The Mislaid Architecture of Healthcare
Four Unresolved Issues in the Design of Patient Rooms
In the second century CE, during the reign of Hadrian, the Asklepieion of Pergamon was reached by a lively, 820-meter-long colonnaded concourse, the Via Tecta, which was lined with the purveyors of elixirs and talismans. The architecture of this Roman center for physical and psychological health was integral to the healing experience, which was at once both social and individual. In the underground tunnel that led from the central square of the complex to the cloverleaf treatment center, patients were taken out of the hustle and bustle. In this passage to the inner sanctum, the sensory experience of the pilgrims was reduced to the rhythm of the light of small apertures in the ceiling, to the smooth stones underfoot, and to the bubbling of spring water running in channels along the floor.
Evidence-based design has greatly improved the efficacy of our contemporary healthcare environments, but the seductive reduction of the decision-making process to a “science” is sometimes insufficient if not misleading. Besides the obvious conflation of desired fiscal and medical outcomes that are sometimes at odds, inconvenient research findings – those for which design solutions are not apparent or that conflict with other, more marketable elements of a design – are downplayed. The role of interpretation by decision-makers, including designers, has by no means been written out of the equation. This is not a criticism, but rather a call to take note of this inevitability – and to reformulate the potential of design for our current day Asklepieions.
The observations that follow were prompted by research conducted in 2014 in preparation for an invited lecture on contemporary issues in healthcare design given to the administrators and medical chiefs of staff of GATA, a large military hospital in Istanbul. In particular, I was drawn in by the way in which "evidence" conceals the agency of decision-makers, particularly their prioritization of certain issues over others. In this article, I suggest four areas in need of further attention in the design of person-centered patient rooms.
I. "A" is for Architecture
In describing, respectively, the laboratories and private studies at the Salk Institute for Biological Studies, Louis I. Kahn distinguished between the “architecture of ducts and pipes” and “the architecture of the oak table and the rug.” Tribute should be paid to both in their place, for their purpose. But the demands on the contemporary patient room, unlike those on the laboratory and study of the biologist, do not allow these to be disengaged. The contemporary act of healing – for which the mind needs some respite, some restorative solitude – must take place in a space where pipes are inevitable.
Architecture establishes the logic and security of place, freeing the minds of patients, caregivers, and visitors.
On the surface, many ideal prototypes of the patient room take heed of the table and rug, but Kahn’s statement is not about decoration and furniture selection. The subject that the prepositional phrase modifies is “the architecture.” As functional planning and the technical aspects of design come to be ever more dictated by research findings, these pipes are adorned with – even hidden by – an appliqué of cozy hominess – or worse yet, of a parametricism that subverts the very design research it purports to represent. Either way, they are veneers designed to signify an idea about healing to the patient.
But architecture is something more substantive. It is neither the shape of the room nor the choice of materials, but the genius loci. It establishes the logic and security of place, thus freeing the minds of patients, caregivers, and visitors for their respective charges in the process of healing. We have yet to see the design of a patient room that, as Peter Zumthor writes, is neither a message nor a symbol, but "an envelope and background for life…, a sensitive container for the rhythm of footsteps on the floor, for the concentration of work, for the silence of sleep."
II. Accommodating the Unwilling
In Turkey, where I live, it is taken for granted that someone from among a patient’s family or friends stays at the hospital overnight. This cultural phenomenon is not the rule in many, particularly Western, healthcare systems that, moreover, have restricted visiting hours. Yet empirical studies find that the cost of feeding an extra individual is easily offset by the net savings resulting from the many benefits of round-the-clock visitors – emotional and decision-making support, increased safety, relieving caregivers of nonclinical assistance, more effective communication with caregivers, and patient satisfaction.
The question of accommodating visitors has rarely been taken up as one of changing culture and social norms.
With an “if you build it, they will come” mentality, standards like those of the Facility Guidelines Institute have long advocated for additional space for family and visitors, both within and external to patient rooms. But the question has rarely been taken up as one of changing culture and social norms. In Turkey, the social pressure – let us say, mechanical solidarity – far outweighs the discomfort and inconvenience of a fold-out sleeper chair. In societies where this is not the case – where the very notion of guests staying overnight in a hospital is foreign – the balance must be tipped. The design of accommodations for visitors must not only be sufficient and comfortable, but – like a business hotel – must compensate for the sense of security of which overnight guests are deprived by the very fact that they are away from home, allowing them to otherwise function as usual.
III. Negotiating Caregiver-Visitor Interactions
The primary counterargument against expanding the role of visitors in the healthcare environment is the distraction it can entail for doctors, nurses, and personnel. Indeed, this has been the justification for limiting visiting hours in general. The circulation spaces for staff and visitors coincide, a fact that not only increases happenstance encounters between them, but emboldens visitors to turn to caregivers for inconsequential matters.
The onus of ironing out the issues of caregiver-visitor interactions have become matters for operations and policy.
At the level of theory, a potential planning solution to this conundrum was proposed by Maartje van Roosmalen in her thesis for Eindhoven University of Technology: separate entrances to patient rooms from a perimeter corridor exclusively for visitors. But when it comes to praxis, this proposal is easy to dismiss. In a sector where capital outlay and financial outcomes figure prominently, a redundant corridor is low-hanging fruit for the value engineer. Moreover, patient rooms are left with no external wall – indeed, van Roosmalen’s proposal specifically concerned ICU units where windows are plausibly of lesser consequence.
As such, this issue is whitewashed among the many tradeoffs in the design and planning of facilities – and the onus of ironing it out become matters for operations and policy.
IV. Social Isolation
Leaving aside the fact that the evidence points to the efficacy of single patient rooms, the primary complaint of patients is the social isolation that such rooms entail. Their only access to the outside world is the ward corridor, a link that contemporary patient room designs do not exploit, and not without reason. Indeed, whatever potential these hallways offer in terms of social interaction is negated by the fact that they are principally the often hectic, stressful workplaces of hospital staff.
The need for solitude and social interaction – even just for a nod of the head to a passing stranger – is fluid.
But the broad assumption that the success of single patient rooms is correlated to a desire among patients for uninterrupted, absolute privacy should be dispelled. In terms of the design implications, not only is there no one-size-fits-all solution to the appropriate degree of privacy of a patient room, but any given patient's need for solitude and social interaction – even just for a nod of the head to a passing stranger – is fluid.