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Saturday, June 22, 2024

How Do You Design a Better Hospital? Start With the Light

Just as medical care has evolved from bloodletting to germ theory, the medical spaces patients inhabit have transformed too. Today, architects and designers are trying to find ways to make hospitals more comfortable, in the hopes that relaxing spaces will lead to better recovery. But building for healing involves just as much empathy as it does synthesizing cold, hard data.

“Part of the best care might be keeping people calm, giving them space to be alone—things that might seem frivolous but are really important,” says Annmarie Adams, a professor at McGill University who studies the history of hospital architecture.

In the 19th century, famed nurse Florence Nightingale popularized the pavilion plan, which featured wards: big rooms with long rows of beds, large windows, lots of natural light, and plenty of cross-ventilation. These designs were informed by the theory that dank indoor spaces spread disease. But wards offered almost no privacy for patients and required plenty of space, something that became difficult to find in increasingly dense cities. They also meant a lot of walking for nurses, who had to trudge up and down the aisles.

Over the next century, that focus on natural light faded in favor of prioritizing sterile spaces that would limit the spread of germs and accommodate a growing raft of medical equipment. After World War I, the new norm was to cluster patients’ rooms around a nurses’ station. These designs were easier on nurses, who no longer had to trek long corridors, and they were cheaper to heat and build. But they retained some of the trappings of older-style residential treatment facilities, like sanatoria where patients would convalesce for long periods of time; both mimicked fancy hotels with ornate lobbies and fine food, measures intended to convince middle-class people that “they were better off in hospitals than at home when seriously ill,” Adams wrote in a 2016 article on hospital architecture for the Canadian Medical Association Journal. This design, she argued, was meant to give people faith in the institution: “a tool of persuasion, rather than healing.”

In the late 1940s and 1950s, hospitals transformed again, this time becoming office-like buildings without frills or many features meant to improve the experience of being there. “It was really designed to be operational and efficient,” says Jessie Reich, director of patient experience and magnet programs for the Hospital of the University of Pennsylvania. Many of these rooms had no windows at all, she points out.

By the middle of the 20th century, the hospital had become sort of the opposite of what Florence Nightingale had envisioned, and many of those buildings, or ones modeled after them, are still in use today. “The typical hospital is designed as a machine for delivering care, but not as a place for healing,” says Sean Scensor, a principal at Safdie Architects, a firm that recently designed a hospital in Cartagena, Colombia. “I think what’s missing is the empathy for people as human beings.”

Although Nightingale had been operating largely on anecdotal evidence that light and ventilation were important, she had been right—but it took over a century for scientists to gather the quantitative data to back her up. For example, a pivotal 1984 study published in Science followed patients after gallbladder surgery. The 25 patients whose rooms had views of greenery had shorter hospital stays and took fewer painkillers than the 23 patients whose windows faced a brick wall.

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Numerous recent studies show that exposure to nature and natural light can reduce pain, and that even a brief contact with the outdoors reduces stress. One 2019 study published in Frontiers in Psychology followed a group of 36 city dwellers for eight weeks and tested their saliva for biomarkers, including the stress hormone cortisol. The researchers found that spending just 20 minutes outside reduced people’s cortisol levels by over 20 percent. Another 2019 study found that taking regular breaks in outdoor gardens eased stress for ICU patients and their families. 

“The ambient environment influences our senses,” says Rana Zadeh, co-director and co-founder of the Health Design Innovations Lab at Cornell University. “The spatial environment influences how we can move and circulate. These are important in healthcare settings.”

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The same is true for psychiatric facilities, where design can help lower stress by reducing crowding and noise and increasing exposure to gardens and natural light. In one 2018 study published in the Journal of Environmental Psychology, researchers concluded that a Swedish hospital that used those design-based interventions lowered patient aggression so much that the staff decreased the use of physical restraints by 50 percent.

Starting in the 1980s, Adams says, hospital designers began to shift away from favoring efficiency and office-like buildings and back towards light, open space, and positive patient experiences. Today, many buildings have large, central atria, similar to those at a mall or airport. Because that architecture is so familiar, Adams says, it makes the hospital less frightening and makes medical care feel more normal. “The hospital has come to look like a shopping mall or a spa,” she says. “It makes you feel like, ‘Oh, I’m just at the mall. I’m not really here for my cancer treatment.’”

The Hospital of the University of Pennsylvania is one of the most recent examples of this trend in patient-centered design; in October, they opened a new pavilion to house the emergency department and in-patient care for the cardiology, neurology, neurosurgery, oncology, and transplant departments. “One of the things we know is that sleep is really, really critical to healing,” says Reich, who was one of many hospital employees who worked with the architects to finalize the design. So the new more-than-500-room building uses an “onstage/offstage” design to minimize noise and disruption. Private patient rooms are “onstage,” lining the outside of the building. Supply and medication rooms and staff break rooms are “offstage,” clustered in the core. Separating the two reduces noise and gives staff more private space, too. Each nursing specialty is now housed on the same floor, making it easier for nurses to coordinate care instead of having to travel between floors to consult about a patient.

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Every room also has a large window, which Reich says helps promote patients’ circadian rhythms, or sleep-wake patterns, “because it allows them to understand when it's day.” It’s also meant to prevent common hospital complications like delirium by giving patients a connection to the outside world that can help orient them in time and space.

But not all design ideas end up being good solutions. When designing the new Centro Hospitalario Serena del Mar in Cartagena, the architects thought it would be great if patients were able to open their windows to get a breath of fresh air. “But there were practical issues,” says Scensor, whose firm designed the new building. Dust could get in and cause infections. Or the tropical humidity could wreak havoc on the hospital’s carefully-controlled environment.

Instead, the firm chose windows that were giant, but sealed, prioritized greenery, and made the space easier to navigate. Scensor points out that when people enter hospitals, they’re often anxious and confused. But thoughtful design can help. Color coding or using different building materials to differentiate departments can make it easier for patients to find their way. Safdie Architects also designed an interior garden to help orient people in the building and provide a sense of calm, and reduced glare by using indirect lights that would be less harsh than overhead fluorescents. “It’s not about luxury or extravagance,” Scensor says. “It’s a basic thoughtfulness about people feeling cared for and respected.”

But the trouble, says Adams, is that just providing open or green space isn’t a cure-all. People respond to spaces in different ways. In one 2010 study published in Social Science and Medicine, she examined how children and parents reacted to the atrium at the Hospital for Sick Kids in Toronto, Canada. Some families loved the space; it felt like an escape from the clinic. But other children were terrified. When they were in it, they saw other sick kids, some of whom looked scary because of burns, surgical scars, or the effects of chemotherapy. “What it tells you is that everybody sees these spaces in different ways, and a problem with the postwar hospital was that it assumed a kind of middle class, suburban perception of everything,” she says. “We’re trying to get away from that now and have a more multicultural perspective of space.”

The best solution, she thinks, is variety. Even if airy spaces help many patients, hospitals should provide options: spaces where kids can run and make noise, ones where families can gather, and ones where people can find quiet and privacy. “There are many, many needs, and the needs are always changing,” says Adams. Medical technology, social expectations, and what happens in a hospital are all constantly evolving. The best buildings might just be the ones that can keep up.


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