Designing Hospital Emergency Departments for a Post Pandemic World: The Value of a BaSE Mindset—Biophilia (Natural), Salutogenesis (Healthy), and Eudaimonia (Contentment) in Architectural Design

Abstract

This chapter reports on research conducted across Australia with clinicians during the COVID-19 pandemic in 2020–21. The researchers worked with clinicians in hospital Emergency departments, often the first point of contact at the hospital for many consumers, to investigate ways to make the layout and wayfinding easier, both for consumers and clinicians. Research suggests that a biophilic (bringing in elements of nature), salutogenic (promoting good health), and eudaimonic (supporting happiness and contentment) environment will make Emergency departments in hospitals more positive places, and clinician feedback provides specific examples of how these architectural goals could be achieved.

Take a moment to imagine the following… a dearly beloved family member has been in an accident and is in an ambulance being rushed to hospital. You are following in your car, you don’t know what is wrong or what will happen when you arrive. You feel physically ill, and you are panicking.

While for an Emergency Physician this is just another day in the office, for most people an emergency presentation is a terrifying experience, at one’s most vulnerable time. The often overcrowded and unfamiliar sterile clinical environment with harsh bright lights, busy clinicians (cloaked in personal protective equipment during the Covid-19 pandemic) directing chaos and surrounded by unfamiliar equipment feels both disorienting and frightening. In this chapter, we propose that the standard design of these types of spaces should be reconsidered, to improve the experience for all users, both the consumers and the clinical staff. After a review of academic literature investigating the role and design of the Emergency Department (ED), and drawing upon our qualitative research, which included interviews with clinicians to understand if and how ED spatial environments facilitated or hindered their delivery of positive healthcare, we propose a new approach for designing EDs in a post pandemic world. Our BaSE Mindset is an integrated salutogenic (health promoting) approach, grounded in an awareness of the importance of biophilic (nature centred), and eudaimonic (facilitating contentment) architectural design principles.

1 Flexible and Adaptive Spatial Environments in Hospital Emergency Departments

Typically located at the front entry to a hospital, vulnerable, stressed, and frightened patients who are often also in pain and confused, create their first impression of healthcare facilities based on the ED. Improving the experience of Eds requires a two-fold investigation: (1) considering how patients (and their families) encounter the ED; and (2) understanding the requirements for a functionally optimised workplace for the clinical staff. The ED is a complicated spatial environment, which must comprise entry, exit, admissions, triage, and discharge areas for patients, while also operating as a workplace for clinical staff. A careful consideration of workflows, task efficiencies and productivity, and improved healthcare delivery is critical to facilitate good patient experiences, in additional to reviewing the design of patient waiting areas, and treatment spaces. Importantly, we applied a lens of health promotion and stress reduction, to our review of pandemic adaptation principles, which have impacted the physical facilities required and how EDs need to operate.

The COVID-19 pandemic impacted the operation and design of healthcare facilities suddenly and without and warning. In the scramble to manage the unknown implications of the pandemic, protecting clinical staff and patients from the spread of infectious pathogens, resulted in functionality becoming the primary consideration for hospitals, and EDs in particular. Fear of the unfamiliar fuelled our reactions to preventing virus spread, from diagnosed (and undiagnosed) patients, both within the community and the hospital setting. The health system’s primary reaction was to expand the capacity of hospitals, to admit, triage, and treat patients infected with the coronavirus, while minimising viral spread to the uninfected.

Health system policy and facility issues are outlined in Nigel Edwards’ report, in which he discussed the impact of this pandemic on the UK National Health Service (NHS). He noted that “searching questions will need to be asked about the UK’s overall COVID-19 response, in particular around testing, supply of protective equipment, care home policies and the large numbers of excess deaths” [1, p. 1]. Edwards [1] highlighted the impact of architectural design on infection control and staff capacity issues, including: (1) the necessity for an adaptive/flexible design approach; (2) generous circulation spaces to facilitate staff and patient movement and flow; (3) the provision of a majority of single bed wards to quarantine/isolate infectious patients; and (4) wider corridors to accommodate physical distancing requirements. More specifically, EDs require: (5) more generous waiting areas which facilitate physical distancing; (6) increased provision of isolation and enclosed treatment bays; and (7) flexibility to enable parallel assessment streams for infectious and other patients. Furthermore, (8) other facilities across the hospital must be adaptable, to allow efficient duplication or enlarging, to manage a rapid influx of patients. This may include extra imaging capacity, supplementary waiting areas, and additional lifts to minimise the number of people using each car.

Omar Nadarajan et al. [2] observed how the COVID-19 pandemic highlighted gaps in the design and operation of EDs, which could impact patient care and staff safety and create public health risks. In response, they propose a framework for ED design and workflow, to address the threats posed by infectious disease outbreaks, both now and in the future. This framework built upon four fundamental principles: (1) system—workflow, protocols and communication; (2) staff—human resources; (3) space—infrastructure; and (4) supply—logistics. In the pursuit of ‘healthcare pandemic resilience’, it is important to consider how additional spaces can be rapidly modified to provide temporary ED-intensive care units. Future strategies for providing pandemic resilience include the rapid provision of temporary facilities, This can be achieved by identifying and delivering flexible non-healthcare spatial environments that can be easily re-organised, to ensure adequate healing environment standards, even in a crisis. Flexibility and adaptability, “sectionable” units, multiple facility entry points, and rooms with direct outside access are additional suggested strategies. Furthermore, reconsideration of the design of waiting areas to respond to the specific needs of visitors and families, and the impact of salutogenic design on the stress levels of patients and staff, is critical [3]. Finally, the Danish Ramboll project provides case study examples of European hospitals which adapted in response to the Covid-19 crisis, and note the need for quick organisational responses that include:

creating entirely new modular hospitals, adding extensional spaces to hospitals, transforming existing hospitals or even transforming non-healthcare buildings, such as exhibitions halls, sports halls and convention centres into healthcare facilities, in some cases in only a matter of days [4].

2 The Importance of Healing Architecture

The healthcare system is inherently complex, with the ED delivering an amplified example of unpredictability and the need for dynamic and constant change. Historically, the regulatory, programmatic, and economic constraints of healthcare design provide barriers to accommodating this flexibility, leading to physical spaces that are inflexible, and not easily adaptable for alternative purposes. The design and construction of hospitals is immensely challenging, given the scale and complexity of the projects, expedited timeframes, strained budgets, and continuous and rapid advances in treatment and technologies. In response, some architects now draw on evidence-based design (EBD) practices, to scaffold their hospital design development. In tandem with an awareness of the ecological context (cultural, social, environmental), EBD practices incorporate research evidence; the practitioners design expertise; participatory co-design principles; and a high-level understanding of the organisational context, resources, population, and unique needs [5, 6]. To design resilient, adaptable, and pandemic-ready hospitals and EDs of the future, there is an emerging awareness of and sensitivity to the importance of healing architecture:

Healing design is highly important, or maybe even more important, during a crisis such as a pandemic… The adaptation of newly built hospitals, with high-quality daylight and views, access to outdoor spaces and well-planned staff areas, have exemplified how flexibility goes hand in hand with healing architecture [4].

Our argument here is that, as hospitals and EDs are (re)designed in response to the pandemic, a healing architecture approach is critical. Also known as therapeutic architecture, healing architecture prioritises the thoughtful design and construction of buildings, spaces, and places, to promote physical, emotional, and mental well-being, and actively support healing. Healing architecture focuses on the design of indoor environment qualities such as natural lighting, ventilation, acoustic comfort, connection to nature, and the deliberate integration of colour, texture, and other sensory elements, to create calming, soothing environments. As Lawson explains, for our hospitals to become truly healing environments, they must be designed “in harmony with the care models and procedures themselves” [7, p. 107]. Lawson advocates for what he describes as the ‘lofty’ goal of architecture: “making places so well that people feel better” [7, p. 107].

We argue that creating truly healing spaces will require architects and designers to adopt what we term, a BaSE mindset: explicitly considering how each architectural design decision can purposefully integrate Biophilia (natural), Salutogenesis (healthy), and Eudaimonia (contentment) considerations and elements, to improve the physical and mental health of building occupants. As described below, the three components of the BaSE Mindset and integrated architectural design method, are:

• Biophilic Architecture purposefully engages with and integrates nature, to help to promote health and well-being as well as regenerative physical environments, while positively contributing to the earth’s ecosystems (Kellert et al. 2011). Integrating Biophilic design results in positive outcomes including: increased productivity, focus, creativity and mental restoration, and reduction in absenteeism, low mood and poor health (Kellert et al., 2011).

• Salutogenic Architecture actively facilitates improved health and wellbeing rather than solely providing environments where illness is treated, or healthcare occurs. Through examining comprehensibility, manageability, and meaningfulness, salutogenic architecture provides human-centred, healthy, easily navigated environments.

• Eudaimonic Architecture inspires happiness, and a deep contentment with oneself and one’s life, promoting human fulfilment and flourishing. Recognising that fulfilment does not always imply psychological wellbeing, eudaimonic environments help people to live well, through considering their experiences (how well a person feels), and functioning (how well a person does).

3 Biophilic Architecture: Element One of the BaSE Mindset

Edward O. Wilson [8] believed that “biophilia” is a fundamental human aspiration. People are attracted to life and nature, and this binds us to other living species. Some architects and designers extrapolate these beliefs to underpin the hypothesis that natural environments attract people, and biophilic design attributes will be restorative and health-promoting. In the preface to a book of edited essays, Kellert, Heerwagen [9] examined the linkages between the built environment and the natural environment, and how these impact human experience and aspirations. Specifically, they were interested in how to “achieve sustained and reciprocal benefits between the two” Kellert, Heerwagen [9].

With its emphasis on health-promoting and restorative design, biophilic architecture helps to create a salutogenic healthcare environment. Kellert [10] proposed a list of 72 design attributes for a biophilic environment, covering six elements within two overarching biophilic dimensions—organic and place-based. Based on this work, McGee and Marshall-Baker [11] developed a unified language for salutogenic design and a Biophilic Design Matrix (BDM) to assess paediatric healthcare environments. Roger Ulrich, a pioneering advocate for biophilic design, argued that evidence clearly indicates how this approach to designing healthcare facilities improves occupant health outcomes. Furthermore, he contended that biophilia theory provides evidence that exposure to nature and sunlight in healthcare settings, will reduce stress, lessen pain, and foster improvements in other health outcomes. The practical implication is “that designing healthcare environments to incorporate nature and daylight can harness therapeutic influences… resulting in more restorative and healing settings for patients, family, and staff” [12].

More recently, Australian design researchers Abdelaal and Soebarto [13] take this further in proposing “restorative healthcare environmental design (RHED)”. Based on findings from a study of the Royal Children’s Hospital in Melbourne, Australia, they propose that “Healthcare environments can play a significant role in restoring the four types of human resources: physical, emotional, mental and spiritual”. However, design criteria, guidelines and clinical functionality considerations usually focus on the physical types of human resources, and often pay scant attention to the other three domains [13].

4 Salutogenic Architecture: Element Two of the BaSE Mindset

While Antonovsky’s term ‘Salutogenic’ (1979) is becoming mainstream in hospital design contexts, it is beginning to emerge in other architectural design contexts. Antonovsky described the need for a “sense of coherence” (SOC) to improve health and wellbeing. He believed that “…people who develop the salutogenic ability will live longer, perceive that they thrive in life and enjoy a good quality of life” [14]. Although this theory had little initial connection to the quality of the built environment, it has been increasingly applied in this context, in particular, to the design of healthcare environments. Salutogenic Architecture was developed from a model for socio-environmental influences on health, and actively facilitates improved health and wellbeing rather than merely providing environments where illness is treated, or healthcare occurs. For those promoting the concept, creating the built environment should similarly focus on the qualities that promote wellbeing for those using it. These users encompass the clinical and other staff, the patients, and the broader community who visit or occupy hospital or healthcare facilities.

Using a salutogenic approach to designing healthcare facilities is increasingly claimed by healthcare architects and designers, yet it is often the subject of “marketing spin” by less knowledgeable designers and their clients [15]. Golembiewski [15] notes that salutogenic architecture has the potential to support enhanced patient manageability, comprehensibility, and meaningfulness. By synthesising these processes in a design, the architecture may also help a person through the natural process of recovery. Architecture can be psychologically manipulative, providing a narrative context which affects people’s behaviour, how they are treated by others, and how they feel about themselves. Physical restrictions can be deliberately incorporated to moderate societal behaviour [16]. People are impacted psychologically and biochemically when correlating their emotions. Through examining comprehensibility, manageability, and meaningfulness [17, p. 26], salutogenic theory can provide a positive health dimension to architecture by designing human-centred, easily navigated environments.

Unfortunately, patient manageability usually triumphs over other factors, and therefore the opportunity to give or affirm meaning to patients challenged by fear, stress, and other negative emotions, is often missed. An emphasis on saving capital costs, at the expense of ongoing healthcare operational costs, means that aesthetic considerations often receive less attention and may be considered frivolous. Thus, traditional approaches to design, including preferencing functional efficiencies, are favoured over what may be better yet potentially riskier innovations [15]. Mazzi agrees with this perspective, suggesting that there is a misalignment of how scholars define the theory of salutogenesis and how architectural practice reflects it. She suggests “that design practitioners [should] consider salutogenesis as encompassing all theories related to the environment’s impacts on wellbeing” [18].

5 Eudaimonic Architecture: Element Three of the BaSE Mindset

The study of wellbeing often focuses on the concepts of “eudaimonia” (with eudaimonia also spelled “eudaemonia” or “eudemonia”) and “hedonia”. Differentiating between these terms requires considering their commonly held definitions. Eudaimonia is frequently defined as “growth, meaning, authenticity, excellence” as distinct from hedonia, which may be identified as “pleasure, enjoyment, comfort, absence of distress”. Both terms describe aspects of a life well-lived or a good life [19]. Eudaimonia was extensively espoused by philosophers Plato and Aristotle, when reflecting upon the qualities of good health, with the traditional translation being “happiness”. Life’s objective, according to these ancient thinkers, was to achieve Eudaimonia, best interpreted as fulfilment, human flourishing, or living one’s best life.

Twentieth Century philosophers have reinvigorated use of the word, promoting that it adds an important perspective to understanding wellbeing, human fulfilment, and “flourishing”, and providing a richer, broader interpretation of the narrower concept of hedonia or “happiness”, which refers to pleasure, enjoyment, and the absence of discomfort. Hedonia is a subjective state. Eudaimonia refers to a process, that is, what is worth pursuing in life and its outcomes [19]. Recognising that fulfilment does not always imply psychological wellbeing, but rather, that people focus on living well and realising their full potential (Deci et al. 2008), eudaimonic environments help people to achieve this through considering their experiences (how well a person feels), and functioning (how well a person does).

Huta and Waterman’s [19] classification system for analysing definitions of wellbeing consider orientations, behaviours, experiences, and functioning. The first two categories—orientations (what a person seeks), and behaviours (what a person does)—represent ways of living, what a person chooses to do in life. Eudaimonic Architecture principles align with the second two categories—experiences (how well a person feels), and functioning (how well a person does), typically considered wellbeing outcomes.

In terms of clinical care, Murtha, Stein et al. [20] discuss occupational therapy (OT) and applying a eudaimonic approach to OT practice. A eudaimonic method ensures that care is client-centred, providing meaningful activities, and investigating the meaning of wellness and happiness for individual clients. OT is a dynamic activity that encourages self-actualisation and improves a client’s quality of life. Both hedonia and eudaimonia are concepts relevant to healthcare environments, and consistent with a salutogenic design approach. Eudaimonia was chosen for this study because it aligns with salutogenesis. It is also dynamic and works actively to engage occupants with the healthcare environment, to create a healing and supportive physical milieu.

6 Our HEAL Project

Grounded in an understanding of healing architecture, and our BaSE Mindset approach, this HEAL project interviewed over twenty clinical, nursing, and allied health staff across Australia, to better understand how they experience their EDs. The interviews focussed on “what works and what doesn’t”, when considering the design of their ED spatial environments. The interview guide explicitly reviewed the entry, admission, triage, waiting, examination, treatment, recovery, and discharge or transfer areas, in addition to the staff work zones associated with each of these areas. Participants described: their experiences of working in different hospitals; the functionality of their ED environments during challenging times; and the diversity of patients presenting in EDs, with a recurring emphasis on vulnerable users. Recognising that the COVID-19 pandemic (and the introduction of new safety protocols such as social distancing, clear acrylic protective screens, assigned seating, prescribed circulation routes, and increased hand washing/sanitation) would have an ongoing influence on ED design, we examined how their environments have changed in response to the pandemic. Finally, we asked our participants to suggest how architects could improve the design of EDs, and to explain their visions of an ideal future hospital work environment. Our participants were positioned in hospitals throughout Australia, which provided us with an insight into a range of environments, and different types of patients, that medical professionals encounter in urban, regional, and remote hospital settings.

7 What Works (and What Doesn’t) in Emergency Department Design?

Clinicians described how the design and fitout of ED waiting rooms tangibly impacted the patient experience, with these features deemed as critical in enhancing the ED experience for consumers (see: Fig. 1; note, all figures developed by the project team):

• an approachable, open and clearly visible/positioned triage desk;

• a children’s play area where infectious disease contamination can be controlled;

• digital screens for education purposes and to communicate health advice;

• a taxi phone;

• phone chargers with multiple port adaptors;

• simple access to reliable and free wifi; and

• a waiting room nurse who is engaged to facilitate and improve communication with the patients and their families/carers.

Fig. 1

Supportive environment, welcoming entry, helpful staff (concierge-type service), natural light, self check-in

Wayfinding was often described as a ‘challenge’ which puts pressure on medical professionals who are already feeling over-worked and under-resourced. Wayfinding refers to the process of navigating and orienting oneself in a physical environment. It involves using various cues, signage, landmarks, and spatial information to understand one’s location, determine a route, and successfully reach a desired destination. Wayfinding is crucial in complex spaces like hospitals, to help people navigate effectively. Participants explained that “currently it is like a maze. We need to have coloured lines on the floor or walls for people to follow” and “we would like to put these colour coded lines on the ground where we can say to family ‘Follow the light blue line and you’ll find the coffee machine at the end of it ‘or ‘follow the green line and you’ll find the exit’. We can’t do that in this hospital, so it is difficult to direct family and patients… they all have to be individually escorted inside if they’ve never been here before.”

Clinicians also valued consistency in design and equipment set-up, citing this as highly important in the ED setting: “knowing where the buttons are, and not having to really think and look where you are means you can be on autopilot… it makes your job easier to have these uniform sort of panels.” Recalling past workplaces, ‘hub-and-spoke organisation design’ was perceived as the preferred and most efficient use of space—because of the visibility it provides, as well as the time saving in purposefully locating patients, equipment, computers and staff in a considered way. This organisational design model provides a networked approach to health service delivery. It is provided through a central anchor (hub) which offers a full array of health services, and which is complemented by secondary establishments (spokes) which offer specialised treatment services (see Fig. 2). A clinician explained: “You can stand in the centre and you can look around you and see everything. Patients that you are in charge of and the equipment that you need. That’s better.” In contrast, a ‘modular pod layout’ approach, where the ED is divided into distinct and separate areas, which are linked by a series of corridors, limited staff’s ability to observe their patients continuously and uninterrupted.

Fig. 2

Building form enhances entry of light, surveillance/visibility, and access to external views

Participants described how the Covid-19 pandemic had impacted their practice, with some positive changes cited. For example, one ED reconfigured the placement of the Paediatric Short Stay and Acute departments, to be located side by side, “bringing all the paediatric nurses and doctors together as a team” rather than them having to “walk 50,000 meters between spaces.” An overarching concern was the importance of better meeting the needs of ‘vulnerable patients’ (including children, elderly, mentally unwell, neurodiverse, culturally and linguistically diverse a.k.a. CALD, and Indigenous peoples). Participants unanimously agreed that design solutions which meet the needs of vulnerable groups also benefit other patients, their families/carers, and staff.

Figure 3 illustrates how architectural design can positively influence the experience of work and care delivery, from thoughtful physical planning, (e.g., creating flexibility and one-way flows) to larger-scale master planning approaches. The architectural design diagrams shown in the Figures (drawn by one of the co-author’s, Carthey) illustrate how—although typically unfamiliar with the terminology—participants placed a high value on healing architecture, and embraced the idea of a hospital ED space that was connected to nature (biophilic) (see Fig. 4), fostered health and happiness—especially by offering play spaces for children, and easy, attractive opportunities for clinicians and consumers to easily exercise—and created a positive, happy workspace (salutogenic and eudaimonic).

Fig. 3

Flexible use, expansion/contraction strategies, and repurposed spaces (left), incorporate one-way flows, where possible (right)

Fig. 4

Health promoting light, ventilation, clear layout, and access to views of nature in circulation corridors

Ideally, design solutions should endeavour to address all BaSE Mindset considerations which are so closely interlinked. For example, this could be achieved by: (1) framing views of nature from major circulation routes; (2) designing architectural form to purposefully enhance the entry of natural light and ventilation; (3) ensuring that wayfinding is user intuitive to reduce episodes of anxiety and spatial disorientation; and (4) integrating sensory artwork in children’s play areas [21].

Although this study concentrated on EDs, the results highlight that these spaces cannot be considered in isolation. Rather, it is essential to consider the department in its entirety, and the linkages and connections between this zone, and the other hospital departments—whether immediately adjacent or separated on a different floor or in a different wing. One of the study’s limitations was that only staff members were interviewed, and they were asked mainly about their workplaces. If interviewees mentioned patients, it was generally in the context of accommodating their diversity, efficiency, quality and safety issues. Mostly, interviews tended to result in discussions of staff working practices and the environments that accommodate these. Notably, it was evident that there is significant potential for an application of the BaSE Mindset to improve the design of these spaces, and to address many of the concerns that were raised by the participants. While our project explored the critical staff perspective, future studies should ideally include patients in the data collection, to obtain a more balanced perspective on the issues that affect all users and occupants of hospital EDs.