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The use of natural surroundings, abundant natural light and organic shapes that influence a patient’s positive outcome.

Daniel E. Ubovich, AIA, NCARB Architect

(951) 809-2035 deuaia@hotmail.com

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Healing space™

A thesis submitted to partial fulfillment of the requirements of the degree of Master of

Architecture

NewSchool of Architecture and Design, 2011

By Daniel E. Ubovich

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Copyright

© Daniel Edward Ubovich, 2011

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Healing space™

Though the present healthcare environment clearly provides important help to patients with

serious or rare health problems, it is criticized for a number of faults, some of which are endemic

to the system and others, which develop from what some, consider wrong approaches to health

care. Many voice the opinion that the 'industrialized' nature of care, with constantly shifting

treatments and staff, takes away the human qualities of the patient which prevents more effective

quality of care. More over the architecture and setup of modern healthcare environments is often

voiced as a contributing factor to the feelings of faceless treatment that many people complain

about. Within the last three decades, it has become more apparent that healthcare design has been

in conflict with nature. Recent trends of evidence based design have brought attention to this

problem; numerous design professionals continue to overlook the inclusion of organic shapes,

forms, colors and textures, into the healing environment. Therefore the main purpose of this

investigation was to examine the links between abundant natural light, natural surroundings,

organic shapes and a patient’s psychophysiological outcome. The participants in this study were

residents of two California Veterans assisted living facilities in Southern California who were

interviewed and asked to complete a series of questionnaires, detailing their attitudes,

dispositions and perceptions concerning abundant natural light, organic shaped and natural

surrounds which were represented by four three dimensional manifestations in the built

environment. The results indicated that a majority of the participants’ perceptions of abundant

natural light, natural surroundings, organic shapes, through the use of three dimensional

prototypes generally coincided with the hypothesis.

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After viewing the three dimensional prototypes, most respondents adopted a belief that

subsequently equated to an affirmed attitude and finally resulted in a positive opinion about

them. The results of this study suggest some future direction might include investigating the

relationship between abundant natural light, natural surroundings, organic shapes and a patient’s

psychophysiological outcome as it relates to other venues of the healthcare built settings.

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Dedications

I like to dedicate this Master of Architecture Thesis to my wife Fernanda. There is no

doubt in my mind that without her continued love, support, counsel, patience and editing skills, I

could not have completed this project.

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Acknowledgements

I would like to offer my sincerest gratitude to all faculty and staff at the NewSchool of

Architecture & Design, who made the research program possible. This program has enabled me

to expand and enrich my knowledge and career as an Architect. This life changing experience

has allowed me to overcome challenges and reach goals that I previously thought were

impossible to surmount. In particular, I would like to acknowledge the following individuals that

made it possible for me to complete this research project:

Mr. Jim Engelke, Adjunct Professor for his continuous guidance throughout such a detailed

project. His assistance in helping me focus my thoughts into a simplified, cohesive direction was

invaluable.

Mr. Carlos, Adjunct Professor for helping me see the big picture and at the same time consider

alternate views of urban planning and site planning as a relates to my project.

Mr. Howard Blackson, Adjunct Professor for providing the opportunity for an "outside the box"

experience which allowed me to view architecture and urban planning in an entirely new way.

Mr. David Kopek, Professor for his guidance and support, getting me back on track after my

initial struggle with the subject matter. Furthermore without his focus and experience in

evidence-based design and healthcare research, I'm not sure the project would have been

completed.

Ms. Maris Brancheau, Editor for her valuable time and efforts in assisting me with the editing of

this project. Without professional comments, this document would have been incoherent with

grammatical errors, thank you.

I like to thank my mother and my brother Milan for their continuous support and encouragement

throughout the entire process. A special thank you to and my good friend Hank Spielberg for

helping me with the site surveys, photographs and interviews at one of the case study sites.

I would also like to acknowledge the support and assistance given to me by the staff of the Cal

Vet assisted living facilities in Ventura and West Los Angeles, CA. Especially Brenda Manke,

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Administrator at the Cal Vet assisted living site in Ventura, and Patrick Keelher, Administrator

at the Cal Vet assisted living site in West Los Angeles, for their time spent coordinating the

interviews and surveys. I could not have completed this effort without their assistance, tolerance,

and enthusiasm.

Finally, I would like to thank my fellow cohort students, Sean Clerkin, Raymond Frank and

Steve Courtenay for your support, insight and helping to make this an entertaining experience.

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Table of Contents

Title page i

Copyright ii

Abstract iii

Dedications v

Acknowledgments vi

Table of contents viii

List of figures and tables x

INTRODUCTION 1

REVIEW OF LITERATURE 3

METHODOLOGY 31

RESULTS 52

DISCUSSION 72

REFERENCES 79

APPENDIX A 92

APPENDIX B 93

APPENDIX C 96

APPENDIX D 97

APPENDIX E 101

APPENDIX F 102

APPENDIX G 103

APPENDIX H 104

viii

APPENDIX I 105

APPENDIX J 106

APPENDIX K 107

ix

List of Figures and Tables

Figure 1 4

Figure 2 6

Figure 3 7

Figure 4 10

Figure 5 11

Figure 6 23

Figure 7 24

Figure 8 32

Figure 9 33

Figure 10 34

Figure 11 39

Figure 12 41

Figure 13 43

Figure 14 43

Figure 15 44

Figure 16 44

Figure 17 45

Figure 18 46

x

Figure 19 52

Figure 20 53

Figure 21 54

Figure 22 54

Figure 23 55

Figure 24 56

Figure 25 57

Figure 26 57

Figure 27 65

Figure 28 68

Figure 29 69

Figure 30 71

Figure 31 78

Figure 32 78

Table 1 58

Table 2 60

Table 3 62

Table 4 61

Table 5 62

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Healing space 1

Introduction

While health environments and the use of high-tech equipment, and highly skilled staff

clearly provide help to patients with serious illnesses and rare health problems, they are

considered by some, as diametric to the healing process. One major criticism is the

“industrialized” nature of the care, with its impersonal surroundings and constant shifting of staff

and equipment. This dehumanizes the patient, and prevents more effective care. For many

years, the healthcare design has been in conflict with nature; although, recent trends of Evidence

Based Deign have brought attention to this problem, many architects and interior designers

continue to overlook the inclusion of organic shapes, forms, colors and textures, into the healing

environment. However, Biophllia is a theory that suggests that humans seek an interaction with

other life, in order to feel secure, E.O. Wilson (1984), insists that life as we know it, cannot be

limited to human interaction, and Erich Fromm, (1958 &1964), defines human interaction with

life, to include plants and animals. Concurrently, Topophilia suggests that people form a bond

with a place. Yi-Fu Tuan (1977) says that, as a person's emotional bond to a space increases, so

do familiarity, comfort, and the sense of “insideness.” The healthcare environment has never

been equated with a positive association with place. Del Nord (2009) asserts that the western

paradigm of efficient health spaces, has lost the connection to holistic methods of healing, which

may be a direct result of over sterility, and the absence of life-giving attributes.

Studies with children, demonstrate a preference for organic shapes and colors, Milbrath

(1998); Willats (1997). Therefore, one can speculate that organic shapes are associated with life,

living organisms, and natural phenomenon; Bartholomew (2003); Manning (2009). Rosenberg

& Abelson (1960); Seigal (2005); Fontenay (1981) and L. Jussim, (1991), state that associated

Healing space 2

meaning (belief) can hold equal or similar behavioral results, as the actual encounter (created

reality).

Many healthcare practitioners believe that, the evolution of the natural and organic

healing environment is still in its infancy, and the opportunity to fully integrate natural

surroundings, organic shapes, and sustainable principles into the patient’s setting, is within reach.

Therefore, the purpose of this research project is to study how the relationship between the use of

natural surroundings, abundant natural light, and organic shapes, create a patient’s positive

psychological outcome.

Healing space 3

Comparative research has indicated that there are two contradictory narratives that stretch

over the contemporary healthcare environment. First, “..technology cannot care for the whole

being who is [currently] in a health care crisis", (Hurlock-Chorostecki, 1999, p.20) and second,

“…Humans have an innate bond with nature…. This implies that certain kinds of contact with

the natural world may benefit health” (Frumkin, 2001, p. 234). While it is true that hospitals,

with various specialty departments, high-tech equipment and well trained medical staff, clearly

provide help to patients with serious illnesses and rare health problems, they are considered by

some, as adversely affecting, and antipodal to the healing process, This research and analysis of

the literature was designed to explore and identify the current status of the healthcare

environment, how the recent trends of evidence-based design have impacted that built

environment, the intrinsic relationship between man and nature, man's bond with a "place," and

the idea that exposure to nature has an impact on a person’s attitude, which in turn leads to a

positive belief, and finally, becomes a constructed reality. This study includes a particular view

focusing on direct association between the use of natural surroundings, abundant natural light,

natural shapes, and a patient’s positive psychophysiological outcome.

The current status of the healthcare environment

Loss of natural attributes and the “industrialized nature” of the healthcare environment

According to historic records, King Pandukabhaya (fourth century B.C. royalty of

Sinhalese) built small laying-in homes and hospitals in various parts of Sri Lanka (Aluvihare,

1993). This is the earliest documentary evidence of institutions specifically dedicated to the care

of the sick anywhere in the world. These institutions, expanded in size and complexity as

building technology became more advanced. The First Council of Nicaea (in 325 A.D.),

stipulated that the Christian church provide a place for healing for the poor, sick and widowed. It

Healing space 4

ordered the construction of a hospital in every cathedral town. Among the earliest, were those

built by Saint Sampson in Constantinople, and by Basil, the Bishop of Caesarea. Medieval

hospitals in Europe pursued a similar pattern where the Christian community (monks and nuns),

cared for the sick and diseased. Some were attached to monasteries, while others were

independent and supported by endowments from the property (McGrew & McGrew, 1985). In

fact, the word “hospital” derives from the old French word for Hôtel-Dieu (“Hostel of God”),

which is one of the origins of the word.

Similar to what was at hand in medieval Europe, the present modern day hospital concept

of Christian care, is still used today along with secular public and private institutions. In the

United States, the traditional hospital is non-profit, usually supported by religious

denominations, or non-denominational community organizations (Manco, 2006). These non-

profit organizations are supplemented by large public funded hospitals, usually in major cities

and in county seats. Some are affiliated with research

organizations and/or medical schools. The largest of

these was a public hospital system in New York City,

which includes the Bellevue Psychiatric Hospital, and

the New York University Hospital. The original facility

opened its doors in 1680, as a poorhouse and

workhouse to deal with “vagabonds and idle beggars”

(Knights, 2011, p.1).

In the late 20th

century, for-profit hospital chains

came into being around the country. In order to reduce

overhead costs, some heath insurance providers, (such

Fig. 1, Kaiser Permanente “Template” hospital

recently constructed in Modesto, Antioch,

Ontario, Fontana & Irvine, CA. (Irvine Medical Center shown).

Healing space 5

as Kaiser Permanente among others), standardized their healthcare delivery system by building

“template” hospital configurations, “with the aim of delivering high-quality, efficient medical

care in an increasingly competitive health care delivery environment “(Craig, Hartka, Likosky,

Caplan, Litsky, & Smithey, 1999, p. 2), using standardized equipment, materials and type of

personnel in each location.

Miller (2003), states that one of the major criticisms of the healthcare environment is the

“industrialized” nature of care, with its unfriendly surroundings and constant shifting of staffing

and equipment. This dehumanizes the patient, and prevents more effective care. In most

healthcare physician groups, the doctor you see in the office is not the one that would be

attending to you while in the hospital. The doctors, nurses and medical staff are being placed

under more and more pressure to increase the bottom line, as hospital costs continue to soar, this

leads to rushed and impersonal treatment. The architecture and arrangement of the modern

hospital are often viewed as contributing to the faceless and aloof treatment that many patients

complain about. Moreover, Del Nord (2009) concurs by saying that "After the western paradigm

of efficient health, spaces lost the connection to a holistic methods of healing" (p.274) which

dates back to Aesclepions and Hipporates, who believed that assisting nature by the use of "fresh

air, good diet, purgation, …..and hydrotherapy” was the best treatment (Garrison, 1913).

Disorientation

Taylor (1979) goes on to say that hospitals are commonly regarded as unpleasant places

to be, and in general, the depersonalization, forces the patient to give up control over his or her

daily existence. Her study suggests that some patients cope with depersonalization and loss of

control by exhibiting “good patient” or "bad patient" behavior. The "good patient" may actually

Healing space 6

be in circumstances that exhibit anxiousness, depression, or helplessness, whereas the "bad

patient" may display anger and react against "a perceived arbitrary removal of their freedom.”

The study concludes by saying that these cognitive behaviors show a pattern of health risks to the

patient and staff (p.156).

Overcrowding, stress and burnout medical staff

Other negative attributes associated with

the current hospital environment include long

waits and overcrowding, which in turn produced

staff burnout, role conflict, and unconstructive

job satisfaction and produced harmful

psychological health risks to the medical staff

and patients. Bowmen (2010) points to

simultaneous hospital closings in Manhattan and Queens, back in February 2009, "resulted in 17

hour wait times at one facility in patients receiving emergency care in a hospital café". Other

examples about the current healthcare paradigms describes how overloaded physicians, nursing

shortages and overcrowded facilities, lead to stress in the work place, which contribute to

appalling patient care, Ehrenclou (2008). Also, a study by Needleman, Buerhaus, Mattke,

Stewart & Zelevinsky, (2002) confirms Ehrenclou (2008) findings: That a relationship between

the number of hours nurses spend per patient, equates to superior patient care. “A higher

proportion of hours of nursing care provided by registered nurses, and a greater number of hours

of care by registered nurses per day are associated with better care for hospitalized patients.”

(Needleman, Buerhaus, Mattke, Stewart & Zelevinsky, 2002, p.1715), See Fig. 2.

Fig. 2, Relationship between nursing hours per patient and patient recovery outcome.

Healing space 7

Therefore, the inverse to that would be that the less

nursing staff available, the poorer the patient outcome is. A

similar study by Peltier, Dahl & Mulhern (2009), concluded

that there is a relationship between the perception of

healthcare providers’ work environment and poor patient

care outcome:

Health care is an extremely people-based industry. Much of the emphasis on the people

side of health care is on procedures – the myriad of processes for handling patients

including checking-in, preparing for treatment, medical procedures, food service,

discharging, etc. A key take-away from this study is that, in addition to what health care

workers do, emphasis needs to be placed on how the employees feel about what they do.

Patient experiences will not be good if employees are not happy.

All three paradigms create a cycle that impacts the patient’s recovery and well being

(Peltier et al., 2009, p. 1)., See Fig. 3.

Recent studies have shown that, the same old model for healthcare delivery and

outcomes, cannot keep pace with the current cultural and exogenous forces now impacting the

healthcare industry. A new survey by the American College of Emergency Physicians reveals

that despite health reform, 71 percent of emergency physicians believe that ER visits will

continue to rise, and that crowding and overcrowding will intensify. Furthermore, 54 percent of

the 1,800 physicians surveyed, predict that the number of specialists, such as neurosurgeons and

cardiologists, who will be willing to respond to ER calls, will drop (Beaulieu, 2010). Studies on

nursing performance and increased turnover have shown that the care giving environment is

filled with stress, anxiety, ethical conflicts, and unrealistic work demands. Various studies have

Fig. 3, Cycle of interdependencies

between the healthcare work

environment, and how it affects the patient outcome.

Over burdened

staff

Over burdened staff

Stressed and unhappy

employees

Stressed and unhappy employees

Over crowded faculties and or poor work environment

Over crowded faculties and or poor work environment

Poor patient

outcome

Poor patient outcome

Healing space 8

demonstrated that, nursing is stressful, and that the incidence of occupational stress-related

burnout in the profession is evident, and is not getting any better (Bégat, et al 2005). At the same

time, more and more hospitals are closing due to acquisitions and lack of Medicare

reimbursement. Other studies by Piko (2006) also conclude that prolonged staff related burnout,

"has a special significance in healthcare where staff experienced both psychological/emotional

and physical stress" which can have major behavioral and health implications to the patient. The

findings of this study showed that emotional exhaustion and depersonalization scores were

higher while scores on personal accomplishment was lower, as compared to other industrialized

nations and U.S. samples. "Burnout, particularly emotional exhaustion, was found to be strongly

related to job dissatisfaction".

Stress and burnout have also impacted the quality of the general practice, as well. The

continuity of care which has always been associated with the doctor – patient relationship has

been put under pressure in many places of practice and seems to be expanding due to larger

teams and more registered patients, thereby threatening the likelihood of patients staying with

their own general practitioner, Frederiksen, H. B. (2009). This phenomenon has led to increasing

levels of distress, on the part of patients towards professionals and institutions, which in turn

have led to increased levels of poor communication and conflicts, which have resulted in violent

actions against healthcare professionals, in some cases, Garcia – Calvo (2009).

The relationship between the increased cost of healthcare and delivery

An upward trend in the cost of healthcare has caused a financial burden on individuals

and families. In agreement with a study by Yu, Dick, & Szilagyi (2008), medical costs between

2001 and 2004, a family, with children with special health care needs, has increased their risk in

2004 for having financial burden exceeding 10% of family income. Other phenomenon

Healing space 9

associated with the rising healthcare costs are the conglomeration, buy-outs and mergers of

independent hospitals into vast healthcare systems which increase buying power for the

conglomerates, but decrease completion for insurance providers, leaving the patients out in the

cold.

Columbia/HCA, the largest private healthcare provider in the world (according to

Wikipedia), based in Nashville, TN, has acquired over 200 IOs (Independently Owned), or NFPs

(Not For Profit) hospitals, reducing the amount of providers in at least 25% of the country. Rick

Scott and Richard Rainwater, co-founders of Columbia/HCA, are on a mission to turn their

hospitals into the “Walmarts” of the healthcare industry, by instituting austere cost cutting

measures, and re-engineering processes to use less-skilled, lower paid people (Flower, 1995).

Evidence Based Design in the Healthcare environment

Philosophical underpinnings

Previously I discussed the theory that, a restorative environment will be able to assist in

the treatment of the physical body, as well as, support the spiritual requirements of the patient

through the use of: organic environment with sustainable features, natural shapes and forms,

natural patterns and processes, abundant light and space, and place-based relationships and

connections to nature. The theoretical underpinnings of my topic are based on the philosophy of

Hippocrates, around 450 B.C., where he saw in nature, an inherent power of healing which

worked unceasingly to create bodily health: “Everything in nature tends to re-establish that

perfect harmony that constitutes normal life. Every force in the individual tends to preserve a

perfect equilibrium and, if it has been disturbed, to re-establish order and harmony” (Garrison,

1913; Stone, 2003, p. 2).

Healing space 10

Subsequently, others like Monsignor Sebastian Kneipp, Florence Nightingale, Dr.

Benedict Lust, and most recently, Barbara Dossey, RN have kept the ideals of, what is now

known as Naturopathic medicine applicable in the modern era (Lust, 1937; Lindlahr, 1999;

Montag,, 1951; Dossey , 2009). Hippocratic medicine was humble and passive, which coincides

with the concept that, a restorative environment and the healing power of nature ("vis medicatrix

naturae" in Latin), can produce a positive medical outcome. This holistic philosophy of healing

was gradually disregarded with the advent of the 17th

Century. Hippocrates was still regarded as

the source of medical wisdom, but a scientific revolution created by Newton in England and

Descartes in France, changed the state of affairs. Newton taught

that, mathematics was the rationale behind the celestial mechanics

that explained the motions of the moon and the planets. When he

published Philosophiae Naturalis Principia Mathematica

(Mathematical Principles of Natural Philosophy), it gave credence

to the idea first put forward by Democritus long ago, that all

physical phenomena could be explained in terms of simple natural

laws (Stone, 2003).

As a result, the philosophy of mechanism gained prestige,

and medical thinking began to move in the mechanistic direction, where the body is like a

biological machine and doctors are in control of the healing process, no longer guided by nature.

This paradigm shift of philosophy (cultural/discursive system), from nature to logic of

mathematics, not only took place in medicine, but also in architecture and the built environment

of healthcare. In lieu of art and ornamentation, with natural sculptural elements (based on the

values of nature), the adopted international style of the machine age, produced healthcare designs

Fig. 4, an example of the use of

natural sculpture and ornamental

elements in healthcare design,

courtesy of Robert A., Pratt,

A.I.A.

Healing space 11

with glass and steel based on the

ideals of simplified forms, and

unadorned functionalism (Pratt,

2006; Stone, 2003), See Fig. 4.

The architect Le

Corbusier called his designs

“machines for living,” like Villa

Savoye, which represented a

complete break with the past, and an expression of the political times. This philosophy of logic

and mathematics (from Newton et al.), and the machine age (from Le Corbusier et al.), have been

with us since the early 19th Century, but because of the work of Noble Laureate Lllya Prigogine,

and the modern science of genetics, Newton’s, Einstein’s and Schrödinger’s determinism and

“time symmetry” to explain everything on the basis of extensions of celestial mechanics has been

shattered. I believe that, we are at a beginning of another paradigm shift in the healthcare

therapeutic and built environment, back to adapting a naturopathic philosophy (Prigogine, 1996;

Stone, 2003; Guiton, 1982; Frampton, 1992; Le Corbusier’s Villa Savoey, 2008, p. 1),

See Fig. 5.

Positive trend

The reviews of literature suggest that if the built environment was modified, it would

improve the quality of life of the patient and family members. Studies from Ulrich (1984 &

2000); Rubin (1998); Fontaine (2001) and Cama (2009) purport that a change in the way

healthcare facilities are designed can have the capability of fostering improved patient outcomes.

In accord with the research conducted by Ulrich et al. (1981, 1984 & 2000) manipulating

Fig. 5, Le Corbusier’s Villa Savoye, Poissy, France (1929-31).

Healing space 12

surroundings, aesthetics and architectural features, in a healthcare setting, including noise

reduction, sleep promotion, family support areas, spatial disorientation reduction, music, art,

nature, light quality and air quality can produce a positive effect on a patient’s recovery.

In attune some researchers indicated that music therapy can be quite effective; It is easy

to administer, relatively inexpensive, noninvasive intervention they can reduce anxiety and pain

and provides patients with a sense of control and separation from the multiple environmental

stressors they are experiencing. Affirming with a study by White (2000) "Patient satisfaction and

outcomes clearly have improved after music therapy sessions have been implemented". In

contrast to White's (2000) study, research by Silverman (2008) claim that music therapy, from

clinicians and researchers, have reported a lack of evidence that music therapy is successful in

reducing stress and anxiety in patients (Ornstein, 1990; Silverman, 2008).

Dunn (1995) believes that the use of aromatherapy, massage and the use of natural

sounds of nature "offer a means of increasing the quality of sensory input that patients receive, at

which as well as reducing levels of stress and anxiety"(p. 34). Their study tested 122 patients that

were admitted to intensive care units were randomly allocated to receive either massage or

aromatherapy associated with water sounds. 77% of the 122 patients tested reported

"significantly greater improvement in their mood and perceive levels of anxiety, there were also

felt less anxious and more positive than immediately following the therapy, although the effect

was not sustained" (p. 34).

Cama (2009), one of the main proponents of the use of evidence-based design in

healthcare interiors, says that "the main problem with this is delivery of the research to the field".

She goes on to say that the research is “out there”, but it is slow getting to the design studio. The

cycle of innovation for the improved clinical practice models and supporting architecture, is

Healing space 13

offset by antiquated mindsets that see status quo as too difficult to change. On the clinical side

of the equation, the research identifies a need for the improvement of nursing techniques, but

misses the true role nurses play in their relationship with the patient. The issue here is one of

technology versus the application of Hippocrates’s holistic healing, of “re-establish[ing] that

perfect harmony" Stone (2003) with the patient; treating all aspects of the patient’s

psychological, physical, social, and mental needs, not just their relationship to monitors, gages

and readouts (Dossey, 2009; Marcus, 2002; Chan, 2001; White, 2000; McCarthy, 1991; and

Byers, 1997).

The relationship between man and nature

Man seeking nature

A review of research has indicated that most of the investigations have centered around

environmental health, specifically the hazardous effects of various environmental exposures,

such as toxic chemicals, radiation, and biological and physical agents on the public. However,

some kinds of environmental exposures may have positive health effects. According Kahn

(1999), the term “Biophilia”- was coined by Edward O. Wilson in 1984, referring to what he and

his colleagues hypothesize as a fundamental, generally based human need and preference to

associate with nature and life. Wilson (1993), states that the biophilic instinct emerges

unconsciously, through reasoning, emotions, art and ethics. It “unfolds” from early childhood,

onward (Kahn, 1999, p. 2). Recent studies have shown that even a minimum connection with

nature, through a window, increased productivity and health in the work-place, promotes healing

of patients and reduces the frequency of sickness in prison, (Ulrich, 1981; Farley & Veitch,

2001; Frumkin, 2001). In his landmark book Biophilia, Wilson examined how our tendency to

focus on life and lifelike processes might be a biologically based need, integral to our

Healing space 14

development as individuals and as a species, which at the time, caught the imagination of various

thinkers and included the views of some of the most creative scientists of the late 20th

Century,

each attempting to amplify and refine the concept of biophilia. Presently authors have expanded

this idea to suggest that humans have an innate bond with nature more generally, which implies

that certain kinds of contact with the natural world may benefit health. Evidence supporting this

hypothesis is presented from four aspects of the natural world: animals, plants, landscapes, and

wilderness (Frumkin, 2001). This research, across many disciplines, has been brought together to

support the hypothesis that exists a fundamental, generally based human need and propensity

affiliate with life. That is biophilia. In harmony with Kahn (1999) it is important because the

biophilia hypothesis could provide a unifying framework across numerous disciplines to

investigate the human relationship with nature.

Kahn et al. (1999) found that "Naturalistic experiences often reduce stress, sharpened

sensitivity to detail, enhance creativity, and provide intellectual stimulation and physical

fitness"(p. 19). Most of research has indicated that even a minimal exposure with nature reduces

the instant and long-term stress, sickness of prisoners, and calms patients before and during

surgery, and promotes healing after surgery (Kahn, 1999; Kellert, 1993; Wilson 1993).

The intrinsic relationship between man and nature:

A connection between living systems and perception

There is considerable evidence demonstrating the connection between man and nature,

Whitaker (2010) describes Humberto Maturana and Francisco Varela's theory of autopoiesis,

where living systems exhibit a sort of circularity in their form and organization, which are

interconnected to themselves, the environment and other organisms. All living components are

interconnected so as to make a single whole structure, where no single component either starts or

Healing space 15

ends because the "set of structural connections" (p. 2) cannot be reasonably described as a linear

series of dependencies, Instead, it is an interrelated web of interdependencies in which each

component is mutually dependent on all the others in "adding up" (p. 2) to the entirety of a viable

structure. There is one such "systemic" (p. 2) framework addressing living systems,

phenomenology, and their cognition in terms of these essential makeup and framework.

(Maturana & Varela, 1988). In line with Maturana et al., (1988) man's "reality", of these

interrelated systems, is interactive. Moreover, man's reality is mutually constructed and agreed-

upon view of reality is in fact, "a shared set of assumptions and perceptions” (p. 239). We see

these realms simultaneously, because we have agreed that this is what is "out there." Together,

we bring forth the world we experience as objective reality and an individual's "reality" is

constructed from his or her (or its) perceptions, and these perceptions are interactive with the

environment. This is what Maturana et al., (1988) calls "unity" (p. 239), they elaborates this by

noting "Everything said is said by an observer. The qualification of all 'knowledge' with respect

to a given observer is both the epistemological foundation and the explanatory focus of

autopoietic theory" Whitaker (2010, p. 2).

The correlation, here, with Prigogine's world systems theory, where Prigogine (1996)

speaks of a new language for the understanding of complexity of life (organism, ecosystem, and

social system), Chaos, fractals, dissipative structures, self-organization, and complex adaptive

systems, and the partially unknown or at least unpredictable world of multiple possibilities is

significant, for it represents a salient departure from Newton’s deterministic, postempiricist,

paradigm structure. Prigogine (1996) suggests that as our knowledge of natural realities expands,

then emerges into more complete perspective requiring a fundamental reconstruction of both the

real makeup, upon which human life is built upon, and the symbolic makeup of our rational

Healing space 16

schemata (Gunaratne, 2003). Thus the focus of the literature forges a connection between man

and nature, whether perceived, constructed or rational.

The connection between man, plants, animals, and life

An influential book by Fromm (1956) depicts the origins of human history. Though

thrown out, and disconnected with the original unity with nature, man still clings to those

primeval bonds and consequently "tries to identify with the world of animals and trees, in order

to reconnect, unify, and remain ‘one’ with the natural world” (p. 59). However, in the 20th

century, we have been overwhelmed by an almost magical ability of man to understand and

control our physical environment. Has this century’s remarkable technological progress led most

people to believe that what science does know about nature or it will someday know and that this

knowledge will eventually lead to more control over nature (Briggs, 1992)? Simonds (1961)

continues by posing additional questions: "So what is man's alternative? What is left for him to

do? Is it possible that man can invent a wholly artificial environment where he can better fulfill

his potential destiny? How can he better fulfill his potential destiny? “This prospect seems

extremely doubtful" (p. 6). If you look back and analyze man's most successful ventures in

planning it would show that his greatest improvements, to the environment, came by integrating

his work with nature, by bringing nature's hills, ravines, sunlight, water, plants, and air

sympathetically into the design of the landscape. Van loon & Merriman (1999) rebukes The

Greeks and Romans by saying that they had never bothered about the future but instead establish

their own paradise, then came the Middle Ages, men built himself a paradise beyond the highest

clouds and turned the world into "a vale of tears for high and low" (Simonds, 1961, p. 7). Van

loon & Merriman (1999) goes on and depicts the Renaissance, where men no longer looked

towards heaven for paradise, but tried to establish their paradise on the planet through learning

Healing space 17

and a state of mind. "Now" (Simonds, 1961, p. 9) states that modern man, with his great

knowledge and power to create, has disregarded nature's, topography, topsoil, air currents, water

sheds, and the forests'. Are we tempted to believe that we can conquer nature? There are those

who hold that the years from now, man will finally subject nature to his control. "Let us not

delude ourselves; nature is not soon to be conquered by puny man. Conquer nature! How can we

conquer nature? We are – blood, bone, fiber, and soul – a very part of nature” (p. 26). Simonds

(1961) asserts that man, came from nature, is rooted in nature, and is nursed by nature. Man's

every heart beat, every neutral impulse and every thought wave, are very acts and efforts are

governed by nature's own bracing law. Fromm (1956) also admits that man is from the animal

kingdom, from the instinctive adaptation, that he has transcended nature – although he never left

it; he is still a part of it. Simonds (1961) continues by providing the following axiom:

The naturalist tells us that if a fox or rabbit is snared in a field and then kept in a cage, the

animal’s clear eyes will soon become dull, his coat will loses luster, and his spirit will

flag. So it is with man too long or too far removed from nature. For man is first of all an

animal. He is a creature of the meadow, the forest, the sea, and the plain. He is born with

the love of fresh air into his lungs, dry paths under his feet, and the penetrating heat of the

sun on his skin. He is born with a love for the feel and smell of rich warm Earth, the taste

of sparkle of Clearwater, the refreshing coolness of foliage overhead, and a spacious blue

dome of the sky. Deep down inside the soul of animal – man is a longing for those things,

a desire something compelling, something quiescent sent, but always there (p. 6).

Healing space 18

The relationship between organic shapes and children

Research has shown that children also have an inherent connection with nature.

According to Simonds (1961), children perceive images as objects in space, while the adult "with

a more highly developed minds and more selective eye" (p. 139), perceived relationships: in

order to comprehend a visual balance, the human eye scans, probes, explores, and wads through

visual impressions at subconscious intervals in which the mind permits, or directs, from optical

limbo and into conscious focus certain visual images. This creative effort of the mind, demands

that the eye "compose" (p. 138) a visual image that is complete and in equilibrium. This

combined joint mind – eye effort is inacceptable equilibrium when it is combined with form –

balance, value – balance, color – balance, and associate – balance. The mind eye team may give

less weight to a massive object that has no associative value, but more weight to one that has

strong associate value or intermediate interest. For example "a ripe apple swing on a branch may

thus outweigh the greatest oak tree in the forest" (p. 138). Therefore there are no to mind – eye,

combinations, scanning a scene, could ever register (with the observer) identical visual images or

combination of images because they seem to have no limits, and the possibilities of selective

composition are endless. But, by a boundless and complicated series of instantaneous

subconscious adjustments each individual "creates" their own balanced and complete optical

impression. The more sensitive and perceptive the mind-eye duo has become, through instinct or

training, the richer, the more delightful the visual world becomes. Additional research by

Milbrath (1998), shows that young children will instinctively use a circle to represent a face or

sun and a triangle to depict a roof of a house. When such shapes are used unmodified and whole,

the can be thought as modular elements that a child uses symbolically with a little attempt at

visual realism. The frequent use of whole "organic" shapes such a circle and triangle in a

Healing space 19

drawing did not statically diminish talent groups or ages of children in the cross-sectional

sample. Never the less, the percentages of children by age suggest that circles were drawn more

frequently by the youngest children (29%, 16%, and 8%), respectfully.

Relationship between man's bonds with place

Topophilia: man’s reception, attitudes, and values of place

"Space "and "Place" connote many things to many people, denoting many experiences

that relate to where we work and live. Tuan (1977) suggests that place is security and space is

freedom: "we are attached to the one and long for the other" (p. 3). Whether one considers sacred

versus "biased" space (p. 43), mythical space and place, time in a new (or experiential) space, or

cultural attachments to space, they all have a special meaning to the observer. As part of this

research about city imagery, and how people perceive and bond to a certain place, Lynch (1960)

describes how a good environmental image creates the feeling of security, overcomes the fear

that comes with disorientation, and promotes a harmonious relationship between the possessor

and the outside world. “It means that the sweet sense of home is strongest when home is not only

familiar, but distinctive as well” (p. 4). The researcher goes into great detail on how

environmental images are assimilated, processed and understood by the observer. Lynch (1960)

explains that the perception of environmental images is a result of a two-way process between

the observer and his environment. The progression involves understanding the dissimilarities and

relationships of the surroundings, which the observer takes up, then with great flexibility, and

within his own understanding, organizes, selects and gives meaning to what he sees. The image,

now developed, has its own limits and emphasizes what is seen; meanwhile the image is

continually being tested and filtered against a predetermined perception in a continuous

interacting process. "Thus the image of a given reality may vary significantly between different

Healing space 20

observers" (p. 6), depending on the observers’ predisposition, attitude or outlook. The logic of

the image may come about in several ways. There may be little in the image that is organized or

noteworthy, but "the mental picture" (p. 6), may gain identity through familiarity. One person

may discern the objects easily while others look at it and see disorder and chaos. On the other

hand an object, which seen for the first time, may not be acknowledged because it looks familiar,

but becomes identified because it fits a predetermined stereotype, already created by the observer

(Lynch, 1960). For example; any Southern Californian teenager might recognize what an “In-N-

Out Burger” sign suggest, but the same sign would be indistinguishable to someone from the

eastern part of the country.

Tuan (1974) talks about place, space, and environment in terms of "Topophilia": where

he combines sentiment with place, which takes on many forms and creates a great range of

emotion and intensity.

It is a start to describe what they are: fleeting visual pleasure; the central the life of

physical contact; the fondness for place because it is familiar, because it is home and

incarcerates the past, because it invokes pride of ownership or of creation; joy in things

because of animal health and vitality (p. 274).

Therefore, Tuan (1974) concludes, since humans are one of the "dominate" (p. 64, 165,

193 and 219) factors in controlling the environment, it is of great importance, when considering

environmental issues, to take into account mankind's bond with place.

Behavioral setting theory

The research on Behavioral Setting by social scientist Roger Barker, who first developed

his theoretical framework on a behavior setting, in the late 1940’s, and studies by Schoggen

(1968) on ecological psychology could bridge a gap between the foundational work of Maturana

Healing space 21

& Varela (1988) on Autopoiesis, the insights developed in American Pragmatism, Continental

Activity Theory and the relationship between man's connection with place. Consistent with

Schoggen (1968), behavior settings exists at the interface between the standing patterns of

behavior and the milieu (environment), wherein the behavior is happening in the "milieu"'

(environment), and the "milieu" (environment), in some sense "matches" the "behavior". In

technical parlance, the "behavior-milieu interface" is called the synomorph, and the "milieu"

(environment) is said to be circumjacent and "synomorphic" to the "behavior". By correlating the

following theories, the literature evidently indicates that man interacts and shares his perceptions,

undertakes a pragmatic, systemic, functional, behavioral, and environmental relationship with

space and place:

1. Autopoiesis, Maturana & Varela (1988),"a shared set of assumptions and

perceptions" (p. 239).

2. The American pragmatists, Williams (1907), “It is high time to urge the use of a

little imagination and philosophy. The willingness of some of our critics to read

any but the silliest of possible meanings into our statements… is as this credible

to their imagination is anything I know in recent philosophic history. Schiller says

the [truth] is that which 'works'" (P. 234).

3. Activity theory and Nietzsche, Magnus & Higgins (1996),"the subject is [the]

consequence to the activity, in Nietzsche view, and not the activity's originator"

(p. 239).

4. Behavioral Settings theory, Schoggen (1968), "[behavioral settings theory] has

made important contributions to our understanding of behavioral – environmental

relationships" (p. 167).

Healing space 22

Restorative design with nature

Nature in the healing environment

In the last half of the 20th century, researchers have found that designing healing

environments inspired by the biodiversity of nature (of biology, chemistry, computer science,

environmental psychology and evolutionary anthropology, and neurosciences) supports the

healing process. Research has shown that ancient and modern people have used the natural

elements around us for healing, such as a sacred spring, reflective pond, a quite grove or

magnificent mountain peaks. For centuries, men have sought these safe places for healing of the

mind, soul and body (Huelat, 2008). Hippocrates believed in the “healing power of nature” (“vis

medicatrix naturae” in Latin). Affirming his theory, the body’s vital essence or spirit contains

within itself the power for re-balancing and healing. The word disease (“dis”, meaning apart

and “ease” meaning balance), describes a loss of balance and harmony (Garrison, 1913).

Reviews of research have revealed that healing environments Inspired by "watching clouds float

overhead, gazing out the window at a grove of trees, or seeing a serene sunset brings relaxation

and pleasure" (Huelat, 2008, p. 3), including (Ulrich, 1981, 1984 and 2001; Del Nord, 2009;

Mizan, 2004; Farley, 2001 and Kahn, 1999). Other studies by Ke-Tsung Hang (2010) and

Ornstein & Sobel (1990) concur that the use of scenic beauty "openness" and "water features"

connote a high correlation with preference and restoration. Similarly research by Park (2004)

show that patients exposed to ornamental plants in the simulated hospital environment

significantly improved female students' pain tolerance, "this was indicated by longer pain

tolerance time during the cold pressure test (C PT), lower self – rating scores on the pain

intensity, and lower electrodermal activities (EDA) responses of students who viewed plants as

compared to ’no plants’" (p. 1). And other research by Walch (2005) present medical evidence

Healing space 23

that postoperative patients who are exposed increased to amounts of natural sunlight during their

hospital recovery period indicated decreased stress, pain, analgesic medication use, and pain

medication costs. Moreover research testing people's understanding and perception of what types

of natural environments they prefer, and psychological benefits they seem to derive from

wilderness experiences, and why exterior garden areas/courtyards are especially important. The

Kaplan & Kaplan (1989) studies have clearly indicated that their attention restoration theory,

"despite all the variations, there remains substantial consistencies. The strongest of these is the

importance of nature itself… seems to be as close to universal as one can find." However, how

can these natural manifestations be incorporated into a healing environment, so that a "nature

appreciation" (Simons, 1961, p 75) becomes a part of patients' daily lives? Simons, (1961)

recommends projecting colors, certain areas of interior paving, structure walls or overhead

planes into the landscape whereby creating a control transition from interior to exterior, from

refined to the natural. Similar to what is incorporated into the Temple of Tofukuji in Kyoto,

Japan, (see Fig. 6). Chan’s (2001) research on cancer

patients, bereaved wives and divorced women, treated in

this type of environment ”emphasizes an Eastern

approach" (p.2) along with traditional Chinese medicine

(which conceptualizes the body, mind, cognition,

emotion and spirituality into an holistic approach)

showed "significant improvements in physical health,

mental health, sense of control and social support" (p.1).

Fig. 6, Temple of Tofukuji in Kyoto, Japan. An

example of incorporating natural manifestations

of nature into the healing environment.

Healing space 24

In this view, health is professed as a harmonious equilibrium that is part of the relationship of the

“'yin' and 'yang': the five internal elements (metal, wood, water, fire and earth), the six

environmental conditions (dry, wet, hot, cold, wind and flame)” (p.3).

Another example of incorporating the Simons et al. (1961, p 75) "nature appreciation"

concept, would be to use the "seven principles of a healing environment," developed by the

Danish -born , Swedish architect, Erik Asmussen. Coats (2001) provide some plausible tactics of

how to create life – enhancing architecture that deals with the whole person: body, soul and

spirit, as described by Asmussen's seven principles of

"healing architecture" (p.243): 1). unity of form and

function, 2). Polarity, 3). Metamorphosis, 4). Harmony with

nature and site, 5). The living wall, 6). Color luminosity,

and 7). The dynamic equilibrium of spatial experience.

Asmussen believes that architecture should be "nurturing,

responsive and alive,” with “dynamically shifting spatial

balances, organically expressing forms, subtly luminous

colors and biologically healthy, natural materials" (p. 240).

According to Coats (2001), the Asmussen's Rudolph Steiner

seminary – cultural house, represents how a design can harmonize with its site, amassing

metamorphosis with its surrounding green hills, be in "equilibrium" with his form, functions and

"free – flowing spaces", See Fig. 7.

Fig. 7, Erik Asmussen's Rudolph Steiner

seminary – cultural house, represents how

a design can harmonize with its site,

amassing metamorphosis of its with its

surrounding green hills, be in

"equilibrium" with his form, functions and "free – flowing spaces"

Healing space 25

Relationship between belief and reality

Social constructivist perspective

To understand the connection between the association between a belief and reality, the

research must take into consideration the philosophical epistemology compositions of Étienne

Bonnot de Condillac and Denise Diderot. These 18th-century philosophers contributed to our

modern day understanding of belief and reality. While Condillac's philosophy considers that all

knowledge was gained through the senses, Diderot's idea of self came from the understanding of

materialism. Diderot believed that a man was born a certain way but society and life's problems

wore away something of its original shape. Diderot's materialism was inspired by his

understanding of contemporary biology and the continuity between organic and inorganic matter.

This idea was that life was merely matter organized in a particular way, and death was merely a

moment in the construct passage between inert and in adamant forms (Seigal, 2005).

The researcher explains that through his writings, Condillac established that all human

faculty and knowledge are transformed through sensation only, to the exclusion of any other

principle, such as reflection. To prove his point on "sentationism", he imagines a statue

organized inwardly like a man, animated by a soul which has never received an idea, into which

no sense-impression has ever penetrated. He then unlocks its senses one by one, beginning with

smell, as the sense that contributes least to human knowledge. In accordance with (Seigal, 2005),

Condillac believed that the abstract signs that people came up with and believed in, were based

on nature and eventually the connection between the word and nature was lost. "When the use of

those signs became familiar, the origin was forgotten, and people were so weak as to believe that

they were the most natural names for spiritual things. “It was even imagined that they perfectly

explain the essence and nature of those things, though they only express some in imperfect

Healing space 26

analogies" (p. 178). Hence, Seigal (2005) concludes that knowledge is based on a normative

systemic process of environment and human sensations. Furthermore Seigal (2005) explains that

Diderot, in many of his works, wrote about a subject or character, which read like

improvisations, and assigns associated meaning to them, such as in the book Rameau's Nephew.

Diderot engages in a spirited dialogue with an eccentric and colorful music-teacher, nephew of a

well-known composer, whom he sometimes met in the garden of the Palace Royal. The

participants, called I and He (Moi and Lui), disagree and agree about many things, but in reality

many of the opinions expressed by Lui are those of Diderot himself, which are found in many of

his other writings, as well. In other works, such as Jacques the Fatalist and his Master and his

Essay on Dramatic Poetry, Diderot portrays many of his characters in contradictory terms and

dualistic roles. For example, in Jacques the Fatalist and his Master, Jacques's key viewpoint is

that everything that happens is "written up above" like a "great scroll" (p. 187), which is unrolled

a little bit at a time, on which all events, past and future, are pre-determined, yet he still places

worth on his events; he is not a passive character. In other words, Diderot described the way we

are all moved to say things by unconscious associations among words and objects, concluding

"Oh how much even the man who thinks the just an automation" (p. 199). The research might

conceivably interpret all this as behavior of a person whose inner divisions led him away to

imagine himself and others as possibly other than they were. On one hand he constructs a

confined reality with materialistic principles, but at the same time, speaks to us while standing

outside the universe, conclusions not too dissimilar with research previously cited (Maturana &

Varela, 1988); Prigogine, 1996).

Healing space 27

Perceptions and aesthetics

Current research has shown that most social psychologists consider belief to be about an

association rather than a characteristic of a thing. Lang (1988) asserts that an attitude is a result

of a combination of belief about something with a value or hypothesis connected to it. For

example a building with pointed arches may be a defining characteristic of Gothic architecture;

"such windows go well in ecclesiastical architecture" (p. 19) is an associate characteristic. Many

such beliefs are verbalized in architectural writings and polemic theories, but many are inferred

just by observing what architecture is. The same can be said about organic shapes and natural

geometries. He continues by explaining his theory about belief as it relates to values,

motivations, attitudes and direction whereas values are interconnected to motivations and define

the attractive and repulsive elements of the world. Anything that a person desires or

complements has a positive value (for that particular individual); anything that is despised

therefore has a negative value. Value, therefore symbolizes a link among a person's emotions,

motivations and behavior. Attitudes, on the other hand, about a specific built environment or

natural surroundings have "rationalized" value, which leads to a belief" (p. 19). Although

people's attitudes might have a certain direction, strength, characteristic or perceived truth about

it, their attitude about something is mostly attributed to their belief. Direction of the attitude is

very important in the formulation of a belief. If one, during the formation of the attitude,

evaluates an object or environment and perceives its differentiations, strengths and/or

weaknesses (of an object) an action takes place which either reinforces or hinders the subsequent

belief. "Because one likes a particular set of symbols [it] does not necessarily mean that one will

use them" (p. 19).

Healing space 28

Lang (1988) said the primary goal of design has always been an aesthetic one, "the

creation of delightful rooms, buildings, townscapes, and landscapes" (p. 11). He promotes his

argument, by referring to existing studies done by Santayana (2003), who researched aesthetic

experience with a number of people and had found it useful to characterize their experience of

the built environment, in three distinct categories: Sensory aesthetics, formal aesthetics and

symbolic aesthetics. Sensory aesthetics involves the arousal of one's multidimensional

noncognitive systems which is the product of colors, odors, sound, and textures of the

environment. Moreover, Santayana, (2003) continues and says that formal aesthetics in

architecture, and design, is mainly about the "appreciation of shapes, rhythms, complexities, and

sequences of the visual world" (p. 11) which can also be applied to the hearing, aromatic, and

touching worlds as well. In symbolic aesthetics, people gain pleasure by applying an associated

meaning of their surroundings via the use of their senses and the "affect" (emotion or feeling) is

the aesthetic dimension that leads us to an understanding of the positive and negative attitudes

that people have about embolic meanings available in their environments.

Nasar (2008) also talks about formal and symbolic aspects of aesthetic quality in the

slightly different approach. He contends that there are two ways the environment affects the

assessment of aesthetic quality: formal and symbolic (or associational). A formal analysis

focuses on the attributes of the object, as part of the contribution to aesthetic response which

would include such properties such as size, shape, color, complexity, and balance. A symbolic

analysis, of aesthetics, centers on features that come about through experience and produce an

implied meaning associated with something else. Although a Ford or a Mercedes might have

similar formal attributes they definitely produce a different meaning to the observer. Likewise an

artificial flower (might look like a real flower) will have different meanings if the observer

Healing space 29

realizes it's artificial. However, a symbolic analysis centers on such things as style and context.

Other research by Berleant (1998) indicates an approach to environmental aesthetics considers

the human person as an active contributor in a context that includes and is continuous with the

participant. “A person is the perceptual center, both as an individual and as a member of a socio-

cultural group, of his or her life-world whose horizons are shaped by geographical and cultural

facto” (p. 84).

Additional review on visual aesthetics indicated that one of the central issues relating to

architecture and environmental planning, save for modest scientific evidence concerning the

manner is in which interior environments influence human behavior. For example studies by

(Locasso, 1976) have indicated problems in experimental design, measurement, and

methodology, but there appears to be little solid experiential evidence that demonstrate that

attractive interior spaces have any sort of beneficial influences on human functioning and

behavior. Early works of Maslow and Mintz (1956) have received much exposure in

environmental psychology in the environmental – design disciplines. They looked at the effects

of "beautiful" and "ugly" rooms on respondents attitudes, perception, or dispositions and the

amount of "energy" in "well – being" reflected in photographs of human faces. One of the

renowned experiments involved two rooms, one decorated as a comfortable office and contained

a mahogany desk and chair combination, a rug, drapes, paintings, sculptures and other items in

the other was a plain room, painted battleship gray with single overhead bulb, suspended from

the ceiling, a plain desk, and three worn-out chairs. The room was very disorganized and

shuffled with papers scattered throughout, messy trash bins and papers strewn on the floor which

gave the impression of a "janitors storeroom" (Maslow and Mintz, 1956, p. 248). "People who

saw the so-called "comfortable office", described it as ‘attractive,’ ‘pretty,’ ‘comfortable,’ and

Healing space 30

‘pleasant’” (Maslow and Mintz, 1956, page 247 The people who saw "janitors storeroom"

described it as an "ugly", disgusting, and repulsive room (Maslow and Mintz, 1956, page 248).

The results indicated that the "beautiful room" gave significant higher ratings to those

dimensions than the "ugly" room. The Maslow and Mintz (1956) study has been widely quoted

and discussed in literature and in general has come to be regarded as that quote "classic" study in

the area of environmental psychology.

Further research has pointed toward a number of other models for mutually supportive

attitudes of people's likes, dislikes and predispositions. Studies like (Heider, 1946), Osgood and

Tanenbaum (1955) and the Rosenberg, (1980) congruity model. All show that two people may

have different reasons for holding the same attitude but can still agree. In addition, some

attitudes are more strongly held than others and consequently are less likely to change based on

the influence of other people with weaker ones as it applies to people's perception of Levittown

or Las Vegas, for example (Lang, 1988).

Healing space 31

Methodology

The Hypothesis

Among skilled nursing/assistive living environments, there is a direct relationship

between the use of natural surroundings, abundant natural light, organic shapes, and a patient’s

positive psychophysiological outcome.

The Approach

Qualitative research

Positive/postpositive research adheres to a single object reality (ontology), which is

established through the five senses by the use of microscopes, telescopes and sonograms, while

at the same time making every attempt to separate the inquiry from the object of inquiry, so that

the research will not be tainted (epistemology). The stereotype of the scientist with the white lab

coat comes to mind, testing and observing. Then more tests and more observations, focusing in a

single goal: to find his or her version of reality or “truth”. This quantitative way of looking at the

world works well for the objective scientific paradigm, but the research and the researcher

cannot get into the context and examine it. If there was a positive/postpositive research study of

an atom or a rabbit, the researcher can only observe, make assumptions or deduce knowledge

about what the atom or rabbit is doing, with no knowledge of its context or relationship to others,

or other realities around it.

In contrast to the previous system of inquiry, the ontology of the naturalistic paradigm (to

know what it is “out there”), is to look at more than one “reality”. Speaking holistically, the

introduction of naturalistic systems of inquiry must utilize and be functionally interwoven with

the sophisticated paradigmatic research solutions. The study must be of the “whole cloth”,

where each piece of cloth is interrelated to the total. If one aspect is isolated from its context, it

Healing space 32

will destroy much of its meaning. The corresponding epistemological position is that, it is

neither possible nor advantageous for the research to establish a value-free objectivity

(Erlandson; Harris; Skipper & Allen, 1993). To a certain extent, the researcher in the naturalistic

inquiry is part of the context of the research and a theoretical assumption: why would a resident

or client want organic shapes, natural light and natural surroundings?, Would be very beneficial

in the investigation, (See Fig. 1). Doing a naturalistic study of inquiry with qualitative

information about realities (paradigms), associated with the assisted living residents, healthcare

staff, and facility administrators, would give the researcher the ability to get inside (and study),

the relationship between natural surroundings, abundant light and organic shapes, and a patient’s

positive outcome. By learning each constructed reality, we will be able to share with the

stakeholders (of each reality), and at the end, construct a new reality (or realities) that would

enhance both the

researcher and

stakeholders, and

provide a foundation

for a new assisted

living prototype based

on holistic thinking,

and a framework of

multiple analysis of

organic shapes and sustainable principles.

Fig. 8, in this naturalistic inquiry, each respondent has its constructed reality,

with its own boundaries and understating of the whole, which has a corresponding behavior.

Healing space 33

The Black Box Metaphor:

Suppose this naturalistic inquiry is represented by a “Black Box” (See Fig. 2). To begin

the study, the researcher climbs into the Black Box, and to his surprise, finds a light on inside.

Once inside, the researcher starts to distinguish various constructed realities of the stakeholders

and respondents, then determines how they are related, and choose among the respondents for

qualities interconnected to the research, or the researcher could test their own constructed

realities (which are data found in other documents or records), against the constructed realities of

the stakeholders. As the researcher operates and moves around inside the circle of stakeholders

(the social context) of the Black Box, they bring that information into contact with each other’s

constructed realities, so that they can mutually understand and expand this new shared vision that

will bring empowerment, communication and positive development among the interconnected

realities. During this movement inside the box,

among the stakeholders, the researcher will be

sharing constructed realities, and building common

direction and understanding. From this process, a

final outcome will emerge. Erlandson; Harris;

Skipper & Allen (1993) states “From this process,

the final shape of the study, and the form in which

it will be reported, gradually emerges. Allowing

for the emerging process is fundamental to the

naturalistic design and methodology...” (p 68). In

past studies, one of the major findings was called

“Mutual Simultaneous Shaping” (Erlandson; Harris;

Skipper & Allen, 1993, p. 16). Lincoln & Guba,

(1985), describe among other things, that the factors

observed were also bound together in a whole pattern

like the woven pattern of a cloth, each part interconnected and dependent upon each other. Each

part was both, cause and effect of every other part, “Any solution to the problem would have to

be a holistic one addressing the overall pattern of the

Fig. 9, the black box a naturalistic inquiry, looking

at ontological assumptions of the respondents

constructed realities in conjunction with their

preferences, dispositions and attitudes of organic

shapes, abundant natural light and natural

surroundings.

Healing space 34

organization’s behavior and not just some one portion of it”, (Erlandson; Harris; Skipper &

Allen, 1993, p. 12).

Case Study

Another way of attaining vital information for a naturalistic inquiry is to use a case study

approach, so that the researcher can investigate the phenomenon of the constructed realities in a

real-life context, especially when the boundaries between phenomenon and context are not

clearly evident, Yin (1981a, 1981b). In other words, the case study is relevant when you want to

understand a real-life phenomenon in depth, and its relationship to its natural surroundings.

Moreover, Yin (2009) continues by saying….

The case study is preferred in examining contemporary events, but when the relevant

behaviors cannot be manipulated. The case study relies on many of the same techniques

as a history, but it adds two sources of evidence not usually included in the historian’s

repertoire: direct observation of the events being studied and interviews of the persons

involved in the events. Again, although case studies and histories can overlap, the case

study’s unique strength is its ability to deal with a full variety of evidence-documents,

Assumptions Reality: Qualitative paradigm

Ontological Assumptions Shared and interconnected The realities are seen by the

researcher as subjective,

constructive and multiple

Epistemological Assumptions The researcher is inside the box

with an interactive link between

researcher and respondents

Researcher interacts with

respondents inside the box

Methodological Assumptions Observation, case study

research, collection of existing

data , documents & interviews

Inductive process of “Mutual

simultaneous shaping”

Fig. 10, Summarization chart of the Black Box study.

Healing space 35

artifacts, interviews, and observations-beyond what might be available in a conventional

historical study (p. 11).

In order to adhere to a case study approach, five prominent characteristics should be met.

First: the study questions who, what, where, when, and why. In this particular case study, an

empirical inquiry reveals why a resident or client would want organic shapes, natural light and

natural surroundings, integrated into an assisted living/healthcare environment. The

respondents’ perception of organic shapes, natural light and natural surroundings, in the context

of an assisted living/healthcare environment, adds unambiguous methodological specifics, depth

of knowledge, and the final quantities analysis.

Second: proportions-exploratory rational and the purpose of the exploration. When

Christopher Columbus went to Queen Isabella to ask for support for his “Exploration” of the new

world, he had to have some reasons for asking for three ships, (Why not one? or five?), and he

had to have some basis for going westward, (Why not South or East?). His search began with

some rationale and direction, even if his initial assumptions might later have been proved wrong

(Wilford, 1992). The magnitude, rational, and purpose of this case study is, is simply to use

what is accessible and available to the researcher, like Christopher Columbus, he chose the first

three ships that would bring him the highest probability of success (Wilford, 1992).

In my research, the three ships will be a multiple case study of two existing assisted

living projects, located in Southern California, in which I was the Architect, and had access to a

large portion of the design and site information. The decision to use these two sites became

evidently clear, when familiarity with personnel, logistics and site access, came into play.

Moreover, as part of the over-all design, the client, California General Services Administration,

dedicated additional land at the Ventura site for a future additions. Third: what is the case or unit

Healing space 36

of analysis? A definition of a single case study is an individual, or clinical patterns, or derelict

men. Or in a multiple-case study, it can be about decisions, attitudes, preferences, programs, the

implementation process, and/or organizational changes, (Platt, 1992). Feagin; Orum; Sjoberg &

Gideon (1991) describe some classic examples of single case studies in sociology and political

science. Examples of multiple case study research include, church involvement, city life, gender

roles, white-collar crimes, family structure, homelessness, and other types of social experiences;

but within these two cases, the research is combined with qualitative and quantitative tactics, to

provide a wide-range insight to the final substantiation of data, which answered why these

groups were chosen. Fourth: connecting the data to the proportions, in other words, the study

must have a reliance on multiple sources of evidence within the case proportions, or delimits of

the cases. Yin (2009) calls it “Linking pattern matching, explanation building, time series

analysis, logic models or cross-case synthesis”. And fifth, power to generalize the theory behind

the study. The core of a case study is its focus on a phenomenological relationship, within a real-

life setting inside the metaphorical black box, but it can lead to generalization that will be

applied to a new manifesto. The findings of correlation research are universal from a

representative sample to a larger population; therefore, a concept or “theory” embedded in the

cases can be generalized, reproduced, and ultimately incorporated into the final prototypical

design solution as well. Yin (2009), argues a similar point where a case study's strength is its

capacity to generalize to a theory like an experiment can be generalized to a theory, which in

turn, can be tested through other experiments.

The study of a group

Another approach to the research study is to emphasize an in-depth engagement with the

respondents as a group, where the aim is to learn about the relationship between symbols,

Healing space 37

expectations, unspoken knowledge, communication, beliefs, likes, dislikes, attitudes, and

perceptions of a cluster. The premise of this exploration is to understand and analyze the

individual variables predicting an event: a positive psychophysiological outcome. By using a

multiple regression formula to represent how one independent variable (X) is used to predict a

single dependent variable (Y). The predicted value of (Y) is a linear transformation of the (X)

variables such that the sum of squared deviations of the observed and predicted (Y) is a

minimum. The computations are more complex, however, because the interrelationships among

all the variables must be taken into account in the weights assigned to the variables as presented

by (b).

From my hypothesis, the relationship of the variables can be defined as follows:

The dependent (or criterion) “Y” variable would equate to: the patients/residences positive

psychological outcome. The independent (or predictor) variable “X”, would equate to: The use

of natural surroundings, abundant natural light, and organic shapes, (such as a circle or

curvilinear wall). The weighted vale of “b” is assigned the number 1 (the interrelationships will

have the same weighted value for simplification). Therefore, the predicted outcome of the

variables could be represented in the following multiple regression formula:

eXbXbXbXbXbbY 55443322110 .

A positive psychophysiological outcome, associated with one’s beliefs as being positive,

translates down to the cellular level, where a calming environment appears to influence improved

immune responses, linked with positive mental states, Mizan (2004).

Now that the variables have been identified, the research “setting” (Grout & Wang, 2002)

defined, the connection between the meaning of the variables, and the group in the natural

surroundings, becomes apparent as the study unfolds. At the conclusion, the data will lead to

Healing space 38

explanation of unexpected or anticipated outcomes, between the rural group and the urban group.

There might be a possibility that there are obvious similarities, or no similarities, or maybe an

unexpected generalization or theory that can be applicable to the research solution.

Holistically thinking, the setting comprised of two veterans assisted living facilities,

located in Southern California, (see chart below). According to the VETERANS HOMES OF

CALIFORNIA, an assisted living facility is an apartment-style habitat, designed to focus on

providing assistance with daily living activities. They provide a higher level of service for the

elderly, which can include preparing meals, housekeeping, medication assistance, laundry, and

also do regular “check-ins” on the residents. Basically, they are designed to bridge the gap

between independent living, and nursing home facilities. “In general, assisted living combines

housing, personal services, nursing and health care, in an environment that promotes maximum

independence, privacy, and the choice for people too frail to live alone, but too healthy to utilize

a 24-hour nursing care." Kraditor (2001).

Healing space 39

Quasi-experimental research

The final approach to this study, includes a quasi-experimental of the two selected sample

“case studies” assisted living groups, (Campbell & Stanley, 1966; Cook & Campbell, 1979;

Shadish, Cook & Campbell, 2002), sequentially, in order to gain further insights or

understanding, and the extent of meaning behind the research topic with the application of quasi-

experimental techniques:

Perform an explorative pilot comparative study to identify real and metaphoric

representations from natural elements of wind, earth, fire, metal, sight, sound, touch and smell,

using the Sensationalism and Reflection philosophy of Condilloc and Diderot (Seigel, 2008) and,

Site One (Rural) Site Two (Urban)

Location 10900 Telephone Road, Ventura,

CA.

11500 Nimitz Avenue, Los Angeles,

CA.

Beds 60-bed Residential Care Facility

for the Elderly (RCFE), also

known as assisted living.

84-bed Residential Care Facility for

the Elderly (RCFE), also known as

assisted living, 252 skilled nursing

beds, and 60 beds for dementia

long-term care

Completion date 2009 2010

Predominate

stakeholders

Administrator: Ms. Brenda Manke

Asst. Admin.: Patrick Keleher

Administrator: Mr. Louis H. Koff,

Asst. Admin.: Robin Mackey

Group Administrators, facility staff,

nursing staff and California

veterans, 62 years old and older

Administrators, facility staff,

nursing staff and California

veterans, 62 years old and older

Services All healthcare needs, meals,

transportation, and activities are

provided by the Veterans Home of

California–Ventura, in partnership

with the VA Greater Los Angeles

Healthcare System.

All healthcare needs, meals,

transportation and activities are

provided by the Veterans Home of

California–Los Angeles, in

partnership with the adjacent United

States Veterans Affairs campus,

Westwood CA.

Massing/construction Single story/OSHPD 2-Type V-A Four story/OSHPD -Type I-A

Fig. 11, Description of the group research setting

Healing space 40

Correlate that data with manifestations of natural elements of the built environment (three

dimensional prototype representations), as it applies to George Cantor’s set theory (Dauben,

1990).

The resulting qualitative data, acquired from the pilot comparative study, the

correlation study, three dimensional prototypes/questionnaires and key interviews, were plotted

on an impact assessment grid for analysis, Erlandson (Harris; Skipper & Allen, 1993). What

then, are the defining characteristics of a quasi-experiment? And what commonalities of

previous studies, from Campbell & Stanley (1966) et al., can we draw from, and apply to this

study? Specifically, there is five: First, the use of a treatment or independent variables,

(symbolized as “X”), are manifested as natural elements of the built environment (three

dimensional prototypes); Second, the measurement of outcome or dependent variables,

(symbolized as “Y”), are tested as a positive belief that becomes reality, in association with

organic shapes and natural surroundings, Social constructivist perspective, (Katz & Rothenberg,

2005) and (Snyder, 1984 ); Third, a clear unit of assignment (to the treatment); Fourth, the use of

a comparison, or control group; and Fifth, focus on causality. In this study, the “unit “ are the

rural and urban case studies, where the key common features, to this, and all experiments, is to

deliberately vary something, so as to discover what happens to something else later, to discover

the effects of presumed causes. In quasi-experiments, the cause is manipulated and measured,

and occurs before the effect is measured (Shadish; Cook & Campbell, 2002).

Healing space 41

Methods

Participants

Research participants were: 25 residents, 5 residential care staff, and 1 administrator from

the Ventura VA assisted living facility; and 25 residents, 5 residential care staff, and 1

administrator from the VA West Los Angeles facility. Ethnicity of participants was not

evaluated. All study participants, had at least six months living or working in the facilities. The

participant average profile is based

partially on the U.S. Department

of Health and Human Services

Report (2002), and partially on

statistics supplied by Cal Vet

Homes, in Ventura and West Los

Angeles. The residents, 65-74

years old, are 13% of the sample

population. The residents, 75-84

years old, are 37% of the sample

population. The residents, 85

years old or older, make up 50% of

the sample population. The respondents

that are white make up 91% of the sample,

while only 9% are non-white. As to

gender, 75% are male and 25% are female

(due to fact that the case study population is derived mainly from United States armed service

personnel). Income level, 69% make less than $10,000 a year, 19% make $10,000-$20,000 a

Fig. 12, Example of the Effects matrix, Effects of Nature

crossed referenced with LEED 2009 criteria and Effects of

Nature crossed referenced with a review of literature (above),

see appendix A, B & C.

Healing space 42

year, and only 12% have a yearly income of $20,000. Health-wise, 11% are in excellent or very

good health, 34% are considered in good health, and the remaining 55% are in fair or poor

health.

Instruments

To gain an understanding of what are the positive or negative attitudes, perceptions or

dispositions towards organics shapes, natural surroundings and/or sustainable principles, an 8” x

11-1/2” matrix was developed, with symbols of the basic elements of nature, which are Wind,

Water, Earth, Fire and Metal located on the top row. Symbols of sight, sound, touch and smell

are located on the left column, then crossed referenced. Finally, each crossed reference variable

was assigned one or more adjective “descriptors” that are assigned to each description of the

combination or sight/wind or touch/water. In the example (Fig. 12), the cross reference

wind/smell, the associated adjective descriptor/variable is aroma. For wind/touch, the associated

adjective descriptor/variable is the sensation of air movement.

Next, an 8” x 11-1/2” review of literature matrix was developed from excerpts from

literature, poetry and related research were assigned to the combination of the human senses and

elements of nature in order to enhance the experience of or reveal any previous knowledge of the

effects of nature. For example, the correlation between sight/wind and touch/wind describes

wind as “soft stirrings that rustles leaves and grasses on summer afternoons to the biting storms

that threaten life and limb, wind touches us all every day of our lives” (DeBelieu, Jan, 1998) or a

research study by Kline (2010) indicated that audio stimuli of natural sounds or music used in

conjunction with distracting visual elements provided stronger evidence of pain reduction which

points out how the combination of touch and water can produce positive effects for patients.

Other combinations revealed negative associations, such as touch and fire. In the book Fire,

Wambaugh (2002) describes an October evening in South Pasadena, CA where a wave of flame

Healing space 43

swept through a large home improvement center, snuffing out the lives of four innocent people.

One firefighter said “The temperature near the fire reached 110° it felt like someone was firing a

hairdryer in the mouth every time it took a

breath”.

Subsequently an 8” x 11-1/2” matrix

of sustainable principles were prepared and

cross matched to reveal how past studies,

literature and poetry of natural elements and

the current 2009 LEED criteria (Fig. 12). For

instance, the variable wind/touch was linked

to a study by Toftum (2004), indicating

indoor air, at a maximum temperature range

and very high air velocities, up to around 1.6

m/s, has been found to be acceptable at air

temperatures around 30 degrees C. However,

the pressure on the skin and the general

disturbance induced by the air movement

caused the air movement to be undesirable.

But another study by Zhou, X. (2006)

suggested that, dynamic air supply could

reduce the velocity and still maintained

comfort and also meets LEED 2009 indoor

Fig. 13, example of how wind/water/earth and metal, combined

with sight/sound/touch and smell to reveal corresponding

metamorphic manifestations of natural elements (images).

Fig. 14, example of a three dimensional manifestation in the

built environment in a built environment with simulated

textures and colors.

Healing space 44

air quality requirements. Other combinations, such as Healing Gardens (Marcus & Barnes,

1999) match up well with LEED’s

Heat Island, open space, view, habitat

and storm water management criteria.

To further embody the effects

of nature, the review of literature and

sustainable principles of nature were

then cross referenced into a new 8” x

11-1/2” matrix, (Fig. 13), where each variable is

assigned a corresponding image to the written adjective

“descriptor” of related literature, poetry or past research

to help form a language pattern that translates the

abstract into physical prototypical terms, and bridged

the gap between the concept word/thoughts, and the

intuitive or artistic line of thought. Creativity research,

illustrates how using a linguistic devise such as a list of

related words (e.g. air movement against the face,

body, feels damp, dry, dusty, etc), with images of how

wind affects people, induces the transformation of thought into physical reality, based on

philosophy of sensationalism and reflection (Tyson, 1998) and (Sigel, 2005).

The evolution of wind/touch/air movement variable produces a new language pattern for

design, in the form of a manifestation of natural elements of a built environment (three

Fig. 15, example of a three dimensional manifestations of natural elements in

a built environment cloud formations or landscape scenes, through artificial

lighting, LED screen technology.

Fig. 16, example of a pilot exploratory correlation study

in which the metaphoric images are compared and

correlated with a three dimensional prototype, then

documented.

Healing space 45

dimensional prototypes, Fig. 14), with an organic

shape and/or materials, such as smooth stones,

that might have good or bad implications.

For example, a curved wall of smooth

stones might be acceptable, but located near

higher air movement, might cause noise, and

presumably fear, which is considered

unacceptable. However, lowering the air

velocity, using a dynamic supply register, would

reduce fear, which then becomes more

acceptable. This, in turn, creates energy

savings, which equates to a sustainable

principle. Other three dimensional models (Fig. 15), showing similar language patterns, such as

sight/earth lead to an ultimate design with organic characteristics, depicting natural light and

emulating cloud formations and/or landscape scenes, through artificial lighting and LED screen

technology. Studies have shown that greater restorative effects arising from experiences in

nature (Hartig; Mang & Evans, 2006), reduce stress and anxiety. Additionally,

sight/earth/sound/water prototype models, referring to language patterns of abundant natural

light, theorized pain and stress reduction (Malenbaum; Keefe; Williams; Ulrich & Somers,

2008), (Ulrich; Zimring; Quan & Joseph, 2006) and (Ulrich, 2008). By bringing the outdoors in,

nature stimulations with both, visual and auditory distractions, can be shown as diverting and

engrossing, therefore it is more effective for relieving severe pain and/or stress (Malenbaum et

al., 2008 and Ulrich et al., 1993; Tse, Ng, Chung and Wong, 2002).

Fig. 17, example of a questionnaire: Showing a three

dimensional prototype of a built environment with

questions relating to natural light.

Healing space 46

From the evolution of wind/touch/air movement variables, review of literature,

sustainable cross referencing and assigned images, an exploratory comparative study, where the

metaphoric representations, from natural elements (images), were compared to the design with

the manifestations of natural elements of a built environment (three dimensional prototypes), to

determine if they were analogous. The date, time and comparative decisions were recorded on

an 8 1/2” x 11” matrix for documentation purposes (Fig. 16). At the end of the exploratory

study, the three dimensional prototypes with the

most resemblance to the natural manifestation,

were incorporated into a survey questionnaire.

Interview guidelines

To design healthcare environments that

captures organic shapes, natural surroundings and

sustainable principles, which result in an increase

of patients’ positive psychophysiological outcome,

the researcher must understand environment

behavior of who does what and when, in

relationship, or lack of, between people’s attitudes,

perceptions and dispositions of organic shapes,

natural surroundings, and sustainable principles

within the context of a physical setting. By

looking at how two case study environments affect people’s ability to see, hear, touch, smell and

perceive their environment and each other, we were able to understand how environment can

impair or improve, the residents’ and/or staffs’ positive psychophysiological outcome. Basically,

Fig. 18, example of a body language guide, to

document respondent’s perceptions during the

interview.

Healing space 47

this was done by asking questions, taking notes, performing surveys through questionnaires

(Figs. 17) and performing focused interviews with residents, staff and key stakeholders, using

an interview/ body language guide (Fig. 18).

Interviews with residents, staff, and administration, gained important insight and

knowledge about what the respondents feel about the use of organic shapes, natural

surroundings, and sustainable principles in a healthcare environment. It also helped the

researcher understand how the data adapted into the larger, interpersonal, social, and cultural

context of the study. The researcher went into each interview with the following objectives:

Introduce and explain the reason and goals of the research project.

Lead the interviewee with a mixture of conversation and embedded questions.

Encourage

o Opinion/value questions, but start out very simple

o Experience/behavior questions

o Knowledge questions

o Sensory questions

o Background/demographic questions

Keep track of body language as the interview proceeds

Take detailed notes

Be sure to thank the interviewee

The following is an example of some initial questions at an interview with a staff member

at the VA homes:

Interviewer: What is your general feeling about this facility?

Staff member: I really like it

Interviewer: What do you particularly like about it?

Healing space 48

Staff member: I really like the way it feels, open to the courtyards at the common areas and

hallways.

Interviewer: What do you mean when you say “It feels open”?

Staff member: I mean that it makes me feel closer to the outside garden areas, during work

Procedure

13 to 25 participants at each case study site were randomly chosen by the staff and the

researcher to review each of the four questionnaires that showed a rendered three dimensional

prototypes, of the built environment and three or four other questions relating to organic shapes,

abundant light, and natural surroundings.

Then the participants will review the rendered three-dimensional prototype, of the built

environment, and be asked to rate the image, on a Likert scale, from 1 to 5 (1 being least and 5

being very), how comfortable would you feel in a room like the one portray in the questionnaire.

During the process of answering the other question the researcher and the respondents

participated in brief open-ended interview, in order to understand their perception, like or dislike

of windows, natural light, views, natural surroundings, and organic shapes and materials. There

is also space on the questionnaire for respondents to write about their feelings regarding the

three-dimensional prototype, windows, natural light, views, natural surroundings, and organic

shapes and materials.

Interviews of administrators and key stakeholders will be audio taped and take the form

of an open-ended nature in which the researcher will ask the respondents for opinions about the

questionnaires, natural light, natural surroundings and organic shapes and materials as it related

to their assisted living environments..

Between interviews the audio tape will be played back and the data "unitized" into the

smallest pieces, as possible, so that the common words, phrases and ideas emerge into

Healing space 49

categorical designations (Lincoln and Guba, 1985). This heuristic process will allow the

emergent pieces of information to standalone and determine the respondents, preferences, likes,

dislikes and attitudes about their relationship with natural light, views, natural surroundings and

organic shapes and materials, which of course is associated with each interviewee's version of

their constructed reality.

Design application

As part of the design process, and prior to preparing the new manifesto/programs for the

diagrammatic design solution, a Quality of Life questionnaire was distributed among the four

administrators at the two study sites, asking them to rate five basic psychological needs as

adopted by Maslow (1987). In his positive theory of motivation, Maslow identifies five basic

human needs that necessitate satisfaction in order for an individual to continue to exist.

According the Maslow (1987), once the fundamental need of physical survival is fulfilled, other

needs, such as: safety and security, social/belonging and self-esteem emerge, until a person

reaches the need for self actualization and understands “What a man can be, he must be”

(Maslow, 1987, p. 91).

The Quality of Life questionnaire will be used to quantify the five basic human needs in a

hierarchal structure in order to form criteria for design of the new diagrammatic archetype at

Ventura, CA. Study site.

Implementation

The results of the pilot exploratory comparative study resulted in, four- three dimensional

manifestations of the built environment (prototypes) which were incorporated into the following

questionnaires:

A living ceiling

Healing space 50

Natural light and views

Bringing the outdoors in

A living wall

The questionnaires were disseminated as part of a quasi-experimental of the two selected

sample “case studies” assisted living groups in Venture and Los Angeles, California, (Campbell

& Stanley, 1966; Cook & Campbell, 1979; Shadish, Cook & Campbell, 2002).

Description

Prior to disseminating the questionnaires, arrangements were made with the two assisted

living facilities for permission to access; however it became clear, after initial phone calls and

meetings, that the availability to the sample pool would be limited to certain days, times and

specific locations. Based on security requirements, the researcher was not able to wander freely

and converse with residents, administrators and staff. However fifty two, out of an expected fifty

surveys were realized, though research regarding sample size indicates that there are “no rules

for sample size” (Erlandson; Harris; Skipper & Allen, 1993, p. 83). Hence, canvassing the

Ventura and West Los Angeles case study sites at three separate occasions produced a rich

purposive sample, suitable for the study.

Interviews with facility administrators, nursing staff, and other stakeholders were also

limited due to availability of the person, and time constraints of the project, however the

researcher was able to interact with about five to eighteen residents, and about two to four

administrators at each site. Open-ended interviews were conducted with the residents and staff,

while administering the questionnaires and touring the facilities. The in-depth interviews with

facility administrators and major stakeholders, approximately eight, ran concurrently with the

survey distribution as well. Each interview lasted about 20 to 40 minutes, even given these

constraints, the researcher was able to have an interactive dialogue with the respondents that led

Healing space 51

to an informative reconstruction of their past, present, and future attitudes/dispositions, regarding

the use of abundant natural light, organic shapes, and natural surroundings (Erlandson; Harris;

Skipper & Allen, 1993).

Furthermore, it is recommended that any future attempts to interview and administer

surveys at any state or privately administered assisted living facilities, should allow for

additional time for greater accessibility and procurement of security clearances in order to assure

a productive inquiry.

Healing space 52

Results

The completed questionnaires were assembled, disseminated, classified, and then the

respondents’ replies were analyzed three ways: as a combined total of all of the respondent’s

replies, each response/per questionnaire, and a correlation between Rural vs. Urban case-study

sites. The comfort scores are shown as scatter charts, as it was the clearest way to display the

overall score at a glance, while the other answers are depicted in a standard text format, for more

concise viewing. Finally, the correlation examination was best shown as tables, which made for a

quick and easy way to compare one study site verses the other.

Questionnaires

As part of A Living Ceiling questionnaire, respondents were asked to rate a three

dimensional manifestations of the built environment (see Fig. 19) “On a scale of 1 to 5 (1 being

least, 5 being most), how comfortable would you feel in a room like this?”The results are

indicates on a scatter chart below, see (Fig. 20). The average Likert score was 3.

Fig. 19, respondents rated this three dimensional manifestations in

the built environment as part of A Living Ceiling questionnaire.

Healing space 53

The results from the rest of the questions from the A Living Ceiling questionnaire were:

1. If there were a place where you had a ceiling that looked just like clouds, would

you enjoy it?

YES-76%, No-23%

2. How often would you use a room like this, if you had access to it?

Very often-7%, Often-53%, Sometimes-23%, Rarely-15%, Never-0%

3. Please describe what you would feel like if you were in a room or area like this?

"not confined", "free feeling", "wide open", "lack of privacy", " too much

light", "feel comfortable", "insecure", "relaxed", and "positive".

Fig. 20, indicates how

the respondents scored,

after they reflected on

the three dimensional

manifestations in the

built environment.

0

1

2

3

4

5

6

0 2 4 6 8 10 12 14

Co

mfo

rt L

eve

l

Participants

Living ceiling comfort level

Comfort Score Linear (Comfort Score)

Healing space 54

As part of the Natura Light and Views questionnaire, respondents were asked to rate a

three dimensional manifestations of the built environment (see Fig. 21) “On a scale of 1 to 5 (1

being least, 5 being most), how

comfortable would you feel in a room

like this?”The results are indicates on a

scatter chart below, see (Fig. 22). The

average Likert score was 4.

The results from the rest of the questions from the Natural Light & Views questionnaire

were:

1. Are there windows, where you live, that allow you to look out without making an

extra effort, such as opening blinds, standing, or straining?

YES-92%, No-7%

2. How often do you look out the window during the day?

Fig. 21, respondents rated this three dimensional manifestations

in the built environment as part of the Natural Light and Views

questionnaire.

0

1

2

3

4

5

6

0 2 4 6 8 10 12 14

Co

mfo

rt L

eve

l

Participants

Natural light & views comfort level

Comfort Score Linear (Comfort Score)

Fig. 22, indicates

how the respondents

scored, after they

reflected on the three

dimensional

manifestations in the

built environment.

Healing space 55

Very often-23%, Often-62%, Sometimes-15%, Rarely-0%, Never-0%

3. Please describe how you would feel while looking out to a garden or courtyard

area?

"very peaceful", "refreshed and calm", "looking out a window gives you a

sense of freedom", "comfortable", "freedom", "scenic views of landscape

is soothing and relaxing".

4. Do seasonal changes affect your mood?

Very often-0%, Often-23%, Sometimes-62%, Rarely-15%, Never-0%

As part of the Bringing the outdoors in questionnaire, respondents were asked to rate a

three dimensional manifestations of the built environment (see Fig. 23) “On a scale of 1 to 5 (1

being least, 5 being most), how comfortable would you feel in a room like this?”The results are

indicated on a scatter chart below, see (Fig. 24). The average Likert score was 4.1.

Fig. 23, indicates how the respondents scored, after the y reflected on

the three dimensional manifestations in the built environment.

Healing space 56

The results from the rest of the questions from the Bringing the Outdoors In questionnaire

were:

1. Are there any exterior/interior gardens or courtyards, where you live, that you

enjoy?

YES-76 %, No-23 %

2. How often do you use the garden area(s) or courtyards during the day?

Very often-31%, Often- %, Sometimes-15%, Rarely-38%, Never-8%

3. Please describe what you would feel like during a visit to a garden or courtyard?

“very peaceful", "serene", "quiet time for meditation and thinking",

"refreshed", "too much light", give you the sense of freedom",

"comfortable", "freedom"

4. Do garden areas or courtyards affect your mood, while there?

Very often-8%, Often-38%, Sometimes-38%, Rarely-8%, Never-8%

0

1

2

3

4

5

6

0 2 4 6 8 10 12 14

Co

mfo

rt L

eve

l

Participants

Bringing the outdoors in comfort level score

Comfort Score Linear (Comfort Score)

Fig. 24,

Respondents

rated this three

dimensional

manifestation in

the built

environment as

part of the

bringing the

outdoors in

questionnaire.

Healing space 57

As part of A Living Wall

questionnaire, respondents

were asked to rate a three

dimensional manifestations of

the built environment (see Fig.

25) “On a scale of 1 to 5 (1

being least, 5 being most), how

comfortable would you feel in a room like this?” The results are indicates on a scatter chart

below, see (Fig. 26). The average Likert score was 3.2.

The results from the rest of the questions from the Living Wall questionnaire were:

1. If there were places where you had a room or space with natural materials like

this, would you enjoy it?

0

1

2

3

4

5

6

0 2 4 6 8 10 12 14

Co

mfo

rt le

vel

Participants

Living wall comfort level score

Comfort Score Linear (Comfort Score)

Fig. 25, Respondents rated this three dimensional manifestations in the built

environment as part of A Living Wall questionnaire.

Fig. 26, indicates how the respondents scored, after they reflected on the three dimensional manifestations in

the built environment.

Healing space 58

YES-77%, No-23%

2. How often would you use a room or space like this, if you had access to one?

Very often-7%, Often-15%, Sometimes-24%, Rarely-39%, Never-15%

3. Please describe how you would feel in a room or area like this?:

"enclosed", "peaceful", "creative", "comfortable", "feels like I'm in a fish

tank", "I like the materials, but not the windows", "feels like him one with

nature", "positive, looks very non-institutional", "not cozy, feels like a

museum"

Tables 1 through 4 depict results from a correlation examination, comparing the two case study

sites’ comfort level score, enjoyment, access, and moods:

A Living

Ceiling

questionnaire

Average

comfort

level score

Would you

enjoy a room

like this?

How often

would you use a

room like this?

Describe what

you would feel

like if you were

in a room or

area like this?

Ventura case

study site:

(Rural)

3.6 Yes-72%

No-28%

Very often-15%

Often- 28%

Sometimes- 43

%

Rarely-14%

Never-0 %

Not confining,

freedom of

movement, feel

comfortable,

too much light.

West Los

Angeles case

study site:

(Urban)

4.3 Yes-83 %

No-17 %

Very often-7 %

Often-83 %

Sometimes- 0 %

Rarely-0 %

Never-0 %

Not feel secure,

to open, very

positive, open,

free, relaxed,

refreshed, trees,

awesome.

Table 1 compares the respondents’ replies to A Living Ceiling questionnaires between the two selected case study sites.

Healing space 59

Natural

Light and

Views

questionnaire

Average

comfort

levels

score

Are there

windows,

where you

live that

allow you

to look

out?

How often would

you look out the

window during the

day?

Describe

how you

would feel

while

looking out

to a garden

or courtyard?

Do seasonal

changes affect

your mood?

Ventura case

study site:

(Rural)

4 Yes-85 %

No-15 %

Very often-14 %

Often-72 %

Sometimes 14 %

Rarely-0 %

Never-0 %

Comfortable,

sense of

freedom,

positive, life,

enjoyable

view.

Very often-0

%

Often-14 %

Sometimes-57

%

Rarely-29 %

Never-0 %

West Los

Angeles case

study site:

(Urban)

4 Yes-100 %

No-0 %

Very often-33 %

Often-50 %

Sometimes 17 %

Rarely-0 %

Never-0 %

Quiet time

for

meditation,

very creative,

refreshing,

calm, too

much light,

like to see

people go by.

Very often-0

%

Often-3 %

Sometimes-66

%

Rarely-0 %

Never-0 %

Table 2 compares the respondents’ replies to Natural Light and Views questionnaires between the two selected case study

sites.

Healing space 60

Bringing the

outdoors in

questionnair

e

Average

comfort

level score

Are there

exterior/

interior

gardens or

courtyards,

where you

live, that

you enjoy?

How often do you

use the garden area

(s) or courtyards

during the day?

Describe

what you

would feel

like during a

visit to a

garden or

courtyard?

Do garden

areas or

courtyards

affect your

mood, while

there?

Ventura case

study site:

(Rural)

3.4 Yes-71 %

No-29 %

Very often-14 %

Often-0 %

Sometimes 14 %

Rarely-57 %

Never-15 %

Peaceful,

comfortable,

welcome,

creative, very

relaxing,

soothing.

Very often-0 %

Often-28 %

Sometimes-42

%

Rarely-15 %

Never-15 %

West Los

Angeles case

study site:

(Urban)

4.8 Yes-83 %

No-17 %

Very often-50 %

Often-17 %

Sometimes 60 %

Rarely-17 %

Never-0 %

Peaceful,

relaxed,

refreshed,

pine trees,

meditate,

plants, very

positive.

Very often-70

%

Often-50 %

Sometimes-33

%

Rarely-0 %

Never-0 %

Table 3 compares the respondents’ replies to Bringing the outdoors in questionnaires between the two selected case study

sites.

Healing space 61

Average

comfort level

score

If there were

places where

you had a

room or space

with natural

materials like

this, would

you enjoy it?

How often do

you use the

garden area

(s) or

courtyards

during the

day?

Describe how

you would

feel in a room

or area like

this?

Ventura case

study site:

(Rural)

3.3 Yes-85 %

No-15 %

Very often-0

%

Often-28 %

Sometimes-

44 %

Rarely-14 %

Never-14 %

Like natural

surroundings,

feel like in a

fishbowl,

comfortable,

enclosed,

peaceful,

creative.

West Los

Angeles case

study site:

(Urban)

3.3 Yes-85 %

No-33 %

Very often-33

%

Often-0 %

Sometimes-0

%

Rarely-67 %

Never-33 %

Feels like a

museum,

likes the

match natural

materials, not

cozy,

positive, non-

institutional,

and feel like

one with

nature.

Interviews

In order to triangulate respondent’s opinions, dispositions, attitudes about natural

abundant light, organic shapes and natural surroundings against the data from the questionnaires,

the researcher audio taped, then documented the open-ended interviews with administrators, staff

members, and residents at each case study site, then correlated the words and phrases that they

all shared, which was a part of the dialog relating to the four questionnaires. As stated in the

Methods section of this study, the common words and phrases were compared using “unitized”

into categorical designations based on type of interviewee (Lincoln and Guba, 1985). The table

Table 4 compares the respondents’ replies to A Living Wall questionnaires between the two selected case study sites.

Healing space 62

below is a tabulation of the interviewee’s common words and phrases in relationship to the case

study site location (Rural vs. Urban). An analysis of the table reveals the frequent word or

phrase common to all interviewees and case study sites, raked from most to lease commonly

used:

1. Natural light

2. Views of natural surroundings

3. Gardening

4. Wayfinding

5. Security

Interviewees

Administrators Staff Residents

Loca

tion

Ventura case

study site:

(Rural)

Gardening

Orientation

Wayfinding

Clear and visible

access

Security

Natural light

everywhere

Lots of natural

light for staff and

residents

Windows

Social areas

Simple wayfinding

Courtyard view

everywhere

Private storage

areas

Gardening effects

the mind

Views

Like natural

surroundings

West Los

Angeles case

study site:

(Urban)

Natural light,

critical to a resident’s

well being.

Garden areas

Views

Exterior

dining/social areas

Adequate space for

common and

garden areas

Garden and

courtyard views

Need for

Recreation areas

Cozy areas

Non-institutional

Not enough

Recreation areas

More gardens and

planting

Security

An Interpretive-historic confirmation

Nature, landscape and scenery have been around from the first days of man. Beginning

with the earliest Egyptian through modern man, the depiction of natural elements in religion, art,

Table 5 compares the type of interviewees’ frequently used words and between the two selected case study sites as shown in

bold italicized.

Healing space 63

literature and architecture has been a continuous stream of symbols, signs and metaphors. In

Egyptian art, one finds remarkably precise elements of flora and fauna that shows the way nature

affects the soul, and reveals a spiritual light deep inside all natural phenomena. By 5,000 BC,

the Mesopotamia agrarian cultures around the Tigris and Euphrates Rivers emerged, focused

around the symbolism of religious manifestations of their sky god An, wind god Enlil, earth god

Enki (god of rivers, wells, and canals), and Ninhursaga, the goddess associated with soil,

mountains, and vegetation. By the third millennia B C, the pre-Socratic philosophers, abstracted

the entire phenomena as a singular "physis". To the Greeks, nature philosophically meant many

things, or "all things; nature is the heavens above, the earth beneath, and the waters under the

earth" (Tuan, 1974, p.132), which was exhibited in scenes of Greek tragedies, and later in the

Roman theater, in pottery, and even in landscaped gardens. Later, medieval Christian thinkers

(adapting that Aristotelian cosmos), did not see nature as inclusive of everything, but thought

that nature had been created by God; her place lay on the earth, below the unchanging heavens

and moon which was demonstrated in the Hortus conclusus, an emblematic attribute of the

Virgin Mary in medieval and Renaissance poetry and art, where one could be enclosed in a

private and protected cloister, for reflection n order to reflection and worship. Today, when we

speak of nature, we speak of countryside and the wilderness; that pre-civil condition described as

"nature, or the state of nature… Still unspoiled, phusis" (C.S. Lewis, 1967, p. 62) or a

picturesque representation of landscape. Now nature takes on an idealized or symbolic

sedimentation, which is so prominent in the urban cultures of our time. The idealization of

"wild" nature as superior to "human" nature goes back to Rousseau, whose rhapsodic

descriptions of the natural beauty of the Swiss countryside struck a chord in the public, and may

have helped spark the subsequent nineteenth century craze for Alpine scenery. Spontaneous

Healing space 64

symbolic meanings are said to arise from directly perceivable analogy, between the visual

surface, and the structure of the object, (such as a building), corresponding generic

characteristics of organic shapes, (such as height and depth or breadth), openness, closure,

outgoing, or withdrawal. Many of these empathies are said to develop from observations from

the natural world, the human body, or nature itself (Lang , 1999; Arnheim , 1977). Therefore,

respondents’ appeal, disposition, preference towards natural light, natural surroundings, garden

views, security and spatial orientation, have been confirmed through an historic analysis of

nature, landscape, scenery, and organic shapes.

Design application

Pre-design

The results of the Quality of Life questionnaires that were disseminated between the

administrators at the two case study sites revealed the most important need in relationship to an

assisted living environment was Shelter, food, water, followed by safety and security, followed

by Self-actualization, Independence, Interaction, Aesthetics, Belonging and finally Self-esteem.

The ranking and Liken score for each was as follows:

Ranking Human Need Liken score

1. Shelter, food, water, etc. 7.1

2. Safety and Security 7

3. Self-Actualization 6.9

4. Independence 6.26

5. Interaction 6.25

Healing space 65

6. Aesthetics 6.24

7. Belonging 6

8. Self-esteem 5.5

The quantitative findings of the quality of life questionnaire were then correlated with

human senses to form design

criteria as an initial step in the

design process. The attributes,

displayed as images and text

descriptors formed a basis of

understanding that was used as

a programmatic mile stones in

the new manifesto. Each sense

and human need produced

corresponding image and text

descriptor which was then

ranked, from top to bottom,

according to importance. For

example the corresponding

image and text descriptor for

sight and shelter created an

image of comfort. Likewise, the

corresponding image and text descriptor for sound and shelter created a family gathering.

Fig. 27 design criteria matrix: Correlating the human senses and human

needs for a basis of design.

Healing space 66

Consequently the combination of sound of a family gathering would rank higher as a design

objective than the combination of smell related to self-esteem. The aim will be to incorporate

each combination of the human senses and human needs, along with the natural light, natural

surrounding and organic shapes into the program/manifesto.

The Program/Manifesto

As part of the interview process with the Administrator of the California Veterans’ Home

in Ventura, CA the researcher poised the question: What kind of proposed facility would

harmonize with the adjacent assisted living complex? Many types of healthcare environments

for the elderly came up during the discussion, but one common topic pointed to a configuration

that is becoming more accepted, it is named: Continuing Community of Residential Care

(CCRCs), which offer persons 60 years of age or older, a long term continuing care contract that

provides for independent living units, residential care/assisted living services, and skilled nursing

care; usually in one location, and usually for a resident’s lifetime. Specifically CCRCs provide

housing, meals, transportation, activities, in addition to a continuum of care that includes assisted

living and nursing home care. Increasingly, CCRCs have health clinics, wellness programs, and

specialized dementia care services.

Historically, CCRCs were founded and operated by non-profit religious organizations,

(e.g., Presbyterians or Episcopalian and Baptist Homes), or by fraternal organizations. Although

non-profit organizations still dominate the CCRC scene (i.e., more than 80% of CCRCs in

California are operated by non-profits), for-profit providers (e.g., Marriot, Hyatt, Sunrise Care),

are increasingly entering this lucrative market with urban based, very upscale and expensive

CCRC communities

Healing space 67

Based on interviews with the administrators at the two case study sites, I concluded that

their primary vision would be to incorporate or encapsulate a CCRC adjacent to the existing

assisted living facility, where a veteran can come into their campus, and receive multiple levels

of care, and remain there the rest of his life, without going out into the community for end of life

care. This arrangement of care has long term benefits for the patient and the community, by

allowing a consistent level of care from pre-retirement to end of life. One of the main attractions

of CCRCs is the peace of mind that comes from meeting one’s long term care needs, in a single

setting. It takes away the guesswork and aggravation of arranging for future care needs, and

produces a real sense of security, in knowing that one’s plans for long term care are already in

place. According to the information obtained from the interviews, administrators’ state that there

is also the added bonus of no longer maintaining a house. They argue that moving closer to

one’s children or siblings can increase interaction, and strengthen their informal support system.

Therefore and most importantly, getting the care close to family relieves the concern of

becoming a burden. Additionally, a primary value for couples is the ability to remain together,

or at least be on the same campus, if one spouse requires a higher level of care. Although this is

not strictly “aging in place” (i.e., living together in one’s independent unit), CCRCs offer the

option of aging in a community or on a campus.

Healing space 68

Accordingly, the results of the research and interviews are incorporated into a new

manifesto/program matrix, which specifies the programmatic requirements for a Holistic –

Centered Care, which embraces the geometry and functional aspects of a Continuing Community

of Residential Care facility, also incorporating the use of natural surroundings, organic shapes,

and quality of life attributes, to enhance the patient's positive psychophysiological outcome.

Archetype diagram Elements

As part of the diagrammatic archer type plan development, the designer must consider all

of the previous research data, quality of life attributes as well as each function from the inner-

most point of generation to the outer most point of off- site target boundaries. To start the

progression, we must review and analyze how the proposed plan elements correlate to basic

human senses to optimize the site-structure unity. Five basic human needs, as adopted by

Fig. 28 a new archetype manifesto/program that incorporates holistic-centered care, continuing community of residential

care design objectives as well as incorporating abundant natural light, natural surroundings, organic shapes and quality of

life attributes

Healing space 69

Fig. 29 shows how generic building configurations correlate to basic human senses to optimize the site-

structure unity and the subsequent Holistic-Centered/CCRC site diagram.

Maslow (1987) and the findings of the quality of life questionnaire were matched up against five

geometric building configurations, chosen randomly, and representing five common shapes

found in site planning and landscape architecture (Simonds, 1961; Coates, 2001; Grahn, 2001).

Each generic configuration was then compared to a human need to determine if that

configuration

embraces the

characteristics

or traits of

that particular

need. The

compatibility

level was than

delineated as

degrees of

green dots to

degrees of

red dots. For example the ovaliod configuration is very compatible with the need for shelter

which received three green dots, while the buckshot configuration seems less likely to represent

shelter, only receiving two red dots (Fig. 29). The conclusion of the comparative analysis reveals

that the ovaliod, finger and checkerboard are best suited meet the five basic human needs,

therefore a variation of this configuration should be considered as part of the Holistic-

Centered/CCRC archetype diagram.

Healing space 70

Archetype diagram

The final phase of the design culminates with a Holistic-Centered/CCRC archetype

diagram integrating all of the research findings based on the hypothesis: Among skilled

nursing/assistive living environments, there is a direct relationship between the use of natural

surroundings, abundant natural light, organic shapes, and a patient’s positive

psychophysiological outcome. To this end the image below signifies a schemata where the use of

natural surroundings, abundant light, organic shapes, the quality of life attributes and three levels

of care (as indicated in figure 10) can be implemented as a guideline to augment any assisted

living residential environment.

Healing space 71

Fig. 30 a new archetype design diagram that reflects the manifesto/program incorporating holistic-centered care, continuing community of residential care (CCRC) design objectives as well as abundant natural light, natural surroundings, organic shapes and quality of life attributes.

Healing space 72

Discussion

Summary

This researcher’s main objective was doing a naturalistic study of inquiry with qualitative

information about realities (paradigms), associated with the assisted living residents, healthcare

staff, and facility administrators, and to understand and study the relationship between natural

surroundings, abundant light, and organic shapes; based on wind, water, earth, fire, metal, sight,

sound, touch and smell, and a patient’s psychophysiological outcome. To know what it is “out

there”, is to look at more than one reality among participants and staff's living environments, and

discover if there is in fact, a direct connection.

The secondary objective incorporated the findings into the preparation and completion of

a program/manifesto, and a new archetype Holistic-Centered/CCRC designthat could serve a

diagrammatic outline, or road map for future endeavors.

Delimitations

The study was deliberately confined to the assisted living/healthcare environment, in two

case study sites located in Ventura and West Los Angeles, California based on the following

criteria:

1. Feasibility: the strategies and tactics of how, what, where, to test my hypothesis,

lend itself towards limited scope of an assisted living healthcare environment,

rather than a more complicated acute care hospital setting.

2. Access: typically state operated facilities are easier to access due to freedom of

information acts, allowing uncomplicated access to the respondents, compared to

more restricted security requirements associated with acute care hospitals.

3. Familiarity: As the Architect of Record for the two projects, I had access to a

large portion of the design and site information, which facilitated the development

of the three dimensional prototypes, site analysis, new manifesto/program, and

diagrammatic archetype design.

Healing space 73

Assumptions

My findings indicate that some of the early assumptions attributing stress, patient

disorientation, and the “industrialized” nature of healthcare, support evidence (Ulrich, 1981;

Farley & Veitch, 2001; Frumkin, 2001), that a connection with nature through a window or

scenic representations of natural surroundings, increased productivity and health in the work-

place, promoting healing of patients and reducing the frequency of sickness and stress (Ulrich,

1981; Farley & Veitch, 2001; Frumkin, 2001). In particular Farley & Veitch (2001) states…

The most consistent finding in the literature is that people prefer natural rather than built

or urban views from windows. Windows with views of nature were found to enhance

work and well-being in a number of ways including increasing job satisfaction, interest

value of the job, perceptions of self productivity, perceptions of physical working

conditions, life satisfaction, and decreasing intention to quit and the recovery time of

surgical patients.

Moreover, the results of my study also supported the findings of Mizan (2004), that point

toward a connection between nature and positive psychological outcome through exposure to

indoor plants, natural materials, aquatic sounds, music, abundant natural light and colors. The

effect of the environment seems to “extend to a cellular level, which improves immune

responses, linked with positive mental states mediated by a calming environment…”

Healing space 74

Interpretation

The strongest examples of solidarity, included in this research study, found that the

desire/use of abundant natural light, and the use of interior/exterior landscape gardens as part of

an environment, scored very high in all questionnaires, by both individual respondents, and as

part of a correlated analysis of the two case study sites. Close to 100% of the respondents, said

windows and views are important, and four out of five respondents rated the three dimensional

prototypes of "Natural light and views" and "Bringing the landscape in" as being very

comfortable. Some of the respondents’ descriptions included "very peaceful", "refreshed and

calm," "looking out a window gives you a sense of freedom" and "scenic views of landscape are

soothing and relaxing". Conversely, the study also indicated mixed results when respondents

viewed the three-dimensional prototype regarding "A living wall". 77% of the respondents

indicated that they would like to be in a room with natural materials, and rounded (organic)

shapes; however, only 39% indicated they would visit that same space, if they had access to it.

The descriptors similar to "enclosed", "creative", signify positive direction of the perception

towards acceptability of the space, however, other descriptors approximating "not cozy, feels like

a museum", indicates negative feelings or perceptions of the same spatial representation.

Strengths of the current study

The methodological strengths of the study included the questionnaires, which were used

to describe and/or predict the phenomenon, based on the hypothesis and the surveys, which were

designed to understand and determine environment behavior of who does what and when, in

relationship, or lack of, between participants, perceptions, and dispositions of organic shapes,

natural surroundings, and sustainable principles within the context of a physical setting.

Particularly, the most beneficial aspect of the questionnaires and the surveys, were the use of the

Healing space 75

three-dimensional manifestations in the built environment, and the interaction that took place

between the investigator and the respondents, while reflecting on the prototype representations,

which gained the most insight.

Limitations

Equally, the correlation pilot study and the open-ended interviews had its limitations as

well. While the correlation pilot study was exploratory, and provided a swift approach to

empirically examine the relationships between the two dimensional manifestations of the effects

of nature, and the three-dimensional manifestations in the built environment, it was limited in

control and sample size. Moreover, open-ended field interviews had drawbacks as well, hence

they were difficult to predetermine, execute soundly, and accurately analyze, even though I

believe that the "unitization" methodology was sound.

Implications

The study had some unexpected findings regarding the use of the three-dimensional

manifestations in the built environment, and the subsequent mixed results from the respondents;

however, some possible explanations might come from the way the prototypes were interpreted.

Each observer associated their own values and sense of importance to the representation, as part

of their own constructed reality; hence, each participant had a different explanation for the same

image. This may be true in the light of research that has previously been done, exploring how

environmental images are processed, and the relationship connecting natural scenic beauty,

preference, and restoration which suggests the implication that further studies should be

considered. Moreover, the current study has provided data to suggest that, patients/residents

respond holistically to abundant natural light, organic shapes, and natural surroundings rather

Healing space 76

than in a systematic or in a heterogeneous manner, and that these conclusions imply how

healthcare design can be approached.

Conclusions

Can nature be incorporated as part of a universal principle, into the empirical science of

healthcare design? Can the polemic design philosophies as espoused by Virtuvius, Antoine

Laugier, Francesco Milizia, Charles and Henry Greene, Frank Lloyd Wright, Erik Asmussen,

Lauri Baker, and John Lautner, to name a few, be included as part of a new manifesto for the

patient/resident? Yes, of course. However, today we must begin to understand that “organic

architecture" (Wright, 1943), equates to more than framing the view at Falling Water, the use of

clinker bricks for a foundation wall, or even the use of art, ornamentation, or sculptural elements.

Moreover, we must also be cognizant that the scientific developments that followed Newton,

Einstein, and Schrödinger did not account for the whole relationship between man and his

environment, and that the vibrant theories of Lllya Prigogine, Humberto Maturana and Francisco

Varela should be reviewed, examined, and serve as a foundation for future healthcare built

environments.

It is my theoretical conclusion that a large amount of the respondents’ perceptions of the

variables, through the use of three dimensional manifestations in the built environments, were

holistic, made up of the natural parts, reflected then associated with a value premise and belief,

which subsequently equated to an affirmed attitude and finally, a positive psychophysiological

outcome. As the repondents preceived and experienced abundant natural light, organic shapes

and natural surroundings in the three-dimensional manifestations in the built environment they

gained an holistic understanding of that particular healing space. The subsequint process as

Healing space 77

diagramed in (Fig. 31) produced a phenomenon: a positive psychophysiological outcome, I call

this the “healing space effect”, Hence the theory of the healing space (Fig. 32) emerged.

Directions for future research

The results of this study suggest some future directions for research, aimed at the

understanding of the relationship between “healing space” (based on wind, water, earth, fire,

metal, sight, sound, touch and smell), and the “healing space effect” in connection with other

venues such as acute, intermediate or hospice care environments. Perhaps combining the

dichotomized research strategies, found in evidence based design, with the holistic findings of

this study could form an all-embracing umbrella of work.

Indubitably, the interpretive-historical developments commencing from the Age of

Reason, points out the dangers of a priori thinking, a lesson that should never be forgotten. "The

world, in fact, is still dominated by those who put the conclusions at the beginning," (Norberg-

Schultz, 1980).

Healing space 78

Healing space 79

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APPENDIX A – Effects of nature correlation study

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APPENDIX B – Review of literature on the effects of nature correlation study

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APPENDIX C –Sustainable principles correlation study

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APPENDIX D –Exploratory correlation pilot study

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APPENDIX E –Metaphoric images of nature correlated with the Effects of nature

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APPENDIX F-A living ceiling questionnaire

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APPENDIX G -Natural light and views questionnaire

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APPENDIX H-Bringing the outdoors in questionnaire

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APPENDIX I-A living wall questionnaire

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APPENDIX J- Philosophical underpinnings

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APPENDIX K- Natural inquire flow chart