“There is no better designer than nature”
Hello. Welcome to Compassionate Nature, the weekly digest of research on a psychological topic relating to compassion or nature connection. The words of fashion designer Alexander McQueen introduce this week’s topic of biophilic design.
Forty years ago in 1984 a study was published in Science by Roger Ulrich. It has become a famous study and has been cited by nearly 9000 other papers.
In the paper Ulrich describes the analysis of patients recovering from gall bladder surgery in a US hospital. Hospital data of 46 patients taken from the period 1972 to 1981 was used to create 23 pairings matched by gender, age and health conditions. The patients were aged between 20 to 69 years old, with no serious post-surgery complications and no mental health conditions. There were more female (30) patients than men (16). All the patients had been in a room with a window during their stay in hospital. Within each matched pair the window provided one patient with a view of trees while the other patient had the view of a brick wall from an adjoining building.
Ulrich’s analysis of the patients levels of pain relief, anxiety relief, minor complications, nurse’s notes and post-surgery duration in hospital revealed some difference in the pairs. Patients who had the view of the trees were statistically more likely to leave hospital around a day earlier, had more positive comments about their recovery in their patient notes, and took weaker pain relief than those looking out at the wall. It was a small sample of patients who were in hospital for a relatively short term and compared a natural view to a very uninteresting non-natural view. However along with further studies by many others, including Ulrich, the idea that exposure to natural stimuli within clinical and hospital settings can aid recovery and reduce stress is now an established one.
Which leads onto the idea of biophilic design.
Several people, including Stephen Kellert who co-wrote The Biophilia Hypothesis with E O Wilson, have developed a series of principles around biophilic design, which can be defined as supporting connection with nature through direct and indirect contact with natural stimuli within a built environment. Biophilia relates to the theory that we have an evolved, innate connection and affective relationship with nature and natural stimuli.
However biophilic design is more than just inserting natural elements into the design. To be successful, biophilic design must be authentic around a design that uses natural elements to support and foster the wellbeing and health of those who use the buildings and spaces. It looks to foster an emotional relationship with nature through repeated and sustainable engagement with natural aspects within the design and to minimise environmental impacts. Direct contact includes elements such as the role of light, air and water within the design, the provision of views of landscape and ability to observe the weather. Indirect contact includes the use of natural materials, naturalistic shapes and colours, and providing opportunities to notice natural events such as colour changes or ageing of materials.
Please note this is a short overview of the design principles and there is much more involved in the design than I have covered. If interested in learning more the books by Stephen Kellert are worth considering.
A trio of recent papers help to explore further the role of biophilic design within healthcare and clinical settings and the benefits this may afford those who work, visit or stay in them.
Reviewing the design
A 2023 review by Bekir Tekin,, Rhiannon Corcoran and Rosa Gutiérrez provides insight into the critical aspects of biophilic design from patients and staff viewpoints to help inform design considerations within hospitals. The review selected 9 studies published from 2016 to 2020, of which 3 were assessed as high quality, 4 as good quality and 2 as low quality. Of the 9 studies, 4 were from the USA, 3 from Australia, 1 from the UK and 1 was a UK-Netherlands study. The authors analysis was split by outpatients, inpatients and staff perspectives.
For outpatients important aspects included the hospital setting to be welcoming, with a good use of natural light, providing a quiet environment with an outside view and featuring natural colours and materials. For inpatients the setting should be relaxing and feel safe, with a view of the outdoors and the use of natural light. It should have fresh air, greenery and allow patients to notice seasonal changes. Again the use of natural colours and materials was mentioned, as was the easy access to a natural outdoor environment. For the staff, a safe and quiet setting was a priority. They also wanted fresh air and natural light, along with a view, while indoor greenery was of a lower priority to them. While there were differences in the priority across the three groups, the use of natural colours and materials, airflow and natural light, a sense of safety and protection from overstimulating factors are common key design considerations.
The authors go onto suggest health setting design considerations for the three groups. For outpatients these included the use of natural materials in the welcome area, with light, spacious and quiet waiting rooms with seats near windows. For inpatients these included having a line of sight through a window, which had one way glass for privacy, natural background sounds and the use of high quality fake plants if real plants could not be used due to infection risks. Lastly for staff they suggested access to private spaces, views to the outdoors, access to outdoor spaces and reduction in visible clinical apparatus would be helpful. General design considerations included the use of natural colours and materials, low stimulation and the ease of movement within the settings.
The review is limited by the small number of relevant case studies available and the selected studies are from only a few countries, with two being deemed as low quality. Additionally some of the selected studies were not specifically measuring biophilic design. However the findings reflect some of the key biophilic design priniciples and I thought it interesting to note the subtle differences in the priority of design elements between the two types of patients and the staff.
Plants
I noted that in the review the use of fake plants was considered appropriate but only when a real plant could not be used in a clinical setting due to health risk. A 2023 review by Anahita Moslehian and colleagues at Deakin University in Australia helps to understand those risks and reflects on the benefits associated with indoor plants in healthcare settings.
The review selected 28 papers that either aimed to explore the physical and physiological benefits or the health and safety risks associated with indoor plants across various healthcare settings. The main analysis was supplemented with a further 64 papers based on other, non-medical settings.
Of the main 28 papers, 16 were focused on the risks, with a third of those relating to immunocompromised patients and a third on the infection risk from vase water. Of the risk-related studies, 13 were conducted in actual hospital settings and 3 were lab based. They used biochemical analysis of soil, air and water samples to determine risk levels. The 12 papers which considered benefits were conduced in various healthcare locations, from general hospital settings through to specific clinics and used self-report questionnaires and medical measures to assess the benefits. The 28 studies came from either the US, UK or European countries.
The risks were focused on infections and allergic reactions. Microbial infections were assessed in the reviewed studies with relation to exposure from soil in potted plants, water in vases and fungi within the soil. There was little evidence that these presented a high risk of infection, with only an allergic reaction to fungi in soil noted as a potential risk.
The benefits were split into physical and psychological. General health benefits were associated with the calming and comforting presence that indoor plants appeared to provide in clinical settings, which was reflected in reduced blood pressure measures, lower levels of pain relief administrated and improved air quality measures. Psychological benefits included appearing to support stress management and patients self-reporting greater subjective wellbeing.
The authors highlight a number of mitigations that can address the risks including good plant maintenance undertaken by non-medical staff, avoiding the disturbance of potted plants soil and using woodchip or stones as a mulch to reduce soil exposure. They also suggest good routines around changing water in vases and the use of water treatments.
As it was a scoping review it does not provide a view of the quality of the reviewed studies and also includes some wider materials than just peer-reviewed studies. The studies are only from a small number of countries. However the findings suggest that the risks from plants in healthcare settings for the general population may be less than perceived and mitigations can be taken. There may be some more considerations required though where patients are immunocompromised. The risks should be considered alongside the wellbeing benefits that indoor plants appear to offer within healthcare settings.
One thing I noticed in both of these reviews was that while staff were aware of the potential benefits of indoor plants, they were a low priority for them, which appeared to be related to the additional work that looking after the plants may introduce.
Getting virtual
A 2023 study by Dawoon Junga, Da In Kim and Nayeon Kim delves deeper into assessing the benefits of biophilic design in hospitals, using a virtual reality (VR) environment and brain activity measurements to assess emotional responses to different levels of biophilic elements.
The authors used electroencephalogram (EEG), where electrodes are placed on the scalp to measure electrical activity and frequency band of the activity across the brain. Different frequencies are associated with emotional and arousal states. This was supported by self-report measures relating to emotions and state anxiety levels. The study took place in Seoul, South Korea and involved 63 participants with an average age of 24 years old, of whom the majority were female. They were divided into three groups and using VR they individually viewed a single-occupancy hospital room based on South Korean hospital standards. After providing baseline emotion and anxiety levels, each participant viewed the VR room with no biophilic elements as the control condition. They then supplied their emotion and anxiety levels again before viewing one of three biophilic designed rooms, which included either a plant wall, a nature based digital wall or both plant and digital wall. After viewing this they supplied their emotion and anxiety levels for a third time. The controls and the biophilic design viewing each took 2 minutes.
The participants EEG data was analysed using both machine learning and statistical analysis methods. The machine learning analysis showed that the biophilic designs resulted in increased activity within frontal regions of the brain, associated with cognitive processing such as attention and memory. The statisical analysis revealed changes in frequency bands suggestive of calmness, relaxation and visual stimulation from viewing the biophilic rooms. This was supported by the participants third set of self-report measures which also showed a reduction in negative emotions and anxiety. There was also an improvement in positive emotions from viewing the digital and plant wall design.
There are some limitations. Only one machine learning model was used which may limit the findings and the brain activity indicated from the EEG data is open to interpretation. The participants state anxiety was measured so a similar study could consider the influence of biophilic design upon trait anxiety. The sample were also young, mainly female participants which may affect the generalisation of the results. I also wondered about the long term influence of the different biophilic design elements given this research was conducted using very short 2 minute viewings, which a future study could look at.
The study findings do point further towards the benefits that incorporating biophilic design elements can provide to patients, which may aid recovery and enhance their time in hospital.
As I was finishing this piece I spotted a BBC News item on the use by Addenbrooke Hospital in Cambridge of a nature-based mural on the wall and part of a MRI scanner which has been developed to reduce the clinical nature of the room and help patients to stay calm in what can be a very claustrophobic environment. Having had an MRI scan I can testify it is an intense and enclosed experience, and the artwork the hospital has used makes it look much less threatening.
It probably seems intuitive that having elements of nature or natural aspects would be beneficial within healthcare and hospital settings. Biophilic design goes further than adding in some nice plants, playing birdsong in the background or having a nice view out of the window though. It embodies nature into the whole design of the built environment, to foster an engagement and connection with nature with us that is assumed to be a deeply evolved one. That is helpful at all times, and may be even more so during periods of ill health or recovery from surgery.
Ulrich’s often quoted paper was a small study, with lots of limitations, confounding factors and a lack of generalisability. However the body of evidence for the apparent help that natural aspects and elements can have upon patient recovery, staff morale and visitors is fairly well established, in part inspired by his work and theories around stress recovery.
Biophilic design is not just for hospitals. It is appropriate across the whole of the built environment, to foster a connection with nature and perhaps induce more care towards the environment. And that is such an important thing to foster, alongside our health and wellbeing.
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References - all open access
Jung, D., Kim, D. I., & Kim, N. (2023). Bringing nature into hospital architecture: Machine learning-based EEG analysis of the biophilia effect in virtual reality. Journal of Environmental Psychology, 89, 102033. https://doi.org/10.1016/j.jenvp.2023.102033
Moslehian, A. S., Roös, P. B., Gaekwad, J. S., & Van Galen, L. (2023). Potential risks and beneficial impacts of using indoor plants in the biophilic design of healthcare facilities: A scoping review. Building and Environment, 233, 110057. https://doi.org/10.1016/j.buildenv.2023.110057
Tekin, B. H., Corcoran, R., & Gutiérrez, R. U. (2023). A systematic review and conceptual framework of biophilic design parameters in clinical environments. HERD: Health Environments Research & Design Journal, 16(1), 233-250. https://doi.org/10.1177/19375867221118675
Another really thought-provoking piece. It doesn’t surprise me that natural design would promote wellness, calmness and healing. I think the thing people hate the most about hospitals is the ‘clinicalness’ - if that is a word. I personally find light spaces, a view of the outside and plants calming in themselves, without the medical additions. Thanks Chris!