Being out amongst greenery can help accelerate patient recovery, making the integration of biophilic design into medical institutions an indirect method of promoting healing. — University of Pennsylvania
Over the past two decades, healthcare architects have rediscovered a forgotten, but simple fact: Built environments affect the health and well-being of patients and staff.
As a result, they have been designing institutions that provide opportunities to experience nature by incorporating “biophilic” design elements.
These might be as simple as strategically-placed potted plants that elevate mood and quell anxiety, or more grand atria and gardens that span indoor and outdoor spaces.
The Sheppard Pratt psychiatric hospital in Baltimore, Maryland, in the United States, is one such example.
The institution was developed to provide mental and behavioural healthcare in a way that patients, staff and visitors could cultivate connections with the community and “with the nearby hills, hollows, creeks and wetlands”.
Wood battens frame the lobby walls, while ceilings in large spaces imitate a forest canopy.
Windows allow sunlight to stream inside and provide views to courtyards and gardens.
Sheppard Pratt president and chief executive officer Dr Harsh Trivedi states that their design goal was “to dispel every misconception of what a psychiatric hospital is”.
Nature-enriched institutional spaces are a far cry from the desolate images many Americans maintain of psychiatric institutions.
Yet, the movement toward biophilic design is taking hold.
St Elizabeths Hospital, a psychiatric hospital in Washington DC, was the setting of Canadian-American sociologist Dr Erving Goffman’s classic book Asylums, in which he analysed how the dehumanisation of patients unfolded in an oppressive and austere environment.
It has now incorporated evidence-based design principles to support the healing and well- being of patients and staff.
Many mental health institutions shuttered in the second half of the 20th century.
This was the result of changes in psychiatric medical practice and theory, and the subsequent awakening to the abuses and mistreatment that too many patients endured.
These closures show that architecture alone is not enough to provide patients with high-level care and that we must continuously evaluate and improve based on changing needs and circumstances.
The demand for mental healthcare and services has increased substantially over the past several decades, and our current treatment modalities have lagged.
One way to catch up is to refocus our attention on the growing evidence demonstrating patients’ environments can enhance (or impair) health and healing.
More specifically, we recommend policy reforms across a range of design choices:
The latter is crucial, but should not come at the expense of patients’ freedom and dignity.
For example, while anti-ligature bathroom fixtures may reduce suicide, breakaway doors that provide little privacy should not be the default design direction for all patient rooms.
Accepting some risk means that accreditation standards and legal reforms should accompany the transition to biophilic designs.
Offering open-air, light-filled green spaces should be an integral part of patient-centred care.
Design rooms with windows that offer views of green spaces, trees, water or other natural elements to enhance the healing environment.
Provide opportunities and spaces for community engagement.
We must be careful not to repeat the voyeuristic practices of the past, but rather, cultivate opportunities for meaningful engagement, enjoyment and relationship-building.
This should help to balance tensions between patient autonomy, safety, well-being and cost.
This is in order to evaluate how, or if, institutional biophilic environments are advancing care goals.
Such systems should employ the methods of learning health systems – ones that integrate data and experience with external evidence and findings into practice.
We acknowledge that such changes won’t be easy; they demand a shift in thinking from risk management to prioritising health and well-being.
However, these are not mutually-exclusive goals as institutions like St Elizabeths and Sheppard Pratt have shown.
Ultimately, we believe that healthcare architectural and design decisions are ethical choices.
Healthcare designers, practitioners and policymakers should aim to create biophilic clinical spaces that enhance patients’ potential of recovery and healing, while also reducing clinician stress and burnout.
We encourage policymakers, payers and clinicians to recognise the built environment as a healthcare intervention itself – recognising it as a means of providing holistic, compassionate care.
Dr Meghan Crnic is a lecturer in the history and sociology of science and Dr Dominic A. Sisti is an assistant professor of medical ethics and health policy at the University of Pennsylvania in the US.
