Healing Architecture

More and more hospitals in India are realising the importance of healing architecture, finds out Nancy Singh.

The light of dawn penetrating through the large windows and soft music playing in the background - this is not the image that flashes across your mind when you think of a hospital, but its time you change that perception. More and more hospitals today understand the importance of 'healing architecture', a concept which is gradually making its presence on Indian shores.

How Healthy is Healthy?

"We do healing design which you refer to as 'healing architecture'," clarifies Hussain Varawalla, Senior Architect, HOSMAC, Mumbai. "I would define it as creating environments that make you feel good. To a certain extent, we generalise by saying that if you feel good you will 'heal' faster. I do not think in that sense that a surgical wound will heal faster, but your mind will heal faster," adds Varawalla. So, basically, it means that an environment that accentuates the healing process is 'healthy'. "Healthy-hospital design is a harmonious blend of nature and architecture, that promotes health and aids early recovery in those who are sick," echoes Dr Shakti Gupta, Author of Modern Trends in Planning and Designing of Hospitals, Principle and Practice.

But to what extent can a building actually augment the healing process? The argument is that patients get personal attention from the staff only few times in a day and are left alone most of the time. This is where an environment can play a contributory factor to their sense of well-being and actual recovery. "The quality of space in such buildings affects the outcome of medical care, and architectural design, thus playing an important role in the healing process. Hospitals should provide a cheerful, inviting ambience, and a caring and healing environment," says Rajeev Pathni, Resident Administrator, AIIMS, New Delhi.

In a case study at South Downs Health NHS Trust in Brighton, UK, it was found that the original accommodation for the mentally ill comprised 15-bed wards in typical Victorian brick institutional buildings with high ceilings. These were replaced with a new medium secure mental healthcare building, using only single rooms and now known as Mill View Hospital Hove. In the newly-designed wards, patients showed significantly higher levels of satisfaction with respect to their surroundings. Ratings given by patients for the newer hospitals were significantly higher for appearance, overall design and spatial organisation. Patients were particularly pleased with their own private area, whether it was a room of their own, or a bay in a multiple bed ward. Significantly, more patients in the newer wards felt that the environment had helped them feel better.

Remarkably, patients also gave significantly better ratings to the actual treatment. They also thought more highly of the staff treating them. In most cases, these were actually the same people treating them! Some of these differences were not statistically significant, but the overall picture is clear. In a mental health hospital, it is normal to record patient behaviour, including all instances of verbal and physical abuses. These results are quite remarkable as well. While the number of incidents of verbal and physical abuse remained largely the same, their severity dropped significantly in the new wards. The number of instances of patients injuring themselves reduced to two-thirds. Patients who become distressed and are considered a danger to themselves are normally put for a period into seclusion in a safe room under intense supervisory care. The amount of time for such cases was reduced by a remarkable 70 per cent in the new unit with an average reduction of nine days, from 13 to four in a typical stay. A clear and consistent picture emerges. Patients in new buildings seem to spend less time in the hospital and appear to feel less physical pain and are psychologically calmer.

Looks do Matter

"It is important that a hospital does not exude a 'sick building syndrome'" - Henning Lensch Managing Partner RRP Architects & Engineers Munich

Without a doubt, the moment you enter a hospital it is the look you judge. Even though it may not have much to do with the kind of treatment or efficiency, aesthetics do go a long way in determining the preference of that hospital. "It is important that a hospital does not exude a 'sick building syndrome' with artificial air-conditioning systems, which might also cause infections and other hazards," explains Henning Lensch, Managing Partner RRP Architects & Engineers, Munich, Germany.

Most hospitals use artwork and graphics to have a cheerful look and exude warmth. Though it need not necessarily come under the confines of 'healing-architecture', nevertheless it is a significant factor in making a patient or a visitor comfortable when they enter the premises of a hospital. "Artwork gives a sense of warmth and nobility to the space," agrees Surendra Hiranandani, MD, Hiranandani Group. The walls of Hiranandani hospital are decorated with nature paintings with various hues.

But there are limitations as well, architects believe. "Graphics and art can be important in a paediatric hospital, but our parameters change as we age," says Sandip Agarwal, Director, Edifice, a Mumbai-based architectural firm. But what if one can add an element of art with an aspect of 'healing'? Bangalore's Columbia Asia Hospital is a good example. It has used art work from a Malaysian artist who has made paintings as per Feng Shui. "I don't really know the relevance it has, in terms of healing, but yes, they are said to 'harmonise' with the elements of the surrounding. For us, they help in giving a bright look to the hospital," says Tufan Ghosh, CEO of Columbia Asia Hospital.

Myths

An ICU with a window view, at Asian Heart Institute, Mumbai to prevent ICU psychosis

So are these methods capital-intensive? "These measures are really cheap! All additional technical installations for air-conditioning could be more expensive than a proper design, with courtyards and windows and natural cross-ventilation," says Lensch. In fact, "hospitals, which do not care for the 'basics' of good architecture, need a lot of artificial measures — technical help to compensate factors missing in a room. This is more expensive and not as appropriate as a good design," he adds. The belief is that some features can actually lower initial capital costs and life-cycle costs can be reduced significantly. Operating a properly designed building is a lot less expensive, and has a positive impact on the environment. Our emotions and ability to heal are affected by what we see around us. Well thought out architecture and well planned colour schemes and design are the cornerstones on which a pleasant work-place is built. Therefore, it is worth taking a holistic approach from the start, when addressing factors that affect emotional impressions in a hospital environment.

Perception of a Room

A room gains its shape and visual qualities from the co-ordination of materials, colour, design, proportions and the light characteristics from daylight or electrical light. In general, it is a matter of achieving a balance to a clearly logical/functional architectural approach. "The design objective of a hospital forms the basis, of which the first objective is that it should be clear. Now, clear means it should be simple and luminous and should have a refreshing look," says Agarwal. A room is not just four walls or floors and ceilings. The room, as we perceive it, is made up of physical boundaries derived from light, sound, and views to adjacent environment, for example, windows. From a psychological point of view, it is important that those who spend time and work in a room perceive its boundaries in the form of visible difference between the floors, ceiling and walls. A feeling of being in a delimited room creates security and this is vital for healing. A room too large for its function can feel empty and exposed. It can also be seen muddled, as its boundary surfaces are difficult to perceive, alternatively a small room can easily feel cramped and enclosed. So, it is not easy to achieve the right size.

Colour Environment, Happiness and Efficiency

Perception of colour is emotional or objective. Emotional perception of colour means that they are felt to be warm or cold, beautiful or ugly, calming or exciting, depending on the person. They also have symbolic value, which also often has cultural roots with the meaning of a colour differing from culture to culture. The right colour scheme has a proven influence in the well-being of the patients and the staff. "Swiss and German researchers have done in-depth studies in the 70s. It is proven that colours like yellow and orange have a positive impact on the patients, blue cools them down, while red is hot," informs Lensch.

Colour choice, lightness, darkness, colour strength and contrasts can even be used to achieve diametrically opposed effects such as calm or chaos, hot or cold, cosy homeliness or perception of an institutional environment.

"Colours play an extremely important role. Permanent colours define the objective of hospital. So a children hospital will have different colours than say, a heart hospital," says Agarwal. Most hospitals have a brighter look in OPD areas, and a toned down look in secluded areas. Says Dr Vijay D’Silva, Director, Critical Care, Asian Heart Institute, Mumbai, "Places with plenty of movement will contain photographs and a brighter look, but secluded areas like ICUs can do with shades of whites."

A good example of colours is the Bristol Royal Hospital, for Children, UK, made by Ray Smith, a painter. Smith's involvement with the design team during the development of the arts strategy was critical in ensuring that art would be integrated within the fabric of the new hospital. The Trust and Design team wanted colour to be a key feature of the interior and Smith was selected in part for his specialist knowledge and understanding of colour as a painter. Starting from Level 3 (Level 2 is the main entrance) the dominant colour is a warm orange/red. This moves up to yellow, to green, to blue and finally to a combination of blue and violet on Level 7. Colour is most intense or saturated at key public orientation points - the stairways and lift lobbies. The concentration of vibrant colours allows a visitor an almost instinctive sense of place/direction. Responding to indications from children that clinical and non-clinical areas should not be confused, the intensity of colour gradually recedes as one moves from these 'hot spots' of colour at key public spaces, towards the patient or treatment areas where a more neutral ivory shade predominates.

Unique designs were developed for each level based on simple themes suggested by the dominant colours. For example, yellow suggested sandcastles or a seaside theme, and blue-violet introduced the potential for an outer-space concept. Interior lighting is an integrated element of the colour scheme. Many areas of the hospital do not have access to natural light, although the architects have maximised the effect with large windows on staircases and lift lobbies. Discreet light fittings and a simulated daylight create light, which in tandem with the colour scheme.

Nature Rules

Natural light may have a major significance but not without other attributes like sound, smell and visuals. Ultimately, it is the senses that need to be revitalised as it is an integral part of healing. "If you can break a harsh reality of the hospital wall, it takes the fear out," explains Agarwal.The upcoming One World Hospital and Healing Center (OWHC) in Bangalore is a case in point. It will use light, space, water, colour, sound, smell and nature to foster a spirit of healing and compassion. In fact, uniquely, it will be in the shape of a palm, with each finger accommodating general wards, medical ICU, executive suites and a grieving room for families. "Design of the hospital is inspired by the hand, the primary instrument of healing," informs Maureen Berlin, Founder and CEO of OWHC. Larger hospitals have 'healing-garden' that has access to a library and cafeteria for patients. Serene landscapes have formed an integral identity of Kochi's Lakeshore Hospital, which is surrounded by backwaters. "Most of our rooms have a view of the backwaters. Patients can even go boating and we also have boat-ambulances," says Philips Augustine, MD, Lakeshore Hospital. The Wockhardt Hospital at Bannerghatta Road in Bangalore is facilitating an all glass-walled patient's room with a garden in the centre till the seventh level. "We use more of yellow light in the corridors and other areas," says Vishal Bali, CEO, Wockhardt Hospital Group. Pune's Aditya Birla Hospital also has a green-gallery. "This enables sunlight to come directly into the area which can be viewed from the ICU, NICU and general wards as well," tells R Singh, Manager-Operations, Aditya Birla Hospital.

Tune in for Good Health

It has been proved that certain music enhances efficiency, performance and acts as a de-stresser. Internationally, many hospitals use music in OTs. OWHC will have music playing in operating theatres, in patient wards as per their choice and also in labour rooms. "The requirement for music mainly comes from doctors," says Berlin. Over the past few decades, music therapy has secured a legitimate place in the healing arts, and the practice continues to grow. Sound is the first 'sense' that human beings are exposed to early on. In the Himalayas, sacred healing chants are being performed daily by Buddhist monks for over 2,000 years. Even deaf people can sense vibration in the part of the brain that is normally used for hearing, according to a research by the University Of Rochester School Of Medicine.

Experts also feel that there should to be a fair balance of sounds and that it is important to have good sound absorbing materials that can control the ambience noise. "Think about a noisy place with a lot of action in the background, people crying and shouting, noise of construction etc. It is definitely not a good place to have peace to recover," cites Lensch.

Light Strikes

"Even today, Government hospitals are the best designed" - Dr Devi Shetty Chairman Narayana Hrudayalaya

Let there be light. No, this is not some motivational guru preaching, but a mantra that architects vouch for. More and more studies are substantiating this fact that natural light has a huge impact on healing process. There is mounting evidence that light is critical to human functioning and can be extremely beneficial to patients as well as staff in healthcare settings. Dr Devi Shetty, Chairman, Narayana Hrudayalaya, says, "Our ICUs are in the exterior of the hospital which ensures that enough light penetrates the room." This is particularly helpful for those who suffer from 'ICU psychosis' which is a disorder in which patients in a ICU or a similar setting become temporarily psychotic. "For such patients, bringing them towards the window, makes them feel normal," informs Dr Shetty. In a similar case, Asian Heart Institute has also provided a view through windows. "A beautiful view does not matter. Even the normal hustle-bustle of city life can keep the patient oriented," says D’Silva. As an example of disorientation, he cites, "If you have seen movies, in some, the police uses strong artificial light when interrogating, so the person becomes frustrated and disoriented." In contrast to artificial light, daylight cannot be controlled; it varies in strength and colour depending on the time of day and weather. Despite this, architects strive to utilise daylight as much as possible as it is a free source. Besides, architects can daylight to give shape to buildings and rooms by using shadow effects, contrasts, etc.

While it is essentially patients that are focused upon when we discuss the idea of healing architecture the people working in the premises cannot be forgotten. Normally, Operating Rooms (ORs) do not have window views, which in contrast is not the case at NH, as the ORs have a view of a garden, "which is a unique concept and unlike anywhere in the West," says Dr Shetty. The line of reasoning being that surgeons work 14-18 hours and are stressed. Similar is the case with Dr LH Hiranandani Hospital where every ICU and OR has a glass sealed window for natural light which synergises with the centralised air-conditioning systems, to maintain temperatures as glass heats easily. The huge atrium of the Hospital is also a good example of maximum utilisation of natural light. "The atrium helped us utilise the maximum of the limited available space," says S Hiranandani.

The special focus was upon providing a feeling of space and comfort in the interiors, "be it through elegant use of design to create vastness, a grand atrium or lounge area with excellent lighting to soothe, comfort and calm the patients," elaborates Hiranandani. Even Aditya Birla has a huge atrium with large cafeterias and shops

A significant attribute of a hospital is to facilitate patient movement and operational efficiency and space is a very important aspect to accomplish this goal. In an interesting study by scientists, mice were caged together and they relatively showed higher levels of aggression, than the group of mice that had enough space to roam around. "The patient floor has to be designed in such a manner that there is less mobility to reduce commotion and chaos and today's portable machines make it possible to directly reach the patient in his room," says Dr Shetty. Most hospitals today have very small corridors, which leads to more chaos. "I believe, even today Government hospitals are the best designed, as they all have big corridors with huge ceilings and large windows. You may have expensive marble or granites but what about mobility?" asks Shetty. In a similar expression, Dr D’Silva agrees, "Many hospitals are designed with a 'hotel-like' concept as the philosophy is -the more , the merrier."

Too Late for Already Existing Ones?

So, most hospitals, as we know, generally do not belong to this genre of healing architecture. So how easy or difficult would it be to turn them into 'healing-architecture'? 'Very difficult'- in an unanimous observation by all, even though it must be evaluated individually, as it would require major structural changes and hence it would be cheaper and feasible for a new construction to have a healing-architecture. “Even a fresh coat of appropriately coloured paint, plants, appropriate artwork, maintaining cleanliness generally would be very cost-effective," suggests Varawalla.

The Three Ns

Yes, it is the three Ns that form the core of healing-architecture' -"The key words here are nature (green plants), natural light and natural air," concludes Lensch, "and healthy architecture has a proven influence on people's well-being." In short, healthy design needs a multi-disciplinary approach involving architects, healthcare professionals, hospital administrators, interior designers, landscape architects, environmental scientists to form a perfect ensemble of healing-architecture.

nancy.singh@expressindia.com