Buildings That Heal

Contributions from neuroscience in designing the built environment

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How can a building improve a person’s recovery from injury and illness? Understanding the link between the brain and built environment sheds new light on how we design healthcare facilities, enhance the patient experience and build the evidence-base for human-centred design, write Prof Heidi Muenchberger and Prof Mardelle Shepley.

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Research evidence over the past decade confirms that the physical environment can significantly improve patient outcomes and expedite patient recovery ^(1,2). In the US alone, $200 billion will be spent in the next 10 years on re-designing patient care environments ⁽³⁾, making the potential impact of this investment substantial. In Australia, one of the five ‘building blocks’ of the National Health Reform Strategy 2011- 2015 ⁽⁴⁾ is Infrastructure and Physical Environment with a focus on maximising patient experience in healthcare environments. In recognition of this, architects and planners have re-visited inpatient therapeutic environments to optimise patient outcomes ⁽⁵⁾.
Recent innovations in the design of hospital environments that have been shown to improve patient health status include decentralized nursing stations, patient education centres, positive diversions (artwork, gardens, water features), flexible spaces for advanced treatments (robotic surgery), doubledoor bathroom access, single patient rooms and greater access to natural light ⁽⁶⁾.
As a result of these advances in health architecture and design, healthcare institutions are rapidly re-inventing themselves as holistic healing environments ⁽⁷⁾. A healing environment not only provides essential physical features of safety, security and necessary medical treatment, but it actively facilitates the holistic health of sick people ⁽⁷⁾. Hamilton ⁽⁸⁾ identifies that a healing environment is “the result of evidence based design that has demonstrated measurable improvements in the physical and psychological states of patients and staff, physicians and visitors” (p. 78). There are several contemporary examples of holistic approaches to healthcare design in Australia, such as the Olivia Newton John Cancer Centre, Melbourne Vic, and the Marie Bashir Mental Health Centre, NSW. A recent seminar hosted by Professor Julie Bernhardt at the Florey Institute, Melbourne, Victoria highlighted the intense multi-disciplinary interest in the field of health design and healing environments.
Much of our knowledge around creating healing environments has originated from earlier investigation about what doesn’t work in buildings. Sick building syndrome and stress-inducing environments have received considerable research attention in the past, particularly in relation to occupational health and safety of workplaces. Evans and McCoy ⁽⁹⁾ contributed a preliminary set of environmental dimensions inter-related to an individual’s experience of stress, namely stimulation, coherence, affordance, personal control and restoration. Healing environments would appear to address these important elements.
However, knowledge relating to the causal physical and psychological processes underlying a person’s experience of the built environment is largely unknown. Examining what works and why in design from a biological perspective will undoubtedly create greater opportunities for developing even more responsive, restorative and optimised human spaces. Imagine a rehabilitation unit that helps people with brain injury or stroke plan better, remember more and remind them of who they are. Or learning centres that facilitate improved brain function and performance. Answers to these questions will come from the interdisciplinary efforts of neuroscience and architecture.
New insights and approaches to design are being considered as a result of work into particular elements of brain function, including sensory experience, circadian rhythms and motion detection, memory and emotional status. The Nobel prize recipients (2014) for Physiology and Medicine, Profs John O’Keefe, May Britt Moser and Edvard Moser, mapped the neuroscience of direction and location positioning in the human brain and together with Prof Jill Leutjeb determined the neural pathways of wayfinding. These findings alone have critical implications for how we understand highly disorienting environments such as hospitals and aged care facilities. Recognising the potential for deeper understanding of design and the built environment, neuroscience researchers and architecture practitioners from around the world combined their interests in 2002 to form a National academy of Neuroscience for Architecture (ANFA) based in the US to examine the interaction of brain science, human behaviour and architecture and to advance new approaches in design. This remains an important initiative that will foster interdisciplinary practice and advance the field of health design beyond aesthetics and post-occupancy datasets.
There are important opportunities within this emergent field that may facilitate improved design of health facilities and have broader relevance to chronic illness and injury sufferers including dementia, mental health, cancer and other mixed patient populations where there is an emphasis on optimising the design of rehabilitative environments.
Fifteen years ago, Day (10) demanded more emphasis on the therapeutic use of design in dementia settings. In particular, how the building layout, approach to personalisation within the built environment, lighting, sound and orientation, access to secure outdoor areas could all be better researched to enhance the experience of early, mid and late stage dementia patients. Design impact in these areas has been well reported through post-occupational evaluations where behavioural improvements, emotional stability and medication compliance have improved up to 40 per cent with simple interventions.
Indeed, some of the most important neuroscience implications for the built environment originate from the injured brain. Understanding how an injured brain responds to certain environmental stimuli provides novel ways of addressing deficiencies in the environment for the general population. In order to create more tailored environments and nuanced design, attention to the areas of the brain that require additional attention can be translated to how we think about building tailored environments for the general population. To this end, certain illness and injury populations require more attention to particular parts of sensory, behavioural and cognitive experiences that could otherwise be replicated in innovative designs for the general population to optimise environmental experience.

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“New insights and approaches to design are being considered as a result of work into particular elements of brain function ...”

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Design and Human Evolution
The relationship between biology and behaviour of design is evolutionarily focused. Human survival was likely dependent upon biological predispositions that supported wayfinding, place identification, and the processing of sensory information that both educated and supported safety.
This notion is inspired by Appleton’s Prospect and Refuge Theory11, which suggests that humans prefer experiences that combine stimulation and information (prospect) within the context of an environment that offers some degree of control and protection (refuge). Those of our species that had the opportunity and inclination to learn through visual/spatial experiences without jeopardizing safety were more likely to endure and therefore propagate. We can infer from this that the injured brain is likely to seek adequate levels of stimulation for survival and healing.
The optimal level of stimulation will likely vary according to the individual. Lawton and Nahemow address this issue via the Environmental Competence/Press Theory¹², which postulates that humans function best when the challenge of the physical environment is in keeping with their ability to process the experience. This ability varies across the life span and modulates for a single individual over the course of the day, depending on stress levels, health status and other factors..
Prospect and Refuge Theory and Environmental Competence/Press Theory have served as basic concepts for environmental psychologists who are increasingly making their research available to design practitioners. Due in part to this translational approach to design research, evidence-based design has become a dominant inspiration for healthcare architects in the 21st century. Reflecting this trend, in 2009 the Evidence-based Design Accreditation and Certification exam (US) was initiated to accredit design professionals as practitioners of research informed design. More than 1000 healthcare architects had achieved certification by 2012 and the number is growing rapidly¹³. Using findings provided by researchers, healthcare facilities have added spaces that support the presence of families to increase patient satisfaction, gardens intended to reduce stress, and decentralised nursing stations that allow for higher supervision of patients.
Our understanding of how a building may influence who we are, what we see, what we think and how we feel is vastly underdeveloped yet critically important in designing ‘next generation’ environments. Examining how the built environment is processed in the normal and injured brain through multi-disciplinary efforts will provide unique knowledge about what constitutes optimal spaces. Architects, neuroscientists and environmental psychologists can apply this knowledge innovation to tailor environments to various population groups and actively change human perception through design.
Examples of major brain injury conditions and design implications for therapeutic environments*
Some neuroscience principles that have implications for architecture:

• The child brain and the adult brain are different. Two distinct neural profiles exist, rather than a ‘grown up’ version.


• Environments can induce brain change. Neuroplasticity means that the human brain makes new axonal connections in response to external stimuli.


• Neural adaption and excitation follow different neural pathways and optimum levels of neural function can be detected.


• Emotions influence memories. Emotional responses to place influence our memory (and expectation) of place.


• Sensory perception is everything. Sensory modifications (light/sound/touch/smell) can influence the way we experience pain and loss, how we feel, behave and what we remember.

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References
1. Commission for Architecture and the Built Environment, (2009). Future health: Sustainable places for health and well-being, London: CABE.www.cabe.com
2. Veitch, J.A., (2008). Investigating and influencing how buildings affect health: Interdisciplinary endeavours. Canadian Psychology, 49(4), 281-288.
3. Malkin, J. (2012). Healing environments as the century mark: The quest for optimal patient experiences in Wagenaar, C. (Ed.), Amsterdam, NAi Publishers. Pp259-267.
4. National Health Reform Strategy Building a 21st Century - Primary Health CareSystem - Australia’s First National Primary Health Care Strategy Australian Government Department of Health and Ageing.
5. Veitch, J.A., (2008). Investigating and influencing how buildings affect health: Interdisciplinary endeavours. Canadian Psychology, 49(4), 281-288.
6. Curtis, S., Gesler, W., Fabian, K., Francis, S & Priebe, S. (2007). Therapeutic landscapes in hospital design: a qualitative assessment by staff and service users of the design of a new mental health inpatient unit. Environment and Planning C: Government and Policy, 25, 591-610.
7. Carr, R. (2010). National Institute of Building Sciences Whole Building Design Guide http://www.wbdg.org/design/health_care.php
8. Hamilton, K., & Watkins, D. (2009). Evidence-based design for multiple building types. Hoboken, NJ: Wiley.
9. Evans,G.W & McCoy, J.M. (1998). When buildings don’t work: The role of architecture in human health. Journal of Environmental Psychology, 18, 85-94.
10. Day, K., Carreon, D., & Stump, C. (2000). The therapeutic design of environments for people with dementia: A review of the empirical research. The Gerontologist,40(4), 397-416.
11. Appleton, J. (1975). The Experience of Landscape. London, UK: John Wiley.
12. Lawton, M.P. & Nahemow, L. Ecology and adaptation in the aging process. In Eisdorfer, C. & Lawton, M.P. (Eds.) Psychology of the aging process. Washington, D.C.: American Psychological Association, 1973.
13. The Center for Health Design (2015). Evidence-based Design and Accreditation. Retrieved January 28, 2015 from https://www.healthdesign.org/edac/about
14. Selected Imagery by Christopher Frederick Jones
Ref: Kandel, E., Schwartz, J., & Jessell, T. Principles of Neural Science. New York. McGraw-Hill, 2000.
Prof Heidi Muenchberger
Prof Mardelle M Shepley
Prof Heidi Muenchberger (Fulbright Scholar, Griffith University and Centre of National Research on Disability and Rehabilitation Australia,) and Prof Mardelle M Shepley (Department of Design and Environmental Analysis, College of Human Ecology, Cornell University, New York)