIGURE 17. An interconnected series of outdoor spaces included in the thesis proposal for North Shore hospital. FIGURE 18. (opposite) A series of garden spaces connected via a large, meandering outdoor corridor. Healing Garden at Good Samaritan Hospital, Portland, Oregon.

154

Care in Place

Opportunities to design a series of landscapes The healing power of nature is powerfully enhanced when it supports other desirable activities beyond the basics of being in a plant-filled space.89 A hospital’s strict zoning codes prescribe certain locations as appropriate for certain uses for development but often it limits loftier promises of producing liveable environments. Landscape design in a series of connected spaces with a series of looped pathway systems/routes creates attractive opportunities to stimulate a range of behaviours.90 A broad range of spaces inspires movement and exercise places for both contemplative walking, recreation and aerobic exercise, so that patients do not fall into a state of lethargy and inertia. The subtleties of nature and materiality also allow people to sit and view for long periods in one setting, allowing for contemplation, within a range of settings that enable them to feel safe with some sense of enclosure sans the feeling of being in a ‘fishbowl’.91 Spaces tend to be used where emotional support, like companionship, or a sense of community is found.92 There are convincing grounds for contending that natural landscapes foster access to social support93 and social interaction94 and provide opportunities for positive escape and sense of control with respect to stressful clinical settings.95 These settings encourage people to gather together and experience social support, and enjoy the recovery process. Even the most superficial contact with people might just be enough to create a sense of social cohesion. From a public access perspective, studies on the proximity between green and residential areas, and connectivity and walkability of neighbourhood (or the ease of movement to reach green space) show that people appreciate accessible and safe spaces that foster cohesion within their neighborhood and will use them for recreation and social points.96 97

89 90 91 92 93 94 95 96 97

Marcus and Barnes, “Historic and Cultural Overview,” 4. Lawrence Frank, Howard Frumkin, and Richard Jackson, Urban Sprawl and Public Health: Designing, Planning, and Building for Healthy Communities (Washington D.C: Island Press, 2004), 151. Marcus, “Healing Gardens in Hospitals,” 318,19. Ulrich, “Effects of Gardens on Health Outcomes: Theory and Research,” 44. Choudhary et al., The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity, 22. Ulrich, “Effects of Gardens on Health Outcomes: Theory and Research,” 43. Marcus, “Healing Gardens in Hospitals,” 319. Vries, “Nearby Nature and Human Health,” 79. Bell, “Challenges for Research in Landscape and Health,” 260.

Care in Place

155

E UK UP

OA D

EP LAK

SH AK E

SP E

Student Area (120 Shakespeare Road)

AR ER

North Shore Hospital: Ground Floor Dialysis Centre

Ward 15 Older Adult Health Services (OAHS)

Te Ohanga O Pikihuia

Ward 14 Older Adult Health Services (OAHS)

SH EA

AC E

LINKWAY TO DIALYSIS CENTRE

Maori Health Services

MRI

Lifts

Chapel

N 4 E

C AN

Radiology

MAIN CORRIDOR

Lifts to Ward 2

Cardiology Procedures

Outpatients Day Clinic

Outpatients Clinic

N 3 E

ADU

Orthopaedic

ADU

Stairs

Telephonists

Mammography

ADU

Lifts

E NC

Discharge Lounge

ED/ADU Reception

Ward 11 General Medical

Stairs

Gynaecology Outpatients

A TR

N 2 E

Main Reception reception

N 1 E MAIN HOSPITAL ENTRANCE

Foyer Foyer Pharmacy

Cafe

ERG

Triage

Older Adult Health Services (OAHS)

Allied Health

Tower Lifts

Stairs

Oaks Day Room

Older Adult Health Services (OAHS)

Meeting Rms 21&22

Allied Health Gym

Radiology Conference Room

Pool

Outpatients Physiotheraphy

Meeting Rms 1&2

ORL Registras

Ward 12 Older Adult Health Services (OAHS) (Kingsley Mortimer Unit)

Allied Health

ENC

AMBULANCE ENTRANCE

Emergency Department

ED ENTRANCE

Best Care for Everyone

FIGURE 19. North Shore Hospital Ground Plan. FIGURE 20. (opposite) The art of navigation in the hospital is likened to the view from the road.

156

Care in Place

5.4 WAY-FINDING Hospitals can be described as a series of static spaces immersed in a network of constant dynamic movement, both within the hospital and between hospital and city. Their scale, usually above that of human perception, makes the development of way-finding crucial, way-finding referring to an individual’s information-processing capabilities as they relate to architectural elements. Way-finding is often described as an emerging issue (intelligent planning) from more recent and contemporary architecture, but way-finding takes place in every stage of life (since the beginning of time) and is essential for survival.98 People want to reach their destination within a hospital as quickly as possible and get quality and prompt service without confusion or question. A way-finding strategy is a subliminal tool that strives to make the navigation of hospitals painless and positive, and deliver frustration-free experiences by providing pertinent and memorable information at critical locations. The objective is to provide the ‘big picture’ to first-time visitors through a consistent and logical layering of cues, allowing for a variety of people, languages, and cognitive abilities to absorb and process the information.99 Way-finding needs to serve the actual purpose of making the ergonomic design of movement processes in everyday life easier, especially in hospitals where often people are debilitated, and the large-scale setting that can disorient people.100 Orientation in time is facilitated through the exposure to rituals and events around the patient, keeping him in touch with the world beyond the hospital.101 In well thought-out systems, a patient is likely to gain some understanding of his changing state through his changing experience of the setting, be it locations he or she is moved to or able to seek out. The patient who understands how the organisation operates and where people can be found is likely to have a greater potential to actively circulate to find help or go for a walk, than one who can only wait in hope that care will come to him. Conversely, poor way-finding strategies can – as history confirms – create ‘commute impedance’, or the feeling of being blocked in efforts to move around. This results in built catastrophes, anonymous complexes producing more anxiety, an alienating experience separating patient from people by a labyrinth structure,102 and pervasive situational loneliness. Poor way-finding can also make patients reluctant to move, or leave their rooms for fear they won’t find their way back.103 98 99 100 101 102 103

Ufuk Dogu and Feyzan Erkip, “Spatial Factors Affecting Wayfinding and Orientation,” Environment and Behaviour 32, no. 6 Nov (2000): 731. Marcia Vanden Brink and Steve LaHood, “Aesthetics and New Product Development,” in Evidence-Based Design for Healthcare Facilities, ed. Cynthia McCullough (Indianapolis: Sigma Theta Tau International, 2010), 31,32. Joachim Fischer and Philipp Meuser, “Goodbye to the Wheelchair Ramp,” in Construction and Design Manual: Accessible Architecture, ed. Joachim Fischer and Philipp Meuser (Berlin: DOM publishers, 2010), 15. Alex Anthony Baker, Richard llewelyn-Davies, and Paul Sivadon, Psychiatric Services and Architecture (Geneva: World Health Organization, 1959), 26. David Canter and Sandra Canter, “Building For Therapy,” in Designing for Therapeutic Environments: A Review of Research, ed. David Canter and Sandra Canter (Great Britain: John Wiley & Sons, Ltd, 1979), 6. Laura A. Carlson et al., “Getting Lost in Buildings,” Association for Psychological Science 19, no. 5 (2010): 284.

Care in Place

157

Legibility What is often not articulated is the need to design for quality of spatial legibility. A dialogue on a building’s legibility involves not only the use of design interventions in a way-finding strategy but other variables such as personal comfort, ease-of-use and comprehension of space, and is result-oriented. Legibility allows individuals to become familiar with their surroundings faster, and makes it easy to read a building.104 105 Recognition plays a crucial role in legibility in the form of 1) the use of familiar cues or landmarks, 2) the degree of architectural differentiation between different areas of a building, 3) use of signage, and 4) building configuration in ease of comprehending overall building layout.106 Way-finding is often heavily reliant on graphic information and verbal information. However, in a complex situation, the array of information can also be too confusing, especially when individuals are being bombarded with a spectrum of stimuli from marketing techniques, signage, sounds and crowds; and with hospitals, the added stress and trauma.107 In such cases, an information overload could result in an intake of information as an ultimate coping device, and reduced ability to process information. Often, signage cannot overcome architectural failures. Also, it takes time to ‘learn’ map content.108 Studies have thus suggested that in the process of incorporating qualities of place into way-finding, using local and architectural characteristics in navigation would seem natural rather than forced.109 Legibility depends on the degree and quickness of familiarity an individual has with a given setting; if familiarity is increased to sufficient levels, initial difficulties in orientation may be overcome, and seldom is disorientation felt. And if familiarity alone does not explain disorientation, then other factors such as visual or spatial features of the environment ought to be considered.110 While symmetry is often used for a hospital’s legibility, what is rarely mentioned is that the monotony caused by repetitive use of elements can result in a lack of security and confidence in moving through space, to the extent of getting lost, and causing more stress. Conversely, asymmetrical aspects create more legibility; the more distinct the place, the more easily it serves as a cue to guide human 104 105 106 107 108 109 110

158

Care in Place

Dogu and Erkip, “Spatial Factors Affecting Wayfinding and Orientation,” 731,32. Lawson, “Healing Architecture,” 102. Dogu and Erkip, “Spatial Factors Affecting Wayfinding and Orientation,” 733. “Spatial Factors Affecting Wayfinding and Orientation,” 732. Aysu Baskaya, Yusuk Z Ozcan, and Christopher Wilson, “Wayfinding in an Unfamiliar Environment: Different Spatial Settings of Two Polyclinics,” Environment and Behaviour 32, no. 6 Nov (2000): 842. Ibid. Dogu and Erkip, “Spatial Factors Affecting Wayfinding and Orientation,” 732.

FIGURE 21. A combination of atrium, floor detail and layout in creating legible spaces. Academisch Medisch Centrum (AMC), Amsterdam, 1981-1985.

experience and decision-making behaviour. Furthermore, landmarks or zones with a strong character may favour certain spatial identification in the sense of being somewhat distinct. This creates spaces that are unique and distinguishable. Landmark knowledge precedes route knowledge, and both precede configurational knowledge. People remember layouts more accurately if they have visually discriminable subjection.111 Distinctiveness is primarily achieved by the form and volume of space, and few but strong visual cues (colour, large open atrium); many eye-catchers conversely cause more confusion.112 Lighting is another opportunity to aid legibility. Based on the level of illumination in an area or pathway, the designer can deter or encourage its use. People are generally drawn to light, along with changes in the finish level of floor and wall. Conversely, lighting can dramatically enhance features and colours to draw them out of the visual palette and reinforce the way-finding story.113 A clear hierarchy or demarcation of spaces distinguishing between formal public spaces and confidential private spaces for clinical treatment, connects scientific endeavours to holistic, humanistic sensitivity.114

Orientation strategy: The use of focal points Spatial organisation is considered the most important piece of quality way-finding design because it makes the space easier to understand. Identifying zones in a building, creating clear sightlines from vantage points, and organising the different areas can promote and improve way-finding. Strategies for legibility reflect cognitive processes about and the proclivity toward way-finding as well as what is available in the environment.115 Generally speaking, strategies fall into two categories: route, or linear, strategy and orientation strategy.116 Orientation strategies use sources of information so individuals can orient themselves. A map is a good example of this type of orienting information. An example of an effective way-finding strategy 111 112 113 114 115 116

Baskaya, Ozcan, and Wilson, “Wayfinding in an Unfamiliar Environment: Different Spatial Settings of Two Polyclinics,” 843,44. Dogu and Erkip, “Spatial Factors Affecting Wayfinding and Orientation,” 733. Brink and LaHood, “Aesthetics and New Product Development,” 32. Susan Francis, “European Hospital Design,” in Changing Hospital Architecture, ed. Sunand Prasad (London: RIBA Publishing, 2008), 160. Brink and LaHood, “Aesthetics and New Product Development,” 32. Dellinger, “Healing Environments,” 53.

Care in Place

159

is a large and unique fountain. There can only be one of these within the building for it to be effective. The fountain serves as one point in a set of points in giving directions. For example, go to the fountain, take a left, and so on, and it can also be used as a point of reference or pivot point in the orientation strategy.117 Clearer focal points assist in way-finding.118 One way to substantiate the meaning of place is to utilise opportunities inherent within the notion of centre, a concept of relativity intuitively ingrained in collective consciousness, used to identify, describe and allude to the gravity of items in everyday life. We can define it as a position that commutes with every other components of that grouping as well as a place of origin. As derivations of position and source designate either explicit or implicit locations, the connective relevance of centre and place is further amplified, and can be interpreted physically by their existence, functionally by use, and symbolically by representations. It can also be categorised to scale levels, organizational qualities, and whether they are either occupied or occupiable. Altogether it supports place-making in an architectonic sense, and comprises a middle and periphery.119 One of the most fundamental interpretations of centre involves its egocentric nature which implies its use as a means of bearing, where one’s person is visualised as the focal point of the world one occupies and experiences. Centres are externalised as referential points in the environment to enable orientation, for man to develop out his need to find a familiar position from the chaotic aspects of an irregular and unpredictable environment. If this convergence is meaningful, then great events of existence can be experienced.120 If applied to a campus hospital, different buildings, for example, become bearings if they differentiate between themselves with different characters/qualities. This differentiation is enhanced by certain/ restrained sense of geometric rhythm entered into façades and arrangements to reduce overwhelming feelings.121 In a building with multiple entry points, each entry should provide a unique feature specific to that location. This feature not only serves as a cue on entry, but more importantly, it provides assurance to the visitor on the exit. Depending on the scale of the building, each floor can also be developed with a specific visual story or theme that is layered and integrated with interior finishes, artwork, and colour. The combination and coordination of these elements serves to knit the entire visual story together.122 117 118 119 120 121 122

160

Care in Place

Brink and LaHood, “Aesthetics and New Product Development,” 32. Betsky, “Framing the Hospital: the Failure of Architecture in the Realm of Medicine,” 74. Robinson, “Place-making: The Notion of Centre,” 145,46. “Place-making: The Notion of Centre.” Betsky, “Framing the Hospital: the Failure of Architecture in the Realm of Medicine,” 74. Brink and LaHood, “Aesthetics and New Product Development,” 32.

Linear strategy: Routes with character Linear strategies use point-to-point information to connect static and dynamic spaces. For example, a person would obtain directions from point A to point B; if they needed to go farther, they would obtain directions from point B to point C and continue in a linear fashion. Traditionally, the architectural approach was to divide spaces into their specific functions (served) connected via corridors (servant), but today as the corridor becomes more significant in daily use, those distinctions have been blurred.123 Major hospital routes can potentially be long, bleak, featureless and too symmetrical, the antithesis of comfort and reassurance.124 F. Beer is credited with the initiation of the corridor hospital, where all rooms are arranged alongside internal walkways.125 Impersonal city streets also create an atmosphere of anonymity, whereas a street rich in tangible enterprises gives them identity. Real people are not the statistical people of the planning authorities, but are all unique and are not interchangeable in the least.126 The aim of a successful strategy is to assist people in orientation, enhance their sense of security, enable them to reach their destination in good shape, and avoid exhaustion or despair. It is important to identify what a person experiences as he or she navigates through the building, and consider how the building’s features, such as long, straight corridors versus curved corridors, help or hinder the journey through and perception of the space. Connectivity is crucial not only to make one’s journey ‘progress’ visually, but to keep one connected to the outside world.127 Something in the visible distance that attracts the attention is an age-old ruse; providing views of the outside at the ends of corridors or full-height windows whenever possible helps people remain cognisant of their location in the building. Likewise, dead-end corridors should be avoided and circles create for perambulating around rather than pacing back and forth.128 Exercising control over the environment and its design elements without disconnecting from the outside world leads to faster and more effective recovery, and choice in involvement in space in patientoriented settings.129 130 123 124 125 126 127 128 129 130

Christian Norberg-Schulz, “The Return to Modernism,” in An Architecture of Poetic Movement : Altered Perceptions, ed. Peter Pran (England: Andreas Papadakis Publisher, 1998), 7. Haggard and Hosking, Healing the Hospital Environment: Design, Maintenance, and Management of Healthcare Premises, 53. Cor Wagenaar, “The Architecture of Hospitals,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 28. Richards, “Communities of Dread,” 117. Dellinger, “Healing Environmaents,” 53. Haggard and Hosking, Healing the Hospital Environment: Design, Maintenance, and Management of Healthcare Premises, 53. Roger Yee, Healthcare Spaces 5: Are you Feeling Better? (New York: Visual Reference Publications Inc, 2002), 14. Hamilton, “Evidence Based Design and the Art of Healing,” 275.

Care in Place

161

CASE: Helsingor Psychiatric Hospital by BIG, PLOT, Moe & BrĂ¸dsgaard, Denmark, completed in 2006. To many psychiatric patients a safe and calm environment is crucial to their well-being, where surroundings, that reminds them of their illness, cause instability and the feeling of being insecure. Experientially this hospital appears as anything but a hospital where the architects avoided all clinical stereotypes; the traditional hospital hallway without windows and rooms on both sides as well as artificial easy-cleaning materials like plastic paint and linoleum floors. In this design, all materials utilse their own natural surfaces. Functionally the psychiatric clinic is organized into 2 main programs; a residential program and a public treatment program. By using a snowflake structure in organising the residential program, each patientâ&#x20AC;&#x2122;s room is oriented toward its own part of the landscape, either facing the lake or the surrounding hills; 162 Care in Place

between these rooms emerges a new collective space embraced by offices and populated by small patios.The public treatment program is organised as 5 individual pavilions fused to a central space, and individual units contain offices and treatment rooms to one side and waiting areas to the other side. Grounding the hospital on two different levels allows the building to grow into the landscape. Half hidden in nature, it avoids spoiling the view from the existing somatic hospital and at the same time provides its users with a multitude of experiences of the lake and woods. At places where the building is half rooted underground the green lawn slips over the roof, making the clinic a natural environment for the cure of mental illness. Through the gradient between centralisation to decentralisation, it provides a series of personalized sections with a maximum of autonomy and intimate spaces where the users can feel themselves almost at home. For example. part of the hospital

contains observed treatment areas where patients for the good of self protection and their surroundings will have limited freedom to move, though without feeling claustrophobically trapped. It also offers rooms for socializing and spontaneous meetings between people and at the same time opportunities for seclusion and contemplation. FIGURE 22. 22.1 Topographical view, also showing corridor entry from the general hospital 22.2 The creation of sunken courtyards 22.3 The decentralised layout allows corridors to have full exposure to the greenscape. 22.4 Low-rise forms to preserve views of the landscape 22.5 Use of local, raw and unrefined materials create aesthetic points for contemplation and rest. 22.6 Daylit interior spaces

Designing hospital streets to have places of contrasting atmospheres avoids a sense of monotony and also allows people to meet informally;131 over time with recognition they are able to envisage their areas and make themselves familiar with them. For those same reasons, the hospital shouldn’t have too big a floor-plate.132

From legibility to barrier-free, mobility and freedom Barrier-free building constitutes the road back to the town of short paths, and thus acquires ecological relevance. Freedom from barriers makes an environment that is functional, and both easily accessible and usable, and makes possible an independent and self-determined lifestyle which encourages mobility and integration in the cohabitation of all groups of people.133 Barrier-free architecture is valued by far more people than the debilitated, for whom it eases participation in private and social daily life. Debilitation or disablement does not only mean that one has to get to grips with one’s environment with permanent physical constraints, but also relates to physical situation. Barrier-free building means that the world must be so designed that it is open to all people, irrespective of their given physical condition or age, without assistance and without restriction.134 While the need for convenience is not restricted to a minority, barrier-free building no longer represents a design challenge for fringe groups, but is rather the expression of the emancipation of society as a whole.135

131 132 133 134 135

Francis, “European Hospital Design,” 160. Baker, llewelyn-Davies, and Sivadon, Psychiatric Services and Architecture, 25. Fischer and Meuser, “Goodbye to the Wheelchair Ramp,” 5. “Goodbye to the Wheelchair Ramp,” 11. “Goodbye to the Wheelchair Ramp,” 12,16.

Care in Place

163

164

Care in Place

CHAPTER SIX: AUSTRALASIAN CONTEXT

Care in Place

165

Photo of Auckland City Hospital, from the University of Auckland School of Architecture.

166

Care in Place

6.1 FIGURE 1. Photograph of Auckland City Hospital with its surrounding cityscape, from the University of Auckland Architecture Studios.

THE AUSTRALASIAN CONTEXT

As is commonly seen overseas, hospital design in Australasia is typical of infrastructural architecture, where form doesn’t follow function, but rather is bullied by it.1 Over time, the tide has been stemmed with respect to endless representations of institutionalised functionalist models. As much as they struggle to be seen as architecture, they are nonetheless an essential component of society and a significant element of the urban fabric. Therefore, they are most deserving of reclamation of the respect, enthusiasm and creativity of architects as they attempt to humanise.2 In the shift from looking after the sick to treating the sick in the twentieth century, and having steered away from earlier images of buildings housing infectious people, hospitals are now brought closer to habitation and recognised as key civic buildings.3 Today, many of these mega-complexes are beginning to give way to more contextual buildings that seek to re-establish meaningful dialogue with patients and visitors and the city. This chapter summarises the Australasian healthcare backdrop and several key prevalent issues that have gained currency over the decades. One can start by looking at Australia, where hospitals were the major emblems of modernist architecture, and many hospital designers travelled widely out of a motivation to review the latest international developments, and out of a growing concern with ways to design for physical health for a then-isolated country.4 Post-war aspirations and desires for a kind of noble civic edifice, emblematic of modern medicine with strong underlying social purposes were seen as affirming and comforting places. Such notions which prevailed from the 1940s through to 1960s aligned with the aspirations, both aesthetic and ideological, of late modernism, for they recognised generosity of spirit and gave testament to the collective public good. From an urban design perspective they give something back as sites of speculation, recuperation and change.5 Australian hospital culture shares similarities with its European and North American counterparts to varying degrees. Despite being largely rebuilt in the last two decades, the buildings look almost identical to those of the northern hemisphere and feel almost context-less, dealing in importation of forms developed in the UK without indigenous processes of brief and standard-setting.6

1 2 3 4 5 6

John Walsh, “Medicinal Architecture,” Architecture New Zealand, no. Nov/Dec (2003): 31. Darryl Carey, “Exercises in Total Design,” Architecture New Zealand, no. Nov/Dec (2003): 56. Sarita Chand, “Architecture and the Hospital,” Architecture Australia 91, no. 4 Jul/Aug (2002): 64. Cameron Logan and Julie Willis, “International Travel as Medical Research: Architecture and the Modern Hospital,” Health and History 12, no. 2 (2010): 116. Chand, “Architecture and the Hospital,” 56. Lawrence Nield, “Changing Hospital Design in Australia,” in Changing Hospital Architecture, ed. Sunand Prasad (London: RIBA Publishing, 2008), 223.

Care in Place

167

Arthur Stephenson of Stephenson and Meldrum (now known as Stephenson and Turner), one of the very few Australian healthcare architects of that time, regarded modernist architectural expressions as the signal building form in reflecting honest functions with an applied whiteness and cleanness, where both moral and physical health were achieved through hygiene.7 In line with overseas thinking, it relies heavily on nineteenth-century medical theory by Goubert, who contended that hospitals were places where miasmas and filth would be driven out by the beneficial action of air, water and sun. Salubrity was thus a priority with light and air gaining crucial design roles; this explains an evergreen connection between hygiene, function and modernism.8 Hospitals designed by Stephenson became the foundations for Australian functionalist Modernism, which captured the presence of the scientific, medical and programmatic, and aesthetics without ostentation.9 It is not surprising that Stephenson should find his inspiration in European discourse where they were on the whole more modestly equipped than their American counterparts and arguably placed greater emphasis on the building as an instrument of healing;10 11 the ‘rationalised’ form of architecture expressed building functions in the simplest form and in the most appropriate materials. New designs were austere and captured the imagination in the direction of obtaining light and air. It reflected an almost sacred sense of the significance of ‘light adoration’ which was highlighted by an emphasis on the passage of light between inside and out, and seems to have grown out of a somewhat literalminded belief in the connection between transparent built form and the possibility of making illness and health visible to medical science.12 While finding little design inspiration from North America and Britain for their conservative design approach13 and focus on clothing their structurally and programmatically advanced design with decorum and stylistic propiety,14 Stephenson’s design methodology was shaped by their rather prosaic professional discourse on rational hospital organisation and management, which also laid great emphasis on the need to create positive publicity for individual hospitals and the hospital field at large as an image of healthful modernity.15 16 This incited tendencies to present institutional, industrial 7 8 9 10 11 12 13 14 15 16

168

Care in Place

Cameron Logan, “The Modern Hospital as Dream and Machine - Modernism, Publicity and Transformation of Hospitals, 1932-1952,” Fabrications 19, no. 1 (2009): 70. Julie Willis, “Machines for Healing,” Architecture Australia 91, no. 4 (2002): 46. “Machines for Healing,” Architecture Australia 91, no. 4 (2002): 47. Logan, “The Modern Hospital as Dream and Machine - Modernism, Publicity and Transformation of Hospitals, 19321952,” 77. Logan and Willis, “International Travel as Medical Research: Architecture and the Modern Hospital,” 118. Logan, “The Modern Hospital as Dream and Machine - Modernism, Publicity and Transformation of Hospitals, 19321952,” 77. Willis, “Machines for Healing,” 46. Logan, “The Modern Hospital as Dream and Machine - Modernism, Publicity and Transformation of Hospitals, 19321952,” 78. “The Modern Hospital as Dream and Machine - Modernism, Publicity and Transformation of Hospitals, 1932-1952,” 70. “The Modern Hospital as Dream and Machine - Modernism, Publicity and Transformation of Hospitals, 1932-1952,” 76.

FIGURE 2. Graphic Representation of hospital ‘throughput’ from Royal Melbourne Hospital, from Annual Report for the Year 1937-8. FIGURE 3. “The Vision Splendid”, cover picture from Annual Report, Royal Melbourne Hospital 1938-9 - the portrayal of the indestructibility of hospitals, and to be like machines.

projects in a visually appealing, and purposefully modern, graphic format which highlighted advanced architectural expression. Published renderings and photographs of the hospital buildings served as a kind of dreamscape of modern life and the modern institution.17 Therefore, the strong movement towards European architecture was diluted by the need to present projects as an integrated, efficient configuration.18 Their niche, as described by Lawrence Nield, was a “bleakly literal approach to sterility” – far from their initial intentions.19 International modernism dispensed with all that window-courtyard ‘nonsense’ in favour of artificial synthetic environments – displaying an unquestioning belief in the innovation of economy of scale precepts.20 Additionally, while extensive and wide-ranging hospital programmes were introduced in 1980, the state, under a budget, forced down design fees and abandoned benchmark systems. Similarly, Sarita Chand of Bligh Voller Nield notes that architects get overwhelmed by ‘hard’ function issues even when guided by the best design intentions, which left Australian hospitals in a vexed situation, with a litter of 1960 and 1970s buildings comprising eight to 10 floors of narrow ward floors stacked vertically on podiums. Design driven solely by technical knowledge and exclusive towards the resolution of essential architectural elements creates clumsy layouts and cosmetically enhanced spaces. She argues for the need for hospital design to incorporate the more humanistic design quality that architects can provide, and for a more balanced approach between the clinical functional requirements of a hospital and a more humane architecture.21 Chand and Lawrence Nield also feel that hospital buildings overall are still laid out in traditional configurations; the failure to look beyond user requirements has led to the ‘diagrammatic’ hospital.22 It is not enough to just tweak old typologies: if healthcare services have changed radically – especially towards community and preventative health – buildings have to change towards being less isolated and more enmeshed with the urban fabric.23 The few hospitals designed for greenfield sites are described as large, inept manifestations of functional health planning diagrams with little regard to context or architecture; further ambivalence came from the inability of society to deal with the sick, torn between including them in normal life and segregating them at the periphery.

FIGURE 4. Royal Melbourne Hospital by Stephenson, Melbourne FIGURE 5. Waiblingen Krankenhaus, Stuttgart, Germany 192628, which along with Aalto’s Paimio Sanatorium became a key inspiration for Stephenson for its streamlined balconies and ‘machinist aesthetic’. Photo by Richard Docker, 1928.

17 18 19 20 21 22 23

“The Modern Hospital as Dream and Machine - Modernism, Publicity and Transformation of Hospitals, 1932-1952,” 70. Logan and Willis, “International Travel as Medical Research: Architecture and the Modern Hospital,” 123. Elizabeth Farrelly, “Taming St Vincent’s,” Architecture Australia 91, no. 4 Jul/Aug (2002): 58. “Taming St Vincent’s,” Architecture Australia 91, no. 4 Jul/Aug (2002): 59. Chand, “Architecture and the Hospital,” 64. Lawrence Nield, “Hospitals are not designed for the 21st Century” (paper presented at the Architects for Health Architecture Week 2003, London, 2003). Chand, “Architecture and the Hospital,” 65.

Care in Place

169

‘Total Design’ It has been iterated that there is a need for a stronger focus in Australasia on the prevention and management of chronic diseases to also ‘keep people out of hospital’.24 Given the many societal factors that can have an impact on health, it is ironic to continue to focus on treating the urgent cases rather than reinforcing the incentives for prevention and primary care; often one continues to treat the dying when perhaps one should do more caring instead.25 Ultimately, it makes sense for the fewer and larger existing hospitals to provide a total care experience.26 As a relatively young country, New Zealand has mirrored European, US and Australian trends, rules and regulations of health, and hospital work tends to go to either large practices, such as Jasmax and Stephenson & Turner, or smaller specialist firms such as Chow:Hill Architects and Klein Architects.27 Klein Healthcare, a specialist healthcare firm since 1996, opines that as much as clinical projects can be very satisfying, a significant amount of the design work is taken up with onerous negotiations and consultations to include an operational perspective,28 and the responsibility of designing for the longterm process for both built form and infrastructural synergies.29 This is important as these projects are constantly under the scrutiny of the public especially when they are some of the rarer architectural projects, and in contemporary times, are also increasingly driven by cost and rapidly evolving clinical processes and technology. Many perceive the role of the architect as a professional super-speciality and elitist.30 Within New Zealand there is much mention of adopting a ‘total design’ model, whereby architects multi-skill themselves to take on an integral approach to simplify a complex commission; in that sense, they fill other associated roles such as project management. This, in theory, leads to a more intimate involvement in design, and allows for more meaningful responses at the strategic and conceptual design level, in both form and process.31 A total design model, according to Darryl Carey of Chow-Hill, rather than meaning the adoption of generic or modular approaches throughout to allow effective management of change, rather necessitates a thorough understanding of specific healthcare knowledge and international trends to facilitate constant benchmarking, which is essential to the logical and informed progression 24 25 26 27 28 29 30 31

170

Care in Place

Gareth Morgan and Geoff Simmons, Heal+h Cheque: The Truth We Should All Know About New Zealand’s Public Health System. (Auckland: Public Interest Publishing, 2009). A Prescription For Change (Wellington: Public Interest Publishing, 2010). A Prescription For Change (Wellington: Public Interest Publishing, 2010), 17. John Walsh, “A Specialist Practice,” Architecture New Zealand, no. Nov/Dec (2003): 58. Chris Bourke, “Operating System,” Architecture New Zealand, no. Mar/Apr (2001): 58. Walsh, “A Specialist Practice,” 58. Corbett Lyon, “Interrogating the Type,” Architecture Australia 91, no. 4 Jul/Aug (2002): 57. Carey, “Exercises in Total Design,” 56.

of design.32 This is echoed by Nield who calls for a more hands-on understanding of hospital praxis than the ‘usual’ public service expectation of fitting architecture to health planning diagrams.33 However, there is a tendency for architects to often exhaust themselves and forget the key tasks of producing inspiring and caring environments,34 and the need to keep remembering to design for critical moments in lives and deaths.35 Often under these constraints, the most efficient strategy is also to pick an option from many and keep moving forward, even when there is no one-fit model.36 This is where flexibility becomes a significant design principle to anticipate those requirements decades ahead.37

The debate between the domestic grain and the civic building Care and place in hospitals is facilitated through the investigation of local place and care within the immediate context, and in Australasia, deinstitutionalisation in healthcare is seemingly highly synonymous with domestication. This is largely reflected in the fact that many of these buildings are built where people live,38 and there has been a shift since the 1990s towards the employment of residential architectural language in the likes of brickwork, pergolas and domestic detailing as an aesthetic strategy to subvert the prevailing language.39 There is conflict, however, in the need for the hospital to be reminiscent of home. On one hand, advocates prefer the diminishment of the banality of commercialism, which in turn conveys the ideals of trust, comfort and intimacy.40 It is also often noted, however, that hospital architects tend to try to make it too much like home or make them wear domesticity too openly.41 – that they elide the specificity of home and forget that the hospital is not always a safe place. In the attempt to domesticate the institution they have abandoned the public face of the hospital. All at once the hospital has to juggle between being a building of civic significance and of the ‘homely’ accommodation.42

32 33 34 35 36 37 38 39 40 41 42

Ibid. Farrelly, “Taming St Vincent’s,” 60. Carey, “Exercises in Total Design,” 56. Walsh, “A Specialist Practice,” 59. Ibid. Ibid. Lyon, “Interrogating the Type,” 57. Ibid. “Healthy Smile Dental,” Artichoke, no. 25 (2010): 108. “Interrogating the Type,” 57. “Health Projects,” Architecture Australia no. July/August (2001).

Care in Place

171

172

Care in Place

Transfixed by user requirements and models of care, the healthcare industry has failed to investigate the ‘hospital building type’ or indeed look at which is happening in other large ‘people’ buildings.43 Nield therefore advocates for large span and flexible ‘warehouses’ as future forms for healthcare architecture; while this comes with an accompanying negative connotation in the discussion of care and place, he argues that it is more about dealing with events rather than ‘fixtures’,44 and that his strong commitment to modernism defines an approach to design as a framework for human activity and occupation, wherein the consequence and substance of architecture is more important than form.45 The loose-fit great shed would then allow hospitals to resemble a kind of urbanism, a mixed-use dynamism allowing for departures from the zoning and specificity of the current hospital.46 He continues: “Nothing gives life to fabric and buildings more than apertures, porosity and transparency. Apertures allow connection to, and understanding of, air and wind. They make darkness and light. Openings proclaim habitation – or more often a story of habitation. Orderly habitation is often portrayed by openings, while shutters, curtains, vines, flower boxes and barbecues on balconies are less orderly, but intriguing, signs of habitation. We are surprised to see habitation in some buildings today, as they are so sealed and shiny.” (Lawrence Nield, 201247)

FIGURE 7 & 8. Interior courtyard space in Apollo Health Centre, Rosedale, and Auckland City Hospital, Grafton, both in Auckland. Often the employment of apertures and open plan spaces create a point of intensity in deep building plans that have the propensity to be bland and boring, and connect people to life on the other side of the building, and even to street activities and everyday life. (opposite) FIGURE 9. Use of local plants in Nelson Hospital FIGURE 10. Facades as a means of navigation in Sunshine Hospital, Melbourne. FIGURE 11. Desigining around topography in Kyneton Hospital, Melbourne.

For Nield, the connection to place in architectural practice does not merely come from a reduction of the urban grain, but from a combination of qualities; in this case, the permeability between interior spaces and external environment. It therefore becomes possible that even bigger buildings could be situated in smaller town centres and still be able to concentrate on architecture and on integration into the cityscape, in their aim to be both symbolic of a healthy city as well as a humane, well-placed one.48

43 44 45 46 47 48

Nield, “Hospitals are not designed for the 21st Century.” Ibid. The Portfolio of Architects & Designers in Australia and New Zealand, “Australian Institute of Architects Gold Medallists,” http://www.domaindesign.com.au/proNews/pronews/57.html. Edwin Heathcote, “Architecture and Health,” in The Architecture of Hope: Maggie’s Cancer Caring Centres, ed. Edwin Heathcote Charles Jencks (London: Frances Lincoln Ltd, 2010), 90. Lawrence Nield, “Four techniques: Lawrence Nield,” Architecture Australia 101, no. 2 (2012). Heathcote, “Architecture and Health,” 90.

Care in Place

173