HEALING ARCHITECTURE FOR HOSPITAL

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School of Architecture
Delhi Technical Campus, Greater Noida
Affiliated to – Guru Govind Singh Indraprastha University Delhi

HEALING ARCHITECTURE IN HOSPITAL DESIGN

Submitted by: DIPESH ANAND
Enrollment no. 064181001613

Submitted to: AR.ANKUR TRIPATHI

Submitted in partial fulfillment
of the requirement for the Degree of
Bachelor of Architecture

Batch: 2013
Date: 11/21/2016

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ABSTRACT
Winston Churchill concisely expressed the effect of architecture and our surroundings with the
comment that: “We shape our buildings and later they shape us.”

The intent of this dissertation is to explore how architecture can inform healing or provide spaces
and events where healing can take place. We as human beings have an inner connection with our
environment by physical, mental, emotional and spiritual means. Healing cannot be understood in
isolation from the factors that operate in the dynamic life of an individual. These include the self,
the family, the community, the environmental context within which life is carried forth, and the
world of spirit or essence.
Furthermore, the arts and art therapy have, over the years, been used to heal different aliments
such as cancer, mental illness, aids, addiction and the elderly have been successful in doing so as
it heals across all ages and race. The question I pose is can architecture do the same? Besides,
can architecture play a superior role in healing? In our built environment we often interact with the
buildings themselves without knowing the fact of relationship between building and surroundings.
Can we create those interactions by evidence based design methods? This dissertation
summarize the principals of life enhancing role of architecture and planning in the healing process.
Through a theoretical approach including the history of healing architecture and the introduction of
architectural and anthropological theories, the project defines four main parameters that should be
included in the design of future spaces for social support: Functions that reﬂect the everyday life,
materials & textures with a homely atmosphere, importance of daylight in hospitals and details
with interior design in the human scale.
The study also comprises of case studies of two hospital which lies in Delhi NCR, india (1.
Medanta hospital , gurgaon 2. Fortis hospital , gurgaon ). Both the hospitals are multi specialty
in nature. This study includes the innovative solution for healing environment inside and outside
the hospital building through site planning , building planning , interior of the room , views, social
spaces such as waiting areas, atrium , corridors, food court , healing gardens , etc.

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ACKNOWLEDGEMENT

The Research Paper presented here would not have been possible but for the guidance &
support of
Ar. Tanya Gupta, HOD, School of Architecture for extending her support & valuable
guidance whenever wherever required.
DIPESH ANAND ,Guide & mentor for her/his relentless pursuit of high academic
standards, the can-do attitude & imbibing professional ethics have helped this project meet
high academic standards & professional working.
My parents who have taught me to strive for perfection in everything I do.
Any other person
And also my friends & colleagues who were always around to help me.
Appreciation & gratitude is owed to them.

DIPESH ANAND
Student
(_2016_)
Batch

Date - 12th december 2016.

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HEALING ARCHITECTURE IN HOSPITAL DESIGN

TABLE OF CONTENT PAGE NUMBER
1. Introduction 7
1.1 Preamble :- ( aim & objective , methodology and scope) 7
1.2 What is healing ? 8
1.3 What is healing architecture? 9
1.4 Historical background 11
1.5 Evidence - based design 12
1.6 Present and future of healing architecture 15
1.7 The future use group 15

2. Space for social support 19
2.1 Introduction 20
2.2 Public space elements (Edward t. hall and Gehl theory) 22
2.3 Homely atmosphere (sense of personalized environment) 22
2.4 Theoretical approach 34

3. Salutogenic design models 50
3.1 Antonovsky’s Theory of Salutogenesis 51
3.2 Alan dilani - psychosocially supportive design 53
3.3 Roger ulrich - theory of supportive design 57
3.4 Jan goelbiewski - neurology of supportive design 59

4. Precedent case studies 60
4.1 Fortis hospital , gurgaon , India 61
4.1.1 introduction 62
4.1.2 reason of this case study 72
4.1.3 Salutogenic design method and evaluation 73
A. Mapping out in relation to Antonovsky's sense 73
of coherence factor
B. Evaluation model in relation guidelines set through 88
study of Edward t. Hall and Gehl theory.

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TABLE OF CONTENT PAGE NUMBER

4.2 Medicity , gurgaon , India 92
4.2.1 introduction 93
4.2.2 reason of this case study 94
4.2.3 Salutogenic design method and evaluation 99
A. Mapping out in relation to Antonovsky's sense 99
of coherence factor
4.3 Analysis / interviews 110
4.3.1 interview
4.3.2 analysis

5. Conclusion 114

6. Bibliography

7. glossary

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1. INTRODUCTION
1.1 Preamble :- ( aim & objective ,
methodology and scope)
1.2 What is healing ?
1.3 What is healing architecture?
1.4 Historical background
1.5 Evidence - based design
1.6 Present and future of healing
architecture
1.7 The future user group

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1. INTRODUCTION
The overall aim of this research is to study the life enhancing design in hospital
architecture which increases the healing property of a building through architecture and
planning guidelines. The goal of such healing spaces are they can reduce fear , stress ,
tension and give relief for some time which actually results in healing of the patient. The
study has also been carried out to acknowledge the critical experience of patient , staff
and visitors in hospital buildings.
For detached spectators it seems obvious that, when building and planning hospitals, the
architectural environment surrounding patents, families and staﬀ , should support the
medical treatment in friendly welcoming and accommodating environments. However, the
majorities of our current hospitals are built on another foundation, and are often
considered the direct cause to stress, anxiety, frustration and generally longer
hospitalization due to the unsuited facilities and environments in today’s health care
system.
This dissertation is done to have a clear and comprehensive information on how to create
a healing environment in light of growing healthcare demand in India. The aim is to have
a humanizing architecture that can positively contribute to the healing process. It should
make the patient enjoy the best of bioclimatic comfort. Healthcare Design must also
satisfy professional requirements.
The physical environment of the healthcare facility should firstly do no harm and secondly
facilitate healing process.
1.1 Preamble :-
Objective - The aim of this research paper is to obtain an in-depth understanding of the
physical aspects in hospital design and how these physical aspects play important roles in
creating a healing environment. Other objectives of the present paper are:
• To acknowledge the critical experiences of patients, staff and visitors in hospital
buildings,
•Importance of daylight in hospital architecture,
• To outline the physical aspects in healing environment,
• To investigate the previous and current research available on the subject of health and
environment, design for healing and the effect of day lighting on human beings,
• To examine the elements of physical aspects of existing project brief of public hospitals,
•To study the need for social support during hospitalization,

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• To promote social interactions and support ,
• To promote homely atmosphere,
•Study the connection of building and nature.

Methodology - An extraction and assembly of the body of knowledge and on-going
research of healing environment in hospital design is apprehended in this paper. It is
intended to identify potential research areas on the physical aspects of healing
environment in future hospital design . Methodology employed in this research is literature
review, which is followed up by some architectural functional and planning design ideas.
The key findings will focus on the physical and social aspects affecting the hospital
environment which are the most pronounced influential physical factors affecting
bedridden patients.
Scope - The scope and the intention behind the design concept healing architecture is,
as described, not a new way of thinking, but is rather a continuation of earlier assumptions
that the surrounding environment, daylight, nature views and access, etc., had a healing
aﬀect on patents.
This research focus on recovery of the patient which reduces the rehabilitation time which
in turn reduces the stay time in hospitals. The research intends to change the mind of the
designer and improve the designing techniques used by the architect in designing a
hospital.
1.2 what is healing ?
Healing is the process of re-establishing harmony within the organism. Illness implies a
loss of this balance and the need for reintegration with the body’s natural ability to heal
and regenerate. Healing cannot be understood in isolation from the factors that operate in
the dynamic life of an individual. These include the self, the family, the community, the
environmental context within which life is carried forth, and the world of spirit or essence.
Healing is dependent on reestablishing successful relationships and developing reciprocity
between these factors. In fact, healing is not a process of curing or fixing, but rather a
return to balance between all of these components1. Health, therefore, is understood as
the presence of this balance; illness is its lack. Far from being inert containers, spaces can

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be understood to be fully participant in the healing experience. It is possible to conceive
and create structures that heal. Although materials, structure, and equipment are part of
this Endeavour, equal footing can be granted to the land, the natural world, the
community, our ancestors, and the spirit in all of this.

1.3 what is healing architecture ?

modern hospital + hermitage = future hospital

Hermitage - 1. Homely atmosphere
2. Connection to nature
3. Social structure institution
4.daylight factor
As introduction, the project will describe and define some of those terms used when
considering health care architecture, and according to the planning of future hospitals, the
concept healing architecture is introduced. For detached spectators it seems obvious that,
when building and planning hospitals, the architectural environment surrounding patients,
families and staff, should support the medical treatment in friendly welcoming and
accommodating environments. However, the majorities of our current hospitals are built on

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another foundation, and are often considered the direct cause to stress, anxiety, frustration
and generally longer hospitalization due to the unsuited facilities and environments in today’s
health care system. As a response to the current state of modern hospitals and as a weighty
tool in the discussion of our future health care settings, the term healing architecture has gain
ground. It is best described as a design concept, which represents the vision of encouraged
human well-being and healing influenced by well-designed architectural surroundings.
Thus we have explained an equation that says the importance of architecture in hospitalization
which reduces the healing period through its various examples given below:-
1. Homely atmosphere or hermitage -
 Authentic healing modalities
 Individual process
 Spiritual guidance
 Hermitage club spa - anti stress
 Hermitage workshops
 Yoga centre
 Meditation centre in nature
 Architecture of hermitage should be in relation to natural built environment.

2. Connection to nature -
 Nature window views
 Garden accessible to patients
 Nature art : no abstract at
 Daylight factor
 Internal courtyard connected to ward , patient room
 Quiet in the ccu (coronary care unit)
 Music during minor surgery
 Air quality
 Landscaped courtyard
 Floor to ceiling windows
 Therapeutic benefits
 Landscaped setback
 Front porch - (overhang may scale down the size of the building)
 Entry garden
 Plaza(include trees, shrubs, overall is not of green image , but of a paved urban plaza).

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 Roof terrace( potentials for expansive views).
 Viewing/ walk in garden
 Sound of water and attraction of birds to the fountain are particularly appreciated ( roof
garden)
 Roof garden for mood change
 Wide walkways outside patient rooms provide a buffer from garden activities.
 A covered patio style coffee shop provide and shelter for an outdoor eating area within a
garden.

3.social structure -
 Green lawn for social improvement in structure.
 Imaginative maze for children.
 Covered sitting terrace or patio within a nature surrounding.
 Single occupancy vs multi occupancy patient room study.
 Elements in the social dayroom.

1.4 historical background

In the 17th and 18th centuries, the dual emergence of scientific medicine and Romanti- cism
fortuitously combined to encourage the re-emergence of usable outdoor spaces in hospitals.
The intention behind the concept of healing architecture seems immediately obvious and
straightforward, and it seems rather strange that not all hospitals are based on these concepts
of integrating the architectural environment as support for the medical treatment. However, the
idea of a beneficial effect on patient’s healing process sup- ported by well designed
surroundings is not a new concept. In fact, these ideas may be traced back to thoughts and
ideas evolved in the 18th century. At that time, leading doctors and nurses proposed changes
in the layout and design of hospitals in order to reduce the danger of contamination by
designing smaller wards and increasing ventilation. Later these theories are followed by
Florence Nightingale, who in Notes on Hospital from 1859 published her philosophies and
thoughts of the supporting effect of aesthetic environmental settings for the patient’s physical
and psychological condition. In Denmark, the first public hospital is planned by request of king
Frederik V in 1752. At that time, the medical knowledge was underdeveloped and the
experience of building health care settings were naturally lacking. In the 17th and 18th
centuries, the dual emergence of scientific medicine and Romanticism fortuitously combined to

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encourage the re-emergence of usable outdoor spaces in hospitals. The notion that infections
were spread by noxious vapors spawned designs that paid special attention to hygiene, fresh
air, and cross-ventilation. The so-called pavilion hospital became the predominant form
throughout the 19th century. Two- and three-story buildings linked by a continuous colonnade
and ventilated with large windows marked the design of the influential Royal Naval Hospital at
Ply- mouth, England. Recommendations for hospital garden de- sign written by German
horticultural theorist Christian Cay Lorenz Hirschfield at the end of the 18th century uncannily
foreshadow the findings of researchers such as Roger Ulrich at Texas A & M University, who
documented in one study the healing benefits of a view onto vegetation for patients recovering
from surgery (Ulrich, 1984).

1.5 Evidence - based design
when architects , interior designer or any other firm wants to design hospitals they consults
politician or decision -makers regarding the new super specialty hospitals , all the issues
related to designing and physical spaces which enhance healing power of the building
through appealing and sensory design solutions, the term often we use " the evidence
based design'. an individual using this method makes his decision based on research
papers and evidence gathered from experienced client operations. an evidence-based
design should results in improvements to productivity , customer satisfaction and economic
estimation.
It was initiated on the basis of evidence-based practice and evidence-based medicine,
evidence-based design is linking the physical environment with better patent outcomes by
using the best current research evidence to guide design decisions, thereby moving towards
a new fundamental design process. (hamilton 2003 and ulrich et al 2004).
The extend of evidence-based design research is increasing. In 2003, more than 600
studies—most in top peer-reviewed journals—that establish how hospital design can impact
clinical outcomes.
The research team found studies that bond the physical environment to patient and staff
outcomes in four areas:
1. Reduce staff stress and fatigue and increase effectiveness in delivering care
2. Improve patient safety
3. Reduce stress and improve outcomes
4. Improve overall healthcare quality

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A basic requirement for the architect and the design team is to study or examine perfectly
the research data to have relevant and use of EBD results in a specific building project
followed by a re-contextualization before implemented in a project (Hamilton 2003 and
Hamilton 2004).EBD this way not giving answer related to hospital planning it just
documenting the influential factor of architectural environment ,which have a great influence
on our mind.
Evidence based design in healthcare architecture is not solely capable of ensuring future
well-designed hospitals even architects and planners play a crucial role in evolving the
process. as a requirement in current world and expectation by decision - makers , its an
obvious task for designer to explore more on this field to create future healing environment
for patients , staff and visitors.

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THE ARCADE AT FOTIS HOSPITAL , GURGAON

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1.6 Present and future of healing architecture

The idea behind the concept of healing architecture is not a new concept but is rather a
earlier explanation in more advanced techniques that the surrounding environment, daylight,
nature , views and access,.. etc. had a healing effect on patients. in todays planning of new
modern hospitals has shifted to patient-centered care and the well-being of the patients and
their families, attempting to balance the building codes , functionality and aesthetic
considerations.
Today we are building upon this rational thinking , however with a broadened mind.
evidence and science is no longer limited to medicine , they are also related to interior and
architecture of hospitals. Developed as an extension of evidence-based medicine, research
within the field of architecture and its eﬀect on patent outcomes is still gaining ground,
documenting the benefits of patents hospitalized in well-designed environmental settings
(Ulrich et al 2008 and Hamilton 2003). today most of the hospitals are build on EBD method
for increasing the healing power in our future hospitals.
Through EBD, various proofs has been found, that the sensory perception patents meet
during hospitalization have an impact on their experienced level of stress, and if high, this
will reduce the immune system causing higher level of infection disease and delayed wound
healing. This way, undue noise, interrupted sleep, lack of daylight and generally
dissatisfying environments, will all be factors that aﬀect the level of stress negatively.
(Frandsen et al 2009, Ulrich et al 2008, Francis 2002 and Horsburgh 1995).

1.7 The future user group

1.7.1 PEOPLE AFFECTED BY CANCER
When any patient is diagnosed with cancer, a range of arrangements and precaution are
made, usually the treatment is done immediately after being diagnosed. these treatments
are often performed while at home or hospitalized in the relevant surgical ward. suffering
severe symptoms then it is shifted to oncology ward for treatment.
The patients in our future hospitals are described as being more sick and weak than today’s
patients - due to enhancement of ambulant treatments and a general more eﬀective
procedure, resulting in faster discharges. (Juhl et al 2008 and Kehlet 2010) According to the
extrapolation of the expert panel, patents in future oncology wards, will this way only be
hospitalized in 2-3 days in average – typical through their most critical period of illness.
(Sundhedsstyrelsen 2010, Juhl et al 2008 and Danske Regioner 2008)

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with this elaboration of future patients, and the relative short period of hospitalization , it may
be argued, that the patient experience in hospital is not much of importance as compared to
medicinal approach . As such a logical conclusion that on the other hand would be a direct
continuation of mistaken arrangements of previous hospitals from 1960`s , with layout and
design not according to human scale, finally resulting in long duration of hospitalization and
hospital environment without sensory elements.
I believe that this is the time to stop counting patients as number treat them as humans and
patients, like everyone else , having social attraction and basic need for encouraging social
interaction. otherwise, we will simply build the same hospitals again and again.
The fight against the cancer is not solely doing research in medicinal treatments , but it is
required that what cancer does to a human being , its physical and psychological conditions.
Especially through several course of disease it is essential to have social interaction with
their closeness to feel safe and comfort in hospital environment.

1.7.2 Social relation influence on cancer

Health, and persons in a partnership have this way a generally better health than singles.
This may result from the positive inﬂuence by our close relationships, or may in
some cases directly related to the social and emotional support. (Zachariae & Christensen
2004) The human is generally a social creature, and our relationship with other people – our
social relations – is a central aspect of our life. The amount of social support that cancer
patients is experiencing, and especially the possibilities to discuss ones disease and
treatment with other cancer patients, is considered very helping in the stressful periods of
the disease. (Zachariae & Christensen 2004)
The diagnose of cancer generally cause depression , stress , tension , anxiety among the
cancer patient and their families. the risk of developing a profound depression is increased
due to isolated social spaces and lack of control over the situation. the patients are
experiencing upturn process of adaption in order to accept and understand the disease,
changed prospect, various treatment., etc. at that point of time social support is much more
of need to conquer depression and stress.

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1.7.3 Patients to patients

Cancer is a very difficult disease to handle and it is very much important to have social
support during these situations for comfort and support. other patient suffering from same
disease regard as a useful support for them, especially for increasing hope and belief. they
may are from different places, but they communicate in same language at that time (
Rasmussen 2003).
The solidarity with other patients may range from intense intense conversation and social
support to inspiration of other patient activities and actions. that's why patient don't feel left
alone with their disease. particularly at time of changed treatments social support from other
patient is proven useful.

1.7.4 Patients and their families

A serious disease cancer not only affect the patients but solely the entire family. Partners,
parents, children, close relatives are also implicated by the disease and long period of
treatment. As it is important that families facing same situation get socially interacted with
each other at equal status. in these forums , families can talk about the problems facing
them without influencing the patients. Families to cancer patents are experiencing a tough
psychical stress, but their well-being is rarely in focus. Depression, confusion, anger,
sadness and other negative feelings and emotions are often unavoidable consequences for
the relatives to a cancer patient, which may be overcome or reduced with increased social
support to the families themselves. (Hansen & Thastum 2005)

1.7.5 Social support in future oncology ward

Though we have stated that social support is very much of importance in treatment of
cancer in order to satisfy their mental condition. the main focus in designing phase there will
be patients themselves and the need of their families will be taken into considerations. there
will be such living areas in single patient room for the social interaction of their families so
that they do not feel that they are totally in medical staff .

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A current space for social support in medanta hospital , gurgaon

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2.Space for social support
2.1 public space elements
2.2 Homely atmosphere (sense of
personalized environment)
2.3 Theoretical approach

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2. SPACE FOR SOCIAL SUPPORT

2.1 INTRODUCTION

In chapter two of this research, hospitalized patient` requirement for social interaction and
social support has been identified. Day by day patient`s general level of stress and fear
increased not only due to changing pattern in disease. Also struggles to perform normal
activities like low level of visits from family and friends may occur a factor of fear. the future
planned single bedroom hospitals is furthermore increasing the rate of fear and stress ,
loneliness and the need of social support in hospitalization is playing a crucial role in future.
spaces for social support interlinked with hospitalized patients is much more important which
will enable knowledge sharing and diverts inspiration among the patients.
Social support in future hospitals is encouraged through social interaction that may vary in
different levels and variation. The social interaction can be done through informal meeting
which we experienced in our daily lives such as, we experienced in trains , mall, parks , gym
, city square, etc. and complete social relationships like we experienced in our homes in
safe and physically well being surroundings. Through these measures social interaction will
increase and knowledge sharing and inspiration with patient of equal status are potentially
responsive. The physical surrounding have potential to have ideal settings where common
areas are constructing both initial contact and developed social relationships. In this
contrary the social space may seen as intersection between a public space and a homely
environment. Usually our everyday activities are performed with our family and friends,
while in the hospital these simple familiar activities suddenly are occurring with unknown
people in a semi-public space.
If we improved these social spaces then the healing power will also get increased and may
even considered as an influential elements in regard to healing architecture. There are,
however, not found any specific EBD research that define detailed aspects in regards
to design and physical planning of these spaces. (Ulrich et al 2008) Instead, the project is
stating the thesis that by introducing architectural and anthropological theories, a more
thorough understanding of the human perception of space and even specific transferable
architectural aspects There are, however, not found any specific EBD research that define
detailed aspects in regards to design and physical planning of these spaces. (Ulrich et
al 2008) Instead, the project is stating the thesis that by introducing architectural and
anthropological theories, a more thorough understanding of the human perception of space

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and even specific transferable architectural aspects may be defined and incorporated when
designing social spaces with inviting, attractive and sensory aspects in future hospitals.

Lobby of American hospital in Dubai

Social spaces in future hospitals may be seen as an intersection between public
spaces and homely environments.
Social support during hospitalization is experienced in various levels of intensity. The need, the promotion and finally the
development of social interaction is the main essential steps towards the potential social support.

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Patent restaurant at Lund University Hospital

THE PUBLIC SPACE ELEMENTS
2.2 HOW TO ENHANCE SOCIAL ATTRACTION

2.2.1 PUBLIC SPHERE ENVELOPES THE PERSONAL SPHERE

In this chapter will introduce some of the general theories regarding social interaction and
human behavior in the public space that architects and designers has used until now when
planning and designing urban Scapes.
Giving the possible privacy with some social spaces are necessary and are stated as a
basic qualification of rapid recovery. But constant withdrawal and always keeping oneself to
oneself so as to be spared social contacts and confrontations is often one of the symptoms
of mental illness, and so care is concerned with developing the patient’s social capacity.
The social element also has to be gradually stepped up, but of course depending on
individual situations. The design of the physical environment, accordingly, must support the
individual patient’s gradual expansion of his / her personal sphere. from patient`s own bed to
open door to green or entering to another patient room and sitting down to such social well
being corner to talk. Moving out to the social green area , sit on a bench near green plants ,
having a cup of coffee. Meeting a relative in cafe`. Going on a tour of hospital visit. All these
activities get used to patient daily lives which never make them felt that they are hospitalized
or progressively widening the social context.
Elements in the social dayroom at Lund
University Hospital

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There we should shape the rooms, or shape “rooms within the room”, make small niches or
seating areas of varied character where people can “take a pew”. 14Normally speaking,
mentally ill persons have a larger bubble of personal territory. But the places created must
still make people feel encompassed and secure.
In pune "Mukthangan De-addiction centre" observed that patient rooms are placed near the
amphitheatre space near the natural elements like trees, sunlight and
gentle wind to heal their agitation. The language of making public activity inside the private
spaces are done also in Mukthangan
rehabilitation centre with the help of
well lit amphitheatre space in the
centre enclosed by rough wall to give
those agitated people a sense of
protection.
 social participation and elective
seclusion
 successive expansion of the
personal sphere
 parts with different degrees of
seclusion and publicity
 secure and intimate seating areas
on the fringes of the public zone

2.2.2 Call for social contact

Now I will discuss writings by architect and professor Jan Gehl and anthropologist Edward
T. Hall, in their theories described in Livet Mellem Husene (Gehl 2003), Byer for Mennesker
(Gehl 2010), and The Hidden Dimension (Hall 1973), respectively.
The call for social contact between individuals is a concept that covers many diﬀerent
variations, from simple unpretentious contacts to more complex and emotional
conversations and intercourse. (Gehl 2003). Jan Gehl defines in Livet mellem Husene
(2003), the various contacts by their intensity, where close relationships have great intensity,
and the passive and casual meetings have low intensity. From this figure (below), the public
space primarily represents the casual and passive kind of contacts, which compared to the
more intense contacts are considered modest. However, they stll possess great quality and
Mukthangan De-addiction centre, Pune by
Sirish Beri, Amphitheatre Space

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worthiness, as autonomous contact, or as the basis for more developed kinds of contact.
For instance, as maintenance of existing relationships, and especially as inspiration of acts
and activities, that other people are performing. (Gehl2003) If this basic social contact is not
obtainable, the boundaries between isolation and social contact are too pronounced, and
you are either alone or in binding connection with
others. The social contact on the low intensity scale is therefore an evident and important
possibility for persons to interact with others on a casual level, and perform as transition
between various kinds of contact. (Gehl 2003). The establishment of such common
attractive and inviting social spaces are very much required for day meeting to interact
socially patient with equal status for social support which enhances their knowledge about
such situation.
2.2.3 Activities in the public zones
In regards to activities in the public space, Gehl (2003) defines three types; essential
activities, optional activities and social activities – all with diﬀerent demands to the physical
environments. The essential activities which are performed they are regardless of the
physical planning of social environment , they are not in contact to such areas, this may be
the medical treatment.
Social contacts sorted by their intensity.

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The optional activities are generally those activities which are done when they are desired
and these activities are only seen if the physical environment are in proper condition. in
respect to this optional activities are common facilities, relaxing walk, informal conversations
,etc. however, if the public or the social space is not in proper condition then only essential
activities will be there.

2.2.4 Sociofugal and sociopetal spaces

The physical environment often performs a very specific character in regards to social
interaction also concerned anthropologist Edward T. Hall (1973). In the writing "The Hidden
Dimension", he refers to a research study performed by doctor Humphry Osmond, who
ascertained that some types of spaces, for instance waiting rooms in train stations had the
ability to keep people apart, while French cafes did the opposite and made people engage
interaction. He defined the arrangements that discouraged social interaction as sociofugal
Activities in the public space is depending on the quality of the physical
environment.

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spaces and the spaces that encourages and enforces the development of interpersonal
relationships as sociopetal. Meanwhile Osmond had observed in his psychiatric ward
apparently patient wee talking less to each other after such change in arrangement of
furniture in such a sociopetal arrangement, the social interaction increases in that same
ward. When designing future hospitals we should keep in mind the statement of Edward
T.Hall and change can be made through such small arrangements which can change
sociofugal spaces to sociopetal spaces. Layout of furniture plays a very crucial role in
enhancing the social interaction suppose if the chairs are placed back to back then the place
automatically turned into sociofugal spaces. however, if the layout of the chairs are
immediately changed they are face to face then the place changes to sociopetal spaces.
In some occasions the sociofugal setting would be preferable, for instance when studying or
reading, and what is considered sociofugal in one context might even be sociopetal in
another situation depending on the occurring activity and the people involved.
The challenge for the architect is consequently to design spaces with accordance between
the physical space and intended function and to maintain diversity between the
diﬀerent spaces in order to give people the choice for social interaction or privacy depending
on the circumstances and their own state of mind.

2.2.5 Detail designing

Small detail of furniture arrangement can change the character of the space , if prioritized by
an architect, social spaces of the future hospitals can be improved.
In regards to the human interaction in public spaces, this is best unfolded on the horizontal
level, where it has a rather large area of function. On this level, the social visual field is
capable of intercepting other person’s features and mood in distances up tll 20 meters, and
in shorter distances (1-3 meters), where we normally perform social conversations, our
visual senses are supplemented with other senses in order to form a general impression of
the person we are talking to. (Gehl 2003) Hall (1973) defnes very precise personal
distances, where 0,45 – 1,30 meter describes the close social contact between family
members, for instance around the dining table. Distances between 1,30 – 3,70 meter is
defining the more public social distance between friends, colleagues, etc. and is usually
seen in comfortable seating arrangements. These personal distances inﬂuence many details
in the planning of social spaces, and for instance this aﬀects the sizes of tables. If too small,
two patents not knowing each other, would most likely not sit at the same table, as their

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intimate distance would be violated. Too large tables however, may make it difficult for
patents to talk together across the table. Studies through the design phase are to consider
these aspects in order to develop social spaces where patents find it natural to meet and
engage contact.

Through other studies of human behavior in public spaces, Gehl (2003) argues, that the
social activities has its own self-prevailing effect, where human actions attract attention and

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thereby more people. These studies show an instance , that the use of benches are
depending upon their orientation , where those situated where more human activities are
done neither in quite green environment. (Gehl 2003) As well as the sizes of furniture the
orientation and layout also have significant importance in regards to use and social
interaction.
Finally, the placement of furniture in the room is noticeable, where seating environments
along with the inner facades of common open spaces or in the transition zone between two
areas usually are preferred. In these places ones individual exposure is limited, and it is
easier to create an overview of the surroundings and to feel comfort in these situations.
(Gehl 2003)

.Piamo Sanatorium, Alvar Aalto, View of Lounge room with special
furniture

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Shri. Siddhivinayak Ganapati Cancer Hospital

Location: Miraj, Maharashtra, India
Project Work Status: Completed Projects
Project Completed: 1997
The main idea behind the project was to create an environment that does not convey the
conventional, dull, dark, smelly and confined ambiance of a typical hospital. Good light,
ventilation and a lively open interaction with nature became the paramount criteria. The
hospital building is well illuminated and ventilated, incorporating plants and landscaping to
bring about colorful, bright, soothing and reposeful mood. The landscaping and building
have thus somewhat therapeutic value.

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2.3 THE HOMELY ATMOSPHERE (SENSE OF PERSONALIZED
ENVIRONMENT)
HOW TO DEVELOP SOCIAL INTERACTION

As concluded, my research is that spaces for social support in future hospital environments
is defined as an intersection between the public space and physical environments with a
comfortable, homely atmosphere - a social place, where patients engage meetings and
social interaction, thus enabling social support.
The first step towards social support is consequently for the patients to meet each other,
which may include the theories of Gehl (2003 and 2010) and Hall (1973), described in the
previous chapter ‘The public space - how to promote social interaction’. The next step is to
develop this initial social interaction to intense level, and this process is believed to require
specific demands of the physical environment. In our daily life these levels of superficial
conversations are usually performed with our families or close relatives in safe and familiar
surroundings. (Rasmussen 2003) When hospitalized, the family contact may be reduced
(Ulrich et al 2008) and the environment today is often characterized by institutional settings
– far from familiar and well-known. Hence, the two aspects that form the basis of this social
interaction and support in our everyday life are apparently not present today.
From architectural point of view it is very difficult to raise the visits in patients room. instead,
other patient and staff can act as a family member at that point of time may be even for
better social support in some health related issues.
In hospitals patient are confined to such environment where the general freedom of choice,
is strictly limited. However, the things concerning the social interaction and the allocated
social spaces do not necessarily have to be so diﬀerent from the spaces we recognize from
our daily life and our own homes. By changing the design of hospital dayroom of patient to
an inviting , familiar and homely environment recognizable for the patients leads to better
social support.
The question remaining is how this home feeling and homely
environment is defined outside home?

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2.3.2 Feeling at home

Home is by the anthropologist Mark Vacher (2006) defined as a connection between a
human being and a physical object. This object is usually a building, although more
primitive units also perform as homes with the same psychological characteristics.
A home is personal and intimate, and not something you can buy. When we talk about
houses we are capable of describing them without mentioning the people living there but
when we describe a home it always belong to someone. (Vacher 2006) Houses are not
only frames for people, people are framed by houses and the things they harbor, at the
same time as people project their own emotions, dreams and hopes onto the things and
the spaces that constitute the house.
That our homes are personal is exemplified by Sjørslev (2007), who define a building as
a house as soon as someone moves in, although this house is not a home until it is
personalized and the resident have supplied his individual touch. Our home is therefore
filled with personal objects, memories, heirlooms, etc., and even though our daily use of
these objects may be of functional or aesthetic character, the sentimental value often
exceeds the functional value by far. (Sjørslev 2007)
kitchen and dining area in typical room

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Finally, the details and arrangement of furniture should reﬂect a homely environment.
The size of the room, furniture orientation and the room accessories like artwork,
greenery, light fittings, etc. are important aspects that should be incorporated and
considered along with the design of the space, in order to design a holistic social space
facilitating social interaction and support.

2.3.3 Home outside Home
Future social spaces with a familiar and homely atmosphere by implementing some
fundamental characteristics derived from our homes and everyday life. One of these
characteristics is the activities and potential functions of the room. Today many of the
daily activities and routines in the hospital are performed without involving the patent,
where for instance meals are planned in advance, cooked in large industrial kitchens and
served at certain times. Another essential characteristic related to the homely
atmosphere is believed to be the materials and textures of
the dayrooms. Today these rooms are often marked as institutional and are often
decorated and furnished as the bedrooms, hence the distinction between the dayroom
and the rest of the hospital are often immaterial. The materials used in today’s hospitals
(wood, fabrics, textiles, colors, etc.) May be the same as we use in our own home but the
way they are used have very diﬀerent conceptions. Textiles are for instance a material
that is used rather carelessly, and does not
derive the potential as we experience in our
domestic environment. At homes the textiles are
applied for curtains, cushions, blanket,.etc all
adding a tactile perception to the material, which
imply comfort and coziness to the space and
experience. Today this critique may be noticed in
many hospitals, as the high restriction in regards
to hygienic and durability demands have
excluded nearly all tactile materials, including
textiles, from many applications. However, recent
research and development in smart textiles is
improving the potential use of textiles in new
recognizable ways in future hospital
A private space in the sun at Maggies
London

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environments, where the use of tactile and sensory materials, like textiles, would be
possible to implement with great beneficial value. Finally, the details and arrangement of
furniture should reﬂect a homely environment. The size of the room, furniture orientation
and the room accessories like artwork, greenery, light fittings, etc. are important aspects
that should be incorporated and considered along with the design of the space, in order
to design a holistic social space facilitating social interaction and support.

Summary

The homely atmosphere in future hospitals may be difficult to define, as our home is
usually very personal and individual and therefore impossible to transfer directly to
a health care environment. However, it is the research of this project, that by
implementing three fundamental characteristics of our home and everyday life, including
functions; materials and textures and details, it is possible to create a more homely
atmosphere in the social spaces, than we experience today. This atmosphere is
considered beneficial for the more developed levels of social interaction and social
support, as the conversations in safe, comfortable and homely environments are
believed to be more outspoken and emotional than the acquaintances in the regular,
standardized and clinical dayrooms we experience today.
Textile use in a lliving area of single patient room,
fortis hospital, gurgaon

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2.4 THE THEORETICAL APPROACH
HOW TO ACHIEVE SOCIAL INTER ACTION AND SUPPORT

Appealing and attractive spaces for social interaction and support in future
hospitals are depended on the surrounding architecture and the detail of the
physical design, seems easily accepted through evidence-based decision
maker, urban planners and anthropologists if the environment is not providing possibilities
for social activities, there will not be any interaction between patients-hence no social
support. The architectural eﬀects described in the previous chapters, will in this chapter be
compiled in three guiding subjects, including functions (1); materials and textures (2)
and details (3), and through a translating description, their aspects are defined in
regards to the context of hospitals. This theoretical approach will define the main visionary
guidelines for the design phase of this project as well as form the basis of the evaluation
model used in the later following case studies.
The theory described by Gehl(2003) and T.Hall (1973) states that people attracts
people, if the social area remains unattracted then physical environment remain
empty all the time. When patents or their families have engaged social interaction,
maybe through the attractive functions, they should develop these contacts, which call for
spaces recognizable from their own home, partly achieved through a mix of functions –
reﬂecting the everyday life. Following the ideas and theories of the described
anthropologists, the materials and textures should overall assist in creating a familiar,
sensory and homely atmosphere. The final aspect considered as one of the main
guidelines for future social spaces are the details and interior planning in human scale,
concerning scale, personal distances and sociopetal spaces. Often small details change
the way
we experience a room, and some of the main physical elements in today’s hospitals, like
acoustic ceiling sheets, integrated artificial lightning, vinyl ﬂooring, etc. are only
supported by the details of for instance coﬀee serving, greenery, arts and furniture, all
together defining the social space as institutional, inhuman and basically unfit for social
interaction.

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2.4.1 FUNCTIONS
REFLECTING THE EVERYDAY LIFE
We often see uninspiring and unattractive spaces in hospital which is not used by
the patient. Above all , patient should have choice between social and private
space, ideally a gradual transition between them. Private spaces may appear in
single room but a new concept is needed to get complete framework of common
spaces and dayrooms in the future should appear social. This social aspect may derive
from inviting, attractive and socially obvious functions performed by patents and their
families in the common areas of the patent ward.
Accordingly, the specific programming of the common spaces in future hospitals is
essentially important to design very deliberate. Firstly, the patients should engage
acquaintances, through a process that may be compared to the human interaction in
public spaces or the small talks with our neighbor in the front yard. In a future patent ward
these informal meetings may occur in the common dayroom or even in natural ﬂow
intersections and recesses along the hallway. Secondly, the patents should develop these
initial relationships, through deeper conversations and social interaction, which may cause
for more recognizable and familiar settings, reﬂected in the patents’ everyday life. When
considering functions in the common spaces, these might actually be quite parallel to the
activities performed in our daily life and the planning of a patient ward may
even be compared to a regular single-family house having rooms for: conversations and
drinking coﬀee in the living room, relaxing in the lounge area; dining around the kitchen
table; simple cooking in the
kitchen; entertaining around
the television, etc. By
introducing these social
activities in new-designed
patent wards, and by making
them optional and inviting for
both patients and their
families, spaces for social
interaction and support are
believed to have improved
conditions in future hospitals.

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2.4.2 MATERIALS & TEXTURES
FAMILIAR AND HOMELY ATMOSPHERE
Besides reﬂecting the everyday life through planned activities and programming of the
social spaces, materials and textures also have significant inﬂuence on the way we feel,
act and interpret the room, and should reﬂect the familiar and homely environments we
are accustom ed to from our own house.
A deliberate choice of materials for any room, i.e. the visual surface and the tactile
perception, are often under prioritized in many projects, and in health care architecture,
the high demands for hygiene, cleaning and durability are usually decisive factors when
considering materials in both bed rooms and common areas. Consequently, the
spaces often appear clinical and institutional, with standard equipment and furniture,
acoustic ceilings, white plaster walls, etc. As regards to social interaction, these spaces
are predicted to limit the potential, as the patients will adapt their behavior to the
institutional surroundings with no conclusive benefit for engaging social interaction and
social support. Today human qualities are competing against hygienic standards and
general call for durability, and the predominant challenge for the health care architect is
therefore to balance between the homely expression and the rational clinical demands,
keeping in mind that the close compromise may determine the success or failure of the
spaces for social interaction.

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2.4.3 DETAILS
INTERIOR PLANNING IN HUMAN SCALE
"In context of EDWARDT.HALL(1973)and GEHL(2003)"
Small details may change our use and perception of any space rapidly, and if only
prioritized by the architect, spaces for social support may be improved significantly in
future hospitals. First of all, the overall scale of the room should be familiar in size and
easy to overview if more personal conversations should take place, and even in regards
to dimension of the furniture, Hall’s (1973) theories regarding social distances may be
implicated. Smaller tables will for instance force patents to sit within their intimate
distances (0,45 – 1,30 meter), which may be advantageous for deeper conversations and
social support. However, if the patients do not know each other yet, the small table and
intimate distance may be an unconscious limitation for patients to join an occupied table,
and the patients will then never engage important initial contact. The design of details and
furniture should therefore contemplate the intended social concept in the common areas.
In this regard, Gehl (2003) is furthermore describing how the placement and orientation of
furniture in public places inﬂuence the specific use. Seating environments along the
perimeter of the room is usually preferred, where the individual exposure is limited, and it
is possible to create a comfortable overview of the surroundings. Details in the orientation
of the furniture may even define the social status of the room, where a face-to-face layout
facilitates a sociopetal behavior and the back-to-back arrangement is creating a
sociofugal, private space. Ideally the patent ward should provide both private spaces
(sociofugal), passive observational spaces and social spaces (sociopetal) - although not
necessarily in the same room. (Hall
1973). Today, details like light
fittings, acoustic regulators, blankets,
cushions and other equipment are all
details. However, by bringing focus
to these significant details as well,
the future design for social spaces
may become a holistic design
solution creating a homely and
inspiring atmosphere promoting
social interaction and support.

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2.4.4 THE LITERATURE STUDIES (secondary study)
In order to visualize the substance of the parameters (functions, materials and textures,
and details), defend in the previous chapter, three various case studies will in the following
chapter be described and evaluated based on the analysis form stated below. The overall
thesis of this project defining the future spaces for social support as an intersection
between the public space and the homely atmosphere is the overall basis for
choosing three individual cases for analysis and comparison. Secondly, the cases are
selected depending on the patent’s/person’s motivation for attendance, which follow the
three guiding needs defined in Maslow’s hierarchy pyramid (Poston 2009). The basic needs
as exemplified in a hospital (case 1), the psychological needs is exemplified in a cancer
caring centre (case 2), and finally the self-fulfillment needs which is exemplified in a high-
end gourmet restaurant (case 3). To summarize the chapter of the wide-ranging case
studies, a concluding compilation will define the common relevant guidelines for the design
phase.

CASE 1 - LUND UNIVERSITY HOSPITAL

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CASE 1 - LUND UNIVERSITY HOSPITAL
CASE 2- HEJMDAL
CASE 3 - RESTAURANT GERANIUM

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2.4.4.1 CASE 1: LUND UNIVERSITY HOSPITAL
KAVA - SURGICAL EMERGENCY DEPARTMENT
Lund University Hospital is placed in Skåne, Sweden as one of the larger regional hospital
with 980 beds. The basis for this case study is the surgical emergency department
(KAVA) with 24 beds and 4-500 patients per year hospitalized for 48 hours in average.
Patents in this ward may be compared to oncology patients in regards to medical/surgical
treatment and their general physical condition and mobilization. The ward consists primarily
of multi bedrooms, where the beds are separated with curtains. When this specific ward is
chosen as hospital case, it is due to the recent modernization and remodeling performed a
few years ago in connection with transferring the ward. Here one of the focal points, among
others, was new arrangements of social spaces. The recent buildings are constructed in
1968 and is today causing problems with the physical surroundings in regards to patient
treatment and human healing condition. When the ward was chosen to move to another
ﬂoor, staﬀ was given the possibility to rethink the interior layout and organization of the
ward without changing the main construction. Nurses and other members of staﬀ initiated a
process, where future requirements, visions and ideas were discussed and planned for the
new settings. The intention of improving the social spaces was strong, and the fact that it
was even a focal point in the nurse’s vision for a future ward shows appreciated awareness
of its importance. The base in the new dayroom is the staﬀ operated ward kitchen, where
the meals to the entre ward are finalized (after being brought to the ward precooked from a
central). Staﬀ is consequently always present in the room performing a homely activity (in
regards to cooking and not the method), and brings life and atmosphere to the space.
Concurrently, the
kitchen o ﬀers
snacks and drinks
directly from the
kitchen counter, and
mobilized patients
can always get
something to drink
and eat directly from
the kitchen – like in
their own home.
The general use of Dayroom in the KAVA ward (Surgical emergency department). The social space is
placed at the end of the blind corridor leading to the patent bedrooms.

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materials and textures indicates a clinical environment with institutional furniture, vinyl
ﬂooring and acoustic ceilings. Complimentary, there are single specific elements like a fruit
basket, freshly brewed coﬀee, biscuits served in glass jar and blankets in the lounge area
that attempt to drag the room towards a more homely
atmosphere. Along with the kitchen function these small details actually do support the
domestic feeling of the dayroom with added features that may revive memories from
the patients’ everyday life. However, the first impression and the overall experience of the
dayroom as clinical and institutional is still predominantly. The intention of making the social
space homely is noticeable although it lacks in completion of the commenced ideas, and a
deliberate holistic approach towards creating social spaces in future health care
environments are still needed for perfection.

FUNCTIONS
What are the options for residence?
The dayroom is considered the primary place
for residence outside the bedroom, although
there are some smaller furniture
arrangements in the hallway itself. These are
not used during the observation, and they
seem to be placed randomly in the busiest
place of the hallway next to the elevator and
with no seclusion from the semi-public
corridor space.

What are the optional functions?
Besides reading and watching television as
entertainment, the primary activity is
relaxation in the lounge area and dining at
the tables. Secondly, the ward kitchen is an
integrated part of the dayroom, and it oﬀers
self-provide able snacks at the ward buﬀet
and the kitchen counter - patents have no
access to the kitchen itself.

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Does the functions in the
social space invite to
participation?
At the time of observation
(between breakfast and lunch),
there were only a few people in
the room, however occupied for
longer periods. There was
consequently only little social
interaction – maybe because of
diﬀerent activities (snacking at
the dining table and TV
entertainment in the lounge
area). As the functions are
considerably simply there seems to be moderate possibilities to join in occurring activities,
although it may not be inviting as such.

MATERIALS AND TEXTURES
List and short description of used
materials, textures, furniture?
Walls are standard white walls,
ﬂoors are grayish vinyl and
the ceiling of white acoustic panels
with integrated lightning – the same
as the rest of the ward (although
change of color in ﬂoor vinyl); The
kitchen is closed off for patients
due to hygienic demands and
consists of steel and white laminated
surfaces; Furniture in the dining area
are wooden dining tables and chairs
with steel frame and wooden seating; Furniture in lounge area of wooden tables and
armchair and a couch with wooden frame and textile covered cushions.

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How is the room
characterized by materials
and textures?
In regards to materials and
textures, the room is considered
quite institutional, as the vinyl
ﬂoor and acoustic ceiling are
predominant. The furniture in
the lounge area have textile
covered cushions although the
dominant wooden frames and
general design of these are
institutional recognizable.

Are the use of materials and
textures consistent and
deliberate?
The furniture in the lounge area,
kitchen area and dining
area is varied, although it does
not accentuate any stories
or define a consistent use. The
materials in the dayroom
are not distinguished from the
other areas of the hospital, and it
may be diﬀerent to tell the
diﬀerence between v arious
rooms. In general the materials
and textures seem chosen and
applied haphazardly, and there is a overall lack of homogeneity and deliberateness in the
hospital in this regard.

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DETAILS
Scale and partition of the
room?
The main dayroom is large in
scale although with specifically
defined partitions, and the
room is consequently
experienced domestic in scale.
The kitchen area is by a
counter closed oﬀ towards the
patent zone and is physically
separating the room in two.
The patient area are sub
organized in a lounge area and
a dining area of two tables.

Furniture and distances?
The lounge area is furnished
with a 3-person couch and
two armchairs surrounding an
oblong coﬀee table. In scale
it is recognizable from private
homes and the multiple
seating options provide
alternatively choice regarding
social distances; The dining
area consist of two tables with
4 and 6 chairs respectively.
The 6 person table is placed
in the perimeter of the room in
front of the window. The table
for 4 persons is placed in the middle of the room and is not used during observation.

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Other details?
Specific details are worth
mentioning as room accessories
including a fruit basket and
containers with biscuits in the
kitchen area, as well as the
blankets in the lounge. The
intention of making a homely
environment is remarkable,
although not quite succeeded.
The overall impression of
the room is due to the general
use of materials still significantly
institutional and it takes more than just small details to define attractive and welcoming
social spaces.

CONCLUSIVE REMARKS
Lund University Hospital is a case illustrating the good intention of improving the social
spaces in the existing hospital wards. It is a significant progress just to call attention to the
problem of unfulfilled common areas, and with the enhanced focus from the staﬀ, some
hospitals are taking the lead – and in Lund with various success. The fact that a fair amount
of square meters are dedicated to the dayroom is positive, and the room even has some
small elements, where the intersection between the homely atmosphere and the public
space is combined - although not convincingly enough. The room is still experienced quite
institutional, especially expressed by the overall materials like vinyl ﬂooring and acoustic
ceiling sheets, and the lack of tactile and sensory elements. The idea of letting the kitchen
be a central part of the room is in general good and even recognizable from our own home,
but the fact that it is closed oﬀ from the patients may instead work as an amplified reminder
of hospitalization? The kitchen table towards the patent area, is however a self-service are,
which share familiar elements, although the freshly brewed coﬀee, which is chosen for
its homely character, instantly turn institutional when being served in 3 liter coﬀee pot with
stacked industry cups. The small details could easily have been better thought through, and
why should the patients not have access to a smaller part of the real kitchen themselves?

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In general the dayroom in Lund meets many of these adversative examples, where the
intention lacks completion due to small details that easily could have been improved
if they were only in focus. The room is therefore experienced as institutional even though
some positive elements do exist, and the future design of these spaces needs a
more holistic approach towards material use and the general perception of space.
Compared to the other dayrooms experienced in Lund University Hospital, the KAVA ward
is indeed a consolation. On the ﬂoor below the dayroom is a 15 m2 room in the middle of
the building envelope with no windows and natural lightning, and consequently it seems to
be empty most of the day. The spaces for social support in future hospitals should, in
regards to design and planning, be more holistic and well considered, than it is experienced
in Lund.

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3. SALUTOGENIC DESIGN
MODELS

3.1 Antonovsky’s Theory of Salutogenesis
3.2 Alan dilani - psychosocially supportive design
3.3 Roger ulrich - theory of supportive design
3.4 Jan goelbiewski - neurology of supportive design

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3.1 ANTONOVSKY’S THEORY OF SALUTOGENESIS
In contrast to the traditional study of the sources of disease, known as pathogenesis,
Salutogenesis is an approach to medical treatment and healthcare that focuses on the
origins of health. It was developed in the late 1970s by Aaron Antonovsky, a professor,
researcher and medical sociologist who was interested in answering the question of how
most people manage to live relatively healthy lives despite being faced with disease,
emotional and physical stress, social struggles and other challenges: “Given the ubiquity of
pathogens—microbiological, chemical, physical, psychosocial, social and cultural—it
seems to me self-evident that everyone should succumb to this bombardment and
constantly be dying” (Health Stress and Coping ). He wrote: “the question then becomes
not how some concentration camp survivors or poor people manage to stay healthy, but
how any of us manage to stay healthy—the question of Salutogenesis” . By shifting his
focus from disease to health, Antonovsky began to develop a systematic research
methodology with a focus on what promotes health, as opposed to what causes disease.
Finally, Antonovsky was concerned that the pathogenic approach implies a dichotomous
relationship between health and disease; that is, a patient is healthy in the absence of
disease. This idea precludes the possibility of disease and health being interrelated,
simultaneous and multi-dimensional conditions. In the 1990s, architect Alan Dilani
suggested that Antonovsky Salutogenic approach be applied not only to medical treatment
and research, but also, to the physical design of healthcare facilities as a means to promote
health. He suggested the use of Antonovsky theory to create Psychosocially Supportive
Design, a theory and framework that promote health through the design of the physical
environment. In order to understand how Salutogenesis can be applied to design, it is
necessary to identify some key concepts of Salutogenesis, the most notable being the dis-
ease/ease spectrum, the relationship between stress and tension, the role of personal and
social resources that one has available—or as Antonovsky calls these, Generalized
Resistance Resources—and sense of coherence. Antonovsky placed health and disease,
or ease and dis-ease, together on each end of a continuum.

He defined the health ease/dis-ease continuum as a: “multi-faceted state or condition of
the human organism” . He emphasizes that Salutogenesis is not about making a sick
person well, rather it is about identifying their location on the continuum, and mitigating the
stress that may move them towards the dis-ease side . One of the key defining
characteristics of the Salutogenic model is what Antonovsky refers to as a sense of
coherence. He defined sense of coherence as: “a global orientation that expresses the
extent to which one has a pervasive, enduring though dynamic feeling of confidence that

(1) the stimuli derived from one’s internal and external environments in the course of living
are structured, predictable and explicable;
(2) the resources are available to meet the demands posed by the stimuli; and
(3) these demands are challenges, worthy of investment and engagement”

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According to Antonovsky the strength of one’s sense of coherence is
determined by three key factors: comprehensibility, manageability and
meaningfulness (Table 1)

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3.2 ALAN DILANI - PSYCHOSOCIALLY SUPPORTIVE DESIGN

In the 1990s, architect Alan Dilani, proposed that Antonovsky’s principles be applied to
the built environment, specifically to the design of healthcare facilities. Since then,
Dilani and many other architects, designers and theorists have begun to further explore
Antonovsky’s theory and to approach architecture, interior and urban design through a
Salutogenic lens,.
Alan Dilani conceived this idea to promote health “The Psychosocially Supportive Design
approach is offered as a useful theory and framework to guide healthcare designers and
planners who consider how the physical environment impacts wellness factors in order to
promote health”. According to him Salutogenic design not only identifies the cause of stress
it can also introduce the wellness factor that can strengthens health. “The theory suggests
that we not only design for stress reduction, but focus on salutary rather than risk factors”.
Based on his vast research he created a list of design qualities that he argues strengthen
an individual`s sense of coherence.

(Table 2) lists these attributes and categorizes them based on Antonovsky’s sense
of coherence factors.

This includes the designers and developers, as well as the doctors, staff and possibly the
patients and their families. If the entire team understands the impact that design has on a
sense of coherence and in turn on the success of a project, they may be more likely to
support the design process and to encourage the upkeep of the facilities. “The organization
should measure the sense of coherence; the staff should comprehend it and act on it”

3.2.1 Psychosocially supportive design
The quality and character of the designed environment should be considered to be a
powerful instrument capable of improving and strengthening health processes. The
question how health care environments could promote the patient’s health should be a
major issue for designers and planners. Since the new care philosophies (Salutogenic
based perspective) involve both the human body and its psychosocial context the
interaction between the nursing staff and the patients will become increasingly important in
the future.

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One of the conditions for health promotion in hospitals is to create an organization that
provides the major parts of care services as close to the patient as possible, within the
patient’s familiar environment. An emphasis on patient-focused care presupposes a
different building structure, as it requires a decentralization organization. Instead of the
traditional grouping structure the new model for RIT 2000 (University Hospital in
Trondheim), in Norway, has been organized around the patient and his/her disease. The
planning for RIT 2000 has broken important new ground by integrating and extending
concepts such as a patient-centered care philosophy and environmental design, and multi
disciplinary care teams.

Traditional wards where the staff is based somewhere in a room far away from
patient rooms will disappear. In modern wards, there will no longer be a nurse
station but a centrally placed workstation, which is easy to reach, and where the
staff is always available.
From there, the staff should be able to survey and watch a group of patients within a very
short walking distance. This arrangement is called a “cluster”. A ward can consist of two or
three clusters which can easily be coordinated and flexibly used depending on the patients’
demand for care. Communication and contact between staff and patients is made easier in
this way, creating a feeling of security for both staff and patients.
Research has shown that access to nature, daylight and other wellness factors like art and
music can result in the patient using fewer drugs and spending less time in the hospital.
Nature can affect our emotions positively. It can easily catch a person’s attention or interest
and in turn can stop or reduce anxiety while bringing about desirable psychological
changes. It can reduce blood pressure, ease pain and stimulate our senses positively.
An increase in the consideration of wellness factors within design could have beneficial
effects on well being and health processes and thereby creates environments that are not
only functionally efficient but also highly psychosocially supportive.

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3.3 ROGER ULRICH - THEORY OF SUPPORTIVE DESIGN

Although Roger Ulrich’s Theory of Supportive Design does not specifically follow
Antonovsky’s Salutogenic approach, it does support the physical characteristics of Salutogenic
design. The Theory of Supportive Design is a stress-based model that is a marriage of semi
scientific and scientific research. It looks at how design affects healthcare outcomes in a
traditional design setting, using stress as a starting-point. According to Ulrich, manifestations of
stress can be psychological, physiological and behavioral. Ulrich states that instead of working
to mitigate these negative manifestations, the design of traditional healthcare facilities actually
worsens them. Noise, lack of privacy, and visually un-stimulating design elements can
undermine a patient’s sense of personal control or autonomy, whereas, supportive design can
aid in coping with stress and foster improved medical conditions.

Ulrich focuses on three supportive design guidelines :-
1. Design that fosters a sense of control with respect to physical surroundings;
2. Design that facilitates access to social support;
3. Design that provides access to positive distractions

Some of the scientific research done by Ulrich on the :-
A. influence of gardens and plants in hospital and in other healthcare settings.
B. view through the window may influence recovery from the surgery.
C. new spaces where patents through social interaction and support may reduce their
experience of loneliness and fear in the hospital environment.

He identifies general guidelines intended to help inform the designer’s creativity and point the
designer in a direction that will lead to stress-reducing design and that can be tailored to meet
specific needs and goals. Although Ulrich’s model may have helped inform Salutogenic design
and provides some key design characteristics that will alleviate stress, it lacks the integrative
and holistic approach that is key to Salutogenesis. Ulrich’s model is much more specific than
Salutogenesis and does not look at the bigger picture of health promotion through design and
how designers can achieve this goal, from conception to completion. It is still, however,
valuable to recognize Ulrich’s theory, as it is a significant contributor to current Salutogenic
design models.

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CURRENT EXAMPLE :-
The Khoo Teck Puat Hospital (KTPH) in the city / state of Singapore is setting new standards
for incorporating nature into the design and layout of the health facility. Tim Beatley in UVA
Design describes it as “arguably the greenest, most biophiliac hospital in the world”.
Using the principles of biophilic design, and incorporating nature’s influence into the
design of healthcare facilities has numerous positive benefits. With this in mind,
Interface’s Essence range has been designed using natural patterns and hues to create
spaces that echo nature; helping hospitals become places of rejuvenation and healing
rather than decline and sickness.

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3.4 JAN GOELBIEWSKI - NEUROLOGY OF SUPPORTIVE DESIGN
Jan Golembiewski, a leading researcher of the relationship between the built environment
and mental wellbeing, states that: “Salutogenic theory is a particularly useful tool as it is
specific and easily applied to an architectural application” Similarly to Dilani, he maintains
that comprehensibility, manageability and meaningfulness— which support a strong
sense of coherence and foster a natural healing process—have clear architectural
ramifications.
He studies the architecture and design of psychiatric healthcare facilities through the lens of
comprehensibility, manageability and meaningfulness.

1.Comprehensibility- he says, is making sure that perceptual cues are present to assist
perceptual processes. These include attention to texture and materiality, controlling the size
of spaces and the numbers of patients and normalizing environmental features.

2.Manageability- making provisions for patients to exercise control of their environment.
Features such as operable windows or access to sporting facilities can make a significant
difference in the level of manageability a patient may feel. Meaningfulness refers to a
personal or cultural connection and can be enhanced by aesthetics or by consideration of
spatial organization, such as providing spaces for visitors or for special personal
belongings. it is the most special ingredient of sense of coherence.

Golembiewski states that: “Under normal circumstances people have a great deal of ability
to adapt to new surroundings—even in stressful situations… However, when environmental
factors start to erode a general sense of coherence—when meaning, control and
comprehensibility are lost—resistance to disease weakens and perceptual difficulties are
exacerbated, often creating a vicious circle of increased vulnerability and anxiety”.
In his research he found that manageability, comprehension and meaning have significant
architectural ramifications and they are central to Salutogenic design. As well, his studies
that show how environmental factors may erode a sense of coherence and, in turn, will
weaken resistance to disease and perpetuate anxiety

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4. Precedent case studies
5 4.1 Fortis hospital , gurgaon , India
4.2 Medicity , gurgaon , India
4.3 Analysis / interviews

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5.1 FORTIS HOSPITAL, GURGAON , INDIA
5.1.1 INTRODUCTION
5.1.2 REASON OF THIS CASE STUDY
5.1.3 SALUTOGENIC DESIGN METHOD AND EVALUATION
A. Mapping out in relation to Antonovsky`s sense of coherence factor
B. Evaluation model in relation guidelines set through study of Edward T. hall
and Gehl theory.
5.1.4 CONCLUSION

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4.1.1 INTRODUCTION
Location : sector 44, Gurgaon
Site area : 43,303 sq. m.
Built – up area : 65,961 sq.m.
FAR : 1.52
Principal Architect : Ar. Rajinder kumar,
Rajinder Kumar Associates, New Delhi
 Fortis Memorial Research Institute, Gurgaon (FMRI) is a flagship hospital of the Fortis
Healthcare Limited.
 FMRI is a multi super-speciality, hospital.
 FMRI is a set on an 11 –acre campus.
 It has 430 functional beds, with a further planned increase in beds to 1000.
 FMRI is accessible easily by road, It can also be reached using Delhi Metro, as the hospital
is located opposite to the HUDA city metro station
DEPARTMENTS -
 Minimal Access, Bariatric & GI Surgery
 Plastic Surgery
 Ophthalmology
 Pulmonology
 Plastic Surgery
 Dental Sciences
 Internal Medicine
 Cosmetic & Plastic Surgery
 Invasive Cardiology
 Paediatrics
 Minimal Assess Surgery (Gynae)
 C-DOC
 Neonatology
 Liver Transplant, GI & Hepato Pancreato Biliary Surgery
 Mental Health & Behavioural Science
 Radiation Oncology
 Radiology
 Rheumatology
 ENT
 Gastroenterology & Hepatobiliary Sciences

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LOCATION :-

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NIEGHBORHOOD CONTEXT : -

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4.1.2 REASON OF THIS STUDY

There are tremendous reason for choosing this hospital , main aim to create
an environment which should not give a sense of boring hospital. The design
philosophy behind this hospital to provide the health and well being of the
people they serve through integrated, innovative, and compassionate care,
also creates spaces that allow for privacy, rejuvenation, choice, humanistic
scale, feel and experience, communication, and collaboration. The Hospital
should incorporate new trends like wellness, technology and creates a Gen
Next Medical Center which sets new standards for healthcare focusing on
healing & nurturing robust health. At the south corner is a quiet & sun-filled
healing garden for patient, recuperation & areas of respite for staff and
families. All major areas in the hospital will have natural light for healthy and
sustainable environment.
The architecture of this hospital considered the healing source, although
factors like daylight, room atmosphere, sound, music, art and optional privacy,
altogether are believed to assist in creating carefully designed environments
that affects and supports the psychological and physical healing of the
patients.
With acceptance of the architectural inﬂuence on human healing aspects, it is
even more obvious that healing architecture should be incorporated in the
planning of future hospitals.

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4.1.3 SALUTOGENIC DESIGN METHOD AND EVALUATION

A. Mapping out in relation to Antonovsky`s sense of coherence factor

Based on research done by Alan Dilani on theory of Salutogenic by Antonovsky , he
created a list of design qualities which enhance the sense of coherence . In case of Fortis
Hospital there are some design qualities which enhances coherence factor of the building.
Although , in hospital some patients are in stress , anxiety , fear , loneliness , insecurity ,
frustration and generally longer hospitalization due to the unsuited facilities but in case of
Fortis Hospital there are no such situation which demoralize the patient. The design of this
hospital suggest that we not only design for stress reduction , but focus on salutary rather
than risk factors. There are several design features which shift the pathogenic approach to
Salutogenic approach manifests in the built environment. According to Antonovsky the
strength of one’s sense of coherence is determined by three key factors:
comprehensibility, manageability and meaningfulness.

A.1 COMPREHENSIBILITY - It means when faced with stressful situation or
challenge , a person will have the ability to seek meaning in it, and will do his or her best to
overcome it. There are some design characteristics which help in enhancing the sense of
coherence among the patient , staff and visitors , discussed below;-
1. WAY FINDING
 Modular planning of clinical floors to optimizes flexibility and improves way finding.
 Clear organization and simple circulation system within medical areas eases patient
and staff use.
 Flexible floor plates provide shared practice space, systems, and amenities for
various clinical modules and sub-specialties.
 Ward layouts in older hospitals generally provide long corridors organized around a central
nursing station, where medication and charts are located. Research has shown that nurses
spend much of their time walking up and down halls increasing fatigue and stress and
sharply cutting the time available for observing patients and delivering direct care.
 Common console for cathlabs , MRI, X-RAY , AND ICT decreases the circulation pattern
proves efficient for patient and staff.

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SIMPLE CIRCULATION SYSTEM

DIRECTION SIGAGE BOARDS EASE PATIENT USE.
ESCELATORS FOR EASE AND FAST MOVEMENT FOR BOTH VISITORS
AND STAFF.

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PLAN OF THE NIGHTINGALE WARD

VIEW OF THE NIGHTINGALE WARD. ( LESS CORRIDOR SPACE USED IN
PLANNING OF WARD MAKE IT EFFICIENT FOR STAFF AND PATIENCE ).

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2. PERCEPTION
The experience already starts when guest or patient enters the lobby area , where an
welcoming fountain sculpture and reception welcomes the visitor with a holistic experience.
In a beautiful designed combination between the functional space and interior decoration ,
the holistic experience make you feel forget where you really are. When focusing on the
lowest levels of Maslow’s pyramid of needs, the physical and psychological, respectively,
the high-end hospital like Fortis is primarily addressing the self-fulfillment needs of
the visitors, and Fortis is accordingly providing a holistic experience, where design and
atmosphere is united in a multiple sensory expression.

REFRESHING & CONGENIAL ENVIRONMENT FOR PATIENTS BY CREATING A
MODERN, UP MARKET & PLUSH INTERIORS.

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3. LANDMARK
While entering the central courtyard we see a white sculpture titled Loveable Curious Child
– a baby with a stethoscope plugged into the ground, creates a landmark of the hospital
building. Around this sculpture many people take selfie and sit together, seems to be an
vital part of the hospital social space.

VIEW OF A CENTRAL COURTYARD

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4. PLEASURE
It also accommodate a small cinema name as " FORTIPLEX", for visitors it is a recreational
hall where visitors can watch a cinema for several time, so that they will get some
relaxation and stress free time

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A.2 MANAGEABILITY - A person can sense of the situation , problems or challenges
that they face. it also mean making provision for the patients to exercise control over their
environment. Features such as operable windows or access to sporting facilities can make
a significant difference in the level of manageability a patient may feel. “The feeling that a
person is in control of his or her environment and life circumstances is very fortifying… the
feeling that you are totally out of control is absolutely disempowering”
1. AESTHETIC ELEMENTS

2. NATURAL LIGTH
Perception of sunshine contribution
study done for the fortis hospital ( included both patient and staff interviews)
Survey question
Patient Staff
Considered sunlight to be a nuisance 2% 55%
Considered sunlight to be pleasurable 91% 33%
Considered sunlight to be calming 95% 37%
Considered sunlight to be unfavorable 1% 18%

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The study found that these patients subsequently required less narcotic pain medication,
experienced a shorter hospital stay, and had fewer negative evaluative comments in
nurses’ notes.

SECTION SHOWING NATURAL LIGTH PENETRATION IN THE ATRIUM

All major areas in the hospital will have natural light for healthy and sustainable
environment. Skylight at the roof transmitting natural light into the most common &
waiting areas.

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DOUBLE OCCUPANCY ROOM SINGLE OCCUPANCY ROOM
The integration of natural physical environments into treatment for human sufferers has
always proven to be an effective course of action. Elements in nature emulate qualities of
calmness and serenity that are necessary for a healing environment. There are two
benefits of windows: one is daylight and the other is view.

3. GREEN ENVIRONMENT

VIEW OF THE EXTERIOR LANDSCAPING AT THE ENTRANCE PORCH
Landscaping in order at the entrance give visitor and patient a sense of order , decreases
the stress and anxiety among the patient , ultimately arouses a level of coherence factor
among themselves. it also provide a sense of supportive design for patient as plants
represents life , growth and hope. they can provide interest and diversion.

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A.3 MEANINGFULNESS- In the face of a challenge or stressful situation, a person has
adequate their disposal and that they trust , which can help them cope.
1. SOCIAL SUPPORT

ARRANGEMENT OF FURNITURE IN MAIN ATRIUM SPACE increases the social support
among the visitors as they talk to each other about the disease or experience without
knowing the patient, these kind of seating arrangement make these spaces as sociopetal.
The fact that it is only space adds a social unifying value, even though it is still possible for
diﬀerent groups to sit privately at the same sofa at one time. The ground ﬂoor is the center
for social interaction, where people arrange meetings or just engage on informal basis.

ARRANGEMENT OF FURNITURE IN
MATERNITY WAITING AREA FOR
MOTHER is designed in such a homely
attmosphere which reduces stress level
among the patient. The detail with the false
cieling and sofa shows the intention making
the waitinf area comfortable , homely space
but the specific choice of curtain make it
seem clinical in some respect.

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2. MUSIC AND ART
Studies have shown across a variety of
patient groups that pleasant music,
especially when controllable, often can
reduce anxiety or stress and helps some
patients cope with pain.

Wallpaper at pediatric centre Wallpaper at oncology department

Patient Based Art Programs include artwork that is selected based on the unique needs of
each patient groups (such as Cancer, Pediatric, Geriatric, Women, Heart, ICU, Rehab and
Psychiatric). Patient Based Art helps to deinstitutionalize the clinical setting while illustrating

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a sensitivity to location and patient demographics. Patient based artwork can also aid in way
finding by helping to visually identify areas.
A successful healthcare art program consists of a coordinated series of visual elements
placed in public and private spaces throughout the facility. The selection of these elements,
as well as their size and placement, is crucial to the success of the program.
If photographs and slides of nature are viewed positively and reduce stress, it is probable
that artwork that replicates nature would also have this effect. Research on adult patients
suggests that by infusing art into the healthcare setting, patient-focused design may foster
improved moods or reduce stress that would impact the negative thoughts that could impede
the healing process.

ALL PHOTOGRAPHS ARE CLICKED BY
DIFFERENT DOCTORS ACCORDING TO THIER
EXPERIENCE AND ALIGNED IN THE HOSPITAL
CORRDIOR.

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3. VIEWS

VIEW OF THE GREEN AREA FROM DOUBLE
OCCUPANCY ROOM IN SOUTH - EAST
DIRECTION.

VIEW OF THE GARDEN AND THE CITY FROM
SINGLE OCCUPANCY SUITE ROOM IN
NORTH DIRECTION.
Views of vegetation, and especially water,
appear to sustain interest and attention more
effectively than urban views of equivalent
information rate . Because most natural
views apparently elicit positive feelings,
reduce fear in stressed subjects, hold
interest, and may block or reduce stressful
thoughts, they might also foster restoration
from anxiety or stress. in comparison with
the wall-view group, the patients with the
tree view had shorter postoperative hospital
stays, had fewer negative evaluative
comments from nurses, took fewer moderate
and strong analgesic doses, and had slightly
lower scores for minor postsurgical
complications . natural scene had
comparatively therapeutic influences, it
should be recognized that the "built’ view in
this study was a comparatively monotonous
one, a largely featureless brick wall.

brick wall.

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B. EVALUATION MODEL IN RELATION GUIDELINES SET THROUGH
STUDY OF EDWARD T. HALL AND GEHL THEORY.

B.1 FUNCTIONS
What are the options of residence ?
The living area in suit room considered as
primary place for visitors , where visitors
always remain close to the patient. Although
looking at the furniture arrangements in the
living room looks almost like you are in such
a homely atmosphere, which ultimately
increases the sense of coherence among
the patient. The lighting in the room sets a
relax mood of patient and visitors both ,
which changes the pathogenic place to
Salutogenic place.

seating arrangements in the suite room for visitors.

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What are the optional functions ?
You can watch television as
entertainment , the primary activity is
relaxation on the lounge. Other than
this there are no such optional
activities like kitchen counter for self-
provide able snacks in the room.

Does the function in the space in
the social space invite the
participation?
When you arrive in the center staff
is welcoming the guest
accommodatingly and friendly
describing the various possibility in
house. This behavior enhances the
homely atmosphere , arouses a
sense of coherence among the staff
and visitors. The arrangement of
furniture also allows different visitors
to sit together and talk to each
other.

seating arrangements in the cafe area for visitors.
seating arrangements in the central courtyard area for visitors.

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B.2 MATERIAL AND TEXTURE

List and short description of used material,
textures, furniture?
The red color broad strip dominating the central
courtyard is a sound absorbing material which
reduces the bad noise , enhances the healing
power of hospital. Furniture are consists of
couches and armchairs in white upholstery with
colorful accessory cushions and small wooden
tables aside.

How is the room characterized by
materials and texture?
In regards to material and textures , the
space is not seems to be very attractive and
luxury, as the travertine stone flooring and
designed false ceiling generally predominant.
The furniture used in lounge area have
leather covered cushions ,recliners and
general design of these are luxury.

Are the use of materials and textures
consistent and deliberate?
The furniture in the ward area seem to be
institutional , although it does not define a
consistent design as compared to single
occupancy room . The material in the ward
are distinguished from the other areas of
the hospital. There is some lack of luxury in
these common ward as compared to other
areas.

The red color strip dominating interior of atrium
Recliners in NICU waiting areas
Not that much luxury in common ward areas

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B.3 DETAILS
Scale and partition of the room ?
The main suit room is large in scale
through with specially defined partition
with door accessibility and the room is
experienced personalized in scale.
The living area in this category divide
the room into two. The patient area is
kept quiet institutional and a living area
is non institutional.

Furniture and distances ?
The living area is luxury designed with
a 6 - person dining table and one
armchair with a coffee table. In scale it
is recognizable from private homes
and the multiple seating options
provide alternative choice . The l-
shape sofa is placed along the
perimeter of the room and is not used
during observation.

Other details ?
Specific details such as flower pot
at the window bay as well as lamp in
the living area arouses a feeling that
a patient is in his/her home. t is done
to define attractive and welcoming
social space.

The room is divided in patient and visitors use in presidential suite.
There is one dining table and couch for seating.
Small details gives a feeling of home.

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4.2 MEDANTA HOSPITAL, GURGAON , INDIA
5.2.1 INTRODUCTION
5.2.2 REASON OF THIS CASE STUDY
5.2.3 SALUTOGENIC DESIGN METHOD AND EVALUATION
A. Mapping out in relation to Antonovsky`s sense of coherence factor

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4.2.1 INTRODUCTION
Medicity will be a world class 1,200 bed hospital with 10 super specialties, 40
high-tech, air-conditioned surgical amphitheatres equipped to perform robotic
surgery, and much more. On its campus, there will be a medical college and a
paramedical college, as well as a diagnostics and research and development
facility.

Area: 43 Acres

Built Up Area: 15, 00,000sq ft

Client: Global Health Pvt. Ltd. (The Institute of Integrated Medical Sciences & Holistic
Therapies)

Architect: cardinal hardy architects / jodoin lamarre pratte architects / group arcop

Cost: 900 Crores Rs. (Approx)

Status: Design Development

Departments : Division of Endocrinology and Diabetes
Division of Endocrinology and Diabetes
Division of ENT & Head Neck Surgery
Department of Internal Medicine
Department of Ophthalmology
Division of Plastic, Aesthetic & Reconstructive Surgery
Department of Pathology & Laboratory Medicine
Department of Physiotherapy & Rehabilitation
Division of Radiology & Nuclear Medicine
Department of Transfusion Medicine (Blood Bank)
Emergency & Trauma Care
Pharmacy

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4.2.2 REASON OF THIS STUDY

There are enormous reason for choosing this hospital , The prestigious
Medicity project, a state-of-the-art institute of integrated medical sciences and
holistic therapy, will, for the first time in the history of medicine, combine
different streams of medical science such as allopathy, Ayurveda,
homeopathy, naturopathy and unani, to find a holistic treatment for modern
ailments and diseases.
The design philosophy behind this hospital to provide the health and well
being of the people they serve through integrated, innovative, and
compassionate care, also creates spaces that allow for privacy, rejuvenation,
choice, humanistic scale, feel and experience, communication, and
collaboration.
The architecture of this hospital considered the healing source, although
factors like daylight, room atmosphere, sound, music, art and optional privacy,
altogether are believed to assist in creating carefully designed environments
that affects and supports the psychological and physical healing of the
patients. This is a project that is very close to our heart. The Trehan family,
who formulated the vision and encouraged a detail-oriented execution of the
project, were wonderful people to work with. We wanted to create an uplifting
and happy space far removed from how we generally see hospitals. It was a
tremendous opportunity to create a difference, especially amongst people who
were unwell and recuperating.

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NIEGHBORHOOD CONTEXT: -
MEDANTA HOSPITAL

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SITE PLAN :-

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5th floor level plan :- Green color represent healing garden , as it is enclosed
between the buildings, which acts as a central green court or we can say a healing
garden for the patient to increase common activity aoruses the sense of coherence
among the patientand the staff.

N

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10th floor level plan :-

N

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4.2.3 SALUTOGENIC DESIGN METHOD AND EVALUATION
A. Mapping out in relation to Antonovsky's sense of coherence factor

A.1 COMPREHENSIBILITY
1. Way finding
Clear organization and simple circulation system within medical areas eases patient and
staff use. In case of medanta there is no such common ward arrangements which arouses
a problem related circulation of staff and visitors. Ample amount of daylight is penetrating in
the corridor areas so that there will no dark spots in the corridor, proper signage boards
and welcoming staff helps visitors in way finding to their destination.

Daylight in corridor ,but does,nt have soft edges lift lobby showing rectangular dead end

The language of forms in architecture also has a correlation to the feeling one
obtains from the space. For example the natural environment has soft edges, but no
right angles (Red stone). However, the right angles in our everyday life are endless
in the built environment. The architecture of a healing environment can take on the
qualities of natural conditions through imitation in form. While one might feel
constrained and boxed in rectilinear spaces, the ﬂuidity of an organic space creates
no such feeling. Without right angles, the spaces become seemingly less harmful
and comforting to the human eye. "It is not the rectangle which is the problem, but its
life-sapping characteristics. Where materials, textures, colors, light, living line and
human activity can reinvest such forms and spaces with life, the ly None the less, in

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general, one feels on much safer ground with non-rectangular, or shape-moderated
spaces.”-RogerUlrich

2. Colors
As the color of the ceiling and walls are mainly white , slightly change in bedrooms but
although it is kept as institutional look. The ceiling is cement plastered incorporating
various HVAC or piping with adequate cove lighting.

View showing the texture and colors of waiting areas and private rooms

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3. Nature
Medanta come up with the design solution to give natural views to visitors waiting area and
lounge area through floor to ceiling windows. It is evidence that visitors having a view of nature
remain calm and peace. Outside the building there is also an assembly area for the visitors
where visitors walk and talk with each other, in term increase the social support among them.

Stepped terrace landscaping in front of window. visitors having view of terrace landscaping through window.

Green lawn in front of the hospital entrance for social gathering
Green entrance and landscaping in a systematic pattern arouses a sense of control among the patient and
visitors, which realizes the patient a sense of security ultimately increases the coherence factor among the staff
and patient.

Systematic arrangement of shrubs and trees

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4. Pleasure
There is a provision of lounge area for visitors with a capacity of 20 recliners and 15 sofa set
with center table, so that visitors find relax when they are tired or in stress. They can also
watch television and read magazine, it is 24 hrs open for the visitors.
The furniture used in lounge area have leather covered cushions ,recliners and general design
of these are luxury.

View of the lounge area for the visitors for night stay.

A.2 MANAGEABILITY
1.Natural light
Perception of sunshine contribution
study done for the medanta hospital ( included both patient and staff
interviews)
Survey question
Patient Staff
Considered sunlight to be a nuisance 2% 45%
Considered sunlight to be pleasurable 89% 35%
Considered sunlight to be calming 91% 32%
Considered sunlight to be unfavorable 1% 12%

As the orientation of the building is north -south oriented, building has two big bed tower
which is interconnected with one central arm. The two bed tower enclosed an green area in
between which is having shaded area due to south-east block. While talking about the
interior space of bedroom , The bedroom on outer side of south-east block get ample
amount of daylight while the inner face is in shaded region , on the other side north-west
block getting the west sun in the inner side while the outer side is in shaded region. Other
areas like food court and waiting lounges are getting ample amount of daylight. Some
areas like waiting areas in OPD section on above floors are not getting daylight , seems to
pathogenic in that case , which increases the stress level among the patient and visitors.

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Day light penetrating in the food court through double Waiting areas at each floor situated at perimeter of
height glazing , refreshes the mood of visitors. building connected through window.

Healing garden enclosed between the building block not Some waiting areas are not getting ample
getting direct sunlight from east direction. amount of daylight makes them boring .

Bedroom facing south-east direction , ample amount Bedroom facing north-west direction, deficient of
of daylight through window. daylight.

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2. Green environment
Healing landscapes have long been an important aspect of human life. When people first
began erecting dwellings, healing places could be found within nature through sacred
groves, special rocks and caves . With same approach of Roger ulrich , medanta also
accommodates a healing garden or we can say a therapeutic garden on the fifth floor level
for the patient use only.
Healing gardens foster`s the following
elements:
a. Sense of control
Patients/residents must know a garden exists, be
able to find it easily and be able to access and
use the space in an active or passive way. It
should also have areas for privacy that are
shielded from window views. A variety of types of
spaces can aid in allowing users to make choices.
Feelings of control can also be enhanced by
involving users in the design of the garden.
b. Social support
Spatially enclosed settings that allow for
socializing are often preferred by users. Designing
for small as well as the occasional large group
(associated with hospital initiated programs and
large extended family visits) is important.
However, all considerations for social support
should not deny access to privacy (which
undermines patient control)
c. Physical movement and exercise
Mild exercise can be encouraged by designs that
allow for patient accessibility and independence
and provide features such as walking loops.
d. Access to nature and other positive
distractions
Medicinal and edible plant species and those that engage all of the senses are often a
good choice for the design’s plant palette, as are plants that encourage wildlife.

HEALING GARDEN

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e. Sense of personalized environment

Schematic diagram showing the interaction of bedrooms and healing garden adjacent to each other on 5th floor

Above figure shows the spatial assessment of
Medicity based on the green approach,
shows the arrangement of bedrooms along
the healing garden which increases the
physical interaction between the nature and
patient helps in reducing the stress level
among the patient , ultimately enhances the
coherence factor, makes Medicity as a
Salutogenic model. There has been provide
such access control for the visitors , only
patient are allowed in healing garden with
nurse in daytime. There is a department
name as "PANCHKARMA" based on Indian therapeutic surgeries, utilizes healing garden for
the rehabilitation or healing of patient in some case.

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A.3 MEANINGFULNESS
1. Art
When I was in hospital, the photographs on the corridor walls kept my mind off
thermometers and at Gurgaon’s multi-specialty hospital Medanta, the sculpture at the
entrance is very soothing to relatives of patients. Titled the Trees of Life or the Mannat
(wish fulfilling) Trees and made by Rajasthani artist Ruchur Tiwari, the sandstone
structures are 21 feet each in height and stand tall, inviting visitors across religions. On
the base of the tree is a beautiful cluster of mauli, the sacred red thread that relatives tie
while praying for recovery of their loved ones. Not only is the artwork helpful for the
patients but it also touches on the work life of doctors and technicians who work in the
stressful environment. “If I go to a room with a painting, I do look at it and appreciate it.
It’s not only aesthetic but also has an impact on your behavior and provides an
environment that is not sterile in terms of thought,” says Dr Randhir Sud, chairman of
the Medanta Institute of Digestive and Hepatobiliary Sciences. Anything that helps any
patient remove emphasis from her or his illness is a huge help.

The Trees of Life installation at the Medanta hospital, Gurgaon, created by Rajasthani artist Ruchit Tiwari.

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2. Views
While visiting the inner wing of bedroom tower , view from the transparent glass window
seems to be pleasant and green. For persons experiencing anxiety or stress, studies
indicate that certain types of nature scenes rather quickly foster more positive feelings,
and promote beneficial changes in physiological systems – for instance, lower blood
pressure. Those patients assigned a landscape with trees and water experienced less
anxiety, and required fewer strong pain doses, than control groups assigned no pictures.
Positive distractions are a small subset of environmental-social phenomena that are
distinguished by their capacity to quickly and effectively promote restoration from stress
(Ulrich, 1999).

View of the nature through different room increases the coherence factor among the patient.

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3. Positive distraction
There are lots of positive attraction in the hospital which make it look like a non
institutional place such as food court , healing garden , luxury lounge area , small
cafeteria , green lawn at the entrance of hospital, etc. Such positive attraction distract
the mind of patient and visitors to a relax mode , thus reduce stress n anxiety among
them. The great majority of patients prefer representational art depicting serene,
spatially open natural environments having scattered trees and/or no turbulent water
features--but consistently dislike abstract art. Although designers, artists, and some
healthcare staff react positively to abstract images, or to art having a sense of
"challenge" or ambiguity, there is evidence that such properties in pictures can
negatively affect patient stress and worsen other outcomes.

Art work in bedroom distract patient mind. Temple and green areas outside the building.

Lavish food court give variety to visitors. Television in patient bedroom distract patient mind.

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4. Patient experience

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5.3 ANALYSIS / INTERVIEWS
4.3.1 interviews ( Therapist interview)

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4.3.1.2 Psychologist interview

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4.3.1.3 Consoler interview

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4.3.2 Analysis

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5. CONCLUSION
The ability of architecture to heal the mental and physical illness with the different planning
parameters and the elements that can enhance healing has been explored. Without
compromising on the need, the ability of all patients to be outdoors in a good environment is, in
my view, the absolutely greatest strength in the design of this caring environment. The
spontaneous process of making architecture, it’s almost as if we formulate our own “abstract”
ideas of what we envisage a space to be, through special images from memory we assemble
architecture to be a part of the real world. It not only seems that art is inherent in all of us, it is
also possible that architecture is inherent in all of us. As an act of healing it is symbolic of our
perseverance as a species to live a fulfilled existence. In exploring art as healing, architecture as
an art and lastly, architecture as a healing space, I can deduce that the common bond between
them is that art does have healing qualities and it can be said that such healing qualities provide
therapeutic harmony in all of us. I believe its effects may be limitless in measuring the benefits to
the Self. The journey of healing through art seems to be a process of retrospection, Self growth
and Self discovery. This investigation has brought about key design objectives that may be
crucial in space making concepts for my healing architecture in healthcare design.

The purpose of creating a green oasis which patients can retreat to unescorted by staff, in my
opinion, has to be achieved. Even in a number of problems where the outdoor environments are
concerned, everyone agrees that the existence of the gardens and light courts is something
absolutely positive and something that is very good for the patients. It is also clear that being
allowed out in the gardens is perceived as conferring an opportunity of greater sovereignty. In
this way I think the aim of increasing normalcy has been achieved.

Patients often experience different needs from time to time, and so the architect should
consciously design the place or the environment so as to facilitate the process which recovery.

In the design process, the architects should consciously reduce the institutional ambience and
create such Salutogenic design which will shift the pathogenic approach . As I see it, there is
scope for the patients to use different parts of the environment, both indoors and outdoors
depending on the stage of the recovery process they have come to. Outdoor spaces are always
with lusting green and the sound of water to heal their agitation. Indoor is more towards the
sunlight that enhance the healing and the ventilation to give the patient high level of
conformability.

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With the aid of my detail study and the precedents I have concluded four connections that has
to be consciously addressed while designing.

1. The connection with the personalized environment - Healing begins when one is in a
space of Homely atmosphere. The physical space however is one that must be comfortable and
a reflection of oneself. The physical environments have great inﬂuence on our social behavior
and the possibilities for patents to engage social activities promoting social support. The
common spaces should provide more than just the possibility for patents to form this basic
contact.

2. The connection to sensory experience : The integration of all the senses helps complete
the highest potential of an environment to allow for healing to emerge. As, Human beings cannot
live without natural surroundings. The symbiotic relationship that exists between the two is one
that has to be nurtured. A physical and visual link with nature has positive beneficial qualities
that help in healing and health in general.

3. The connection with Light: Natural sunlight kills harmful bacteria and cleans air. Apart from
these obvious natural benefits of sunlight, natural light - when controlled - gives a space
character that is sensual so giving a space an emotive quality which can be felt by the end-user.
Light is also a symbol of growth and life as it benefits the natural world in that way.

4. The connection with the City: The city environment is harsh and busy and tends not to offer
many places or spaces of retrospection and contemplation. The site should be a part of the city
but detached from the fast pace. The end user should be able to arrive conveniently with public
transport to the site to allow a large catchment of people seeking a place for healing. The site
should also be in a place that is not difficult to navigate and find.

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8. BIBLIOGRAPHY -
www.hindustantimes.com/brunch/art-is-finding-an-unusual-home-in-indian-hospitals/story-
yk6GAHLQvEFfJYd46rWCVN.html
timesofindia.indiatimes.com/life-style/health-fitness/de-stress/music-therapy-to-heal-cancer-
patients/articleshow/51921616.cms?from=mdr
kgd-architecture.com/portfolio_page/fortis-hospital-gurgaon-i-healthcare-4/
soundofarchitecture.com/blog/architectural-healing-how-the-built-form-changes-lives
archinect.com/firms/project/14168405/medicity-medanta/60103380
Salutogenic Places: Designed to Thrive. Farrow Partnership Architects. YouTube
Golembiewski, Jan A. "Start Making Sense Applying a Salutogenic Model to Architectural
Design for Psychiatric Care." Facilities
Golembiewski, Jan A. "Salutogenic Design: The Neurological Basis for Healthcare
Design" World Health Design Journal.
Dilani, Alan. "Psychosocially Supportive Design." World Health Design Journal
Dilani, Alan. “A new paradigm of design and health in hospital planning. World Hospitals and
Health Services, 41.4
“About Maggie’s.” Maggie’s Centres. The Maggie Keswick Jencks Cancer Caring Centres
Ulrich, R. S. (2000). Environmental research and critical care. In D. K. Hamilton (Ed.), ICU 2010:
Design
for the Future. Houston: Center for Innovation in Health Facilities, 195-207.
Ulrich R S (2004) The role of the physical environment in the hospital of the 21st century: a
once-in-a lifetime opportunity. New York: Robert Wood Johnson Foundation.
Ulrich, R. S., LundÈn, O., and J. L. Eltinge (1993). Effects of exposure to nature and abstract
pictureson patients recovering from heart surgery. Paper presented at the Thirty-Third Meetings
of the
Society for Psychophysiological Research, Rottach-Egern, Germany. Abstract published in
Psychophysiology, 30 (Supplement 1, 1993): 7.
Ulrich, R. S., Simons, R. F., Losito, B. D., Fiorito, E., Miles, M. A. and M. Zelson (1991). Stress
recovery during exposure to natural and urban environments. Journal of Environmental
Psychology 11:
201-230.
Ulrich R, Zimring C, Quan X et al (2006) The environment’s impact on stress. In S Marberry
(Ed.), Improving healthcare with better building design. Chicago: Health Administration Press,
37-61.

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GLOSSARY -

Environment: that which environs or surrounds; surrounding conditions, inﬂuence, or forces, by
which living forms are inﬂuence and modified in their growth and development.
Heal: to restore or be restored to health
Health: the general condition of the body or mind with reference to soundness and vigor
Well-being: a good or satisfactory condition of exis tence; a state characterized by health,
happiness, and prosperity
Psychology: the scientific study of the human mind and its functions, esp. those affecting
behavior in a given context.
Flexibility: responsive to change; adaptable
Meditation: a stylized mental technique... repetitively practiced for the purpose of attaining a
subjective experience that is frequently described as very restful, silent, and of heightened
alertness, often characterized as blissful
Urban: Characteristic of the city or city life.
Evidence-based: entails making decisions about how to promote health or provide care by
integrating the best available evidence.
Therapeutic: having or exhibiting healing powers.
Spirit: the principle of conscious life; the vital principle in humans, animating the body or
mediating between body and soul.
Body: the physical part of a person
Mind: the element of a person that enables them to be aware of the world and their experiences,
to think, and to feel; the faculty of consciousness and thought.
Habitat: the natural home or environment of an ani mal, plant, or other organism.
Sequence: a set of related events, movements, or things that follow each other in a particular
order.
Sequence: a set of related events, movements, or things that follow each other in a particular
order.
salutogenis -Salutogenesis is a term coined by Aaron Antonovsky, a professor of medical
sociology. The term describes an approach focusing on factors that support human health and
well-being, rather than on factors that cause disease (pathogenesis).
pathogenesis -The pathogenesis of a disease is the biological mechanism (or mechanisms)
that leads to the diseased state. The term can also describe the origin and development of the
disease, and whether it is acute, chronic, or recurrent.

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