From Formalistic to Evidence Based Design in the Healthcare Sector

As we transition our discussion from formalistic to evidence based design, we situate it in the healthcare sector as healthcare’s focus is to restore a human being’s mind, body, and spirit—promote ones dignity—which is made visible through the act of healing and the outcome of wellbeing. As there have been distinct architectural phases in this industry, it is easier to observe the impact of physical space on the outcome of healing, wellbeing, and the promotion of dignity.

In healthcare, a narrow focus on formalistic design during the 1980s paralleled technological advancements and the need for infection control, efficiency, and patient safety. Architectural design responded with stark, noisy, unattractive, and antiseptic- smelling facilities (Ananth 2008) that afforded patients and family members of patients efficiency of navigation and security from germs through lack of color, shiny metal surfaces, tile floors, and reduced ornamentation (Sternberg 2010 : 219). This was a positive advancement that focused on minimizing infection and linked space to health outcomes, a major concern for healthcare facilities (Ulrich et al. 2008).

Broadening towards a more holistic view of human beings, evidence based design (EBD) uses psychological and health-outcome measures to evaluate health benefits of architectural features (Sternberg 2010: 215). There are three main categories within EBD—patient safety, environmental stressors, and ecological health—that drive much of today’s healthcare facility design practices and organizational processes (Ulrich et al. 2008). The exploration of the field began with a report published by Cochrane in 1972. Archie Cochrane, an epidemiologist, demanded that all healthcare research and clinical trials be recorded and follow quality criteria, bringing rigor to the field. After this report the field of environmental psychology considerably advanced EBD research (Proshansky and Ittelson 1970). For example, Zimring (1982) studied various unit layouts to see if one layout was preferred. He further provided an environment that supported social engagement and mitigated stress for the developmen tally disabled. Ulrich (1984) conducted a landmark EBD study, which demonstrated that views of nature are directly correlated to the health of the occupant via reducing pain levels and shortening lengths of stay. The Ulrich study brought a focus to architecture and design and its potential to impact not only the body, but also the mind of human beings.

Based on EBD, the Center for Health Design (CHD), originated by a group of healthcare leaders and designers, came together for the purpose of making safer and more healing hospital environments. The CHD began to collect relevant research that pertained to physical environments and health; yet, architects and designers were not trained researchers, which made the development of high quality studies difficult unless they were tied to an academic institution. A lot of energy was spent on educating the community about what EBD was, rather than on the field’s methodology itself. A myriad of research frameworks were used to conduct studies that were subsequently published in peer-reviewed journals from other disciplines. Even though significant headway has been made in promoting and adopting EBD—such as the establishment of the CHD’s peer-reviewed journal HERD (Health Environments Research & Design Journal) in 2008, EBD remains in its infancy and continues to struggle to establish greater acceptance globally, both in practice and in academia.

EBD links the body and mind in the process of healing, but remains stunted in its advancements. These advancements are keenly focused on the pathogenic approach to health, but are void of a holistic view that includes a focus on the spirit of the human being. These advancements also neglect the role of the environment on mitigating stress caused by environmental factors such as light levels, color, and other aspects (Rashid and Zimring 2008). Over 40 years ago, the focus on formalistic practices towards the twin ends of form and function was critiqued for its disregard of humanistic design practices (Arnheim 1977). This critique, which continues today due in part to the lack of rigor evident in the growth of EBD, made apparent a lack of focus on the respect and recognition of the whole human being embedded in formalistic practices (Bugni and Smith 2002).