The therapuetic value of providing contact with nature in the design of healthcare facilities

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Providing opportunities for people to have greater interaction with elements of the natural world in predominately built environments can not only make such environments more aesthetically pleasing but also result in a range of positive health benefits for the users ^1,2,3, writes Professor Ray Green.

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This observation has led to growing interest among architects, landscape architects and interior designers in the value of integrating natural landscapes and elements of the natural world (plants and animals) into the design of a range of building types, including hospitals, office buildings, factories and schools, with the aim of increasing the health and well-being, productivity, capacity for learning and a range of other positive outcomes for the users; something which is accomplished simply by providing greater opportunities for people to experience nature and natural phenomenon within the context of these types of facilities.
A growing body of empirical evidence in the fields of medicine and health promotion supports the proposition that through the design of healthcare facilities and greater exposure of patients, staff and visitors to natural elements a range of positive physiologic and psychological health benefits can be obtained. Both physiologic (e.g. lower heart rate, reduced blood pressure, better muscle tension and brainwave patterns associated with relaxation) and psychological (e.g. a greater sense of well-being, decreased stress and increased mental alertness) benefits have been documented⁴. Just having views of green, vegetated landscapes from hospital rooms has been shown to be restorative and increase people’s physical and psychological well-being, even to the point of reducing healing times in patients after undergoing major surgery⁵. Merely incorporating visual and auditory representations of natural landscapes in the form of photographs, paintings, digital displays and recordings has been shown to result in measurable health benefits.
The basis for these benefits has been linked to what the Harvard biologist EO Wilson⁶ has termed “biophilia”, or the “innately emotional affiliation of human beings to other living organisms”. Everybody can be affected by having contact with nature in some way, however, children in particular often find natural elements and natural processes that they encounter in their everyday lives to be inherently interesting and have the ability to hold their attention. Even subtle changes in vegetation, the sights and sounds of birds and small animals, the movement of leaves in the wind and other types of encounters with natural phenomenon can elicit a reflective state of mind that the environmental psychologist Racheal Kaplan has termed “soft fascination”⁷. The design of healthcare facilities can provide opportunities for the users to encounter elements of the natural world to elicit this type of response.
Certain natural landscape settings and natural features seem to exert more pronounced physiological and psychological influences on people than do other types of settings. A number of scholars have linked this with an inherent evolutionary predisposition to gather and process information from the environment that would have in the distant past provided survival advantages for our ancient ancestors
Habitat Selection Theory⁸ suggests that our ancient ancestors (people living 60,000 years and more ago) would have found certain landscapes and landscape features to either help or hinder them in their struggle for survival. This theory suggests that contemporary notions of beauty in the landscape would not have evolved if such emotions did not contribute to our species’ survival and well-being in some way. Some scholars who subscribe to this theory suggest that people possess an ingrained fondness for savannah-type landscapes. Savanna type landscapes are those that are relatively open with scattered trees and/or small clumps of trees set in a matrix of grass. This theory maintains that this type of landscape will evoke positive emotional responses in people because this type of landscape was that which was inhabited by our ancient ancestors in our evolutionary past^{9, 10, and 11}. According to this theory people’s fondness for urban parks, and the physical and formal characteristics associated with them, are a consequence of this evolutionary predisposition to like savannah type landscape settings.

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“A growing body of empirical evidence in the fields of medicine and health promotion supports the proposition that through the design of healthcare facilities and greater exposure of patients, staff and visitors to natural elements a range of positive physiologic and psychological health benefits can be obtained.”

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Jay Appleton, a British geographer, has proposed Prospect Refuge Theory¹² to explain why people seem to have a predisposition to like certain landscape settings that afford them prospect, such as elevated locations looking over the landscape, and places that offer opportunities for concealment, or refuge. These are both landscape settings that would have held distinct survival advantages for our early ancestors and now seem to be highly preferred landscape settings for contemporary people.
A Design Framework for Biophilic Healthcare Facilities
Based on the scope and breadth of the available evidence, combined with theoretical speculations about relationships between contact with nature and human health, the author formulated a set of design principles to guide integration of natural elements – plants, animals, rocks – into the design of the new Royal Melbourne Children’s Hospital¹³. Since the site of the hospital is adjacent to Melbourne’s largest and oldest park (Royal Park) there was an opportunity to integrate the new hospital buildings with the park landscape to create a complete park/hospital system. This framework specifies five types of design interventions that include:

• Natural replacements used to evoke vicarious experiences of nature. These are non-landscape elements that are representative of nature that can provide vicarious experiences of natural environments within the context of predominately built settings. This includes such things as imagery and soundscapes of natural environments.


• Opportunities for passive interaction with nature involves strategically placing windows, skylights, viewing platforms and other structures to allow people to come in direct sensory contact with nature and natural environments when they are sitting in, lying in or circulating through the healthcare facility. This principle capitalises on the “borrowed landscape” by using views of surrounding natural landscapes available from within healthcare facility as a way for patients and to experience these landscapes from afar.


• Nature used to facilitate social interaction involves using plants and animals to encourage social interaction. Horticultural therapy relies on this principle to increase social interaction between people aimed at developing to social relationships.


• Nature as the facilitator for physical movement involves the use of natural environments and elements within and around buildings to facilitate ambulation and exercise. This can be achieved, for example, through providing pathways that offer views of alluring destinations to encourage people to move further into the landscape and thereby increase physical mobility.


• Direct, unstructured contact with nature involves strategically placing and displaying natural settings and natural elements with aim of fostering a sense of fascination with plants and animals and other natural phenomena to provide a source of distraction.

These principle range from simply providing passive views of surrounding natural landscapes from hospital rooms to the construction of children’s gardens, water features and planting of an abundance and diversity of greenery and flowering plants in interior and exterior spaces. This extends to the provision of sensitively designed plant and animal enclosures incorporated into the design of the buildings, and which are made visible from different levels to cater to a broad range of user groups and physical capabilities – e.g. wheel chairs. The aim was to use these principles to guide design interventions to achieve specific therapeutic outcomes. For example, hospitalised children can be provided with opportunities to have direct interaction with natural environments and elements of the natural world while they are waiting for, or even while undergoing, medical treatments to provide them with distraction as a way of minimising their anxiety, stress and their ability to cope with pain. It is the combination these types of design interventions and associated therapeutic outcomes that this new biophilic approach to the design of healthcare facilities is based.
The Royal Melbourne Children’s Hospital
The design of a number of new healthcare facilities in Europe, North American, Asia and Australia have consciously integrated elements of the natural world into their designs to achieve specific health outcomes for the users. The Royal Melbourne Children’s Hospital is one such example that has recently undergone the largest hospital redevelopment in the State’s history at a cost of one billion dollars to the Victorian Government. The project, which was completed in 2011 and designed by Melbourne architects Bates Smart and Billard Lease in collaboration with a range of other consultants, involved ripping down most of the existing hospital complex and building a number of new facilities. During the planning process it became apparent there was a unique opportunity for the new buildings to be more closely linked with Royal Park - Melbourne’s oldest and largest urban park – to reap the health benefits that closer contact with nature could impart to the hospital users. To achieve this aim the author was engaged by the State government to develop a set of design principles, as outlined above, that would be used to underpin formulation of the brief for the competition to design the new hospital. The resultant design framework was aimed at both encouraging optimal integration of the new hospital buildings with the park landscape as well as incorporating elements of the natural world into the design of the buildings themselves. Based on these principles, the architects sought ‘to emulate the soft fascination of nature’ and translate the natural settings of the park into ‘a form, colour and patination language for building’¹⁴.
The low raise nature of the master plan allowed the garden spaces to be integrated around the buildings and for sunlight to penetrate interior spaces at different times of the day, which was determined though undertaking time-lapse lighting studies using scale models. The central building is configured to simulate a main street with the Inpatient Unit (IPU) located at the end. A key attraction of this area is a 7.5 meter-high aquarium visible both from this main entry area and from the emergency rooms below, which provides a wonderful source of distraction for the child patients and their relatives (Insert photo of girl and groper and mother with child at the aquarium). The IPU was located deepest into the park to provide patients with maximum opportunities to have exposure to the park landscape. Natural elements associated with the park were also reflected in the design of the IPU rooms, which was guided by studying photographs of the forms, textures and colours associated with features of the park landscape from which a series of biophilic design features evolved, including various building façade treatments.
Conclusion
This emerging “biophilic” approach to the design of healthcare facilities, as well as other types of buildings - e.g. schools, offices and factories - is based on incorporating design features that encourage restoration, healing and health of the users simply through the strategic provision of opportunities for people to have greater contact with the natural world within the context of these types of facilities. The application of these design principles to achieve these types of health outcomes will only be limited by the imagination of the designers and the willingness of governments to provide funding to realise this new and innovative approach to the design of future healthcare facilities.
Professor Ray Green
(BSc, MLArch, PhD) FASLA
Ray Green is a Professor of Landscape Architecture at the University of Melbourne where he teaches and undertakes research. He has also practiced as a landscape architect in the United States and Mexico, South East Asia and Australia. In 2012 he was made a Fellow of the American Society of Landscape Architects (ASLA) in recognition of his achievements in the field. In 2006, the Victorian Government commissioned him to develop a design framework to guide the ‘biophilic design’ of the new Royal Melbourne Children’s Hospital. Ray is the author of Coastal Towns in Transition: Local Perceptions of Landscape Change (2010), co-author of The Green City: Sustainable Homes, Sustainable Suburbs (2005) and co-editor and co-author of Towards Low Carbon Cities: Urban Form and Green Gas Emissions (2015) and Design for Change (1985). He also regularly publishes his research in a range of landscape architecture, urban planning and environmental psychology journals and presents at international conferences.
Endnotes

1. Frumkin, H. (2001). Beyond toxicity: Human health and the natural environment. American Journal of Preventative Medicine, 20 (3) 234-240. p238


2. Kellert, S. R. (2005). Building for Life: Designing and Understanding the Human- Nature Connection. Washington, D.C., Island Press


3. Maller, C., M. Townsend, M., Pryor, A., Brown, P. and St Leger, L. (2005). Healthy nature healthy people: ‘Contact with nature’ as an upstream health promotion intervention for populations. Health Promotion International 21(1): 45-53.


4. Ulrich, R. S., Quan, X., Zimring, C., Joseph, A. and Choudhary, R. (2004). The Role of the Physical Environment in the Hospital of the 21st Century: A Oncein- a Lifetime Opportunity. Center for Health Systems and Design, Texas A&M University, and College of Architecture, Georgia Institute of Technology.


5. Ulrich, R. S. (1984). View through a window may influence recovery from surgery. Science 224(4647): 420-421.


6. Wilson, E.O. (1993). Biophilia and the Conservation Ethic. In The Biophilia Hypothesis. S.R. Kellert and E.O. Wilson. (pp. 31-41). Washington D C: Island Press.


7. Kaplan, R. and Kaplan, S. (1989). The Experience of Nature. Cambridge: Cambridge University Press.


8. Orians, G. H. (1986). An ecological and evolutionary approach to landscape aesthetics. In Landscape Meanings and Values. E. C. Penning-Rowsell and D. Lowenthal London: Allen and Unwin, 1-22.


9. Orians, G. H. and Heerwagen, J.H. (1992). Evolved responses to landscapes. In The Adapted Mind. J.H. Barkow, L. Cosmides and J. Tooby (pp. 555 – 580). New York: Oxford University Press.


10. Heerwagen, J.H. and Orians, G. H. (1993). Humans, Habitats, and Aesthetics. In The Biophilia Hypothesis. S.R. Kellert and E.O. Wilson (Eds.) (pp. 138-172). Washington D C : Island Press.


11. Balling, J. D., and Falk, J. H. (1982). Development of visual preference for natural environments. Environment and Behavior, 14, 5-28.


12. Appleton, J. (1990). The Symbolism of habitat. Seattle: University of Washington Press and Appleton, J. (1975). The Experience of Landscape. New York: Wiley.


13. Whittle K. (2010). The nature of nurture. World Health Design; 3(2): 27-33.


14. Green, R. (2013). Close to Nature. Australian Healthcare Design 2005-2015: A Critical Review of the Design and Build of Healthcare Infrastructure in Australia. Stockholm: International Academy for Design and Health. pp.76-81.