The positive effects on the health and performance of human beings in response to biophilic design of the built environment have been verified by extensive scientific studies in different settings: healthcare facilities, workplaces, children’s spaces, community spaces, etc. The reflection on the principles of biophilic design is particularly interesting when it is applied to healthcare facilities. This is not only due to the high rate of critical and stress factors in hospitals for patients, their families as well as healthcare professionals, but also because the hospital and the city are two separate but interconnected systems, which are visited and used by the same individuals. This relationship is characterised by a certain exceptionality that is precisely due to the isolation of the hospital structure, which is essential to enable the medical practice. The shape of the contemporary hospital has evolved from its initial division into pavilions that almost created a city within the city, to the present-day single-block buildings. This form and organisation have been encouraged and homogenised in Europe since the 1930s with totalitarianism; one may think of the architecture of healthcare facilities during Fascism, in particular tuberculosis sanatoriums to deal with typical poverty-related diseases. These developments have led to the gradual standardisation of healthcare practices for citizens as an affirmation of a democratic principle that was gradually strengthened in Europe since the 1950s, with the introduction of welfare policies. At the same time, the hospital’s architectural design has undergone major changes since the second half of the 20th century. These are certainly linked to the role the hospital has in contemporary society, but also to the recovery of values that are no longer just quantitative and functional, contrary to what happened until the first half of the 20th century. These “new values” translate into a “humanised” vision of spaces that, together with the latest technological discoveries and new treatment and care protocols, influence design choices in contemporary hospitals.
In other words, the change in direction happens with the transition from functions to experience, such that the city and the hospital tend to become increasingly similar, not so much for the hospital structure approaching the urban forms but for the inverse process. Architecture and the city enter the hospital redefining the dimension of the hospital through a progressive introduction, in addition to the diagnostic and therapeutic functions, of commercial, informational and recreational features that have redefined the sense of space and the role of the institution in its territory.
One of the first examples of this trend was the Harlem Hospital Pavilion project in New York with the creation, promoted in 1936 by the Works Progress Administration, of murals that depicted the history of working and leisure activities of the African-American population (the African diaspora from 18th-century African village life to slavery in America to 20th-century freedom). The hospital, in fact, plays a catalyst role within the urban environment, strives to reflect the common culture and tries to recuperate it and make it compatible with its identity. It therefore reflects the characteristics of the space and time in which it is located.
What clearly emerges in the historical and social evolution of hospital design and its relationship with the urban space and the people living in it and passing through it is that the hospital is a privileged place of research to highlight not only the advancement of scientific and medical knowledge (and how these affect quality of life indicators), but also the change in the relationship between humans, the built environment and nature.
However, this is a slow and inconsistent process often determined more by far-sighted physicians and the management of individual hospitals, than by a shared and repeatable approach to space design. This scenario reflects the ever-increasing polarisation between large hospitals with highly qualified staff and specialised equipment, where, at the same time, it is often possible to obtain a comfortable environment for the well-being of patients; and small local hospitals that have limited operating and diagnostic capabilities and are only peripheral nodes in the public healthcare network.
As a matter of fact, in most cases, the design of modern hospitals is still geared towards defining spaces in which the only design goal is the precise definition of environments that ensure the proper operation of clinical and surgical procedures, and only in the best-case scenarios, efficient organisational and administrative functions. Hospital architecture often still reflects medical and healthcare practices from the past: these technically and scientifically complex environments are characterised by information asymmetry, which at the same time expresses and defines the relationship between doctors and patients; this asymmetry emerges from a system of temporal and spatial rules that often sees users confused and disoriented, in a state of psychological inferiority to healthcare staff and the care environment in general. At the same time, hospitals are a crucial element of the public healthcare system, both from an economic and organisational standpoint, and from a symbolic point of view, as recognisable institutions in the community.
In fact, since the days of Cà Granda di Filarete in Milan or of Brunelleschi’s Ospedale degli Innocenti in Florence, the hospital is not only an expression of the culture and sensitivity of designers, but also expresses a symbolic value attributed to it by the community that it is home to, which defines it as a monument, with a precise identity within the urban fabric. This symbolic value coincides with the functional and physical value given by the form, the materials and the internal order. After all, since as early as the Middle Ages, the life of the city itself has been revolving around the hospital in a mixture of religious, civil, ethical, political, economic and financial interests (Bevilacqua 2017).
The hospital remains a place that is not easily permeable to external culture, and despite the interventions of humanisation of spaces aimed at a broader hospitality and the process of interpenetration with the city, it is still a separate world in which the patient fails to fully perceive the organisational rules. At the same time, it is true that the interventions of humanisation have introduced the value of beauty and the recovery of the relationship between humans and nature in the architecture of the hospital, alongside the more economical and social factors. A beauty understood not as an end, from a Kantian perspective, but as an ethical way to allow the individual, as a temporary guest of the hospital, to accept the set of space-time rules that regulate it and be in an emotional condition that facilitates recovery and care (Tartaglia 2009).
A place perceived as dialogic, welcoming, understandable, aesthetically attractive and relaxing promotes the development of a greater sense of trust and activates a positive feedback to the information and the stimulations coming from outside. Stress factors for patients in therapeutic environments are generally related to the inability to control the surroundings, especially in terms of physical and organisational spaces and timings of the place of care. Other stress factors include the lack of privacy, the presence of unfamiliar and often disturbing or potentially anxiogenic sounds and noises, artificial lighting with a low comfort level, and intense environmental smells, which are often familiar due to the association in the lives of most people with the experience of illness.
Design has only recently started to adopt the patients’ point of view, considering not only their physical, but also their social and psychological needs; this has prompted interventions aimed at enhancing the physical, sensory and psychological comfort, improving wayfinding systems and increasing the clarity of the meanings communicated by space design.
Modifying hospitals’ design by humanising spaces and especially through reconnecting with nature offers a therapeutic support that can positively impact on the patients’ psychological and physical well-being; it can also improve their ability to recover, with varying results depending on the different levels of treatment (diagnosis, therapy, recovery) and on the disease in question. At the same time, space design can improve the efficiency levels of an organisation and contribute to economic benefits, both because the staff’s well-being increases, and because it reduces health-related costs. Rooms with plants (especially roses), natural ventilation and light, the sight of, and contact with, nature increase the staff’s productivity and organisational capability. These biophilic design choices also boost the activity of the parasympathetic nervous system, thereby decreasing stress levels and encouraging a general sense of well-being. By promoting staff’s health, biophilic design helps to reduce sick leave, while improving satisfaction and attention levels (Browning et al. 2012; Heerwagen 2000; Raanaas et al. 2011; Ikei et al. 2014; Nieuwenhuis et al. 2014).
Moreover, extensive research that is supported by rigourous empirical data has shown that the beneficial effects of biophilic design are not only found through architectural solutions that encourage direct contact with the external natural environment, but are also obtainable by inserting green or elements of biophilic design within the interior spaces. Such interventions, especially if integrated, allow patients to better manage their emotions, fears and anxieties related to disease. Positive effects have also been verified from the physical standpoint.
One of the earliest studies on the subject was conducted by Ulrich in the 1980s. From an analysis of the medical records of some surgical patients in a Pennsylvania hospital between 1972 and 1981, Ulrich noted that those who could see from their window a natural landscape had significant beneficial effects. In particular, patients with a room overlooking a green area had a shorter post-operation hospitalisation and lower use of analgesics compared to patients who were in similar rooms, but overlooking a built environment. According to Ulrich’s research, looking at greenery and nature reduces hospitalisation time by 8% (Ulrich 1984).
Subsequent international studies have confirmed that 95% of patients and families exposed to direct contact with nature reported lowered stress levels, more positive thoughts and increased coping ability (Marcus and Barnes 1995). In addition, plants in rooms and rooftop gardens in hospitals improve patients’ psychological response to treatment, with lower levels of pain, anxiety and fatigue (Park and Mattson 2008; Matsunaga et al. 2011). Fractal structures and, more generally, natural patterns and shapes instigate a reduction of stress levels due to the stimulation of μ-opioid receptors, which are responsible for pleasure (Biederman and Vessel 2006).
Natural light affects serotonin levels, inducing a lessened perception of pain in patients. A 22% reduction in the use of analgesics and a 21% drop in healthcare costs was observed. Moreover, natural light has positive effects on patients undergoing chemotherapy (Walch et al. 2005; Liu et al. 2005).
Several studies have also demonstrated that the use of natural materials improves the patients’ perception of environmental quality and their recovery from illness. This is because natural materials enhance visual comfort (as they absorb more light than they reflect), and have positive effects on olfactory comfort (for instance through essential wood oils), creativity, overall health and the immune system (Tsunetsugu et al. 2013; Li 2010; McCoy and Evans 2002).
The results of these research projects contribute to defining the concept of “humanisation” of hospitals as “a therapeutic practice that leads to looking at the patient taking fully into account the person’s integrity, encouraging his or her participatory and active role in the therapeutic path and in the social structure of the hospital” (Spinelli et al. 1994). The humanisation of hospitals therefore involves the design of interventions aimed at redefining the environment both with regard to the organisational and therapeutic aspect, and, more generally, to how the hospital is experienced by patients and visitors.
The Scottish painter, writer and landscapist Maggie Keswick was a great believer in the importance of attending to the needs related to the psychophysical well-being of patients, especially in the case of degenerative diseases. She was determined to make the experience of her own illness the manifesto of a revolutionary cultural change. In the last few months of her life, she worked with Frank Gehry to the design of the Cancer Caring Centers that now carry her name. In her view, the patient needs psychological support and therapies that can reduce and mitigate stress, in addition to seeking a cosy atmosphere, spaces full of light and contact with nature. The aesthetic quality of the hospital can therefore help patients to better endure their disease. Many archistars have designed Maggie’s Centers pro bono: Frank Gehry has designed the center in Dundee, Scotland, Zaha Hadid the Kirkcaldy Fife near Edinburgh, Roger Stirk Harbour and landscape designer Dan Pearson have conceived London’s Maggie’s Center and many more have been created in recent years.
What is striking in Keswick’s words is the narration of space and the surrounding environment. Hospitals can often go against the needs of their visitors: lighting from above (sometimes even neon lights), indoor spaces with no outside view and scarce seating, often placed along the walls and increasing the levels of mental and physical stress of patients (Jencks and Heathcote 2010).
However, biophilic design is much more complex than a window overlooking nature or the presence of plants in the waiting halls or inside the hospital rooms. Recently, 14 Patterns of Biophilic Design (Browning et al. 2014) identified a broad view of biophilic design tools and applications as well as opportunities to increase the health and well-being of individuals for the different care levels (stress reduction, cognitive performance and emotion and mood enhancement).
In particular, when it comes to biophilic design, it is possible to convey or promote different types of experiences within hospital spaces. According to Browning et al. the 14 biophilic design patterns can be organized into three categories to illustrate the enhancement of user experience and its biological responses, and potential impacts in different care levels: nature in the space, natural analogues and nature of the space. First, the direct experience of nature (nature in the space) that refers to real contact with nature in the built environment, such as the presence of natural light (positively impacted circadian system functioning, Figueiro et al. 2011; Beckett and Roden 2009), thermal and airflow variability (positively impacted comfort and well-being, Heerwagen 2006; Tham and Willem 2005; positively impacted concentration, Hartig et al. 2003), presence of water (reduced stress, increased feeling of tranquillity, lower heart rate and blood pressure, Alvarsson and Wiens 2010; Pheasant et al. 2010; Biederman and Vessel 2006), or the visual connection with nature for instance through abundance of plants and vegetation indoors or view of natural landscapes (lowered blood pressure and heart rate, Brown et al. 2013; van den Berg et al. 2007; Tsunetsugu and Miyazaki 2005).
It is also possible to conceive interventions aimed at facilitating an indirect experience of nature, referring to the contact with the representation or the image of nature or the exposure of individuals to particular patterns and processes that are typical of the natural world (natural analogues). This type of experience refers to the use of natural materials, the choice of colours that are typical of the natural world, the reproduction of natural forms (decreased diastolic blood pressure, Tsunetsugu et al. 2007; improved creative performance, Lichtenfeld et al. 2012).
Lastly, the nature of the space can affect the experience of patients and visitors through spaces and places. In fact, biophilic design can influence the relationship between the hospital environment and its users, producing positive effects on human health and the feeling of well-being. This can be achieved, for instance, through the use of perspective in interior spaces (which amplifies the perception of the surrounding space), while at the same time conveying a sense of protection (reduced stress, Grahn and Stigsdotter 2010). Other means to ensure patients’ comfort include the proper design of the organised complexity found in hospitals: due to their functions and roles, hospitals are by their very nature complex spaces; however, patients and visitors should perceive that they are organised in such a way that the options and opportunities available to them are presented in clear, understandable and consistent manners, e.g. by means of effective orientation and wayfinding systems that should ensure informative comfort.
Browning et al.'s classification of the nature-design relationship applied to hospital design provides a useful framework to understand how to best systematically integrate the individual’s experience into the design process and the benefits that derive from it.
However, the analysis of the relationship between the individuals and the hospital space must also consider a further pattern (Downton et al. 2016, 2017). Virtual connection with nature represents the pattern that can provide an increasingly immersive experience of nature, thanks to technological innovation that in the last few years has brought the use of advanced virtual reality (VR) tools to the consumer market.
Up to the present day, the main applications of VR envisaged in the medical domain concerned typically surgical training, post-stroke rehabilitation and the treatment of post-traumatic stress disorder. Ongoing studies aim at defining a methodology for integrating VR into biophilic design (including personalised options) in treatment settings (for example, in Italy the project Exploring the therapeutic benefits of biophilic design in hospital settings, carried out by ReLab and Fondazione Policlinico Universitario A. Gemelli, Rome, 2017). As a matter of fact, it is necessary to define and measure the positive effects of the artificial connection with nature and its processes on the patients’ well-being, depending on the various conditions, both with regard to distraction capacity, and pain reduction.