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Theory
Territories of Engagement
in the Design of Ecohumanist
Healthcare Environments
Terri Peters, PhD
1
and Stephen Verderber, ArchD, MArch
1
Abstract
Background: Increasingly, architectural and allied designers, engineers, and healthcare facility
administrators are being challenged to demonstrate success in adroitly identifying and con-
textualizing ever-shifting and expanding spheres of knowledge with respect to the role of energy
conservation and carbon neutrality in healthcare treatment environments and their immediate
exterior environs. Aim: This calls for making sense of an unprecedented volume of information on
building energy usage and interdigitizing complex and at times contradictory goals with the daily
requirements of building occupants. Ecohumanist Design Strategies: In response, a multi-
dimensional framework is put forth with the aim of advancing theory and practice in the realm of
designers’, direct caregivers’, and administrators’ engagement with ecohumanist design strategies in
the creation of ecohumanist healthcare environments. Conclusions: Ten territories for engagement
are presented that both individually and collectively express salient themes and streams of inquiry in
theory and practice, within an operative framework placing the patient, the patient’s significant others,
and the caregiver at the center of the relationship between the built environment and occupant
well-being.
Keywords
landscape and nature, environmental sustainability, evidence-based design, territories of engagement,
research methods
The concept of ‘‘sustainability’’ in architecture
still remains rather poorly defined. Leading archi-
tectural theorist Kiel Moe (2007, 2008) has pub-
lished widely on why architects find the concept
of sustainable architecture ‘‘unreliable’’ at best.
Moreover, architects have publicly commented
that sustainability is not even relevant to architec-
ture per se (Belogolovsky, 2011; Peters, 2010).
Moe views integrated design strategies as having
the potential to support better, and perhaps more
sustainable architectural designs, noting that in
integrative design, there is the acknowledgment
of the social construction of architecture that has
not always been evident in recent periods of
architecture (Moe, 2008, p. 8). He argues ‘‘that
in architecture, all technology is social before it is
technical’’ (Moe, 2008, p. 8). From this, one
1
John H. Daniels Faculty of Architecture, Landscape and
Design, University of Toronto, Toronto, Ontario, Canada
Corresponding Author:
Terri Peters, PhD, John H. Daniels Faculty of Architecture,
Landscape and Design, University of Toronto, 230 College
Street, Toronto, Ontario, Canada M5S 1A1.
Email: terri.peters@daniels.utoronto.ca
Health Environments Research
&DesignJournal
2017, Vol. 10(2) 104-123
ªThe Author(s) 2016
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1937586716668635
journals.sagepub.com/home/herd
could argue all sustainability matters are social
before they can be considered as technical mat-
ters. If the barriers to integrative design continue
to be largely social and cultural, largely due to
communication issues between disciplines and
disciplinary silos, then this is where any current
efforts to overcome this condition must begin.
Interestingly, his book, highlighting 28 ‘‘inte-
grated design’’ examples in North America, fea-
tures not one building designed for healthcare or
with human health and well-being uses first and
foremost (Moe, 2008).
If ‘‘sustainable architecture’’ continues to
remain rather poorly conceptualized and mea-
sured/measurable by architects, and particularly
in the realm of healthcare environments, broader
conceptualizations are needed. One key problem
attributable to the widespread usage on this term
is that it places the preponderance of responsi-
bility on the physical facility side of the equation
when in reality the person and the physical envi-
ronment that one inhabits function transactively,
interactively, dynamically, and across time and
space in healthcare settings. To address this defi-
nitional, and hence, conceptual conundrum, the
term ecohumanism has been put forth (Verderber,
2010). Ecohumanism is defined as a conceptual
framework whereby equal concern is accorded
human well-being as well as the ecological well-
being of a place and its inhabitants. Reflective,
healthcare-focused environmental design practi-
tioners are being called upon by their clients to
provide diagnostic and treatment settings that
respond to both sets of concerns of priorities
simultaneously, more than ever before. The for-
mer set of priorities cannot continue to be traded
off in favor of the latter. Myriad determinants
impact what gets built, and these factors must
be treated as functioning in consort—symbioti-
cally—with the goal of attaining equilibrium
between the attainment of carbon neutrality
together with a highly supportive care setting for
patients, patients’ significant others, and staff
persons. In the coming decade, ecohumanists
will be called upon to deploy bionic engineering,
new building material palettes, assembly sys-
tems, and a host of increasingly carbon neutral
design strategies in this regard (Verderber,
2010).
If ‘‘sustainable architecture’’ continues to
remain rather poorly conceptualized and
measured/measurable by architects, and
particularly in the realm of healthcare
environments, broader conceptualizations
are needed.
In architecture, practitioners and theorists gen-
erally are guided by the assumption that design
shapes the well-being, behaviors, moods, overall
experience, and mental health of the individuals
who inhabit the environments they design. The
Architectural Institute of America (2013) counsels
its members that ‘‘as an architect, your everyday
decisions, large and small, can affect the mental
and physical health of everyone that comes into
contact with your work.’’ Due to this, it is not
surprising that designers and others in the building
industry are increasingly concerned with how peo-
ple respond to their designs. Research has shown
that a majority of building owners, architects, and
contractors care deeply about the health of occu-
pants in their buildings and that this has a signif-
icant impact on their decisions (Bernstein, 2014, p.
24). Further, respondents said that health and well-
being concerns of occupant would likely be of
greater importance in the next 2 years. Despite the
importance of this topic to architects, there are
relatively few peer-reviewed studies in the archi-
tectural literature compared to other disciplines.
For example, researchers in applied psychology
(Beute & de Kort, 2014), medicine (Zadeh, Shep-
ley, Williams, & Chung, 2014), and healthcare
design (Joseph, 2006) are among a number of
researchers in those and related fields to conclude
that natural daylight is a positive therapeutic envi-
ronmental design attribute. Design decisions relat-
ing to building layout, building scale, and choice
of materials have been shown to have impact. In
particular, research has shown that design can
improve patient safety, reduce patient stress, and
improve the work environment for caregiver staff
(Ulrich et al., 2008). Increasingly, designers’ work
emphasizes the experiential dimensions of build-
ings and landscapes as constituent parts of a com-
plex interpretation of sustainability. Sustainability
is generally relegated to economic, environmental,
and social sustainability, with the ‘‘social’’ aspect
Peters and Verderber 105
often poorly defined as a leftover, noneconomic,
nonenvironmental component within the equation.
Concepts relating to people, their perceptions, how
they work, and how they heal are too often general-
ized within the social, that is, human dimension.
Ecohumanism seeks to address this facet of the
work of design professionals but, additionally,
seeks to consider the role of landscape ecology and
the conservation of finite natural resources relative
to the success of the completed built project. With
this said, the scientific foundation for evidence-
based design (EBD) for health as it pertains to a
building’s energy consumption remains rather
insignificant, and what is known remains curiously
nonintegral in the designer’s early stage decision-
making processes. However, recent research by
Alvaro, Wilkinson, Gallant, Kostovski, and Gard-
ner (2016) affords a new look at, for example, the
postoccupancy evaluation (POE) process and why
it has become essential to rethink its limited current
focus in this regard. This research explores the POE
process in the expansion of psychosocial well-
being, seeking a deeper, more design-focused feed-
back mechanism, including transactions between
natural daylight and patterns of socialization.
Meanwhile, debate continues on the role of
‘‘evidence’’ in healthcare design (Hamilton, 2014;
Lundin, 2015). Some architects believe their crea-
tive intuition and past experience are threatened by
empirical evidence generated by others, especially
that which emanates from other disciplines and lit-
erature realms. For example, architects do not typi-
cally seek empirical evidence on whether cluttered
or unhygienic environments are perceived as coun-
tertherapeutic, or whether spacious, daylight-filled,
variegated environments are perceived as therapeu-
tic. The 11 Maggie’s Centers built to date have
aimed to celebrate the particularities of ecohuma-
nist design for cancer patients including concepts of
‘‘kitchenism’’ and meditative spaces (Jencks, 2015,
p. 16), yet these aspects have not been explicitly
grounded in EBD approaches. Promising recent
work in the architectural research literature, how-
ever, is evidenced in the work of Feddersen (Fed-
dersen & Ludtke, 2014), with regard to nursing
home designs and in efforts to improve the lives
of people with dementia.
Sustainable healthcare architecture has been
the focus of recent publications, including the
contributions by Guenther and Vittori (2008,
2013) and Cooper Marcus and Sachs (2013), both
of which employ multiple case studies, photogra-
phy, architectural drawings, and interdisciplinary
reference sources. Guenther and Vittori identify
and define 31 key sustainability indicators, orga-
nized into six categories to measure performance,
specific to resilient–regenerative healthy build-
ings: site planning, form and facade, water,
energy, materials and construction practices, and
community. However, a given building’s history
and potential for future renovation, its architec-
tural connection to surrounding buildings/con-
text, and its aesthetic qualities are not explicitly
explored.
The relationship between sustainable design
and healthcare environments warrants further con-
sideration, particularly as the majority of postwar
health buildings across North America, Europe,
and elsewhere are currently facing renovation and
rebuilding in the coming decade and beyond. This
transactional relationship between sustainability
and concepts of occupant well-being, comfort, and
health promotion is timely. In response, 10 ‘‘terri-
tories’’ that intersect sustainable design considera-
tions, human health needs, and the occupancy of
healthcare facilities and their associated landscape
environs are presented below. They aim to capture
key, in-evidence aspects of this interrelationship
within an ecohumanist perspective. The goal is
to inform, be informed by, and extend beyond the
status quo.
These territories are inspired by a recent influ-
ential essay focused on the territories of urban
design (Krieger, 2009). Subsequent to this essay,
a similar approach identified territories of theory
and practice in educational design/build curricula
in university-based architectural curricula
(Verderber, 2014b). Below, each territory of
designers’ engagement with ecohumanism in the
healthcare milieu is framed as a dynamic, fluid
stream of inquiry using examples drawn from
healthcare buildings in use. Due to space limita-
tions, this overview remains brief, although each
built example cited crosses over into more than
one stream of inquiry, with some crossing into
virtually all of the territories. Collectively, this
compendium aims to represent an interdependent
constellation of concerns (Figure 1). Above all,
106 Health Environments Research & Design Journal 10(2)
the intent is for this compendium to serve as a
basis for further development and reinterpreta-
tion, as conditions evolve across time, space, and
cultural contexts. Engagement is attainable by
means of the following 10 considerations:
1. Minimization of the Carbon Footprint
In ‘‘Minimization of the Carbon Footprint,’’ a
healthcare facility and its site environs are
designed in a manner that strives to achieve car-
bon neutrality with regard to its daily operative
performance. Hospitals are a particularly energy-
intensive building type, because they tend to have
specialized equipment and are continually in use.
Hospitals have an energy use intensity much
higher than all other building types except for
grocery stores (U.S. Environmental Protection
Agency, 2013). Energy use is tied to harmful
emissions that endanger humans and our environ-
ment, and a main culprit is building construction
and daily operation, which contribute almost half
of our harmful emissions (Intergovernmental
Panel on Climate Change, 2014). There is a need
to design all buildings to meet stricter environ-
mental performance targets. The 2030 Challenge
is a voluntary initiative designed to incrementally
lower emissions use to reach carbon neutral levels
by 2030.
In ‘‘Minimization of the Carbon
Footprint,’’ a healthcare facility and its
site environs are designed in a manner
that strives to achieve carbon neutrality
with regard to its daily operative
performance.
Figure 1. Territories of engagement in evidence-based, ecohumanist healthcare environments.
Peters and Verderber 107
Relating to quantifiable, measurable sustain-
ability parameters, energy use is an important
metric. The Leadership in Energy and Design
(LEED) is a certification tool for measuring cer-
tain specific aspects of environmental sustainabil-
ity including energy and resource use in buildings
for healthcare and to date 25 have been certified
LEED Building, Design and Construction Health-
care in the United States (U.S. Green Building
Council, 2016). The LEED certification is not
comprehensive from a holistic or architectural
standpoint, nor does it claim to be. Due to the
complex nature and often-conflicting parameters,
all certification systems or definitions of sustain-
ability are culturally reliant, and must be evalu-
ated contextually, and relative to the starting
point. For example, LEED only measures certain
criteria, and naturally does not measure spatial
quality, the occupant’s satisfaction with the build-
ing, the design’s relationship to history, creativity
in architectural expression, or a wealth of other
criteria that architects find essential to analyze in
relation to sustainability and quality of buildings.
The 2030 Challenge seeks to lower fossil fuel
energy use and harmful emissions (80%less fos-
sil fuel use by 2015 based on 1990s benchmarks).
The baselines are regional or country average/
median for that building type. It makes no dis-
tinction between building size, costs, materials, or
design quality. These ways of measuring sustain-
ability are important because they raise aware-
ness and can spur change but are problematic
because they are not tied to architectural concepts
and vice versa.
It has been proven in many technical studies
and initiatives that the barriers to low-energy
buildings are not technological, but rather social
and cultural. There have been demonstration proj-
ects that show, technically, it is possible to design
to 2030 metrics. For example, ‘‘Targeting 100!’’
(University of Washington, 2012) is a research
project by the Integrated Design Lab at Univer-
sity of Washington in collaboration with a host of
industry collaborators. They analyzed six study
regions in the United States to find how possible
and practical it would be to dramatically reduce
energy consumption levels in hospitals. It was
found that heating energy was the single largest
energy load, and therefore the best target of
opportunity for energy savings. They identified
performance goals and concluded that by highly
integrating a bundle of schematic architectural,
building mechanical, and plant system designs,
it was possible to achieve more than a 60%reduc-
tion in energy, thus meeting the 2030 challenge
goal for 2010-–2015. Using a very simple pay-
back calculation, these energy options would pay
back, on average, in less than 9 years. Much
lower energy-consumptive hospitals are possible,
although they are not yet being built in North
America and even when they are, the term ‘‘low’’
energy consumption is relative and varies greatly
by the building’s situational context. This equally
applies to transportable buildings for healthcare,
as prefabrication of component assemblies and
even entire structures can yield numerous advan-
tages in the manufacturing and construction pro-
cess (Verderber, 2016). There remains a critical
disconnect between theory and practice in the
sustainable design discourse in this regard with
regard to the operative definition of a low-energy
building (Peters & Weyer, 2015).
The question arises: How can the profession and
discipline of architecture move beyond meeting
ever-changing code/regulatory contexts, which can
render any ‘‘low-energy’’ calculation obsolete
within only a matter of years, while creating a
building/landscape design of genuinely sustainable,
enduring merit? There is an ever-growing senti-
ment in architecture, in both education and prac-
tice, that world leading architecture is something
apart—different from—operative, mainstream def-
initions of a sustainable architecture. Further, the
term sustainability itself denotes yet another set of
unwieldy constraints imposed upon the designer.
New ways of conceptualizing low-energy, truly
sustainable design strategies are needed—strate-
gies that are simultaneously restorative/therapeutic
and ecologically based through.
2. Resilient and Regenerative Care Settings
In ‘‘Resilient and Regenerative Care Settings,’’
the healthcare environment is demonstrably ther-
apeutic and restorative for patients and other build-
ing occupants while simultaneously conserving
nonrenewable natural resources. Robin Guenther
argues for ‘‘resilient/regenerative/restorative’’
108 Health Environments Research & Design Journal 10(2)
approaches to a sustainable healthcare, rather than
viewing it as yet another set of burdensome con-
straints imposed upon the designer (Guenther,
2009). Similar sentiments occur in the theoretical
writings of McDonough and Braungart (2002) in
the conceptualization of a cradle-to-cradle philo-
sophy that can extend in the future to entire build-
ings. Guenther calls for diminishing, reducing,
removing the carbon footprint, while concurrently
extending and reconsidering the healing environ-
ment from a therapeutic perspective. The cradle-
to-cradle approach advocated by McDonough and
Braungart has become an influential concept,
although it remains difficult to implement at the
total-building scale. The architecture office 3XN
worked with McDonough to produce a design
guide (Lyngsgaard & Jørgensen, 2013) and built
the Green Solution House (GSH) on the Danish
island of Bornholm using these principles. The
GSH is a high-performing building; all materials
used in the building are either fully recyclable or
biodegradable.
In ‘‘Resilient and Regenerative Care
Settings,’’ the healthcare environment is
demonstrably therapeutic and restorative
for patients and other building occupants
while simultaneously conserving
nonrenewable natural resources.
Rather than doing more with less, it is pro-
posed that designers should just do more.The
recent work of architects Bjarke Ingles Group
(BIG) is guided by a ‘‘hedonistic sustainability’’
approach (Ingles, 2010), with the aim of demon-
strating how green design can be much more
palatable to the designer, of healthcare environ-
ments or otherwise. BIG refuses to accept the
architectural designers’ hardship for the sake of
a greater environmental good, but rather crea-
tively seeks to invoke entirely new ‘‘briefs’’ and
opportunities for design innovation.
Raymond Cole argues that green building stra-
tegies, performance goals, and associated assess-
ment methods currently emphasize the ways and
extent that buildings can and should mitigate glo-
bal and local resource depletion and environmen-
tal degradation. By contrast, the emerging notion
of ‘‘regenerative’’ design and development
emphasizes a coevolutionary, partnered relation-
ship between humans and the natural environ-
ment, rather than a managerial one that builds,
rather than diminishes, social and natural capitals
(Cole, 2012). Ken Yeang (2008), designer of
‘‘bioclimatic’’ skyscrapers and the author of the
influential Ecodesign: A manual for ecological
design (2008), asserts that architects undergo sig-
nificant academic training and yet receive no
coursework or field experience in ecological
design itself. Beyond, there is a need to explore
such design strategies as:
3. Functional Deconstruction
In ‘‘Functional Deconstruction,’’ the scale and
complexity of a medical center is ameliorated
through the redistribution of its constituent parts
to autonomous ambulatory care sites, fostering a
more human-scaled, energy conserving design
outcome. The massive megahospitals built in the
1960s and 1970s came to symbolize all that was
wrong with the late 20th-century high-tech med-
ical machine. The McMaster’s Health Sciences
Center, which opened in Hamilton, Ontario, in
1972, in many ways represented the apotheosis
of the ‘‘bigger is better’’ movement in hospital
architecture. The trend up to then had been to
centralize as many functions and the largest num-
ber of beds, on a single site, premised on the
assumption that a single treatment ‘‘armature’’
or apparatus could be built that would be able
to be midwifed as needs changed. This would,
in theory, render the hospital envelope as never
becoming obsolete. This resulted in massive
interstitial floors sandwiched between inpatient
and related support floors. The overall effect was
one of a place that was absolutely overbearing in
its scale, where wayfinding was extremely chal-
lenging, and where the upfront construction costs
were as high as 40%greater than a conventionally
built hospital at the time. Interstitial megahospi-
tals were built in Canada, by the Department of
Veterans Affairs in the United States, and in a
number of other countries, including Japan, Tai-
wan, the UK, and in Germany (Verderber & Fine,
2000). These institutions were found to consume
enormous amounts of energy, although this
expenditure was justified on the grounds that
Peters and Verderber 109
other savings were being achieved. These places
tended to look not unlike massive automobile
factories and were rather threatening (especially
in the eyes of children) in their institutional inte-
rior/exterior imagery and formal attributes.
In ‘‘Functional Deconstruction,’’ the
scale and complexity of a medical center
is ameliorated through the redistribution
of its constituent parts to autonomous
ambulatory care sites, fostering a more
human-scaled, energy conserving design
outcome.
The movement to reject their massiveness, and
oppressive qualities, would result in the demassi-
fication of the various constituent parts of these
institutions. This process of removing parts and
redistributing them as autonomous care settings
throughout the surrounding community has been
defined as functional deconstruction (Verderber
& Fine, 2000). Functional deconstruction mani-
fests in two different ways. First, it has been (and
continues to be) a process whereby much smaller,
freestanding, diagnostic, and treatment centers,
that is, kidney dialysis centers, outpatient oncol-
ogy centers, surgicenters, primary care clinics,
shopping mall–based clinics, were built by the
thousands, beginning in the mid-1980s. It is a
trend that continues to the present. Second,
newly built medical centers are being composed
as campuses with collections of buildings that
appear to be freestanding yet are in realty con-
stituent parts of a greater whole, umbilically
connected by means of underground passages,
car parks, and the like. An early example of this
site and architectural design strategy was the
Freeport Health Care Village, Kitchener, Ontario,
in 1989, by the NORR partnership, with McMur-
rich and Oxley Architects.
It is far less problematic to inject sustainable
design attributes into smaller scaled building
envelopes, compared to the prior generation of
highly centralized medical center behemoths that
appeared to be giant factories or warehouses. The
Peter and Paula Fasseas Cancer Clinic at the Uni-
versity Medical Center, in Tucson, AZ, by CO
Architects is a freestanding clinic that would have
in prior decades been embedded within the ‘‘main-
frame’’ of its parent hospital. Here, however, it is
sited independently (Jiang & Verderber, 2015). Its
exterior facades are transparent, layered, and tex-
tured versus the harsh concrete exteriors of mid-to-
late 20th-century Brutalist hospitals. This freedom
to explore transparency and dematerialization
allows varied compositional massing, stepped
floor levels, roof terraces, balconies, and court-
yards, providing multiple opportunities for:
4. Landscape Therapeutics and Nature
In ‘‘Landscape Therapeutics and Nature,’’ the
physical landscape and human engagement with
nature are considered key therapeutic aspects of
design and a building’s relationship to its site
environs. Much of EBD research on the topic of
sustainable healthcare facilities relates to the
proxemic availability and access to outdoor areas.
Research on the relationship between nature and
human health status found a restorative effect of
natural views on surgical patients. Further studies
found that patients experience less stress and pain
if they can view nature and other pleasant sur-
roundings (Ulrich, 1984; Ulrich et al., 2008). Sub-
sequent research conducted at the time identified a
condition now known as psychological window-
lessness, whereby a hospital room, while techni-
cally windowed, can yield such a low level of
sensory amenity it is rendered dysfunctional in this
regard (Verderber, 1986, 1987; Verderber & Reu-
man 1987). And yet, architects and landscape
architects often do not work together from the ear-
liest stages of a project to conceptualize the entire
building and its site context from the standpoint of
person–nature connectivity (Verderber, 2006,
2010, 2014). Sustainable healthcare architecture
per se has continued to be only sporadically dis-
cussed as a specific concern, although some nota-
ble exceptions to this pattern stand out. The book
Therapeutic Landscapes: An Evidence-Based
Approach to Designing Healing Gardens and
Restorative Outdoor Spaces by Cooper Marcus
and Sachs (2013) is an important example in EBD
for outdoor health environments. However, the
architectural examples cited focused on large-
scale campus-type buildings, rather than smaller
scale, more qualitative interventions relating to
110 Health Environments Research & Design Journal 10(2)
experience and place. Unfortunately, this further
reinforces the stereotype that EBD cannot be experi-
mental, qualitative, or small scale, even though it
can be, it just typically is not deployed in that way.
From graphic icons depicting the appearance of sus-
tainability strategies to metrics against benchmarks,
the architectural role of intuition, experience, and
unique site responses is less of a focus.
In ‘‘Landscape Therapeutics and Nature,’’
the physical landscape and human
engagement with nature are considered key
therapeutic aspects of design and a
building’s relationship to its site environs.
The Fiona Stanley Hospital in Brisbane
Australia (Figure 2) was completed in 2014 by Has-
sell, in collaboration with Silver Thomas Hanley.
This facility includes a large rehabilitation hospital
where patients often have long stays of up to 6
months and the design of the landscape encourages
exercise as important experiential and therapeutic
design elements. The interior physical therapy
rooms are integrated into public spaces to inspire
people to exercise and to draw people outdoors.
Outside, the architects intentionally designed the
environment to allow patients to tackle physical
features they will encounter once they leave the
hospital, so kerbs, unstable surfaces, slopes, and
stairs are designed features. Discrete markers in
the pavements allow patients to measure their
recovery and set themselves goals for their reha-
bilitation, extending the treatment area outdoors.
The hospital symbolizes a reinvented perspective
on the therapeutic benefits of allowing patients to
engage in significant physical activity while out-
doors, while blurring the lines of demarcation
between ‘‘hospital’’ and the ‘‘public realm.’’
Such design strategies can be in support of and
entirely compatible with:
Figure 2. Fiona Stanley Hospital, Brisbane Australia (2014) by Hassell with Silver Thomas Hanley, is a large state
government hospital and teaching facility with a four-story rehabilitation hospital. The rehabilitation hospital has
an integrated therapeutic landscape where exercise and outdoor activities are central to the recovery process.
Designed landscape elements such as kerbs, slopes, varied surfaces, and paving textures helping patients practice
and challenge themselves outdoors to aid in their recovery. Photograph by Peter Bennetts.
Peters and Verderber 111
5. Residentialism Versus Institutionalism
In ‘‘Residentialism versus Institutionalism,’’
the building/landscape for healthcare challenges
needless institutionality, through experimental
or familiar architectural forms and imagery,
together with new, mixed-use programmatic
combinations thereof. Mixed-use healthcare
environments achieved through combining
health programs with offices, schools, or other
functional purposes—even housing—can be a
way of meaningfully interweaving healthcare
into the community while also offering more
informal, noninstitutional care settings. In the
UK, successful contemporary interpretations
exist of the ‘‘comprehensive health center’’
(De Syllas, 2015), including the Heart of Houn-
slow Centre for Health (2007), London, by
Penoyre and Prasad. Another example, De
Hogeweyk (Figure 3), is a village for aged res-
idents that offers an unusual and pioneering
approach to the design of care environments for
individuals with dementia. The focus of the care
regimen is not on merely ‘‘nursing’’ the elderly
with dementia but rather giving them the chance
to live with dignity by tailoring individual care
services to each resident as needed (Feddersen &
Ludtke, 2014, p. 176). Located near Amsterdam
in the Netherlands, residents live in 23 apartments
within a 15,000 m
2
‘‘town’’ with a supermarket,
doctor’s office, hairdresser salon, restaurants,
small shops, and a theater, all within the footprint
of the healthcare environment.
In ‘‘Residentialism versus
Institutionalism,’’ the building/landscape
for healthcare challenges needless
institutionality, through experimental or
familiar architectural forms and
imagery, together with new, mixed-use
programmatic combinations thereof.
Figure 3. De Hogeweyk Dementia Village, Weesp Netherlands (2009) by MBVDA Architects, is a care village
with 23 apartments and an outpatient care unit as well as a community center, restaurants, shops, and enter-
tainment facilities. It was designed as a multifunctional village within a healthcare environment to give the residents
supportive surroundings for independence and dignity. Image courtesy: Vivium.
112 Health Environments Research & Design Journal 10(2)
A healthcare facility need not in any demon-
strable way appear outwardly (or inwardly)
‘‘institutional.’’ Nor does its sustainability quoti-
ent need to be narrowly defined by its total energy
performance apart from concern for its behavio-
rally or socially based aims. The Skypad is an
example of a healthcare facility designed to look
and function very differently from the typical
cancer treatment unit embedded within a conven-
tional hospital. Orms (2016) designed a 10-bed
specialist cancer treatment center for teenagers
in 2011 in Wales on the site of the University
Hospital of Wales, a noted teaching hospital. This
two-level building is raised on stilts and its bright
blue ‘‘carriage’’ is cantilevered over two impos-
ing 1960s buildings, so that the Skypad is actually
atop the preexisting hospital’s main service tun-
nel. From the outside, this blue form appears
more like a boutique hotel or fine arts space than
a cancer treatment clinic, offering an alternative
for its adolescent patients; it is the first facility of
its kind in Wales. Its architecture allows for
design excellence in inpatient and outpatient can-
cer treatment for young people in a noninstitu-
tional environment. The aim was to encourage
patients to leave their beds, to socialize with other
patients. There are shared rooms where a patient
can close one or more set of curtains for privacy,
as well as private rooms. This treatment center
was funded entirely through donations led by the
Teenage Cancer Trust, therefore linking the cen-
ter to the goal of attaining:
6. Advocacy and Social Inclusiveness
In ‘‘Advocacy and Social Inclusiveness,’’ the
planning and design of socially responsive archi-
tecture enhances the lives of patients and commu-
nities alike, providing sociopolitical empowerment
to otherwise marginalized building occupants.
Within a strong tradition of social inclusion and
innovative contemporary design, many important
benchmark precursors in design for healthcare,
especially in housing and small treatment facili-
ties, can be found in Scandinavia (Peters, 2014).
For example, in Denmark, there have been a series
of small-scale treatment facilities designed by
leading and emerging architects embedded in
communities not on large healthcare/medical
campuses. This allows for a wider range of crea-
tive formal expression, varied user experiences,
scales of intervention, and fuller integration of
healthcare facilities into their community con-
texts. The NORD architects’ Center for Cancer
and Health in Copenhagen (Figure 4) is a metal
clad courtyard building with a folded faceted
roof designed to look noninstitutional. The
building is arranged around interior courtyards,
and the interiors are designed for generous day-
lighting with many open spaces with high ceilings.
The building is designed to disrupt the stigma and
fear surrounding cancer treatment and to encour-
age spiritual and emotional rejuvenation.
In ‘‘Advocacy and Social Inclusiveness,’’
the planning and design of socially
responsive architecture enhances the lives
of patients and communities alike,
providing sociopolitical empowerment to
otherwise marginalized building
occupants.
Another example is the Solingen Care Facility
in Germany by Arbeitsgemeinschaft Monse þ
Molnar, a small-scale building designed to be
socially inclusive and to break down physical
barriers (Feddersen & Ludtke, 2014, p. 42). The
architects of this 20-bed long-term care facility
designed a multigenerational care setting for res-
idents ranging from ages 18 to 60þ, designed to
improve and enhance their psychoemotional out-
look toward life by incorporating interesting pat-
terns, colors, materials, and textures, and diverse
room arrangements in support of occupant needs,
that is, large dining tables that invoke comparable
spaces found in housing for younger persons, and
creating a focus on natural daylighting in social
areas for listening to music and multimedia
engagement. Long-term care facilities are not
usually designed with this level of nuance, and
this building therefore stands apart as an exem-
plar in recent architecture for health.
Another noteworthy recent example of
socially responsive design for health is the inter-
generational nursing home and children’s nursery
school in Hamburg, Germany, by Feddersen
Architekten (Terri Peters visited, March 10,
Peters and Verderber 113
2016). The Seniors Center in Island Park is a care
home with 140 assisted-housing beds. It was
designed to offer healthcare for seniors within
their neighborhood, providing a mixture of uses
to closely approximate a normative neighborhood
ambience and its associated social interrelation-
ships among residents, thereby reducing the
stigma and feeling of isolation often experienced
by these residents. It also doubles as a skills train-
ing and lifelong learning center for the aged. A
nursery school is also housed in the building,
includingadaynurseryforupto60children
combined with an on-site residential unit with
seven apartments for young mothers and their
children. Through creative, occupant-sensitive
planning and design strategies, the lives of
patients and their community contexts can also
be improved by means of:
7. Therapeutic Interior Realms
In ‘‘Therapeutic Interior Realms,’’ the expe-
rience of the building affords a health-promoting
and therapeutic environment on a daily basis,
emphasizing the point ofviewandcomfortof
patients, their significant others, and caregivers.
The network of Maggie’s Centers are health-
promoting places designed to provide emotional,
practical, and social support for people with can-
cer, their loved ones, and friends (Jencks, 2015).
There are 16 built Maggie’s Centers, to date,
designed by award-winning architects known for
landmark architecture and cultural buildings,
rather than a primary expertise in healthcare
design. This group of firms includes Snohetta,
Ted Cullinan, Gehry Partners, Zaha Hadid, and
OMA. Built on the grounds of hospitals, they are
Figure 4. Centre for Cancer and Health, Copenhagen, Denmark (2012) by NORD architects, was planned and
designed to be socially inclusive and to disrupt the stigma of cancer treatment through the design of the building’s
geometry, material, and spatial arrangement thereby creating a socially inclusive environment. Image courtesy:
NORD. Photograph by Adam Mørk.
114 Health Environments Research & Design Journal 10(2)
designed as a ‘‘hybrid building type’’ more akin
to ‘‘a house but not a home, a collective hospital
that is not an institution, a church which is not
religious, and an art gallery that is not a museum’’
(Jencks, 2015, p. 28). The concept of kitchenism
or providing a central kitchen table for collective
eating, socialization, and psychoemotional sup-
port is a dominant programmatic element, and
this functional space is expressed in a unique way
in each center. Every center affords diverse spa-
tial variations, such as seating alcoves positioned
to engage framed views of nature, and each has
intimate spaces set apart from, where people can
feel alone yet still feel connected to others. Each
center provides a meditation room and an adja-
cent space for meditation and yoga. These build-
ings share no prerequisite goal for square footage
energy efficiency or low energy usage, yet they
offer many experiential and mental health bene-
fits and engage with human health promotion in
innovative ways.
In ‘‘Therapeutic Interior Realms,’’ the
experience of the building affords a
health-promoting and therapeutic
environment on a daily basis,
emphasizing the point of view and
comfort of patients, their significant
others, and caregivers.
The provision of therapeutic interior spaces is
the primary focus of The MGM Grand in Las
Vegas which offers their entire 14th floor, 171
rooms, as WELL-certified rooms for guests, and
these are designed to make people feel healthier at
a US$30 per night premium (MGM Grand, 2016).
These rooms focus on experiential design for the
senses, including hypoallergenic sheets, ‘‘energiz-
ing lights,’’ a special air filtration system, aro-
matherapy, warm white room lighting, ‘‘long
wave night lighting,’’ and a Vitamin C infused
shower. This prototype is based on the WELL
standard, a new EBD certification system focused
on health and wellness. It assesses seven categories
of well-being in the built environment: air, water,
nourishment, light, fitness, comfort, and mind
(Delos WELL Standard, 2016). This desire to pro-
mote wellness and to embed this into the materials,
furnishings, and ambient sensory environment of
the room is closely related to architectural:
8. Tectonic Innovation
In ‘‘Tectonic Innovation,’’ the built project
contributes to environmental design discourse
with respect to the advancement of inventive spa-
tial and technology-driven design strategies, and
thereby garners peer recognition and wide influ-
ence within the professional community. The
Lady Cilento Children’s Hospital in Brisbane,
Australia (Figure 5) by Lyons (2016) with Conrad
Gargett architects is a visually striking building,
with a vibrant, colorful facade and bold geometric
forms. The architects aimed to set a benchmark in
sensory design for pediatric healthcare; the build-
ing was designed around the concept of ‘‘a living
tree.’’ A grand central atrium vertically connects
the floors and organizational areas, and it is
accentuated by giant artworks of parrots. Color,
pattern, and texture have been used throughout
the facility with bravado, injecting novelty, energy,
and a sense of playfulness. The building has won
several architecture and healthcare awards relating
to the project’s focus on sustainability, integrated
artwork, and its ‘‘child-centered’’ design. Strong
landscape connectivity was achieved, incorporat-
ing the site’s hillside terrain. Outdoors, patients can
access a secret garden, adventure garden, climbing
wall, basketball court, wheelchair-training ramp,
and a habitable green roofscape.
In ‘‘Tectonic Innovation,’’ the built
project contributes to environmental
design discourse with respect to the
advancement of inventive spatial and
technology-driven design strategies, and
thereby garners peer recognition and
wide influence within the professional
community.
Another example is the renovated Residence
for the Sisters of St. Joseph of Toronto Canada,
by Shim-Sutcliffe Architects (Figure 6). It was
designed as a health-promoting, contemplative
place, integrating various sustainable design cri-
teria while providing innovative architectural
design features (Shim-Sutcliffe Architects,
Peters and Verderber 115
2014). The facility offers 58 residential suites
offering varying levels of personal care and assis-
tance. Located alongside a ravine, the complex is
designed to be naturally day lit and ventilated and
to frame views of its natural surroundings. The
complex incorporates geothermal heating and
cooling systems, solar panels, solar hot water pre-
heating, a green roofscape, rainwater cisterns, and
permeable pavers. This partial renovation of a
1850s historic structure and partial reinvention
by adding a new structure and landscape design
closely relates to the:
9. Inventive Repurposing of Existing
Resources
In ‘‘Inventive Repurposing of Existing
Resources,’’ the built outcome expresses inven-
tive planning and design strategies with respect to
retaining and reinventing heritage protection-
worthy buildings and landscape resources in the
21st century.
In ‘‘Inventive Repurposing of Existing
Resources,’’ the built outcome expresses
inventive planning and design strategies
with respect to retaining and reinventing
heritage protection-worthy buildings and
landscape resources in the 21st century.
In 2014, Penoyre Prasad Architects and Arup
completed the renovation of St Guy’s Tower in
London, UK (Figure 7) by recladding and reno-
vating this landmark 1970s hospital. This 143-m
building is one of the tallest hospital towers in the
world and its Brutalist design remains an impos-
ing urban structure. The retrofit work was primar-
ily intended to remediate various building
technology damage, improve energy efficiency,
and reduce annual operational costs. Prior, the
patient tower had been highly insulated and over-
cladded. It was retrofitted with anodized alumi-
num panels and new window facade systems,
entirely applied from the outside in order to
Figure 5. Lady Cilento Children’s Hospital (2014), Brisbane Australia, by Lyons Architects with Conrad Gargett
Architecture, features a bright color palette and striking materials. It has garnered numerous awards, including the
F.D.G Stanley Award for Public Architecture, the Karl Langer Award for Urban Design, and a Salutogenic Design
Award from the International Academy of Design and Health. Image courtesy: Lyons Architects. Photograph by
Dianna Snape.
116 Health Environments Research & Design Journal 10(2)
minimize interior space disruptions. The work
was carried out while the building remained fully
in use, adding innumerable logistical and patient
care challenges. As well as recladding the tower
structure, which is actually two forms linked by a
bridge, the project reconsiders the immediate
public realm insofar as redefining the connection
of the patient tower to the ground level, improve-
ments in wayfinding, and the enhancement of the
visitor’s experience.
A more ambitious and explicitly ecological
approach in the repurposing of existing resources
occurred in the Mackay Base Hospital renovation,
in Queensland, Australia, by Woods Bagot. This
hospital opened in 2015, and the design was
guided by life cycle and ‘‘future proofing’’ as well
as principles drawn from EBD. The development
of the project and the extension of the hospital
were based on changing demographics in the area,
including an aging local population base, and the
need to mitigate flooding and extreme weather
threats. Work began in 2008 with the aim of repur-
posing existing resources and increasing energy
efficiencies, resulting in ‘‘a major reform to the
existing master plan and a 20%reductioninthe
original construction program, a greater alignment
with the intended model of care/services, and
delivery of a significant ecological sustainable
building’’ (Woods Bagot, 2016).
According to the London-based architectural
firm Arup, modernist healthcare architecture
between 30 and 50 years old within the UK’s
NHS network remains fundamentally versatile
and adaptable to new healthcare-based purposes.
The upgrading of facade alone can accrue signif-
icant major envelope performance improvements
and keep these heritage-quality resources in good
repair for adapted future use. Exterior facade
Figure 6. Residence for the Sisters of St. Joseph of Toronto by Shim-Sutcliffe Architects (2014) features
innovative architectural design strategies, including integration with landscape, connection to the existing struc-
ture, and incorporation of multifunctional sustainable and health-promoting features. It has garnered numerous
awards, including the Living City Award in 2013 by the Toronto and Region Conservation Authority and the
World Architecture News Award for Best Hospital Upgrade Award in 2014. Image courtesy: Shim-Sutcliffe
Architects. Photograph by Bob Gundu.
Peters and Verderber 117
retrofitting can result in new levels of thermal
efficiencies, natural daylight transmission levels
to interior spaces, enhanced natural ventilation,
heating–cooling capabilities, shading, view ame-
nity, associated human safety issues, and signifi-
cant energy performance annual cost expenditures
(King, 2013).
This desire to achieve far more with fewer
nonrenewable resources, and to adopt repurpos-
ing strategies to existing resources, extends to
multiuse and multifunctional designs. A recent
report issued by The Royal Institute of British
Architects (2013) highlights how familial inter-
dependency is being fostered in places with
increasing numbers of extended families living
under one roof to their collective mutual benefit.
Efforts are underway to renovate existing housing
to be more multigenerational and multiuse, for
example, Varberparken Estate in Denmark, which
is a social housing estate that has been totally
renovated and a mix of uses introduced—where
a nursing home is now housed in one of the former
housing blocks (C.F. Møller, 2016).
10. Interdisciplinary Knowledge Mobilization
In ‘‘Interdisciplinary Knowledge Mobilization,’’
in all stages of the design of a building/landscape,
there is acknowledgment of broad-based consid-
erations of sustainability beyond the building
itself, and between participants representing
diverse areas of expertise and perspectives. The
design of healthcare environments is an interdis-
ciplinary proposition, involving multiple areas of
expertise and implementation foci. In relation to
sustainability in healthcare settings, Guenther
(2009) arguesfor the need for ‘‘integrative design’’:
design teams must break down traditional silos
between architectural designers and medical plan-
ners; owners must engage a broader spectrum of
building operations specialists in the design pro-
cess; the process must foster new dialogues between
highly specialized consultants. In short, the process
must encompass broader considerations. It demands
new and unfamiliar tools such as rating systems,
carbon calculators, and climate and hydrology ana-
lytics. As if that were not enough, sustainable
design requires research.’’ (p. 5)
Integrative design is essential to achieving a reflec-
tive approach to design education. In this regard,
the Laboratory for Integrative Design at the Univer-
sity of Calgary’s Faculty of Environmental Design
was founded as a center for drawing together
researchers from multiple disciplines. There,
research teams examine interrelationships between
design, engineering, computer science, material
science, mathematics, and the biological sciences.
In ‘‘Interdisciplinary Knowledge
Mobilization,’’ in all stages of the design
of a building/landscape, there is
acknowledgment of broad-based
considerations of sustainability beyond
the building itself, and between
participants representing diverse areas
of expertise and perspectives.
Figure 7. The St. Guy’s Tower Retrofit Project
(2014), London, UK, by Penoyre Prassad Architects
and Arup features new exterior cladding and restora-
tion of a landmark 1970s NHS hospital. Photograph by
George Rex.
118 Health Environments Research & Design Journal 10(2)
The term ‘‘knowledge mobilization’’ has rap-
idly acquired currency in many disciplines and
can serve as a rallying point for accelerating
evidence-based research in healthcare facility
planning and design (Lawlor, 2013). It is a call
for efforts to make sense of and translate
research-generated knowledge for the better-
ment of society. In the case of evidence-based
research and design in healthcare environments,
many studies have been published over the past
30 years (Ulrich et al., 2008). Yet one question
looms above these contributions to knowledge:
what is the fundamental relationship between
research and creative design innovation, as per-
taining to the design and construction of health-
care environments? Research universities are
committed to the generation of new knowledge,
and as such are tasked with engaging industry
and society to find new outlets for this new
knowledge. Advances in the discipline and prac-
tice of architecture, unfortunately, often occur
randomly, lacking coherent directionality—and
seldom in a smooth, linear progression. How-
ever, as a building is completed and occupied,
it becomes possible to carry out the postoccu-
pancy assessment of its strengths, weaknesses,
and opportunities for improvement. This knowl-
edge is then transferrable to other contexts, so
future errors and omissions can be avoided. The
transfer quotient of this new knowledge, if it
remains unreported in peer-reviewed outlets and
forums, will remain limited. Unfortunately, gen-
uine knowledge mobilization, and innovation
itself for that matter, remains largely discipline
centric (Nichols, Phipps, Provencal, & Hewett,
2013). A completed building, however, requires
the mobilization of myriad types of information,
from the rather mundane to the poetic, and
knowledge mobilization should foster and sus-
tain innovation and experimentation whenever
possible across a spectrum of concern.
Summary and Discussion
The relationship between sustainable design and
healthcare environments warrants further consid-
eration, especially since the majority of postwar
health buildings across North America, Europe,
and elsewhere are facing renovation and/or total
rebuilding in the coming decades. The transac-
tional relationship presented above between sus-
tainable design considerations, patient and staff
well-being and comfort, and their health promo-
tion—taken together as an ecohumanist perspec-
tive—is most timely. The aforementioned 10
‘‘territories’’ of architecture and landscapes for
health seek to articulate the intersection of sus-
tainable design, human health needs, and the
occupancy of healthcare facilities and associated
landscape environs. Each is premised on it being
able to express a key aspect of ecohumanism in
environments for health and well-being.
Designers and researchers who engage ecohu-
manist concepts in the consideration of healthcare
environments will be positioned to fuse these
concerns into a coherent paradigm for profes-
sional practice. These territories illustrate ways
to navigate the challenges of the nettlesome per-
formance gap that persists between building
energy usage attributes and the health promoting,
patient-focused design attributes that evidence-
based designers strive to achieve. To more holi-
stically address critically important concepts of
environmental sustainability in healthcare environ-
ments, conceptual frameworks grounded in ecohu-
manism bring needed clarity and hence can aid in
charting the course of future research. To some,
this conceptualization may appear to be random.
Why only 10? These territories of engagement are
intended to be interpretative rather than prescrip-
tive, and in no ‘‘set order’’ nor intentionally pre-
sented hierarchically or as being limited in scope
or expandability. The essential point is not that a
given building/landscape example is applicable to
only one given territory—when, in reality, any
given building/landscape can apply across all 10
(or more) territories—territories to be articulated
as future events unfold. Rather, the intent is for
others to elaborate upon and amend this initial
conceptualization, as it pertains both to EBD
research in healthcare environments and in daily
professional practice in architecture and in its
allied disciplines. Together, this framework repre-
sents but one holistic cosmology of ecohumanist
concerns. Further broader or, in turn, more fine-
grain, conceptualizations undoubtedly exist.
Future work in this area, regardless, would pru-
dently engage new, patient-focused environmental
Peters and Verderber 119
control technologies currently becoming com-
monplace in healthcare environments. The ability
to attune, or ‘‘tune’’ these care settings to suit
specific comfort levels, can concurrently result
in reduced waste of nonrenewable natural
resources as well as a higher degree of user satis-
faction with one’s care setting. For researchers,
further work is warranted on the health impacts of
passive environmental design together with other
key aspects of sustainable architecture for health.
For example, in the realm of housing, a promising
recent study by a housing association in the UK
has found thermal comfort and energy efficiency
can be linked to health outcomes (Gentoo Green,
2015). Their ‘‘Boilers on Prescription’’ pilot saw
doctors ‘‘prescribing’’ better performing build-
ings, so that elderly patients are kept warmer and
more comfortable, thereby reducing their doc-
tor’s visits. In the future, public policies and facil-
ity management strategies may result in the
retrofitting of aging hospitals with new high-
performing facades as a way to reducing occupant
stress, discomfort, and to promote faster rates of
recovery. There is great potential in the intersect-
ing fields of building energy efficiency and build-
ing performance research, as a means to improve
human health and conserve nonrenewable envi-
ronmental resources.
Researchers have identified a range of eco-
nomic benefits to sustainable healthcare: reduced
operating costs, risk avoided through improved
occupant health and safety, and tangible commu-
nity benefits (Houghton, Vittori, & Guenther,
2009). Green infrastructural systems are another
significant area of inquiry warranting further
research. Much potential exists for extending and
reinforcing architectural/landscape sustainability
concepts in direct consort with the therapeutic
benefits of humans’ engagement with nature and
landscape (Cooper Marcus & Sachs, 2013; Jiang
& Verderber, 2015). Sustainability, from a per-
formance perspective, offers new ways to think
about nature and landscape, beyond just having
an accessible outdoor area. Cooper Marcus found
that positive changes have occurred related to
healing gardens
Leadership in Energy & Environmental Design
(LEED) for Healthcare, the Sustainable Sites
Initiative, and the Environment of Care Section of
the 2014 Guidelines for Design and Construction of
Hospitals and Outpatient Facilities all now include
a requirement or credit pertaining to access to
nature. (2016, p. 172)
However, Cooper Marcus highlights some
impediments to truly innovative indoor–outdoor
design as a single continuum. She notes that few
schools of landscape architecture provide courses
on healthcare design. Also, the quantitative
nature of guidelines can be an impediment, given
that ‘‘access to nature’’ is vague and can be inter-
preted in a multitude of ways (Cooper Marcus,
2016, p. 173). Few design guidelines and consid-
erations enumerate exactly what access to nature
implies, nor if or how they draw on available
research to guide the design of a successful heal-
ing or restorative garden with ecohumanist bene-
fits at stake as well as potential economic and
community benefits. Evidence-based approaches
have much to offer, in helping recenter the dis-
cussion on people and health, and in generating
new knowledge for new and renovated healthcare
facilities to benefit human well-being as well as
the ecological well-being of a place.
Implications for Practice
This article offers an ecohumumanist
framework for conceptualizing intersec-
tions between the often-competing terri-
tories of sustainable design, human health
needs, patterns of occupation, and integra-
tion with landscape.
This article offers 10 examples of ecohu-
manist health designs which engage with
aspects of sustainable architecture, land-
scape, and health.
This article offers an architectural design
perspective into the discourse of sustain-
able healthcare environments.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of
interest with respect to the research, authorship,
and/or publication of this article.
120 Health Environments Research & Design Journal 10(2)
Funding
The author(s) received no financial support for
the research, authorship, and/or publication of
this article.
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