Healthcare Design Gets Back To Nature

Kenneth W. Betz, Senior Editor

Designed by Array Architects, Conshohocken, PA, Penn Family Medicine Southern Chester County in West Grove, PA, opened in 2015. To provide natural lighting, the building features a pyramid skylight spanning 23 x 23 ft. with a 14-ft. 4-in. vertical, manufactured by Super Sky, Mequon, WI, and finished by Linetec, Wausau, WI, in a Sunstorm color 70% PVDF mica coating. Photo: William Lemke. Designed by Array Architects, Conshohocken, PA, Penn Family Medicine Southern Chester County in West Grove, PA, opened in 2015. To provide natural lighting, the building features a pyramid skylight spanning 23 x 23 ft. with a 14-ft. 4-in. vertical, manufactured by Super Sky, Mequon, WI, and finished by Linetec, Wausau, WI, in a Sunstorm color 70% PVDF mica coating. Photo: William Lemke.

Biophilic design may be the next big thing in healthcare design.

Perhaps because of its origins in the academic fields of psychology and sociology, the term is still somewhat unfamiliar in the business world of healthcare construction, evidence-based design, and cost management. But that is changing. There is a growing body of research that quantifies the benefits of biophilic design, not to mention that the green movement and the well-building concept have acknowledged the importance of a connection to nature in their philosophies. The importance of daylight, plants, water, and materials is evident in the evolution of healthcare design as well as the design of other aspects of the built environment, from office buildings to city planning. It just may not have been called biophilic design.

“The terms biophilia or biophilic design are not common in the industry yet, perhaps because they encompass a larger set of possible design interventions,” agreed Catie Ryan, senior project manager at Terrapin Bright Green, a sustainability consulting and strategic-planning firm based in New York, and co-author of 14 Patterns of Biophilic Design.

“Designers and healthcare providers understand how gardens, views, and daylighting make for more pleasant spaces, but they may not understand how subtler elements like natural materials, water features, or refuge conditions can dramatically influence people’s psychological and physiological responses to spaces. Terrapin recommends designers thoughtfully incorporate a variety of biophilic design patterns in facilities, and not just rely on potted plants or larger windows to achieve the health benefits of natural elements,” she said.

Roger Ulrich, Ph.D., EDAC, a professor of architecture at the Center for Healthcare Building Research at Chalmers Univ. of Technology in Sweden didn’t use the term biophilia when he did a study in 1984 that suggested simply that surgery patients recovered better in rooms with a view through a window. But “what few realize is that Ulrich’s famous study was essentially about the impact of biophilic design on the built environment,” said David Navarrete, director, research initiatives, The Sky Factory, Fairfield, IA.

Catie Ryan expanded on the importance of Ulrich’s classic study, which measured the influence of natural and urban sceneries on patients recovering from gallbladder surgery. “Some patients were provided with views to nature, whereas others looked at brick walls. With all other variables equal, his findings revealed accelerated recovery rates and reduced stress for the patients who had views of nature. On average, patients whose windows overlooked a scene of nature were released after 7.96 days, compared with the 8.71 days it took for patients whose views were of the hospital’s exterior walls to recover sufficiently to be released—a decrease of 8.5%,” she said.

“If patients heal faster, their personal healthcare costs drop and hospitals will have greater capacity to accommodate more patients, both of which translate to financial savings. Other more-recent studies have found that daylighting in patient rooms increases recovery rates and decreases the use of pain medications. Artwork of natural scenes reduces anxiety, and healing gardens at hospitals promote health, social connectivity, and pleasurable memories in patients. Incorporating nature and natural elements into the design of healthcare facilities has also been shown to benefit visitors and healthcare-facility staff, mitigating stress and increasing job performance and satisfaction,” Ryan added.

To help connect patients to nature, Crozer-Chester Medical Center in Chester, PA, designed by Charles Cross Architecture PC, Wayne, PA, features a 40-ft.-dia. dome skylight, manufactured by Super Sky, Mequon, WI, and finished by Linetec, Wausau, WI, in a silver color 70% PVDF mica coating. Photo: William Lemke. To help connect patients to nature, Crozer-Chester Medical Center in Chester, PA, designed by Charles Cross Architecture PC, Wayne, PA, features a 40-ft.-dia. dome skylight, manufactured by Super Sky, Mequon, WI, and finished by Linetec, Wausau, WI, in a silver color 70% PVDF mica coating. Photo: William Lemke.

However, biophilic design is a lot more complex and far reaching than a window and a potted plant in the lobby. “Dr. Stephen R. Kellert, professor emeritus of Social Ecology at Yale Univ. and co-editor of the seminal book Biophilic Design (2008), identified 71 attributes of natural environments that have restorative benefits when incorporated into the built environment. Terrapin Bright Green distilled these attributes even further, identifying the most compelling features for commercial architecture,” Navarrete noted.

Their white paper, 14 Patterns of Biophilic Design, identified the patterns of nature with the most qualitative and quantitative research documenting their positive influence on our psycho-physiology. These fourteen elements, or patterns, are classified under the three main categories of biophilic design:

nature in the spacenature analoguesnature of the space.

Nature in the space, for example, encompasses not just the obvious visual connection to nature but non-visual cues such as auditory, haptic, olfactory, or gustatory stimuli. Thermal and airflow variability, the presence of water, varying intensities of light and shadow that mimic natural patterns, and an awareness of natural processes are additional elements of nature in the space.

Nature analogues include symbolic forms and patterns that suggest nature, materials from nature, and complexity and order as encountered in nature.

Finally, the nature of the space is important. View, or prospect, is significant, but so is a sense of refuge. The promise of more information, or mystery, is another attribute of the nature of the space.

Healthpointe, La Mirada, CA, installed several Luminous Virtual Windows in the enclosed interior office space, providing an illusory tropical seascape for employees. Photo: The Sky Factory. Healthpointe, La Mirada, CA, installed several Luminous Virtual Windows in the enclosed interior office space, providing an illusory tropical seascape for employees. Photo: The Sky Factory.

Natural materials are one of the 14 patterns of biophilic design identified by Terrapin, so they are certainly one strategy for making a space more biophilic but should not be the only strategy, Ryan said.

“In any instance, using real materials from nature is preferred to synthetic materials because human receptors can tell the difference. While quality representation of natural colors or patterns in synthetic materials—good enough to make you look twice—may still elicit a positive response among some users, the strategy can also backfire. Have you ever touched a wood table or bench only to realize it’s made of plastic or vinyl? It’s disappointing, and that is not the positive response we should be aspiring to,” she said.

Navarrete, however, makes a case for nature analogues. “It depends on the attribute and the context of its use. It is possible to provide an indirect connection with nature by mimicking materials, colors, shapes, or sequences. In the core of deep-plan buildings, where it is not structurally possible to create a visual connection to the exterior, it is possible to provide a visual and spatially sound experience of open space using biophilic illusions that engage areas of the brain involved in spatial cognition,” he said.

“In this sense, while the skylight or sequence of windows are designed to simulate the real thing, they create an illusory sky or panoramic vista that viscerally connects the observer with a perceived natural exterior. By leveraging our inherent habits of perception, designers and architects are able to change our experience of enclosed spaces by leveraging applied technologies that alter perceived space indoors, including what’s called the perceived zenith, the highest point above the observer, and perceived horizon line, the farthest point in front of the observer,” he explained.

The Mario Lemieux Center for Blood Cancers main reception lounge, Pittsburgh, PA, features eScape 2.0 Digital Cinema Virtual Window, which brings the dynamic beauty of nature—image, motion, and sound—to interior environments. This high-tech illusion features unedited, real-time sequences of wild nature in a unique vertical format to create a credible simulation of a room with a view. Photo: The Sky Factory The Mario Lemieux Center for Blood Cancers main reception lounge, Pittsburgh, PA, features eScape 2.0 Digital Cinema Virtual Window, which brings the dynamic beauty of nature—image, motion, and sound—to interior environments. This high-tech illusion features unedited, real-time sequences of wild nature in a unique vertical format to create a credible simulation of a room with a view. Photo: The Sky Factory

Incorporating new design elements, of course, often elicits resistance because of concerns about cost and return on investment.

“As with most design strategies, planning ahead can avoid additional upfront costs,” Ryan said. “Some stand-alone biophilic interventions are inevitably going to incur upfront costs and certain features can compromise energy efficiency or other environmental performance measures if they are not handled thoughtfully. However, the financial paybacks of biophilic design can far outweigh the implementation costs and have intangible benefits like patient and staff satisfaction and happiness,” she said.

“This is why we often encourage clients and design teams to take a more integrative approach,” Ryan continued. “For instance, strategies for addressing indoor environmental quality issues, such as privacy, acoustics, or humidity, can often leverage biophilic design for a more holistic solution that is less likely to be value-engineered out later in the design process.”

“In terms of environmental performance, well-implemented biophilic design elements more often support energy efficiency or other green-building measures rather than detracting from them. For instance, green roofs can improve energy efficiency and reduce urban heat island effects while providing patients with views and access to greenery. Daylighting reduces energy demand by decreasing electric lighting needs. Natural materials, such as wood and timber, sequester carbon, can often be locally sourced, and can sometimes have lower embodied energy due to minimal processing. For existing buildings, it’s largely a matter of leveraging existing characteristics for the greatest potential benefit and identifying both integrative strategies, such as with mechanical systems, and low-cost interventions for interior retrofits. Interventions don’t need to fill a whole facility, but to be effective they do need to be thoughtfully designed, executed, and maintained,” Ryan said.

The Northfield Hospital Radiology Suite, Northfield, MN, features a virtual skylight to provide the illusion of nature and help patients relax in a stressful situation. Photo: The Sky Factory The Northfield Hospital Radiology Suite, Northfield, MN, features a virtual skylight to provide the illusion of nature and help patients relax in a stressful situation. Photo: The Sky Factory

“Even though the healing powers of nature’s attributes are understood by healthcare designers, they are often poorly applied. For example, by design, most metropolitan hospitals are deep-plan buildings that feature large areas of enclosed interiors, which have the unique disadvantage of isolating occupants—medical staff and patients alike—from visual contact with a natural exterior,” Navarrete said.

“These enclosed interiors have a negative impact on staff productivity and the patient’s recuperative abilities. Designers will often place back-lit photography to simulate a sky view based on the general principle that nature art is conducive to reducing stress. However, representational imagery is symbolic and, while fostering a positive affective effect on the observer, does not trigger a genuine, physiological response to the environment,” he added.

“Properly applied, biophilic principles can be applied to create a simulated portal to a natural exterior that does, in fact, alter the observer’s perception of that same environment, leading to much stronger restorative benefits. This process is called biophilic engagement and it requires a higher level of understanding about the spatial effects of visual stimuli. This is not theory, but applied technology,” Navarrete said.

“Like everything, in order to change the built environment, it requires a commitment to long-term sustainable occupancy for human wellness,” he continued. “Many professionals are caught up in the energy consumed by some biophilic design features without realizing that energy expenses account for less than 3% of overall operational expenditures, whereas the cost of human capital accounts for more than 90% of the budget.”

“Therefore, it makes perfect sense to improve the productivity of our human capital, whether it’s staff or patients, rather than judge design solutions by their energy consumption. The evidence shows biophilic design is an economically sound investment,” he asserted.

Navarrete suggested that there has been a fundamental shift in our understanding of building design because, as Edward Mazria, the founder of Architecture 2030 (architecture2030.org), has noted, commercial buildings have a very long shelf life—about 80 years. In addition, he said, according to the Institute for Building Efficiency, an initiative of Johnson Controls, Milwaukee, more than 50% of the buildings that will still be in use by 2050, have already been built. That means, healthcare practitioners and facilities planners will be forced to find retrofit solutions to maintain older buildings in step with the best architecture that optimizes human health, productivity, and wellness.

Biophilic design may well be one of the ways we can do that.

Connecting with nature isn’t always easily accomplished in the deep-plan healthcare facilities common in the United States. Trends toward smaller, decentralized facilities notwithstanding, these deep-plan buildings are likely to be with us for some time to come.

One solution is to create the illusion of nature where a direct connection isn’t possible. These illusions are not merely decorative representations of natural scenes.

A recent study by Texas Tech Univ.’s (Lubbock, TX) Neuroimaging Institute (Neural Correlates of Nature Stimuli: An MRI Study, published in the Winter 2014 issue of the peer reviewed Health Environments Research & Design Journal) uncovered the neural pathways involved in the perception of open-sky photography used in the creation of biophilic illusions of nature. The study specifically investigated the effects of Sky Factory’s (Fairfield, IA) photographic sky compositions on brain activation.

Initial analysis of the brain maps indicates that the photographic sky compositions shared all of the characteristic neural activations of other positive images, while, additionally, activating several other unique brain regions. Of particular interest to the researchers were the activations found in the cerebellum.

“Brain activation of the cerebellum is often associated with aspects of spatial cognition, in particular the experience of extended space, as well as imagined, or real, motion through that space,” said neuroscientist Dr. Michael O’Boyle. “By way of speculation, it may be that viewing Sky Factory compositions evokes a sense of expansion into or through this extended space,” he remarked.

David Navarrete, director, research initiatives, The Sky Factory, explained why the company’s Illusions of Nature, which is a trademarked term, are different:

“One of the things a virtual skylight has to have is the component of spatial cognition or depth perception. This is achieved partly by breaking up the illusion into components, forcing the eye to put them together. Many people think that our visual perception objectively tells us what reality is, but actually your brain is actively amplifying, suppressing, or editing things based on input from different senses,” he said.

Another principle is amodal perception. “When you see an object when part of it is occluded, the brain doesn’t assume there are two objects there. If a body is seen behind a lamppost, with one half on one side and the other half on the other side, the brain assumes it is one body hiding behind the lamppost. That’s what we do with the ceiling grid,” Navarrete explained.

The Sky Factory’s “open sky compositions” are created in layers that are deliberately composed. There is a super-high resolution layer of foliage; then the clouds are the second layer, which is more diffuse. The blue of the sky is the blue of a high altitude blue that is not seen every day in a major city because of pollution and humidity.

This blue triggers a fourth receptor in the eyes, the intrinsically photosensitive retinal ganglion cells, which are sensitive to color temperature and intensity of light. They also cue circadian rhythms.

Architectural elevators recess the image panels away from the rest of the ceiling plane, and when the viewer looks at them in perspective, it enhances the notion of that he/she sees parts of the image that are incomplete. The brain naturally assumes that the tree branch is behind the grid and the clouds are behind the tree, creating an illusion of depth. Rather than just having a symbolic part of the brain assessing an image based on whether it’s familiar with it or not, the scene engages the cerebellum in trying to assess whether there is depth to the image.

“It has to work in the context of the room, the dimensions in which it’s placed, and where the observer is going to be,” Navarrete concluded.

Nature in the built environment is nothing new. Natural images and gardens have been part of architecture since the earliest times, from the ancient Greece and China to Mexico and Japan. Victorians pushed back against the squalor of industrialized cities, while Henry David Thoreau in the U.S. made a virtue of simple living in a natural environment. The Craftsman movement used natural materials and textures as prominent features of its design.

But biophilia as a term is relatively new. The general consensus is that it was coined by social psychologist Eric Fromm in The Heart of Man (1964).

Roger Ulrich’s study in 1984 compared recovery rates of surgical patients in rooms with and without views, and in the 1990s, furniture manufacturer Herman Miller, Zeeland, MI, commissioned a study that connected productivity to a connection to nature.

Also in 1984, Edward O. Wilson suggested an instinctive bond between humans and other living things in his book Biophilia.

Biophilia was the topic of a 2004 conference and subsequent book in which Stephen Kellert and contributing authors outlined mechanisms for creating a biophilic experience, as well as classifications of user experience. (Biophilic Design: The Theory, Science and Practice of Bringing Buildings to Life, Stephen R. Kellert, Judith Heerwagen, Martin Mador, 2008.)

The next time you check into a hotel room and look around for the desk, it might not be there. Why? Because some chains, Marriott among them, have decided that millennials, apparently the favored target demographic of hoteliers these days, don’t use desks. Perhaps they’re frightened by the once ubiquitous piece of furniture, just as many seem to be uneasy with the automobile, fearing it more even than public speaking, according to one survey by a car maker.

Apparently today’s guests likewise are uncomfortable with hotel restaurants because those have been disappearing, too. It’s way cooler to arrive after a long flight and an even longer trip from the airport in one of those communal vans and then slog about in a dark, cold, slushy city, guided by the glow of one’s smartphone, in search of some adventure in eating. Or more likely some fast-food joint where you could have gone at home.

What will disappear next? Perhaps working light switches, as was the case in one hotel I checked into a while back. Who needs a light switch when you have a luminescent phone in your hand? Doesn’t everyone keep their phone constantly in hand?

It’s been said that younger guests have changed the dynamic of the hospitality industry and want the feel of a Silicon Valley startup. Really? What does that feel like? And don’t they have desks in Silicon Valley?

The Marriott website touts the new design, which, it says, has space for everything. And tables that move with you. Not a desk, mind you, but a little table that looks like a 1950s TV tray table. A photo shows a young person lounging on the bed, TV remote in hand, and a bowl of popcorn at hand on said movable table. Looks nice, but she’s going to be really uncomfortable in that position if she watches TV for more than five minutes. The “new guest room” will be available at select locations soon, the website promises. I can hardly wait.

Not everyone is on board with this new desklessness. The website FlyerTalk (flyertalk.com) has a forum entitled “The Idiots Who Design Marriott Rooms.” Says one disgruntled guest: “I don’t work on my computer cross-legged on the bed.”

And that brings up another point. A few years ago, ergonomics was all the buzz in the office-furniture world. That meant sitting up straight in a properly designed chair, with the computer monitor at the right height, and limiting glare from that letting-the-outdoors-in fad.

Now comes word that smartphones may be ruining the posture of habitual texters and phone gazers. An article in the New York Times claims that people tend to bend their necks forward at approximately 60 deg., making the effective stress on the neck something like 60 lb. A New Zealand physiotherapist reports seeing “dowagers’ humps,” a condition where the upper back is locked into a forward curve, in younger patients, not just in great grandmothers of advanced age.

The posture even has several names: text neck, iHunch, and iPosture. Worse, the author of the Times article notes that slouching with necks bent forward is often observed in depressed patients, and further asserts that posture doesn’t just reflect emotional states but can also cause them. “Slouchers reported significantly lower self esteem and mood,” according to a study published in Health Psychology.

So, if you’ve been texting a lot or slouching with your laptop and you’re feeling a little down in the dumps, there could be a reason for it. Oh, it’s been suggested that slouching might also affect memory and assertiveness.

Of course, by now you’ve heard that sitting is the new smoking in terms of adverse health effects, and it will only be a matter of time until we shame sitters, like smokers, by making them sit on the sidewalk in the snow and rain at least 25 ft. from the office door.
Or maybe not. Maybe we’ll all just lie down on the job. That’s what Altwork, a San Francisco-based company, promises with its Altwork Station, a dentist-chair-like contraption that allows the user to work in a supine position with the computer monitor, mouse, and keyboard hovering overhead. To be fair, one can also stand or sit like a normal person—if sitting in a dentist’s chair all day is normal for you. A few things bother me, though: what keeps the mouse from falling into your lap when you’re reclining? Or do you have to rely on that touchpad thing? Can you really type lying on your back?

One more thought for the laptop generation: Just because they call it a laptop doesn’t mean that you have to put it in your lap. That was just a name they gave it back when they were good at inventing new things but not so good at naming them. I’m pretty sure the position one assumes with a laptop in one’s lap for any length of time is not ergonomic. At the very least, it’s uncomfortable. But, hey, it’s your back.

Kenneth W. Betz, Senior Editor

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