Hospital Outdoor Spaces - Therapeutic Benefits and Design Considerations

8/10/2019 Hospital Outdoor Spaces - Therapeutic Benefits and Design Considerations

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HOSPITAL OUTDOOR SPACES - THERAPEUTICBENEFITS AND DESIGN CONSIDERATIONS

Dejana Neduin, Milena K!lje", Na#a Ku$%&i'-F%li'

Faculty of Technical Sciences, University of Novi Sad, SerbiaE-mail: dejana_neducin@yahoocom, !r!ljes@eunetrs, nfolic@"mailcom

A()$a*$+ The awareness of positive influences of outdoor environment onpatients' healing process has long been present in hospital architecture. Despitethe fact that economic factors had the greatest impact on hospital design during

the past century, which caused a neglect of possible restorative benefits of hospitalsurroundings, recently developed and integrated healthcare systems are morefocused on patients needs regarding the effects of treatments and services on theirsatisfaction. With the aim to reduce costs of medical therapies without sacrificingtheir quality, this new approach resulted in a substantial shift in planning anddesigning of both indoor and outdoor hospital spaces. This paper presents ananalysis of various aspects that need to be taken into account while planning ofhospital outdoor spaces. t proposes a list of design considerations that maycontribute to achieving a healing environment with positive effects on patients'well!being and outcomes of their medical treatments, while simultaneously raisingthe overall hospital's efficiency. "aving in mind specific organi#ational structureand functional flows that an institution of this type comprises, these considerationsare determined, preconditioned and set up to meet strictly defined norms,regulations and criteria. The purpose of this research is to e$amine which elementsand features and to what e$tent may assist in generating a supportive, inviting,

secure and non!threatening atmosphere of the outdoor hospital surroundings thatdischarges negative reminiscences, e$periences or assumptions on how unpleasantthe stay in a hospital may be.

Ke %d)% hospital outdoor space, healthcare outcomes, healing environment# $NT%&'U(T$&N

)os*itals that com*rise buildin"s and their surroundin" outdoor s*aces areamon"st the lar"est and most com*le+ of all *ublic institutions They are "enerallyconsidered as fri"htenin" areas, thus s*atially detached from the rest of urbanfabric in ones mind and entered in case of emer"ency or solely if necessary)o.ever, by im*lementin" a ne. a**roach in desi"nin", it may be *ossible tosoften their *sycholo"ical borders throu"h introducin" ne. contents that .ouldchan"e its *ublic *erce*tion /iven that current trends in hos*ital *lannin"
mailto:[email protected]:[email protected]:[email protected]:[email protected]


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re*laced the old *hiloso*hy of re"ardin" these institutions solely as machines &guerir0#1, they no. em*hasi2e the im*ortance of creatin" a conce*t of *atient-focused hos*ital as thera*eutic environment .hich *rovides *hysical, emotionaland s*iritual comfort to all "rou*s of users This shift in *ractice does not a**lyonly to indoor s*aces, but to outdoor surroundin" as .ell

$f the s*ace .ere to be characteri2ed by its meanin", si"nificance and theim*act it may have on human life, for the *ur*ose of this *a*er hos*ital outdoors*ace .as identified .ith an envelo*e enclosin" distinctive but tem*orary human

*sycholo"ies 3s *atients *erce*tion .hile stayin" in a hos*ital is fre4uentlydistorted, limited and influenced by various e+ternal factors, it is in constant needof a "reater su**ort than in everyday circumstances Thus, .ith the intention tochan"e the ne"ative ima"e of hos*itals as medical fortifications, the o*enness oftheir outdoor s*aces should transmit a messa"e of acce*tance, .hile ma!in" themless isolated fra"ments of an urban net.or! of *ublic s*aces051

The em*hasis in this research .as "iven to various *lannin" as*ects anddesi"n considerations that may assist in "eneratin" a su**ortive, invitin", secureand non-threatenin" atmos*here of the outdoor hos*ital surroundin"s (reatin" anenvironment that .ould be su**ortive, friendly and less stressful for *atients andtheir visitors, and simultaneously more creative and restorative for hos*ital staff arethe !ey elements and issues that need to be addressed durin" *lannin" of hos*italoutdoor s*aces 6oreover, due to their s*ecific function and multifaceted structure,all interventions need to be *lanned and desi"ned accordin" to certain norms andre"ulations and .ith the most concern

5 )$ST&%$(37 83(9/%&UN'

hile revie.in" the develo*ment of hos*itals throu"h history, it may be notedthat the a.areness of *ositive influence of outdoor environment on *atientshealin" *rocess has lon" been *resent in hos*ital architecture Evidence of *lannedrestorative "ardens can first be found in the Euro*ean medieval monastic hos*ices,.here *atients cells bordered and had a direct access to arcaded courtyard ;Fi" #


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Throu"hout the #>th and #=th centuries, hos*ital buildin"s have beensurrounded by rich "ardens in traditional style ;Fi"5 and =1 (onse4uently, these s*acesthat have *reviously been subordinated to the architectural desi"n and consideredonly as unavoidable anne+es to hos*ital buildin"s, became their lo"ical e+tensionand a healthcare factor that is almost e4ually influential as various medicaltreatments


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)os*itals have been hidden behind hi"h .alls and fences for centuries, .hichsubstantially influenced *atients *erce*tion of the environment they felt as forced

into Their strictly defined borders .ere clearly se"re"atin" the sic! from ahealthy *o*ulation, both *hysically and *sycholo"ically $n contrast, todayshos*itals are re"arded as inte"ral fra"ments of the urban fabric that are o*en to thecommunity, same as other *ublic buildin"s, .hile their outdoor s*aces, as ane+tension to the e+istin" urban landsca*e, act as miti"atin" *ublic s*aces bet.eenthe city and hos*ital environment This ne. a**roach in *lannin" and desi"nin" of

both indoor and outdoor s*aces has achieved a shift in hos*itals *ublic ima"e&ri"inatin" from overla**in" of *atients im*ressions .hile stayin" in, a more

*ositive ima"e thus creates *ossibilities for various *ersonal inter*retations of its*hysical andHor *sycholo"ical boundaries that may, to a "reat e+tent, reduce

e+*eriencin" a hos*ital as a secluded environment isolated from the rest of society

> 8ENEF$TS &F (%E3T$N/ 3 G&S$T$IE )E37$N/ ENI$%&N6ENT

3s *reviously mentioned, medical and economic benefits have had the "reatestim*act on the hos*ital desi"n in the *ast century, .hile recently, evidencere"ardin" the effects of treatments or services on *atients satisfaction "ained muchmore im*ortanceSome studies indicate that all hos*ital users e+*erience *ositive

health outcomes from connection to natural environment and access to dayli"ht andlandsca*e vie.s0=1 3 research *roject, based u*on a survey conducted in the US3a decade a"o, deals .ith .hat in*atients e+*ect from the hos*ital outdoor s*aces01 $ts results outline the si"nificance of ac!no.led"in" the outside .orld throu"hsi"hts and scenes from nature, as .ell as the need for homely ;*articularly in alon"-term *atients care


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There are *lenty of conclusions that the influence of *oorly mana"ed hos*italsurroundin" may be ne"ative - various researches in behavioral sciences hasconfirmed that Jhealthcare settin"s may in themselves slo. recovery and induceemotional *roblemsJ01 $n relation to the subjective measures of healthim*rovement, some studies *ointed out that the use of nature in hos*italenvironment reduces stress and de*ression, su**orts an"er and *ain mana"ement,and *romotes a sense of overall .ell-bein"0#C1 To illustrate, in an evaluation offour hos*ital "ardens in San Francisco, a team of e+*erts used a combination of

behavioral observation and intervie. methods0##1 The results sho.ed that, afters*endin" time outside, BK of the *atients felt Jmore rela+ed and calmerJ, 5=Ksensed Jrefreshed and stron"erJ, 55K .ere Jable to thin! and co*eJ and only =Kdid not feel any *articular chan"e %estoration from stress, includin" an im*rovedmood, .as by far the most im*ortant cate"ory of individual e+*eriences derived bynearly all the users 3ccordin"ly, it may be concluded that *eo*les jud"ments and

feelin"s about their environment have a stron" im*act on healthcare outcomes as.ell

%e"ardin" the economic as*ect of im*lementin" natural surroundin"s in ahos*ital desi"n, it should be stressed out that each hos*ital mana"ement is under astron" *ressure to control and reduce costs, yet increase the 4uality of care Sincesome studies indicated that creatin" a stimulative outdoor environment yields lon"-term benefits includin" shorter *atients stays, reduced staff turnover and im*rovedstaff lon"evity 0#51, it may be concluded that additional investments of this !indare financially viable

(oncernin" the aforementioned, in order to achieve a hi"h *erformancehealin" environment .ith *roven effects on *atients, visitors and staffs .ell-

bein", better clinical outcomes and raised efficiency, one of the !ey issuesre*resents a functional inte"ration of outdoor s*ace in hos*itals overall desi"n

= /ENE%37 'ES$/N (&NS$'E%3T$&NS

Glannin" of hos*ital outdoor s*aces that .ould su**ort, enhance and *romote*ositive healthcare outcomes relies on the desi"n considerations set u* to meet

strictly defined norms, re"ulations and criteria They *rovide information andachievable measures .hich need to be incor*orated as early as in the conce*tual

*hase in order to fully inte"rate the use of outdoor s*ace into a hos*itals routine

=# Gotentials of the Site

)os*itals site is certainly one of the most si"nificant "enerators of its formin many as*ects Numerous analyses and investi"ations need to be underta!en bythe desi"n team .ith the aim of truly understandin" its advanta"es, disadvanta"es

and *otentials


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$n an ideal case, o*timal distribution of the total site area of a hos*italcom*le+ should be the follo.in": ACK for the buildin"s, #=K for internalcommunication routes and *ar!in", =CK for vacant area ;5=-ACK in case ofhos*itals .ith a limited ca*acity for future "ro.th< out of .hich #CK is reservedfor recreational areas 0#A1

hile *lannin" suitable locations for different ty*es of outdoor areas, thereare several issues that need to be ta!en into account, such as: environmental factors;e", orientation, insolation, .ind e+*osure, vie.s


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;#< 3ctive e+*eriences are both *hysically and *sycholo"ically beneficial sincethey im*rove *atients cardiovascular fitness and reduce stress and de*ression $naddition, *hysical thera*y and rehabilitation underta!en in a natural environmentmay enhance *ositive results of various medical treatments;5< /iven that, .hile stayin" in the hos*ital, a majority of *atients is constantlyunder a strict re"ime, they fre4uently e+*erience a loss self-esteem or control overtheir lives Therefore, *assive e+*eriences of bein" able to select bet.een see!in"

*rivacy and socially interactin" may be beneficial from a *sycholo"ical *oint ofvie.;A< 'irect or indirect sensory e+*eriences of connection .ith nature and *ositivedistractions involve stimulatin" one or more of five senses, calmin" the mind,reducin" stress and encoura"in" *ersons o.n healin" resources This also a**liesto indirect contact .ith outdoors by vie.in" a distant and nearby nature throu"hthe .indo. of *atients room

=> Iariety of S*aces and Their $nterrelation

(rucial *ro"rammin" and desi"nin" objective is to *rovide a variety ofhos*ital outdoor micro s*aces, tar"etin" different needs of their users Series ofdiverse smaller s4uares and meetin" *oints conventionally located to one anothercan create a co2y atmos*here and variety of e+*eriences rather than a lar"e one;Fi"


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Since the *atients are the most sensitive "rou* of users, by ma!in" their o.ndecision on ho. they are "oin" to s*end time outside, their di"nity, confidentialityand sense of control and autonomy may subtly be reinforced, leadin" to lo.erin"stress level 3 *art of outdoor s*aces should also be desi"ned to encoura"e suitablety*e of e+ercise This can be achieved by includin" loo*ed *ath.ays for shorter orlon"er routes, settin"s for *hysical thera*y, *lay"rounds, meanderin" "arden layoutfor contem*lative .al!in" and jo""in" trails ;Fi" D


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interestin" and challen"in" to the healthy, but to ill they usually *rovo!e counter-indicated effects

= 3ccessibility, Familiarity and Security

3ll hos*ital outdoor s*aces must be desi"ned to be *hysically secure andaccessible to *eo*le of all a"es and abilities, thus contributin" to their *ositive

*sycholo"ical *erce*tion hen feelin" stressed or de*ressed, many users searchfor environments that seem familiar and safe This a**lies to im*lementin" visualamenities .hich are rooted in the subconsciousness of the majority of users andcreatin" outdoor s*aces that are human-scaled and evo!e memories Furthermore,constant monitorin" by the nursin" staff and *rovision of additional medicalsu**ort ;e" o+y"en outlets< may allo. their e+tended use and lead to a hi"herde"ree of comfort

=B Glantin"

2.3.4. reen 5reas

The !ey element of a *ositive healin" and thera*eutic environment is the*resence of "reenery $n "eneral, e+*osure to nature can have a si"nificantlybeneficial effect on *eo*les emotional state - Jthe more the settin" evo!ed anima"e of a rich, "reen "arden, the more it .as used and a**reciated as a *lace to

recou* in com*lete to the hi"h-tech, hy"ienic, fluorescent-li"hted hos*ital interiorJ0#1 3ccordin" to the /reen /uide for )ealth (are 05C1, im*lementation of healthyecosystems in hos*ital outdoor s*aces has si"nificant social, *sycholo"ical and

*hysical benefits derived from *hysical and visual connection to naturalenvironment ;Fi" #5 and #A


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= /reen %oofs

There are many e+am*les of usin" flat roofs as additional outdoor *laces ofres*ite, es*ecially in the hos*itals .ithin city 4uarters .ith a hi"h construction

density Their use may influence and enhance the "eneral 4uality of healthcareenvironment 'e*endin" on the hos*itals *hysical confi"uration, one of theo*tions in case of limited site area is to create accessible or inaccessible roof"ardens visible from the u**er floors of hi"her buildin"s in the vicinity ;Fi" #>1

=#C Iie. &ut

The outdoor hos*ital areas should be visible from *atients rooms, interior*ublic s*aces and corridors, for both security and medical *ur*oses Iie. out isalso *sycholo"ically thera*eutic, since it reduces feelin" of isolation andclaustro*hobia by *rovidin" a constant contact .ith the outside .orld ;Fi" #=: Iie.in" roof "arden,"arrison (emorial "ospital, 8remerton? Fi" #=: Iie. froma *atients room,"itchock (edical enter, 'armouth? Fi" #: al!-in "arden in the lobby,

t. ?incent "ospital, orcester


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=## Successful ayfindin"

Geo*le need to find their .ay around a hos*ital that fre4uently has a verycom*licated functional and or"ani2ational structure Successful .ayfindin" system

is a *o.erful navi"ation tool .hich *rovides necessary information, enablin"decision ma!in" and *lannin" of routes /ood desi"n of strate"ically *laced levelsof information can alleviate disorientation as one of the major sources of frustrationamon" *atients and visitors05=1 &nce a route to final destination is selected,

*atients and visitors need to have continuous access to information or visual cluesalon" their .ay, thus all the information must be constantly re*eated and

*rioriti2ed at crucial *oints, .hich can be enhanced by utili2ation of s*ecific urbanlandmar!s or site features

Style of communication elements, includin" material, color, contrast andte+t, has to be consistent, carefully im*lemented in an overall hos*ital desi"n andshould not be tam*ered out .ith &n the other hand, too much information mayoverload visual communication and confuse the *atient, .hich can induce

*u22lement and fear in an already stressful environment051

(&N(7US$&N

$nte"ration and unity of hos*ital buildin"s and their surroundin" outdoor

s*aces contribute to creation of hos*ital as a small city .ithin a city, .ith its o.ns*ecific *atterns of use Features that are relevant for the 4uality evaluation of any*ublic s*ace may also a**ly to these s*aces, since they should be considered ande+*erienced as a vital *art of urban landsca*e hat ma!es them different fromother *ublic s*aces are their *hysical characteristics, determined and

*reconditioned by s*ecific contents, functional units and communication lines thatall need to be *lanned and desi"ned accordin" to strict re4uirements of modernmedical technolo"y

The a**roach in desi"n *ro*osed in this *a*er is structured u*on the*remise that the *rimary function of the hos*ital outdoor s*ace is creation ofcalmin" environment .hich re*resents an additional healthcare amenity that

*rovides thera*eutic benefits and *ositive health outcomes The list of features thata hos*ital outdoor s*ace may com*rise .as also "iven as an illustration of variousas*ects that need to be ta!en into account in order to "enerate a ne. and more

*ositive ima"e of a hos*ital as a non-threatenin" *lace $n relation to *atientse+*erience, the essence of *resented a**roach may be found in a *ossibility ofcreatin" a common and familiar everyday environment .ithin a s*ace that amajority *erceives as *sycholo"ically bounded E+*eriencin" these s*aces asislands isolated from everyday life occurrences may, amon" others, lead to a loss of

faith in curin" or com*lete recovery, thus the true .orthiness of the outdoor s*acesof modern hos*ital facilities is based on their a**ro*riate and diverse *ro"ram,


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social, *sycholo"ical, environmental and ambient characteristics, .hich can bevalued u*on daily *resence, *ositive e+*eriences and satisfaction of *atients, as.ell as other user "rou*s

$n a lon"-term sense, the role of a desi"n team is to inte"rate hos*italoutdoor s*ace into a hos*itals routine in a manner that .ould hel* com*ensatee+tra costs by reducin" the len"th and cost of thera*ies05B1 This leads toim*rovement of "eneral effects of timely dia"nostics and treatments andcontributes to healthcare *romotin" 4ualities, but re4uires a more com*le+ hos*italinfrastructure and *oses additional considerations to the outdoor *lannin" *rocess

%EFE%EN(ES

# Gonti, /: $n Graise of 3rchitecture, F 'od"e (or*oration, Ne. or!

(ity, #C5 NeduMin, ': %e!onstru!cija i revitali2acija !liniM!o-bolniM!o" !om*le!sa

u Novom Sadu, 63 Thesis, 'e*artment of 3rchitecture and UrbanGlannin", Faculty of Technical Sciences, University of Novi Sad, 5CC>

A 3dams, 3: 6edicine by 'esi"n L The 3rchitect and the 6odern )os*ital#DA-#>A, University of 6innesota Gress, 6innea*olis, 5CCD, *>

> Feldstein, G: )ealth (are Economics, Thomson 'elmar 7earnin", Ne.or!, 5CC>

= Ulrich, %S: Effects of /ardens on )ealth &utcomes: Theory and%esearch, in (oo*er-6arcus, (, 8arnes, 6 ;Eds, No5, #B, **#CB-#5A 7e.is, 8, oroff, 6, &lds, 3: Environmental 'esi"n of (hild )ealth

(are Facilities, %esearch and 'esi"n D=: 3rchitectural 3**lication of'esi"n and Technolo"y %esearch, /eneral Groceedin"s, 3merican $nstituteof 3rchitects Foundation, ashin"ton, #D=, *>=

#C 6ou"htin, (, 6c6ahon-6ou"htin, 9, Si"noretta, G: Urban 'esi"n -)ealth and the Thera*eutic Environment, 3rchitectural Gress, Elsevier7td, &+ford, 5CC
https://www.researchgate.net/publication/12887548_The_Consumer_Assessment_of_Health_Plan_Study_(CAHPS)_survey_of_children's_health_carehttps://www.researchgate.net/publication/12887548_The_Consumer_Assessment_of_Health_Plan_Study_(CAHPS)_survey_of_children's_health_carehttps://www.researchgate.net/publication/12887548_The_Consumer_Assessment_of_Health_Plan_Study_(CAHPS)_survey_of_children's_health_carehttps://www.researchgate.net/publication/12887548_The_Consumer_Assessment_of_Health_Plan_Study_(CAHPS)_survey_of_children's_health_care


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## (oo*er-6arcus, (, 8arnes, 6: /ardens in )ealthcare Facilities L Uses,Thera*eutic 8enefits and 'esi"n %ecommendations, The (entre for )ealth'esi"n, 6artine2, (3, #=

#5 a+man, ) 6, (arner, E 3, 8er!enstoc!, /: ob Turnover and obSatisfaction 3mon" Nursin" )ome 3ides, The /erontolo"ist, Iol5>, No=,#D>, ** =CA-=C

#A 9lis!a, S: 8olnice, /raRevins!a !nji"a, 8eo"rad, ###> Ulrich, %S: Effects of /ardens on )ealth &utcomes: Theory and

%esearch, in (oo*er-6arcus, (, 8arnes, 6 ;EdsA>->A=

55 (oo*er 6arcus, (: )ealin" /ardens in )os*itals, in a"enaar, ( ;Ed-A5

5A /erlach-S*ri""s, N, Enoch-9aufman, %, 8ass-arner r, S: %estorative/ardens: The )ealin" 7andsca*e, ale University Gress, Ne. )aven,#

5> ibid#5= 6iller, (, 7e.is, ': ayfindin": Effective ayfindin" and Si"nin"

Systems - /uidance for )ealthcare Facilities, Stationery &ffice, N)SEstates, #
http://www.gghc.com/http://www.springerlink.com/content/?Author=R.+P.+Misrahttp://www.springerlink.com/content/?Author=B.+Sarbadhikaryhttp://www.springerlink.com/content/q421550178p3/?p=cb0e69bc547348a5b19edc469c084d57&pi=0http://www.springerlink.com/content/q421550178p3/?p=cb0e69bc547348a5b19edc469c084d57&pi=0http://www.springerlink.com/content/q421550178p3/?p=cb0e69bc547348a5b19edc469c084d57&pi=0http://www.gghc.com/http://www.springerlink.com/content/?Author=R.+P.+Misrahttp://www.springerlink.com/content/?Author=B.+Sarbadhikaryhttp://www.springerlink.com/content/q421550178p3/?p=cb0e69bc547348a5b19edc469c084d57&pi=0http://www.springerlink.com/content/q421550178p3/?p=cb0e69bc547348a5b19edc469c084d57&pi=0


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5 'al!e, ), 7ittlefair, G, 7oe, ': 7i"htin" and (olour for )os*ital 'esi"n,7ondon South 8an! University, TS&, The Stationary &ffice, Nor.ich,5CC>

5B NeduMin, ', 9ubet, I, 9r!lje, 6: 6ethodolo"y of %econstruction and%evitali2ation Glannin" of )os*ital (om*le+es, in Pborni! radovainternacionalno" nauMno-struMno" s!u*a: /raRevinarstvo L nau!a i *ra!sa,Vablja!, A-B mart 5CCD, /raRevins!i fa!ultet, Univer2itet (rne /ore,God"orica, **#5B#-#5B

SPOL.A/N.I PROSTORI BOLNI0KIH USTANO1A - TERAPEUTSKIUTICA. I ASPEKTI PLANIRAN.A

Dejana Neduin, Milena K!lje", Na#a Ku$%&i'-F%li'

Svest o *o2itivnom uticaju bolniM!o" o!ruWenja na *roces o2dravljenja !od*acijenata veX du"o je *risutna u arhite!turi 2dravstvenih obje!ata U*r!osMinjenici da su bolnice to!om *rolo" ve!a *roje!tovane na naMin !oji bi obe2bedioda njihov rad bude *rvenstveno e!onoms!i is*lativ, Mime je 2naMaj njihovihs*oljanjih *rostora *ot*uno 2anemaren, savremeni sistemi 2dravstvene 2atite sesve vie usmeravaju na 2adovoljenje *otreba *acijenata, sa dodatnim ciljemsmanjenja tro!ova medicins!ih tera*ija u2 odrWavanje viso!o" nivoa !valiteta svihuslu"a !oje se *ruWaju &vaj nov *ristu* u *romeni *rioriteta o"leda se i u

*laniranju i *roje!tovanju !a!o bolniM!ih obje!ata ta!o i njihovih otvorenih*rostoraU radu je *redstavljena anali2a ra2liMitih arhite!tons!ih i urbanistiM!ih as*e!ata!oji mo"u biti u2eti u ob2ir *rili!om *roje!tovanja i *laniranja s*oljanjih *rostora

bolniM!ih !om*le!sa Njihovim ra2matranjem i *rimenom mo"uXe je ostvariti*siholo!i *odsticajnu sredinu !oja moWe da *obolja efe!te medicins!ih tretmana iubr2a *roces leMenja, Mime se istovremeno *osredno *oveXava i efi!asnostcelo!u*no" 2dravstveno" sistema (ilj istraWivanja bio je da se is*ita na !oji naMin iu !ojoj meri ra2liMiti arhite!tons!i i urbanistiM!i elementi mo"u da do*rinesu ustvaranju !valitetnih s*oljanjih bolniM!ih *rostora !ao tera*euts!o" o!ruWenja

!oje ima *o2itivan uticaj na 2dravstvene ishode

Kljune ei% spol+a@n+i prostori bolniAkih ustanova, #dravstveni ishodi,terapeutska okruBen+a

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Hospital Outdoor Spaces - Therapeutic Benefits and Design Considerations

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